HomeMy WebLinkAbout20082169.tiff I
d DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
1111 •
COLORADO
MEMORANDUM
TO: Judy Griego — Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: July 25, 2008
SUBJECT: Weld County Addendum to the Individual Provider
Contract for Purpose of Foster Care Services and
Foster Care Facility Agreements.
Attached please find the Weld County Addendums to the Individual Provider
Contract for Purpose of Foster Care Services and Foster Care Facility Agreements
for the following County foster care providers:
2008-2009 SIGNED CONTRACTS FOR
COUNTY FOSTER CARE PROVIDERS
PROVIDER
NAME ID MAILING ADDRESS CITY STATE ZIP
Aguilar, Riley and Greeley, CO
1 Melissa 1510493 2081 40th Ave 80634
Pierce, CO
2 Armfield, Pamela 1549727 340 W Shafer 80650
Beasley, Travis and 840 Grandview Longmont, CO
3 Sarah 1552607 Meadows Dr. #A101 80503
Greeley, CO
4 Brilla, Debbie 30451 2018 20th St Rd 80631
5 Brown, Scott and Robin 1524302 301 Hickory Ave Eaton, CO 80615
6 Caldwell, Cynthia 1550399 936 Eichhorn Dr Erie, CO 80516
Combs, Colin and Greeley, CO
7 Hubert, Rebecca 1545310 5937 W 28th ST 80634
CMG 2008-2169
PROVIDER
NAME ID MAILING ADDRESS CITY STATE ZIP
Greeley, CO
8 Corliss, Wade and Loni 1547483 26649 CR 60 1/2 80631
Cowper, Michael and Platteville, CO
9 Alecia 1526756 509 N Sholdt Dr 80651
Crownover, Ernie and Windsor, CO
10 Jennifer 1512351 421 Ventana Way 80550
11 Dietz, Bill and Wilma 8635 21257 Hwy14 Ault, CO 80610
Fisher, Matthew and Greeley, CO
12 Claire 1532312 5022 W 2nd St Rd 80634
Flores, Isaiah and
13 Annette 1534649 302 Maple Ave Eaton, CO 80615
Frederick, CO
14 Frank, Jerry and Diana 1530545 7950 Colombine Ave 80530
Garnet, Steven and Greeley, CO
15 Cindy 1525231 1324 10th St 80634
Gerardy, Jerry and Evans, CO
16 Priscilla 1530549 3408 Cody Ave 80620
Gilstrap, William and 6363 St Vrain Ranch Firestone, CO
17 Lynnette 1525054 Blvd 80504
Hebbeler, Troy and Evans, CO
18 Christina 1522988 3610 Cactus Ave 80620
Greeley, CO
19 Heimer, Sara 1547292 3000 W 19th St 80634
Hernandez, Roberto and Fort Lupton, CO
20 Margarita 1520297 912 Elm Ct 80621
Windsor, CO
21 Hickey, Laurie 1518754 1125 Walnut St 80550
Holmgren, David and Windsor, CO
22 Dawn 1522699 864 Amber Court 80550
Housden, Richard and Aurora, CO
23 Rhonda 1550415 1671 S Troy St 80012
Greeley, CO
24 Hunt, Olen J and Nina 1503154 224 48th Ave 80634
Longmont, CO
25 Hymel, Chad and Tiffany 1540875 1257 Red Mountain Dr 80501
Jackson, Scott and Johnstown, CO
26 Andrea 1536689 425 Hickory Ln 80534
Keaton, Roger(R.C.) and Greeley, CO
27 Eva 1545954 25565 CR 47 80631
Kilgore, Julius and Greeley, CO
28 Pamela 1538189 1740 7th Ave 80631
Greeley, CO
29 Kniss, Kevin and Kelly 1524303 1545 71st Ave 80634
Firestone, CO
30 Knutson, Troy and Stacy 1522516 6250 Stagecoach Ave 80504
31 Laube, Keith and Julie 1514494 14497 WCR 76 Eaton, CO 80615
Kersey, CO
32 Lee, Steve and Brenda 1512263 30932 WCR 50 80644
Greeley, CO
33 Lewis, David and Connie 1523277 2904 42nd Ave 80634
Greeley, CO
34 Loschen, Todd and Alicia 1528352 1747 68th Ave 80634
PROVIDER
NAME ID MAILING ADDRESS CITY STATE ZIP
Maronek, Dennis and Firestone, CO
35 Patricia 1520627 4860 Eagle Crest Blvd 80504
McCreery, James and
36 Tammy 40215 120 Maple Ave Eaton, CO 80615
Greeley, CO
37 McGee, Donna 1539853 1649 31st Ave 80634
Mellmen, Jeffrey and
38 Letha 1547484 352 Laurel Ave Eaton, CO 80615
Greeley, CO
39 Mena, David and Marie 1510691 2905 41st Ave 80634
Middleton, Brian and Greeley, CO
40 Deborah 1537851 2418 W. 24th St Rd 80634
Lochbuie, CO
41 Moore, Earl and Patricia 1517579 135 Poplar St 80603
Murrell, Nicholas and Windsor, CO
42 Terri 1547183 812 Scotch Pine Dr 80550
Newbold, Scott and For Collins, CO
43 Monica 1549222 4324 Silverview Court 80526
Parker, Brian and Greeley, CO
44 Beryldell 1538709 3001 50th Ave 80634
Kersey, CO
45 Plume, Mike and Annette 35126 PO Box 34 80644
Windsor, CO
46 Preston, Daniel and Lisa 1548050 611 Cornerstone Dr 80550
Firestone, CO
47 Purcella, Denise 1551571 10656 Bald Eagle Circle 80504
Rael, Charles and
48 Carmen 1526232 4319 W 15th St Ln Greeley, CO
Greeley, CO
49 Ramos, Julian 37631 2604 49th Ave 80634
Ransome, Christopher Greeley, CO
50 and Mary 1552605 1903 24th Ave 80634
Rasmussen, Dennis and Johnstown, CO
51 Diane 104555 345 Gypsum Lane 80534
Redding, Christopher Greeley, CO
52 and Sonja 1524128 2305 42nd Ave 80634
Greeley, CO
53 Ripka, Gary and Jennifer 1538429 2113 74th Ave 80634
Firestone, CO
54 Rogers, Jeffrey and Tami 1550689 5221 Bowersox Parkway 80504
55 Sears, Alan and Diane 1551278 61 Westward Way Eaton, CO 80615
Sevestre, Lewis and Greeley, CO
56 Maureen 1551169 1717 69th Ave 80634
Shindle, Danny and Greeley, CO
57 Andrea 1550177 1606 Fairacres Rd. 80631
Johnstown, CO
58 Skeldum,William 16666 5113 Saguaro Ct 80534
Slaughenhaupt, Gary
59 and Grace 1544611 30633 CR 78 Eaton, CO 80615
Platteville, CO
60 Slipka, Darrel and Ruby 1525217 515 Shirley Ct 80651
PROVIDER
NAME ID MAILING ADDRESS CITY STATE ZIP
Greeley, CO
61 Steitz, Daniel and Natalie 1546930 1701 Elder Ave 80631
Sugden, Stanley and Greeley, CO
62 Lena 1537224 1251 51st Ave 80634
Greeley, CO
63 Trevino-Rivera, Irene 1506181 4227 W 31st ST 80634
Greeley, CO
64 Van Den Elzen, Dawn 44282 7219 W 20th St Ln 80634
Greeley, CO
65 Walker, Kurt and Jennifer 1546248 1901 15th St 80631
Willert, Melody D and LaSalle, CO
66 Lee, Kimberly 1540372 219 N 4th St 80645
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 Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Aguilar, Riley and Melissa
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o th greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1510493. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
] Weld County Addendum to the CWS-7A
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# I IDOB
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 ❑1Y:)Two times month
02)Three times a month 02%)Once a week ❑3)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 ❑l)Less than a 'h hour per day 01%) %z hour a day
❑2) 1 hour a day 02 %) 1'h-2 hours per day 03) 2'/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑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 feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑l)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.)
❑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) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create 6 the need f services that apply to this child.
TgVF y ht or S ff A
Y0 n w �, � -.a,x t ..
^'' ........4;e,..d.�rf},sk)..Y>.o,.<>k `�.:,..7>.. . ,V,�;�t` °�a • _.5.
Aggression/Cruelty to Animals
❑ O ❑ ❑
Verbal or Physical Threatening
❑ ❑ O O
Destructive of Property/Fire
Setting O O O O
Stealing
❑ ❑ ❑ O
Self-injurious Behavior
❑ O O O
Substance Abuse
❑ O O O
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ O O ❑
Runaway
❑ ❑ O ❑
Sexual Offenses
❑ O O O
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
vS 4MR1
.: �.':t .` '4,xx:s.`�'�5s. n; '.' �a�. .. t :,. xC"h4r `y.'T, a�.�"c•:u._:.°�4z..aa.e.: .�ta„a.� s.__ a.. 'a. ='v".e�,sl';:.� .bx ..
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ El 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
B
Pt
A.e 0-10...$16.32/da $496/month
tri
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 3cirk +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
stio
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
4,3 $29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
BIZ
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 b1,9.1 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
114
Assessment Rate4.0 AP $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L____
Weld County rk
n1 142,c,
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
(Zie OF THE WELD COUNTY
`! DEPARTMENT OF HUMAN
SERVICES
By: By:
Deputy erk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Aguilar, Riley and Melissa
2081 40th Ave
Greeley, C9 80634 `\
By:'._' _
Signature)
WELD COUNTY DEPARTMENT ,4r
OF HUMAN SERVICES
By:
( irector Sig lure)
8 Weld County Addendum to the CWS-7A-7p
1 WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Armfield, Pamela
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this i day of 6t , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms t)i Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1549727. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4`h of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the ��e_&/6 c
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CW S-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F 'TRAILS CASE ID IDOB
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 ❑l)One round trip a week ❑1'/)2 round trips a week
02)3-4 round trips a week. ❑2%)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?
0 Basic Maint.)No participation required 01)Once a month ❑1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%)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 '/z hour per day ❑1'%) 'h hour a day
02) 1 hour a day 02 %) 1'/-2 hours per day 03)2'/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%x) 11 to 14 hours per week
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 011/2)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%:)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑l)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
❑2)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child
Please
't "„' . a "4S.'� "�" „av�i` %}aah'I2 ;;a - v °,"sa wa'T'';
.'R�t a"�wa. y$ "Fitr ii.i. vus" ' t � '',. " +,; x c yti +`f' ₹ :. c tivi }x +
fir
Aggression/Cruelty to Animals
❑ O ❑ 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ O ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ O ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
S-7A
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
° v a .
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
O 0 0 ❑
Medical Needs
(If condition is rated"severe",please complete O 0 0 0
the Medically fragile NBC)
Emancipation
O 0 ❑ 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A.e 0-10...$16.32/da $496/month
figk
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
Fit
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
mml
$23.01
1 1/2 4.66 Respite Care
1.4:„
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
cIfj
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) fig
Effective 7/1/2008
7
Weld County Addendum to the C WS ',
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: atel iala
Weld County Clerk to rd
\$ IS a WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
I86 I r�"'� \^-? OF THE WELD COUNTY
t4�:
1 u i _ DEPARTMENT OF SOCIAL
(C-2e, A/ SERVICES
By: i,u4 4444L.,- - BY: /t-f�G-t_
Deputy C k to the Board Chair Signature
William H. Jerke
AUG 'I 1 2008
PROVIDER:
Armfield, Pamela
340 W Shafer
Pierce) CO /
By:--
gnature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Director Sygn lure)
8 Weld County Addendum to the CWS-7A
a008-a/69
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") beeep,
Travis & Sarah Beasley 22
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this S -day of 2' , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms f the greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
1552607 These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
amp-- a/6.
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child:
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 - Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME 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 ❑1%,) 2 round trips a week
❑2) 3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
❑3'A) 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
02)Three times a month ❑2/i)Once a week ❑3)Two times a week
❑3%)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?
0 Basic Maint.)No educational requirements 01)Less than a 'A hour per day 01%) '/z hour a day
02) 1 hour a day 02 %) 11/2-2 hours per day 03)2'h-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 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 031/2)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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 ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑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?
00)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
f conditions which create the need for services that apply to this child.Please rate the behavior/intensity o
alWIR , '� '"`t :'t' ' '£Lase
r 4114 - c tom.- p w t
i��,i h l
ift i ' iN t� F �{ 4,gi 9 irY 1
, 9 r as� r �i sy '°iiiiiiit, tget.
Mtgrin
. .� �, ... -_•.. .
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ 0 ❑ 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
•
•
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
tt! : �ZrNI'a , ' 4 F 'e [sYaT $l�t �` ,5 xey's
ua^ �, tt a -` " "d Z..2 s' a .`W'R r
..:- 1,.�'mai. �e.m'r a, r s �._R„_'' , .,";;. -ta.�_q�.�. . � ,��` � t T. .
a e• f ,,yye�.. a I r 4 7`.�'s.'+� si
vg i�,: i),y bl�, au a r c 4,2 a . 264 y .# ,�� >>Q a i,aa
nibp
@iL'Z`± hlk; vitt�, f '' . `I v era i.s+ ca' ) - "
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
4
: dkSiv�fi
j12415:3Earg,22:Z4i:FE5AnliiRRECS10154allighiniiknopitalmit
r
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
{2( Total Rate=($30.25 day/$920 month)
;;i"F
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
xc
$36.16
3 1/2 +$.66 Respite Care
'. ; Total Rate=($36.82 day/$1,120 month)
liyF.:
4 $39.45
TRCCF Drop Down +$.66 Respite Care
ralt
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) _
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
S4
ATTEST: ik4
Weld County Cler
c
4 ' WELD COUNTY BOARD OF
?�� -a SOCIAL SERVICES, ON BEHALF
I861 xi Jr
,�,y OF THE WELD COUNTY
7 --N
/- DEPARTMENT OF SOCIAL
s i ,'- /• SERVICES
By: By: .'"2, C✓t
Deputy CI to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
tPROVIDER:
lin !GCIL Or, T7(
(Signature
WOF LD A ER DEPARTMENT
OF SOCIAL SERVICES /�
U
By:
(D rector Signa e)
8 Weld County Addendum to theC�WSS-7AA
c! iVO - /(',5
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Brilla, Debbie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this IQ day of 4,1 , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#30451. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
...7m -,-/i0 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 ❑l)One round trip a week ❑l%:)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?
O Basic Maint.)No participation required ❑l)Once a month ❑1'%)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 ❑l)Less than a Yz hour per day 01%) %I hour a day
02) 1 hour a day 02 '/) 11/4-2 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 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 age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑l) 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.)
O 1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
•
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child
a d °'�i Y° " „`$°ai ° '�'4` " .at rr++ tr '`z s i}%a +. > t�a� x
1ii; `+x k `"mkt c f n}§ ' :a x '� iPs ,'x ' � ,++�"'`
e a t a, t9
'�. i ryr5t`x"} 7*-47 }. •.e a ',t ,� }..' s. .i ��„ }+ t ,� }a, �,:: a�`vx� a�R �
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
El ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ 0 ❑ ❑
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
6 'Y66via i 6!•:::=3, c"'``' .. &""ti i'x .tz41' 'a=YaS a w .Iih. •„,?s.hu 'a�4?a..h.m.x..v.. ,: • xxS.:•W..
' '` s d ins sQt
;. x t 6N c.'.66°T6,—"''r': c _.s,. ''P',."£�grt',' 1c - .a :6i 6:4r:-64' ..
�� 7ir
° +, , �`'" , sey n t s tl t� 4 s `"' vPa' 'a`' - Y .� •`'� kG
?xllt.dimsb�,k,,,, §tihiL..`4ti;3 •. ;4'° 3 : ® al°`:tLifii'ks'5: ..
Inappropriate Sexual Behavior
❑ ❑ 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 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ 0 ❑ ❑
Education
❑ 0 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
c � �
Ate 0-10...$16.32/da $496/month
County Basic >; At 11-14...$18.05/da $549/month
Maint.
Ate 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
1 $23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
,
$29.59
21/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 a: +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4 4.66 Respite Care
TRCCF Drop Down Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Mid)
Weld County Cler
WELD COUNTY BOARD OF
asi fe,-',..1)f SOCIAL SERVICES, ON BEHALF
,,,) OF THE WELD COUNTY
e� P ` DEPARTMENT OF SOCIAL
:11SERVICES
By: /&1Zrn4 .1,9-444, By:
Deputy Cler" fo the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Brilla, Debbie
2018 20th St Rd
Greele ,,AC //O 80631Q . •^A
By AN L. /� t/L{XX ,
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ire or Sig .ture)
8 Weld County Addendum to the CWS-7A
axe a2/6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Brown, Scott and Robin
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1524302. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
-7
ale- a/62
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 4 bogs after a child is placed in
provider's care. Medical examinations need to be Sale ` d within 0 d ys of the child
being placed with Provider and dental examinations need to be ` & within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F I I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 01%)2 round trips a week
02)3-4 round trips a week. ❑2%) 5 round trips a week 03) 6 round trips a week
❑3%) 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
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%z hour per day 01%) %z hour a day
02) 1 hour a day 02 %) 1'/r2 hours per day 03)2%-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
O 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 ❑2%) 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.)
❑l)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'A)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
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CW S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
.:%;: ,E114:}S �a .,r=_:.� 3..w ....... e ,i. , ... .... .r. .......�4...evam&b
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting ❑ 0 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ 0 0 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..l to this child
'9A'f.:'9:.r'"a5"�S�.'?..�3,^.v�... .,_.x".k .. `"+�i..to�..�,... ..sa-, :•:: ..,, ,,..°.. - .. ...::,±�,�'>�.'.43
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ El ❑ 0
Eating Problems
❑ 0 ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
-a sh ma t �x r- "tv;h. rx a• �,.:� nu'vv � ea
•
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 t,pr, 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
P..
4 $39.45
TRCCF Drop Down t +$_66 Respite Care
Total Rate=($40.11 day/$1220 month)
Ath
Assessment Rate x.. $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: lidal"e"
Weld County C d
w WELD COUNTY BOARD OF
is6i T : HUMAN SERVICES, ON BEHALF
1 ' OF THE WELD COUNTY
`n s DEPARTMENT OF HUMAN
-1"n, X71"v SERVICES
. , d 0:0 \\
By: I Is i" i,�l ��'� _'.'./� By: 1-,.)-, e-e. ,,.
Deputy Cl,t to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Brown, Scott and Robin
301 Hickory Ave
Eaton, CO 80615
By:c (Signature)
WELD COUNTY DEPARTMENT ---P,,....---E--e>�-`_
OF HUMAN SERVICES
By: a
(Di r ctor Signatu
8 Weld County Addendum to the CWS-7A
OW—<Wh
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Caldwell, Cynthia
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 2A day of 3 U IVL , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1550399. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
aoaf,-a/ 65
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX TRAILS CASE ID DOB
M F 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 ❑1%z)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
❑3%z)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
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 '/z hour per day 011/2) '/z hour a day
❑2) 1 hour a day 02 %) 1'/z-2 hours per day ❑3)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?
O 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
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.
❑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?
00)Not needed or provided by another source(i.e. Medicaid) ❑l)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
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.
r s �°
•
:yk i .Atr3 1 h a
^}3ea.a asL F.R'Y..�.#uAry ac.f..._.. ..... .. . .. ..... ..r ., vR P%:fX'4L4:.
Aggression/Cruelty to Animals
❑ 0 ❑ 0
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 0 ❑
Stealing
❑ O 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ O 0 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child.
Please
.'k".r'v > s €�°a +y mom+ y1�:.�
eI�1 � ,� $ L'k '.e'=• 7 3vffl �, � v �y s S r ar ?
was��� ;s � 3
r.� R ;.,+ 4a ,.,
3
usY ix - ai S^as} a 'e.F vy f J + t<
dim
k K p yY L
s2 r ,, , i #
Inappropriate Sexual Behavior
❑ 0 ❑ 0
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 ❑ 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 ❑ 0
Requires Night Care
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
ati ' 4 is'v
? I#% F k ....
IfrW4Cili;R:5!,:f:S"Alaillita4444:4k4SVEtiaN0SViiktiwA3kirO h4,1,
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
LaCif /Vie 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 9rel 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
04,1
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
mma
714 $29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 4.66 Respite Care
r. Total Rate=($36.82 day/$1,120 month)
43,00. $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment RateAtiT $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ikaitit
Weld County Cle e Board
L'� WELD COUNTY BOARD OF
r
HUMAN SERVICES, ON BEHALF'; OF THE WELD COUNTY
",1 y� DEPARTMENT OF HUMAN
P-A l `i'
SERVICES
By: By: i k-Gi'
Deputy Cle to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Caldwell, Cynthia
936 Eichhorn DR
WESTMINSTER Erie, CO 80516
BY: C)., n;l V.J.e-4-' CC (,
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By.
(D rector Signa re) t; 8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Combs, Colin and Hubert,Rebecca
and the
Weld County Department of Social Services
for the period from July1, 2008 through June 30, 2009.
The following provisions, made this /w day of ive-D2., , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1545310. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
apeT-a/62
6.. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6., To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F I ID
OB
CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)One round trip a week 01%)2 round trips a week
❑2)3-4 round trips a week. ❑2Yz)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?
0 Basic Maint.)No participation required ❑1)Once a month 011/2)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%z)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?
0 Basic Maint.)No educational requirements ❑1) Less than a 'Y hour per day 01%) %hour a day
❑2) 1 hour a day 02 Yz) 11/2-2 hours per day ❑3)21/2-3 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'%z) 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 01)3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2Yz) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3 Yz)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 ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
, a ���[ s „{ r 1, .i, Rating of Conditions
r i a rN �'t, twsrle sr • (Check one box for each category)
Assessment Area �E 7 • `Lg4.€ Mud Moderate Severe Comments:
0 1 2 3
Aggression/Cruelty to Animals
❑ ❑ ❑ O
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ O
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
D ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ D ❑ ❑
Enuresis/Encopresis
❑ D O O
Runaway
❑ ❑ O O
Sexual Offenses
❑ ❑ ❑ O
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the ne for sservices that a ly to child
�` u r _ s s � .tsyu"''y 5: fr ,. .; '''j!! i 4 ed e y.. '' # this elle ' 'N: �tti.l Y.1/4IMEMENERVI' x. 'si. f : get � 1 ya t inary ,r i
a:iaw ax 4Ac°t+ tcx+ s ,,.nal11 2=1:` „„,„,,,°�i�.}s �e ' ��t r 1 .e,`$ T,' a z 1 e`•a
* i z g' � @F�r c 3e''�'#,. ry� c 111,41t ell a. r�r a: a �� t! xc
' z ¢� 1'V :mi am-N'sth` vnw ea ' kt�
,-.'Swart'...m� `4� a3� ti
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
O ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ ❑ 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 ❑ 0
Education
❑ 0 0 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
. WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
' NEEDS BASED CARE
. RATE TABLE
(Exhibit C)
. .t I . .4hY
F.
/Noe 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
li
Ave 15-21...$19.27/da $586/month
-44
+Res.ite Care$.66/da $20/month
lin/
$19.73
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
tiVS
$23.01
1 1/2 +$.66 Respite Care
:7::: Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
Al $32.88
3 4.66 Respite Care
v. Total Rate=($33.54day/$1020 month)
siti
$36.16
3 1/2 1
A 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
,4
$39.45
4
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Pe
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS=
• IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L���"�"
4
Weld County Cl
sei � � WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
'"F c'` ' OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
,/ SERVICES
By: ` 1 By: i�iL it
Deputy k to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Combs, Colin and Hubert, Rebecca
5937 W 28th ST
Greeley, CO/89634
By: /
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: "
(D ector Signal )
8 Weld County Addendum to the CWS-7A
aalf—a i� .
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Corliss, Wade and Loni
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 027 day of A-pn , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547483. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
n?OD(P- (9/65
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# rvEX TRAILS CASE ID DOB
F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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
❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
❑3%)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 ❑3)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''/ hour per day ❑1%) 'h hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
O 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 feeding,
bathing,grooming,physical,and/or occupational therapy?
O 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.)
O 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.
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?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
'�
�, Y- g# ,,.,
twiexL 5k 4, e5... `4a G.ee.�C°3 R %
4 5 a�S�
q iz� � �. � _ � li ski �' ��"t� g )`
:. ces, x rfi . . ilk " ;�' , ,��,�,s .s.
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
0 O ❑ ❑
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ O ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis
O O 0 ❑
Runaway
❑ ❑ 0 ❑
Sexual Offenses
❑ ❑ 0 ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
:.ii:::,:c„lil
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this 77,
"t" d.'% ;' be a a :te behavior/intensity
,i v ice ≥= a. " i#
r
x- J4:3;1:°'."-,:i:S:Li... :ae�.s' ,x,,,,..:4,....j,,;,...',:::,-;:.'.. "a # v° .x� y "+3 .wu° e v_.x <: s t.,:t a...._..."1'v�
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑ 0
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 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 [II 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
#
a k '#{ fit. ."
' � 41 t, iho.
t3` ,
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
Ll (?5 +Res•ite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
ritt Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
ctaii
ves Total Rate=($36.82 day/$1,120 month)
$39.45
4
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: nL"a'
Weld County and
/`'r WELD COUNTY BOARD OF
el,i K , ' a SOCIAL SERVICES, ON BEHALF
0
OF THE WELD COUNTY
1 DEPARTMENT OF SOCIAL
i SERVICES
By: ° By:
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Corliss, Wade and Loni
26649 CR 60 1/2
Greeley, CO 80631
By:
natu`
WELD COUNTY DEPARTMENT r Yak-Yak-
U ht-
OF SOCIAL SERVICES
By:
( • ector Signal e)
8 Weld County Addendum to the CWS-7A
oQODb'- a/&;
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Cowper,Michael and Alecia
and the
Weld County Department of Human Services
for the period from July 1, 2008A through June 30, 2009.
The following provisions, made this / day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms 4 t1'Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1526756. These services will be for children who have been deemed eligible for
social services under the statutes,rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
amc-- aie 9
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term"litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations wi great s after a child is placed in
provider's care. Medical examinations need to be d w n 1A,d ys of the child
being placed with Provider and dental examinations need to b&within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE IDN SEX
X 'TRAILS CASE ID IDOB
MF
WORKER COMPLETING ASSESSMENT 1HHVt I (DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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%z)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 %z hour per day ❑1%) '/2 hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 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 ape appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week 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.
❑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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 El 0
Stealing
❑ 0 0 ❑
Self-injurious Behavior
❑ 0 ❑ 0
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 ❑ ❑
Enuresis/Encopresis
❑ 0 O ❑
Runaway
❑ 0 ❑ ❑
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑ 0
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 0 0
Education
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gall a
laAl
Weld County Cle d
La WELD COUNTY BOARD OF
1v] HUMAN SERVICES, ON BEHALF
Oltfr
k-,fOF THE WELD COUNTY
`2 ( p DEPARTMENT OF HUMAN
A..-- -'k, SERVICES
By: / 7/44- LJ By: ��c ,-/-1.---,Deputy erk to the Board Chair Signature
William H. Jerke
AUG 1 1 2000
PROVIDER:
Cowper, Michael and Alecia
509 N Sholdt Dr
Platteville, CO
_12
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(D ector Signa )
8 Weld County Addendum to the CWS-7A
&ere— aid
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Crownover, Ernie and Jennifer
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this /3 day of Unit , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms`ot the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1512351. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
aPOOP- a/lo 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A S-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME 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. ❑2%z) 5 round trips a week ❑3)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 ❑1)Once a month ❑i'A)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 ❑l)Less than a'/z hour per day 01%) 'A hour a day
❑2) 1 hour a day ❑2 %) 1'/z-2 hours per day O3)2'h-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
O2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
0 3)Constant basis during awake hours ❑3'A)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑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 O2%) 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.)
Dl)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'A)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.
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 Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
'
y •{5 iY *{,'4��.ek `4+ysaMe 3�y�4 x. 2''g"+' �i- �.*3x, ti +, ak eh Oyu,w`4 4 5 y'i5
ra
= a r+` ppT a F y r k e
.3 .f v S Rip rs lat
1."139414"14"traitr.rT: 2, �a,�� iYF N k,� i 1 ...:..
:�wAJfi:°4 »S.. a 'x"4}'Ww�u. B�Pd._..ai._r°i° .
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
• • BEHAVIOR ASSESSMENT(ExhibitB) CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
i� r , rte „
ti
tt L y" H. 'p y 9R J {i�3
pF `�� $f[{ t p
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ o ❑
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ O ❑ O
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 0
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ 0 0
D FROM BEHAVIOR ASSESSMENT:
CHILD'S OVERALL LEVEL OF NEE
(check level of need) ❑ 0 El 1 ❑ 2 El3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
k � t
to >
� 4
} x .?T :' +
'
Y`
A.e 0-10...$16.32/da $496/month
4�
County Basic ar A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 ," +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
',a• $29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 1fO 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 s.. +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
4.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate . . $30.25 day/$920 month(Includes Respite)
(30 day max) a�
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: g4142/11-44
Weld County Cle
WELD COUNTY BOARD OF
isq Ai( SOCIAL SERVICES, ON BEHALF
P Ct;r. OF THE WELD COUNTY
{ t: DEPARTMENT OF SOCIAL
:.\ SERVICES
By: By: 'I-CT fr+,,A-.
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Crownover, Ernie and Jennifer
421 Ventana Way
Windsor, CO 80550
By:
(Signature)
u
WELD COUNTY DEPARTMENT
(/d a `-\_
OF SOCIAL SERVICES
By:
(D rector Signa re)
8 Weld County Addendum to the CWS-7A
cRGtof- a/6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Dietz, Bill and Wilma
and the
Weld County Department of Human Services
for the period from July 1,2008 through June 30, 2009.
The following provisions, made this / day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#8635. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The tun'"litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# PATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME ZPROVIDER 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 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 ❑1)Once a month ❑1'%)Two times month
O2)Three times a month ❑2%:)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 ❑l)Less than a%z hour per day 01%) '/hour a day
O2) 1 hour a day O2 'A) 1'/r2 hours per day O3)2%r3 hours per day
❑3%x)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 ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/z) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3''/)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
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.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A S-7A
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
hich create the need for services that a..ly to this child.Please rate the behavior/intensity of conditions w
v ? xt
5
d t
5 ' ' .. # tb
16,
! .i i,'61 ::71:‘,;.. .,
� v r :, s 5," 4':�. �t �,"�`�
r.i.4 c.:.vs u..ks frxTe° v -.:t's...— .-.a .?w z a `° r,'° "°
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete El ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
,. k 45, vf ry . :tiy
Y:• : S,g Sys ti 'k� .y +;..:k�} S#
.1 1 e.
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
+$.66 Respite Care
TRCCF Drop Down Total Rate=($40.11 day/$1220 month)
ti
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ikail _"____
Weld County Clerk
''
C �j
�
Vibi , WELD COUNTY BOARD OF si V;C :7,:>-4,-fg HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
nnI �'' .
SERVICES
BYllplt r6 !` (� By: 11- a771siGL—i
Deputy CI to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Dietz, Bill and Wilma
21257 Hwy14
Ault, CO 80610
By: 6-02-2‘ S-4r_
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By: a
Director, i nature)
8 Weld County Addendum to the CWS-7A
OUT-ale
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Fisher, Matthew and Claire
and the
Weld County Department of Social 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 t Agreement remain unchanged.
GENERAL PROVISIONS
I. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1532312. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
t Weld County Addendum to the CWS-7A
doow- / 5
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 ours�iIafter a child is placed in
provider's care. Medical examinations need to be coi e'd�ithm 0 d s of the child
being placed with Provider and dental examinations need to be'` ` ' within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
• •
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID [DOB
M F I I
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 ❑2%)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 01)Less than a%2 hour per day 01%) 1/2 hour a day
❑2) 1 hour a day 02 'h) 1'h-2 hours per day 03)2%r3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑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 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.)
Du Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a l to this child.
ae o` tda qy .
3 .
p 9 �. ! k t '1. !reTEHAPPWrigartI1'7? .�s 1 'V vi i __* d, ;.c AttliiikalOitttiOtNiZeanitgal
y�4. � a"a 4b A tM1`ry�i
� �S 1 1:11 is
iii ;
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ ❑ ❑
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
O 0 ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that appl to this child.
Div vex ° a !. C ! i 4 i I 4=o"w0000lcosoollmos000ctrtok:0:o := soio
A.'Fu ti i. t + :POMP n: ^l}.,
an:;. 4 s
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ O ❑ ❑
Depressive-like Behavior
❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ 0 ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) El 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Pyt r .e �p�4 &S r x
" t tv, '�
u G 5
A•e 0-10...$16.32/da $496/month
County Basic Poe 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/de $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2
+$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate 'VS $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 44112/14144
Weld County C mss 'T�LR.�
eta_=, WELD COUNTY BOARD OF
i o SOCIAL SERVICES, ON BEHALF
�`l f � OF THE WELD COUNTY
& .A DEPARTMENT OF SOCIAL
SERVICES
BY %ltltt? J44i By: 71-1-
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Fisher, Matthew and Claire
5022 W 2nd St Rd
Greeley, CO 80634
By: �__.0c-nA LILY-
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: a_
(Du ector Sign e)
8 Weld County Addendum to the CWS-7A
C7�,S-
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Flores, Isaiah and Annette
and the
Weld County Department of Social 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 th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1534649. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
t7nJ'- a/6 9
a
• 6:' The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CW5-7A
• ' ♦
6.' ' To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX tTRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HHN 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 ❑1%z)2 round trips a week
02) 3-4 round trips a week. 02%) 5 round trips a week 93) 6 round trips a week
❑3'/)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 011/2)Two times month
02)Three times a month 92%)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 01)Less than a 'A hour per day 01%) '/z hour a day
❑2) 1 hour a day 02 'A) 1'/z-2 hours per day 03) 2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1%)5 to 7 hours per week
❑2) 8 to 10 hours per week 92%) 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 ❑11z)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behaviortintensit of conditions which create the need for services that a 1 to this child.
„wirt„ „Wilk Rating of Conditions �7 ��:.,
(Check one box for each category)
s= ?w Assessment Areas None Mild Moderate ' v e Comm ents:
1 2 3
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
❑ ❑ ❑ ❑
Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
• (Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a 1 to this child.
.......... rya '�;.......:.:: �'.._ _
t.a _
s:�.,�'ir�' •.I�.�.�iz�f��'y=_=n;ti �`s' '' ....F: -- "�4', 7c:i, .. _> __ _ ' • Y.h.J... :rti� ;
� ,+....,..,: Rating of Conditions • ,. �,�� �� � '�.-- +:; .....
_ (Check one box for each category, .
z. Assessment Areas N IVIederate Una Comments: ,11 k ?+
0 1 2 3
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) n 0 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
• WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
� "5 r ✓ R
A.e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
Asa 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
,',,,:i7
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
e:.a.
$32.88
3 i., 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
41 $36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 A $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
14.0
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the C WS=
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: "'idli�""."`o'r
Weld County Clerk
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
1S6 OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
(l `�v SERVICES
By: By: Gl�17�%
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Flores, Isaiah and Annette
302 Maple Ave
Eaton, CO 7
1
By: 0v / 44.- ill
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: .1.. ., . . , �... /,.
(Dir- tor Signat le
8 Weld County Addendum to the CWS-7A
,�^�J
atelek _a/. %
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Frank, Jerry and Diana
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / day of 2008, are added to the referenced
Agreement. Except as modified hereby, all terms t Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1530545. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
0708-07/69
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Depaitment and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
•
(Exhibit B)
DENTIFYING INFORMATION
:HILD'S NAME STATE ID# ISEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# I PATE OF ASSESSMENT
\GENCY NAME PROVIDER NAME IPROVIDER TRAILS ID
tNSWERS 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:
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 01%)2 round trips a week
O2) 3-4 round trips a week. ❑2%:) 5 round trips a week O3) 6 round trips a week
O3%) 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 ❑l)Once a month ❑1%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)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 01)Less than a%z hour per day 01%) '/z hour a day
❑2) 1 hour a day O2 'h) 1'//-2 hours per day O3)2'/2-3 hours per day
O3%)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 01)Less than 5 hours per week ❑1%:)5 to 7 hours per week
❑2) 8 to 10 hours per week O2%) 11 to 14 hours per week
O 3)Constant basis during awake hours ❑3'/)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?
❑ 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
❑3%)21 or more hours per week
Y 1. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
r 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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CW S-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.lintiak.� ,g��i — e' e v i i
g Z .= „ A;
r t,:y .=T
Aggression/Cruelty to Animals
❑ DI El
Verbal or Physical Threatening
El ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ ❑ ❑
Stealing
El ❑ 0
Self-injurious Behavior
El ❑ ❑ ❑
Substance Abuse
❑ 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ 0 ❑
Enuresis/Encopresis
0 ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ O ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap•ly to this child.
47 'tal-41 a W .tRaeacianatoristsiszglistimorwit hasase:cialtatemEWARLICaracat, Rae Taw
"ADM!wilpiattu.,. ['??,
x,�l atr '�"iyaifl{lik }
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
• WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
m � . .� r mow . � " y
..€a is. . - -...-:' .- ' —r.s..,.='
TA
7014, A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
31
+Res•ite Care$.66/da $20/month
Da $19.73
po
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
ali
$23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
ra
Total Rate=($33.54day/$1020 month)
32 $36.16
3 1/2 144 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
ral
4 $39.45
TRCCE Drop Down 0.4 +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate li.i. $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 1144#47111-4
4
Weld Cou Clerk tp.the-$oard
rt WELD COUNTY BOARD OF
1861 SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
A DEPARTMENT OF SOCIAL
SERVICES
� 1
By: By: /in
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Frank, Jerry and Diana
7950 Colombine Ave
Frederick, CO 80530
By:
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(D'rector Sign [ e)
8 Weld County Addendum to the CWS-7A
aa'6'-o!/6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Gamet, Steven and Cindy
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 6 day of 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1525231. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID jDOB
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
02)3-4 round trips a week. 02%) 5 round trips a week ❑3)6 round trips a week
❑3%:)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
02)Three times a month ❑2%)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 ❑1'h) %z hour a thy
02) 1 hour a day 02 %) 11/4-2 hours per day ❑3) 2'1-3 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?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1Y=)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 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 ❑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
❑3%) 21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑l)Face-to-face contact one time per month with child and minimal crisis intervention.
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 ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
q 4,. ! € ! i q i
:9.'vv.�vlJHIh.
1Y
Aggression/Cruelty to Animals
❑ 0 ❑ 0
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that appl to this child.
,r v WIN t,v. + ss�"°a a e4 us . §,! 3IEEEJ1e!
it n wa r.
:;;;Cie.
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ 0 0 ❑
Education
❑ ❑ ❑ 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 Addendum to the CWS-7A S-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Ase 0-10...$16.32/da $496/month
County Basic As 11-14...$18.05/da $549/month
Maint.
Asa 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
FAB
$32.88
3 111 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
yfq
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: fiat
Weld County C
WELD COUNTY BOARD OF
1861 �1 SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
%O A DEPARTMENT OF SOCIAL
®`N SERVICES
By: L �✓ / !.! ; By: � 1+
Deputy C .! to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Garnet, Steven and Cindy
1324 10th St
Greeley, CO 80634
By: *X. Q C
is ature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Dtr t r St tatur
8 Weld County Addendum to the CWS-7A p
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Gerardy,Jerry and Priscilla
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions,made this ) day of • , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o th eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1530549. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
S-/) T(9/65
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the C WS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX ITRAILS CASE ID DOB
M F I
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'h hour per day 01%) % hour a day
02) 1 hour a day 02 %) 11/2-2 hours per day 03)2Yr3 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
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
O 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?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
y 'n'b ' y L r, h 0.S% %C'4 _
5`➢v`" 5 h. 3 } 5 K�qi,f4 " * p.l ,d �y't L"ty'. yvk
Aggression/Cruelty to Animals
❑ O ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
•
1; tz ; i' ... ...... .. .o '.'
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ 0 0 ❑
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ 0 0 .❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
� Q .
R` t � " `. r tt m:ltS��W.: Yak +k��Fa
„fig we p,y^iAg
Ase 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
Ave 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
kkt
$26.30
2 +$.66 Respite Care
dat Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
ttiri
Nadi
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate 04 $30.25 day/$920 month(Includes Respite)
(30 day max)
Litff
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
11/11/4
ATTEST: g f ____
Weld Count fl. oard
. 'tJ WELD COUNTY BOARD OF
9-� HUMAN SERVICES, ON BEHALF
,+" ` ' a,
OF THE WELD COUNTY
., t.- ' A DEPARTMENT OF HUMAN
°` ' - a ' ` SERVICES
By: By: �,
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
• Gerardy, Jerry and Prisci
3408 Cody Ave-.
CO306-215 ,1
•
�By: , t._
/ (Si (us)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES ,
•
By:
( 'rector Sign a e
8 Weld County Addendum to the CWS-7A
OW-ai 6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Gilstrap, William and Lynnette
and the
Weld County Department ofwn J crviicces��s
for the period from July 1, 2008 t rdee
The following provist ns, made this / day of 2008, are added to the referenced
Agreement. Except ait modified hereby, all terms t Agreement remain unchanged.
GENERAL PROVISIONS
County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pm-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1525054. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
0,9e -c1/4
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F I I
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 01)One round trip a week 0 I 2 round trips a week
02) 3-4 round trips a week. ❑21 )5 round trips a week 03)6 round trips a week
❑31 )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 ❑1'/2)Two times month
02)Three times a month ❑21 )Once a week 03)Two times a week
❑31/2)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
special education plan?
❑ Basic Maint.)No educational requirements 01)Less than a''/2 hour per day ❑11 ) lh hour a day
❑2) 1 hour a day 02 1/2) 1'h-2 hours per day 03)2'/2-3 hours per day
031/2)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 ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week ❑21 ) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑31/2)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedi
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week 01)3 to 4 hours per week ❑11 )5 to 7 hours per week
❑2)8 to 10 hours per week ❑21/2) 11 to 15 hours per week ❑3) 16 to 20 per week
❑31/2)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑hh)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.
❑31/2)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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWF
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�- Rahn of Conditions
(Check one box for each category
Moderate ? Q ,.;.::•:.• •.:>.•:s�;• C..•....... 0
1 2. 3:
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ O ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
El ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ O
Presence of Psychiatric
Symptoms/Conditions ❑ O ❑ El
Enuresis/Encopresis
❑ ❑ •
❑ ❑
Runaway
❑ ❑ O El
Sexual Offenses
❑ ❑ O ❑
5 Weld County Addendum to the CWS-7.
BEHAVIOR ASSESSMENT CONTINUED
• (Exhibit R)
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)
sment 0,^ Severe ... •:.4o ,.,
one mad jVloderate
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ O ❑
Depressive-like Behavior
❑ ❑ O ❑
Medical Needs
(If condition is rated"severe",please complete ❑ O ❑ ❑
the Medically fragile NBC)
Emancipation
❑ El ❑ O
Eating Problems
❑ O ❑ ❑
Boundary Issues
❑ O O O
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) n0 n 1 n2 n 3
6 Weld County Addendum to the CWS-7,
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
• REC M MENDED
LEVEL
SERVICE :
Level Aa(�,.:.:....
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Res i�te Care$.66/day ($20/month]-___•
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
•l i t z x nF3'.2 i 15•r.M,:"f I r ,i I,G c �
r
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 11411111444
Weld County C lb •rd
122...41)7
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
a OF THE WELD COUNTY
A I,,:1" DEPARTMENT OF HUMAN
' � SERVICES
By: By: /nn"; 6ti r
Deputy CI to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Gilstrap, William and Lynnette
6363 St Vrain Ranch Blvd
Firestone, CO 80
By:
/ ��-
dribeigna
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(Di ector Signa e)
8 Weld County Addendum to the CWS-7A
a —aii'5
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Hebbeler, Troy and Christina
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this Lid( day of Sane— , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1522988. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
,91298-07/6 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 4,8 ) o r after a child is placed in
cAtilr provider's care. Medical examinations need to be ct y�within 1 j1 ys of the child
being placed with Provider and dental examinations need to be s within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX jTRAILS CASE ID !DOB
M F I I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 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?
0 Basic Maint.)No participation required 01)Once a month 01%)Two times month
❑2)Three times a month ❑2%)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 Yz hour per day 01%) '/2 hour a day
O2) 1 hour a day O2 %) 1'/r2 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 ❑1) Less than 5 hours per week ❑1%)5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
❑ 3)Constant basis during awake hours 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
❑2)8 to 10 hours per week O2%) 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.
O 1%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that asply to this child.
� ..": i Y I �6 f r
ijt'LLI"8.. : itter teak ilia 4 tt �r. lax :3 iSv' 9..iit brS.,,, 3. 4it.s'c aL.i t {.:..` .'.a
Rv
X79 .
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
❑ 0 0 0
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis
O 0 0 0
Runaway
❑ ❑ 0 0
Sexual Offenses
O 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child.
i �;hi mac, ,fts s ,,77
ilitt. •,' 'a`r.'S+t;tfa` s , �,L F P e ' F. &,,g a #El �'at tea P s
Y
�
titilniefigagaitest ---,—
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
S-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
r. y �..�"^FikE �l
E t t (SC' t _•, � f »' �
✓ � r 'dr + h } � R s'
4
Age 0-10...$16.32/day ($496/month)
County Basic . Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2R +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
Stz
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
ata
,ar
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4415 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
ergf
Assessment Rate ti.4 $30.25 day/$920 month(Includes Respite)
(30 day max) (,
Effective 7/1/2008
7 Weld County Addendum to the CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L� ��"�"" �"'
Weld County Cler oard
jctj
�" E La WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
$6' 1 OF THE WELD COUNTY
"' Ca DEPARTMENT OF SOCIAL
\'�'' fI`i A SERVICES
N.-CI r
By: By: '--y �G...i
Deputy Clerk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Hebbeler, Troy and Christina
3610 Cactus Ave
Evans, 80620
By:
gna ur
WELD COUNTY DEPARTMENT /
OF SOCIAL SERVICES C
By:
(Dir for Signa e)
8 Weld County Addendum to the CWS-7A
r9eoc-a/6 9
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Heimer, Sara
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
ttThe following provisions, made this / day of Tho t�p l , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547292. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
] Weld County Addendum to the CWS-7A
dO ai�5
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A S-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME N/^ ` + J i1 Ct Cpl I, STATE ID# SEX TRAILS CASE ID DOB
H (, YlC Chu (1 Jt RY M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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%)2 round trips a week
❑2)3-4 round trips a week. 02%)5 round trips a week ❑3)6 round trips a week
❑3'/)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 ❑1'/)Two times month
02)Three times a month 02%)Once a week ❑3)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 01)Less than a%2 hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) 1'/r2 hours per day 03)2'A-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?
0 Basic Maint.)No special involvement needed 01)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
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week 01)3 to 4 hours per week ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
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 Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
a..'x - ` . ' 4 + �. `Nl ,fit' : 977:ut*x.; "xc --.. M'*
.a,°4. agw5 „a a*y,.'u' i e #ut„,,avk,,�' S"`isx•2 .., r a � 'f. '£*'�S. . �',sM.
��°°'` �s, ��"fy, ,y, � •ate 's'sgT •� i ar'�.F '�€ + �5@�a.�'p ��q � �. '* � 5 �, "p�;,�
�, a't #H�3i.?'��,.'�t:y�°i}9n"� 3a� 'ss `4 ":�� �?vh '4 i���2�.'x.'.i. �i .�h4•sS"°i°b"Ta��t4'4d ii" L°°°'� k �w' § ''..��µY�i
#, � - r' ^a e c° ��k,''` ₹,,a'i R°•q0;^ �% y`�'° ay ,tzt
.
&� mss. "a. ° `afitreirst
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 0 ❑
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ 0 0 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..I to this child.
'MI ta" °s ;: L' r - t` `" ' � ` 4h � s°s° • bill!!* i F'°•, ' '' ,u N: '
a'+'e �' b k § ,qT 9 , 'F y " 4 Gist i q g � t P+.h �s',rs�.§4^ ,{
'h`3r.£5,. " �' � 1 � °� Y TM -ly �°,. � ' �;i..."r¢¢,"hiS it s4`.W '�u
ttfig
�'`au
da >q �. �. t - * ,w.s��*�� , �'
:��� 'S ateSk
g 'x, z.. }s tnn.
.v w.� tta '.Fin. .'i:nixa-
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
YkT'. "I�tk ti f - ,x 'o-
3Ra s t
y �
�. ��
- YES s x{� .,
.,, %':,_ (SSi9. { a.k t 's-,,,,,
.La'.3u..r�SSt.d[ ".»."�. CX1:sa�.
A.e 0-10...$16.32/da $496/month
md
01
County Basic A.e 11-14...$18.05/da $549/month
Maint. ON
lief
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
00
Pi $19.73
1
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
-144
$26.30
2 +$.66 Respite Care
liklTotal Rate=($26.96 day/$820 month)
$29.59
2 1/2r....-‘,..1, +$.66 Respite Care
Al Total Rate=($30.25 day/$920 month)
4.
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
K.
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
or
4 $39.45
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate
(30 day max) $30.25 day/$920 month(Includes Respite)
ea
Effective 7/1/2008
7
Weld County Addendum to the CW S-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 1441/121714%
Weld County Clerk oard
#�y, IS
`� WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
isel C 4;,r OF THE WELD COUNTY
^/` �— DEPARTMENT OF SOCIAL
SERVICES
By: BY: 7-7—ti! �Gw�
Deputy CI ' to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Heimer, Sara
3000 W 19th St
Greeley, CO 806341I •
By:� t1 ue l l Pt‘e C
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
( irector Si re)
8 Weld County Addendum to the CWS-7A
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Hernandez, Roberto and Margarita
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this /9 day of nye , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider ID#
1520297 These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
arn8- a/'
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
• (Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX j1'RAILS 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
02)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
❑3'A) 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 ❑l)Once a month ❑1%2)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%)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 '/2 hour per day 01%) 'A hour a day
❑2) 1 hour a day 02 '/,) 1'/,-2 hours per day 03)2'/2-3 hours per day
❑3Y:)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 DI) Less than 5 hours per week 01%)5 to 7 hours per week
92) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours 931/2)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
['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.
❑11/2)Face-to-face contact one time per month with child and occasional crisis intervention.
92)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2Yz)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'A)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) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
vac-.F4!i.Y 3 w!! ..0 g G p - &: 2't.'
S ��� l G!i . ,,., [[��`` �n.T7!'+6 r ! ,a4 $s `t G l.uw4 S 11 4
��ttw"� G' �.. l �v t�.>�.F '�..'� s .! ,t �. `� G3� 3'`" ��Il1' � !
Ns:- � ! 20
' >n.
.:£.� _ 'fib36`�i 7.
i r .1! !@ "M R 4j.{z ht G hA'� 3kN ., t'Mire .ii £ y�Z 3 I k°YL` 3�!!4
T >A 'r� tiu �T { tn"Yv� �5 .
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
•
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
r
11
z 1,' 1 3as a ;�: '' otcond QiRi1 y2 6- I ^� .
+
l � k .�$t1C O�I4� C8 U' i fh t 47'x,,. � ' ��" 'c s ,,' tr y
'iP � t aer � i' (t's�a '�°p v��
C N i?d �gNc ! 1 ys i* x ��,
vu to ,hli 3 ' r ,, n x r hi)
s. .� r is .z ` i , „5 ₹ ,� i"fis 4 .r"i. .ii( + �viya -,,t±.77 & c 1c, s
v.,...�..`., . ..__ ., .: L.,.. .�. .[ ? k�� ........ .... . . .,.F.
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
{;Ba
k1)5 :
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 = +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 112 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 - 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down • 466 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rateri.. $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ik 1 /t all-A j
Weld County Clerk to the Board
4-41 E WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
is6i ?s? OF THE WELD COUNTY
"•J• 4_¢
�: :.a� DEPARTMENT OF SOCIAL
SERVICES
By: By: (CMG
Deputy Cl t to the Board �Ll Chair Signature
William H. Jerke
AUG 1 1 2000
PROVIDER:
Hernandez, Roberto and Margarita
912 Elm Ct
Fort Lt to
By:42 ($7, 44,- O i
( igna
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(D rector Signa e)
8 Weld County Addendum to the CWS-7A
(Awe-07/4 .
t
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Hickey, Laurie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / day of "3"-v n)e , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1518754. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
&c6Yv-&i/0 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
it Department Staff Manual Volume VII and/or County Department Policy and Procedure
• Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A S-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. (' To maintain/access information on the Foster Parents Internet Database On-line System
• (FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10.Z To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F I I
WORKER COMPLETING ASSESSMENT HH# PATE 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
O 3%)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 ❑1%)Two times month
02)Three times a month ❑2%)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 On Less than a'/z hour per day 01%) %hour a day
❑2) 1 hour a day 02 %) 1'/r2 hours per day 03)2%r3 hours per day
03%2)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
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) I1 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 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.
❑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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
• _ i 1 I !' t i I _ t
eit%Ar.."Lt4e%n811,14 it 1
rtelii,WrilThzebekgraiC475 ..may, Ili ills •
2 a
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ 0 0 ❑
Destructive of Property/Fire
Setting 0 0 0 ❑
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ 0 ❑ 0
Runaway
❑ 0 ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�. - it r a , ;� 47:17'. Y .^� tit l�"Eg �'`:y,"s�!r'.,R".�,"-'T! +'Elgilkalr7 .7-t.'et+vP kin gs d ::;:-C,i
rµ�� .��..R � Ida t I 1 I t 1 ���
fiatti
i'3'2y'sYF '� I t% t
4 ,,,iii i.).:%;2t +,isselitakiimotikzAiitim 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
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ 0 ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
l• lra�:,:.m f.�2*�::-.� n�. �k3.�.�.�.':,�.r^' .z4t�,..E3.33Wa.;,..,s
A•e0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
Zif $32.88
3 Knt 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate_($36_82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate ins
$30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 1441414/1164
Weld County Board
-44 -da
WELD COUNTY BOARD OF
MIt i as SOCIAL SERVICES, ON BEHALF
aA OF THE WELD COUNTY
�`` DEPARTMENT OF SOCIAL
� � Q.t SERVICES
By: / /1, . ' By: -
Deputy C1e c to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Hickey, Laurie
1125 Walnut St
Windsor, CO 80550
By: OCR 1112
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: a
(Dir ctor Signal e)
8 Weld County Addendum to the CWS-7A
aeri-are ?
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Holmgren, David and Dawn
and the
Weld County Department of Social 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 th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1522699. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
awe-07/6 2
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID 'DOB
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 ❑1'/z)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 ❑1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'%z)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 On Less than a%z hour per day ❑1%) %z hour a day
02) 1 hour a day 02 4) 1'/z-2 hours per day 03)2Yz-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 On 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 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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
4 T +. §^a'":� M*N7Y ,'°M+°°c sa},�s "6I<- *�iaa r rr, a
°'°��: t 4. � ,1' ;i4 ': a°}'x �°i';vg'"h " 'a.'t V`t? ' :C f v r 4. h'*siW +.�,V° 't .n,$�
�y RbT Y� 4 4 ' fl 3` F§ uki ' ` i't e `4 i a § `S '4'�
re
.4, `� tt `, y _' .nes, +�„
'* .: s # `:ii" =:t' 't 3 ;� 'x'' n -_`F. §a "t °3�&''w ,. �°..
.:^:'^��.��:.:.sx �'v..... :�,.�., tx,xr:�d, w"'�s.,.r�..�° '�ki'.+�as; is`�§,::�
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting 0 ❑ 0 ❑
Stealing
❑ 0 ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ 0 ❑ 0
Runaway
❑ 0 ❑ 0
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County Addendum to the CWS-7A
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
„.„
p ^iA d. v sR M r>
�`&�
�2w
+� a as ' ;3} s e r "[aa +� zxts'a+eg,- a s
"q " = i- fr
. ......".
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 ❑ ❑
Education
❑ ❑ 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
s $� ~ss.� t k `a ' �la ati 3
E 2 z. -. '7,'..:,dF y & d ! A !,0. " I
S i T�yy � �'.� �i� � �3.
i4 ^3II i;N{.g'L.. F'L..X`� .
RIA.e 0-10...$16.32/da $496/month
County Basic Ave 11-14...$18.05/da $549/month
Maint.
Ass 15-21...$19.27/da $586/month
*Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)1-4 $29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 i.. 4.66 Respite Care
9. Total Rate=($33.54day/$1020 month)
LA
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate • $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-71
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gl#4�"�"'_4
Weld County Cler and
WELD COUNTY BOARD OF
X61t\ �° SOCIAL SERVICES, ON BEHALF
-6, OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
' %' A A SERVICES
By: Zi'itket & By: % �G+�
Deputy C to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Holmgren, David and Dawn
864 Amber Court
Windsor, CO 80550
By:
( tgnature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
( ' ector Sign t re)
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Housden, Richard and Rhonda
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this AXday of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of e Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a prerado?rime
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1550415. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME & r61-k1 SrYl i STATE ID# SEX O [TRAILS CASE ID 1DOB /I q ,O 7
WORKER COMPLETING ASSESSMENT HH# I (DATE OF ASSESSMENT
/
AGENCY NAME PROVIDER NAME H_u,^ J,•, PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING I 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%z)2 round trips a week
02)3-4 round trips a week. 02%)5 round trips a week ❑3)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
❑3'/z)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?
0 Basic Maint.)No educational requirements ❑1)Less than a''/2 hour per day 01%) '/ hour a day
❑2) 1 hour a day 02 %) 1'/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?
❑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
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
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.
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.
❑3%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY
NEEDS BASED CARE ASSEDSSSSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.'flitiiy° "S'' t'° ht §, 'i.y4' s . ^' �°' > z W+47:, } t y . \ ii a i {i 17,'''''''"'"11;"'-'"‘
�yt4 411' t3 "+'s a :^ 5' xntics , ?:m .k a± t i ;�a � °y` vd : ,, z s
,, ,,,y-- x .. t'�„„.,.�,.rxa .mss .,�*tg}'w _ a .e 5 �yy ° " 4 4
e 'ta u[, 'tt. .C w t i+, ik s t,; �.ar r - >x�; 9. x d 5 ,,,,,;;;;;;,,/;€,,,?:::,Tr °,, ``sl
a }t f: F'� r1, ,^f. ttamat a A�_�.�^ * . ,� ai*Tn' 't `� �``
agapit i4 ".'�G, Stsv ^it t:u. ..ai 41. t�y*'t.. 'P tz."'":'-';r::''u,..,. 's..td �.°i...%, s
Aggression/Cruelty to Animals
❑ 0 El ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 0 0
Self-injurious Behavior
El 0 0 0
Substance Abuse
❑ O 0 O
Presence of Psychiatric
Symptoms/Conditions 0 El 0 El
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child
r'��it. .,5kykt�.�4 'm it*c d � 'a
T. 4 ns�%v°'`f * � '. t SLY � ? v'J.' �` A'.+4S �� a"
•
:° • v7
..°C>:xa.;�.,:n, ,xad ..._i... .°�ws rd°,;s_. °•»a :a' ,h"sa�ca;: a ... :" �....x,.; .a.__..,.,�,.; __...._.., .....
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ 0 ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
tilt t
r ah Yw. a 1 7
SJt > ro 3
A•e 0-10...$16.32/da $496/month
County Basic tiRi A.e 11-14...$18.05/da $549/month
Maint.
Poe 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
LIM
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Lad/A,
Weld Count i Board
,� WELD COUNTY BOARD OF
¢ , �. o S SOCIAL SERVICES, ON BEHALF
0•c ` h OF THE WELD COUNTY
. l- DEPARTMENT OF SOCIAL
C .` " ' SERVICES
By: g 7 By: '2--vcrk- ✓
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Housden, Richard and Rhonda
1671 S Troy St
Aurora O 80012
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: 1
(Dire for Signatur
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Hunt, Olen J and Nina
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this ] day of ,� , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms the-Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1503154. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A h//'0
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT HH# I IRATE OF ASSESSMENT
I
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 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 O2 %) 1'/z-2 hours per day O3)2%-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 14 hours per week
O 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 O2%) 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?
O0)Not needed or provided by another source(i.e.Medicaid) 01)Less than 4 hours per month
O2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
h'
Aggression/Cruelty to Animals
❑ 0 ❑ 0
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ 0 ❑ 0
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ 0 0
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 0 ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
yy Please rate the behavior/intensit of conditions which create the need for services that a.ply to this child.
�_...._�.,.a.. .+..{�.k .�'cs,. _.__: ..., ,...::e .xv .:.s'a�:r. 4 .�x� _-s v.0..,*. 4� ._._.a...w`+�.„:. _....q: .. .._._. .• . .._........ .wv..�.„: m..'fi'`;y..'
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ 0
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 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Ase 0-10...$16.32/da $496/month
County Basic frirJi 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
,:-- $19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
khq
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
rig Total Rate=($33.54day/$1020 month)
$36.16
31/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gutieW
Al
Weld County Cler and
WELD COUNTY BOARD OF
"
Ellett
SERVICES, ON BEHALF
i's� �' ' �' OF THE WELD COUNTY
�` `!, '' DEPARTMENT OF HUMAN
`._ ' SERVICES
i 7
By: '? ' ' ���� By: /jL✓`
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Hunt, Olen J and Nina
224 48th Ave
Greeley, CO 8063
By:
ign
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(Di CorssgQet)
8 Weld County Addendum to the CWS-7A
dwei--c /(o;
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement between
Hymel, Chad and tiffany t415 JaV 30
and the AM II' /8
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this ?Ai day of , L} J. , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1540875. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
0,901-a/65
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F I I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 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?
O 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
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 ❑1)Less than a'/z hour per day O1'A) 1/2 hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/:-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%r) 11 to 14 hours per week
O 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?
O Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 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.
❑3'%r)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
,' .fug.4 #'x t,t.z , a £t t ,y , :':=,. ,t 4�e � 4 4 a. `1 h 2:
irrr � v f
'+3 tP u -i't s d
a
,d,[, t2ar ""' s ' � as �a c r x�" �..a;;ua+ , �' `',1.1A .b.
-°..dv..�u6,.e"7"ag'��.� �.m .,��$,.aC�. �3r t...�"r3 "� °F '� Ek . -.�..
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ ❑ 0 0
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ 0 ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
`
' � dt.. <•.. 3 e i 1 ` x k '�xx '' ' 'y s. .c ;.y`v+ v+,. xr°;� 4 i x.� y " ky. x�' .a^
t � I
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
O 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
O ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
; tt+
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
Ace 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
tirf
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
FA $23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
fari
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
gat
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 •Nie +$.66 Respite Care
pei Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
tic
Assessment Rate kte. $30.25 day/$920 month(Includes Respite)
(30 day max) Mt
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: )04412671"44
Weld County/(p74�r4to-t oard
.: Le
I
WELD COUNTY BOARD OF
: iiyHUMAN SERVICES, ON BEHALF
c,1:2,1:,J..-
OF THE WELD COUNTY
DEPARTMENT OF HUMAN
`l'` - SERVICES
By: By: 71.4--; �G,�-,
Deputy Cl o the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Hymel, Chad and tiffany
1257 Red Mountain Dr
Longmont, CO 80501
By: NA!-Iitill 4,_\ , �titl i
(Si ature)
WELD COUNTY DEPARTMENT f�i(����
OF HUMAN SERVICES WW'� /t Ly.
By:
(D ector Sig e)
8 Weld County Addendum to the CWS-7A 021‘7
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Jackson, Scott and Andrea
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this t31 S-&day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms offthAgreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1536689. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
t Weld County Addendum to the CWS-7A
OW? CD?/e
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
VU.e, we --R6-Err )adop-t , tvewlevt± ss v20 needs bo.ced
cebrt assessment Viet f be of ono) a5 etotraet sta'es
Out {o be ja i A tA
e. basic yveuh (e_ yak_ veyvd lcss of
clul6k heeds < ST
tl�,!e (Ur( ktili Ll� --tom a c 1 J has c
in(mc.-1✓o-cznc-c C rad-c GAS •-os&r /a -bpf- pa.ru'ct
l ckt to mot c�.6 ((C i.tih -lL Ioster /Adopt. pfraorreAls
IeZ Skid j clue ` bO)79 a 7vsfei-/
ado riaoenti,/ , SJ
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID 'DOB
M F
WORKER COMPLETING ASSESSMENT HH# I I
1DATE 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'%z)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week
031/2)7 round trips or more
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 On Once a month Di Yz)Two times month
02)Three times a month ❑2'/)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?
0 Basic Maint.)No educational requirements ❑1)Less than a''/ hour per day 01%) '/z hour a day
❑2) 1 hour a day 02 %) 11/4-2 hours per day 03)2'/z-3 hours per day
031/2)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%z) 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 01)3 to 4 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'%z) 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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
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?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
3 '� -,*, k2 sr,. r sh+ x x� 5C VI i r^^++ 'may `t !y'a s ,.v,4 h{{ 7- 11x$ .411.;". !b ;lir M1a t e! b a t ' ai
i *yr , ,+
.hiL-� .FN^�-k ER.� tG r ! ze :-� _ t�� �`i
i3M s,ya!
k'-
(YC
ofirmit4 Y i t .,i L $' i . t.`+ '. L y.0 "(e !el t e ,{y{ �' { r"?I4"`F e 4Te
' '. .,...�. .... ...., .. v:' ' .SS K �.:.4ei�.... _., t 'iu..,6biGiv__G h" � ;, �n..
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ 0
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ 0 ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
$ ,Ti b�
r s m 4t.Y �. s s ! ! ' w .f'S fiti• -
_a ,� w i vi�,w( '' rt, v pit on O fore !ir .� ��t dday'v` i F
i,r�,h.}a"i { a5 ,'I" 9 'k � ! . au 4: '**! h3h3, ! #' 4$
. t' ��t��r 3' 't..h, t �''YP,3L p !! 4a'Lar ARS
j `-I''{I :._i4 P 5h sir ,�. .. M h S�
,. ,,,,-, ** i'i vIl fiig:F k- inn 'h`ie 5 j A
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 0 ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
" t a ns t7atj..3 w7v 4�sl
9
ItiminionEniqfta raiVi4 klks: r~°t�� a.,z fifill;iCQ7NENAPEBign!jA in! . x� s
IRRIANIR
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
tg
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$,66 Respite Care
ttt Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
y $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
1,,. *3 ... � js . :sus . .rs . s .i.„..c
ltt
Assessment Rate gig $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ik'"7 �� " "
Weld County Cl e Board
11, E L � WELD COUNTY BOARD OF
`n SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By: M-7 L+--/
Deputy C} •c to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Jackson, Scott and Andrea
425 Hickory Ln
Johnstown, CO 80534
By:
( rure)
WOF O A ER DEPARTMENT
/,_U�
OF SOCIAL SERVICES �/� � '
By: -
(Dir ctor Signa e)
8 Weld County Addendum to the CWS-7A,+�v
07a9 -O7a
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Keaton, Roger (R.C.) and Eva
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 1 day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the A eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1545954. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
] Weld County Addendum to the CWS-7A
ar ?- a/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME 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 ❑PA)2 round trips a week
O2)3-4 round trips a week. O2%)5 round trips a week O3)6 round trips a week
❑3'%z)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 or
special education plan?
❑Basic Maint.)No educational requirements ❑1) Less than a %I hour per day ❑1''/) %l hour a day
❑2) 1 hour a day O2 %:) 1'/-2 hours per day O3)2'/:-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week Dv A) 5 to 7 hours per week
O2) 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 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
❑3'h)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
O 1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 1%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Sart'Lli
Two{v,• ,�4,£ F ..:9 °
4s₹ 1. 'f „` : 4'
,2
Aggression/Cruelty to Animals
❑ ❑ 0 ❑
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ 0 ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ 0 0 ❑
5 Weld County Addendum to the CWS-7A
•
BEHAVIOR ASSESSMENT CONTINUED
. . ' (Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
ss,f
qql
', . -'e..,3 , , > ,fit TR ."„� ' x°� r "' ` +'t' ' � ,:.*4 ,Y aqu e4 ��
•
� igitiAid k` i 1 ailtt
� S.�°.isfi�k dv;ti � ... e
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ El ❑ ❑
Delinquent Behavior
❑ ❑ 0 ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete El ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 ❑ ❑
Education
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
a T-
A.e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
Me 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 Ze +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
-142
$26.30
2 F,1O +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 112 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
144
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 41414'414142/14-1411
Weld County Clerk the Board
°K‘il .IE L WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
Ia
qtr � 9 DEPARTMENT OF SOCIAL
or SERVICES
By: /ill /l(/1 �?`� ll uC/ B �Yw t Y
Deputy Cle o the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Keaton, Roger(R.C.) and Eva
25565 CR 47
Greeley, CO 80631
By: ,t) 14 ti A----
(Signature)
WELD COUNTY DEPARTMENT et/ 11
OF SOCIAL SERVICES �' '
By:
(Dir ctor Signal )
8 Weld County Addendum to the CW�S7-7A q
cQtVJ 9/6,
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Kilgore,Julius and Pamela
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this /9 day of A p,' � , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1538189. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A 9/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
DENTIFYING INFORMATION
:HILD'S NAME STATE ID# SEX tTRAILS CASE ID IDOB
M F
VORKER COMPLETING ASSESSMENT HH# PATE 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.
ME 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 ❑1'%)2 round trips a week
❑2) 3-4 round trips a week. ❑2%2)5 round trips a week 03)6 round trips a week
❑3%)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
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?
0 Basic Maint.)No educational requirements ❑1)Less than a''/2 hour per day ❑1'/2) % hour a day
02) 1 hour a day 02 '/2) 1'/2-2 hours per day 03)2'/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed Du Less than 5 hours per week ❑1'%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑ 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?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week ❑112)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑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) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�' £.�, t ' i 1 ! t 1 k i
I }4
+3 F 4 Yt 3 gq x tf__ ScC 5111�'� 1
Y
4I t Paz zr i 4 `F' - a I d rt x a t 1�
t• aa •
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
o ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
O 0 ❑ ❑
Runaway
O 0 ❑ 0
Sexual Offenses
D ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSEN
(ExhibSSMEit B) T CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
f:PAih gy
u ETngitsme2ti�'�d, ti �v - 7s . xRt. z£ii ..� — cd ' 4y
rti jiYl S b
•
t4 4 I 1 Uli.€(`
Inappropriate Sexual Behavior
O 0 0 0
Disruptive Behavior
O 0 0 0
Delinquent Behavior
O 0 0 0
Depressive-like Behavior
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ 0
the Medically fragile NBC)
Emancipation
❑ 0 0
0
Eating Problems
❑ 0
0 0
Boundary Issues
0 0 0
0
Requires Night Care
o ❑ 0 0
Education
❑ 0
0 0
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 El 2 ❑ 3
6 weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
+2i 1L
� nt �4aw�..`$.
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
6031
1.44 $23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
alzt
$26.30
2 tita
554 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 IPA +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 riga +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/272'4,41.:
+$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
fat
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
nan
Effective 7/1/2008
7 Weld County Addendum to the CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: to#401
Weld County Cler d
-kici i2,11„,/4
(4/
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
asi kil, -' OF THE WELD COUNTY
\, , figs DEPARTMENT OF SOCIAL
\O,.� ,\e SERVICES
R
By: 7 - By: r-2-=/�liU
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Kilgore, Julius and Pamela
1740 7th Ave
Greeley,CO 80631
By: ' VI_A c QC,tX 6 C _�
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES ��A. �� �� ( ��
t
By:
(Direct r Signatur
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Kniss, Kevin and Kelly
and the
Weld County Department of Social 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 th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1524303. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
cQ41J'— &/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services in
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after achild isplaced n f C J
ipprovider's care. Medical examinations need to be completed-within 10 days of the chile)' 1,„ '
being placed with Provider and dental examinations need to be completed within 14 days N.,
of the child being placed with Provider. All documentation of these examinations will be ; ll
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook. /
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# 'SEX TRAILS CASE ID DOB
F I
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 die 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. ❑2'/)5 round trips a week 03)6 round trips a week
❑3%)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
❑3%)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''/3 hour per day 01%) % hour a day
02) 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 ❑1) Less than 5 hours per week ❑1%)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%:) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3'/)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2/) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A I. 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.
❑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) 01) Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
k� `^. t,, e i p t e r , r +
Ss � 794 i ;�t' �irt � _pry r ..r1-3 --atsteittaltttbk-a.W.sa,,FCtiars,14ettatiOtsmeala
'}^ i i epic .1 fi'
tietWei
� r/ a.R - IBASMNI;y es� i �z Y ' xenvt �n
t��,, ,n ' l l t li} l
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ 0 ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ 0
Enuresis/Encopresis
❑ 0 0 ❑
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
.. : :
20it VONFSROMe-MFTFV:11M.:4SaraMin
Ia a ,! . I it t i 63 Y R f
' a7; ti-Att 1
vet iy _v xPSi l� a{n
yr,�3��1t N 1
m 11 �di�i. iiivvi..wi
Inappropriate Sexual Behavior
❑ O ❑ ❑
Disruptive Behavior
❑ ❑ O O
Delinquent Behavior
O O O O
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ O ❑ ❑
Eating Problems
❑ ❑ O O
Boundary Issues
O ❑ O ❑
Requires Night Care
❑ ❑ ❑ O
Education
❑ O ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
'f -'
-
(
3.. ₹� '��
l � 23n N4
ffi k
^� e'fg'
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
1n, +Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
raf
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: atediath
Weld County Cl oard
n C
WELD COUNTY BOARD OF
1861 SOCIAL SERVICES, ON BEHALF
� OF THE WELD COUNTY
(-7DEPARTMENT OF SOCIAL
t SERVICES
Pl\YF\\^C
qq�� y%
By: i�k 1L9(,i _a., By: ?-n----/ Kti...,,
Deputy rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Kniss, Kevin and Kelly
1545 71st Ave
Greeley, CO 80634
By:
(Sign (,
WELD COUNTY DEPARTMENT /�� C )/'( /
OF SOCIAL SERVICES / !
By:
'rector Signal )
8 Weld County Addendum to the CWS-7A
art-C9/6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Knutson, Troy and Stacy
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this 4:9 day of g , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1522516. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
cat- oi/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX ITFtAILS CASE ID OOB
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 011/2)2 round trips a week
O 2)3-4 round trips a week. ❑2%)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 ❑1'/z)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 01)Less than a''/z hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %) 11/2-2 hours per day 03)21/4-3 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 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 ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
O 11/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%z) Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
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 ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the beha�ior'intensity of conditions which create the need for services that apply to this child.
Rating of Conditions �� �'',.;r ARita
(Check one box for each category) 3: � :
Assessment Areas None Mild Moderate Severe Comments:
0 1 2 3
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting O O El ❑
Stealing
❑ ❑ O Cl
Self-injurious Behavior
❑ O ❑ O
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ O
Runaway
❑ O ❑ O
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
5,r ra t ccCcui5L46I:. 1 ha I'! d! M s ;y iY C ! k t 4,e �. A'�i
a tl »..}y t e t tt ' ' .R -sY" >h '' 5,,,,' k !
q,' �3 d'N'2 r "v.:
ib £ � team
�+" v>;h s t f y art - t a !`
.... ..�d�`_�1 ! �',..�f ,fi I' ��`.' 1�. _ __ a c�,,.:3� I ! G, is l.: E�� t, . e� a._. � ...:� '� ilts
litirptf4a '` +� 74- 5a6i g xv�
,,,,,. i =a..s- t .,lL ca ;{�„ i3 , a r a k`wvi[ RE,Mx„+,w tir q` x 33 . +
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 0 ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ 0
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
4444- M p . hr. ti, 1,44I . N. � 14Thir.
amp-sa
kb* fla:E1 - l y
ar - 7 ,a
r r a #E grr v !d yr x,iiric e a
Aqe 0-10...$16.32/day ($496/month)
County Basic ;", Age 11-14...$18.05/day ($549/month)
Maint. 14,
Aqe 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 - +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
I $23.01
1 1/2 ' : +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 > +$.66 Respite Care
D;A Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down -: +$.66($ Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate ,.ti
(30 day max) ri: $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: /With
Weld Coun Board
KS' fwn
KTI9L WELD COUNTY BOARD OF
asi `FVF \ &-,a SOCIAL SERVICES, ON BEHALF
:: h
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By: /1\Mk-Pi-,
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Knutson, Troy and Stacy
6250 Stagecoach Ave
Firestone, CO 80504
By: %Zc,�‘7, g
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Dir c r Signature
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Laube, Keith and Julie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this (3 day of /I147 , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1514494. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
] Weld County Addendum to the CWS-7A /
& — /l'
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME 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
❑2)3-4 round trips a week. ❑2'%)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?
0 Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
02)Three times a month ❑2%)Once a week 03)Two times a week
❑3%)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 01%) 1/2 hour a day
❑2) 1 hour a day 02 %) 1'h-2 hours per day 03)2%:-3 hours per day
❑3'%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1%z)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 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
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
❑2)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑l)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to
r b ,' .,�.`ay ea ab `r ,;: +*sa rxy. + IC §I�.� 3 c I this child. °u p *,
• d a »' + }+4 -3•w9a,�r'4 'kR�•a m at 3 °±.s. 4 4
�u "a a�a •r "+ 4y v s #,��tt a ` � '��::�.�r"tr,l"�,`� b+} 'v 4�'• 'a�a �. v �.
.' '?u •y, ' 'k tom' sY aYnu tat 2 m € •+ v k { *:
`eisA ,t# '-x. .k ke :t1b`s` l e414II`t7:771..y�' s� .. . i.k°' to ' x is a shit gic 'l
w hci �-� 3 a 3 1iN tin; ,- ,'" .i s v*: a o f . *4
....:x_8:3 r n .�t a.+ �tm *✓��,�.`,&dh,�.a.-v'�&���. '�.�t�'�`�; 4 '�°''
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ 0 0 ❑
Self-injurious Behavior
O 0 0 0
Substance Abuse
❑ 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 0 0
Enuresis/Encopresis
O 0 ❑ ❑
Runaway
❑ 0 0 0
Sexual Offenses
❑ 0 0 ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child.
•
v •:r35}.vss.Es'�u vaxs,. h � _ § �+Y� a''`"x i{ Cr'r�"`' 4'`
'#§ 's$"K, *. 4 tau +,
.�y , , ""` v k ate: ' +c § r * 3.§ ..� n r::::A ."'�"'a i,
a
a .. #a �: 'Ek •Kr fi�,t sllekrtar : a��w ?,. . �+ .
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
O 0 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ 0 0 0
Requires Night Care
❑ 0 ❑ 0
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
x �
1 a rr �• -p ^q.. ≥Mfi Si.ixc '1 i s std 1 .
A.e 0-10...$16.32/da $496/month
A
County Basic .e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month)
+Respite Care$.66/da $20/month
$19.73
1141 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
ooe
7.0 $36.16
3 112 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
€t.
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) iz
Effective 7/1/2008
7 Weld County Addendum to the CWS-7.
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: "'"iala
Weld County oard
' :f- WELD COUNTY BOARD OF
y. r r
SOCIAL SERVICES, ON BEHALF
�' s OF THE WELD COUNTY
a Ucv ;�
h . r� DEPARTMENT OF SOCIAL
N ClaI SERVICES
By: By: (tG,.
Deputy Cl tot e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Laube, Keith and Julie
14497 WCR 76
Eaton, CO 80615
By: /kid. k tit-
(Signature)
U
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(D ector Signa e)
8 Weld County Addendum to the CWS-7A �p �7
&v ` ( /e
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Lee, Steve and Brenda
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 3 day of y 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the A Bement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1512263. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
.-OniP x/(0 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME 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 ❑1%a)2 round trips a week
02)3-4 round trips a week. ❑2'/)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 ❑l)Once a month 01%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%z)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?
0 Basic Maint.)No educational requirements ❑1)Less than a%hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %) 1'//-2 hours per day 03)2%z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1/) 5 to 7 hours per week
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 feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week 01) 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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child
x W. i;; 6 nay �e :rff..�, i p "tom U( s I. �d - T '+Yit„ " .,�i
, �s t rtt c s is t. r + PAC .. . . `4 5 `v`''iii +nfi
�'
i`` . R c g� i 4� by w t �'It 'v� i
.it'
5. ' i 3i �'�� t'- 3. °s
"�+ t aT y i
3 Etlact
,i 4 t.
5 py E u c '4 ii �i7�
biort
1:2:34,;) 4;,1'h}9`ti
..�.,.i„ � d. _�s...inTaT�`�i�,•,,,.,��:.;' . ...... . ... ... •
.... i. .. . .,_�.'.::.
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
O ❑ 0 ❑
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
O 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
nc„m+ + - SCP: + .. rr + + 1 tI sti les L.g
.y k + , �i^S g+iI ��� 5 ''._ k p' + s�. '��iH'#+" '5�jrt r # ,n:.
' a„ �`�` 7A. Nit
f"" m1 yk:.i.iat -xa� � a..
� �"a, �rrr� i�ti �� r 'I°`r: +
g :1'414. 1'45 :r+ �trra ,+ 1 ` terony�"
L i + t
• s + vs°"f i4 rev E • a d+ + �� �,• ,a. cair
+ a C x-n'a'" .+ i
+4ui�.+' p. .,'f3 a t"+ s ,zs � 'k4 pt s
4�...:. : . :ka ';:;h( ,. 9 i{n .. .mn.�,:n. t wA = t !':'I'"`ivai.4 a..�}i.
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 0 O
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ 0
Requires Night Care
❑ ❑ ❑ 0
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
4 a � r51 � 6 s
-tot 'et): RMIMMBILMMIMPfill
5C u
it
S 'v,li .I 2 k x "s 3 4 � .k A
i _ Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 m 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
='" $23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
21/2 .' +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 - 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down ". +$.66 Respite Care
tm Total Rate=($40.11 day/$1220 month)
€+s
1111
Assessment Rate
(30 day max) ;s.'.4 $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: a ���a
W ty Clerk to the Board
E La WELD COUNTY BOARD OF
s.
!CA- c SOCIAL SERVICES, ON BEHALF
t 4
)4-9 OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
,'• .1 c SERVICES
By: /alma , .� /�, By: ik-G.
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Lee, Steve and Brenda
30932 WCR 50
Kersey, CO 80644
By: /t..erc
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector i natur
8 Weld County Addendum to the CWS-7A
&cod &h 5
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Lewis, David and Connie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of �u f , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms ot'{he greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1523277. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
,2'6P-0Vó9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the turns and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F !TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT jIIH# �.t I DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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 01%)2 round trips a week
02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week
❑3'/z)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
02)Three times a month 02%)Once a week 03)Two times a week
❑3'%z)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?
0 Basic Maint.)No educational requirements ❑l)Less than a%z hour per day ❑1'/z) %z hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑l)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 ❑3'%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%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.
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) ❑l)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
C;444.;
R i D 1 6 fl f 1
�41F$m '—r
tt.. i 5 e iJ ! � 'f
•lacisat4 4y. !
i
:*:WT.fe-iPt.a.ti0.1.4tatijagilicitiii..icinsa.Q.4 ton,watt
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
S-7A
BEHAVIOR ASSESSMENT CONTINUED
•
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.ASirif4 4 �+ Fri ��iv'-:: 'ar` "'Wirt " '4
.t 4L aI # ' P di E! X6F
A
S� fir,. a '
yCVe VE ! ! t -=1
4 y'rsu 1/1/4 tkAilawatiWIligianitrantrigt: !=;rte,::
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ ❑ ❑ 0
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ 0 0 ❑
Education
❑ 0 0 0
Involvement with Child's Family
O ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Wit- °1 T Wy�'t rpry. y Y 1w -
A•e 0-10...$16.32/da $496/month
County Basic
i A.e 11-14...$18.05/da $549/month
EY
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
p,.
'- $23.01
1 1/2 ' +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
es Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
n G.
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
+$.66 Respite Care
TRCCF Drop Down
.t; Total Rate=($40.11 day/$1220 month)
ex;
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) .
Effective 7/1/2008
7 Weld County Addendum to the CWS-i
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 14.41/471-"4
Weld C to the Board
ev" " ` WELD COUNTY BOARD OF
p x SOCIAL SERVICES, ON BEHALF
gg OF THE WELD COUNTY
i �c
�. DEPARTMENT OF SOCIAL
SERVICES
By: 1 By: M-.71-2'i-n...4
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Lewis, David and Connie
2904 42nd Ave
Greeley, CO 80634 /
By: AS
By:
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ector Sig tare)
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Loschen, Todd and Alicia
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1528352. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID 'DOB
M F I I
WORKER COMPLETING ASSESSMENT HH# PATE 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 011/2)2 round trips a week
02) 3-4 round trips a week. ❑2'%)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 ❑3)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 01)Less than a'/z hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 %) 11/4-2 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 ❑l)Less than 5 hours per week ❑1'%:) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 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?
00)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 Addendum to the CWS-7A S-7A
•
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
n. g w rc 4 a rtt: • '
rt "t x?h'+ fi "u d
� ' ' yak; +� �
£x�x S. ,,„€ R 2 ..c av '`a�, ,�,
to "°�5 n � ` d ,vk �,�.;:sa.av�
vomcw'MS h' ,z."P' i fit;;;T:!!;;;!';,..;!:;;;;;;2;y a z` h
. � !;;; ;;;;; a xv ; r:.;;;;;.; ar t
ie-
'Zero,* -w a 't; E 4 i ° '44;$ m 4 r. i , :4 S y atr "
is -.,,5.; s aT m"iaiat 4,-..h-I : aw ,...n ....... ..x- :�i' <. , .�: k!3a tm tz ".t,t,u(
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ ❑ 0 ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
0 ❑ 0 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis
0 0 ❑ 0
Runaway
0 ❑ 0 ❑
Sexual Offenses
❑ 0 ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that asply to this child.
wnT.. EIR15.3W 4t k 4 , #+ 4i y
tatil W x §a ny , ' Lieli " sazi 4_ i `?;S:23:astEnzibis
;4,1,44
5�P
q�^vi ''`4uy y FL �S�'Y°'5s'�- Y.. 4Y' .7 yt ' irali
an � .v Nq w. n '' * ". 'wlsiZ}z.s;Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ 0 ❑ 0
Depressive-like Behavior
❑ 0 ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ 0
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C) egg
}^'t'., yto-Y75�1p�, "R ! �,y y '' 7
��Ya9 �
� at r ' '�
4s1 � G k'1
g � rc dd
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
Pta
4 $39.45
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate Or $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
Weld County Addendum to the CWS=.
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 44144/14-44
Weld County - oard
WELD COUNTY BOARD OF
ft6 , Y SOCIAL SERVICES, ON BEHALF
Std � OF THE WELD COUNTY
�,. '�,� DEPARTMENT OF SOCIAL
`,.e); . 7,7-4- , SERVICES
By: ?Z' ,Lt' By: l--Ga- A
Deputy rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Loschen, Todd and Alicia
1747 68th Ave
Greeley, CO 80634
By: l LZwl O51 T)
/ISdL n (signature)
WELD COUNTY DEPARTMENT ny` •^ �_ ci�_-____'
OF SOCIAL SERVICES
By:
( it ctor Signa )
8 Weld County Addendum to the CWS-7A
O,9a— ',
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Maronek, Dennis and Patricia
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this cf day of 't• , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1520627. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CW!S--7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
•
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID jDOB
M F I I
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 01)One round trip a week ❑112)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week
031/2)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 ❑l)Once a month ❑112)Two times month
❑2)Three times a month 021/2)Once a week 03)Two times a week
❑3%2)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'h hour per day ❑112) 'h hour a day
02) 1 hour a day 02 %2) 1'/2-2 hours per day 03)2'/2-3 hours per day
031/2)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 ❑112)5 to 7 hours per week
02) 8 to 10 hours per week ❑212) 11 to 14 hours per week
❑3)Constant basis during awake hours 031/2)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%2) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
0Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1) Face-to-face contact one time per month with child and minimal crisis intervention.
❑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%2)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
its i 'lift,d 0 Egl X i _ t -:
Aggression/Cruelty to Animals
❑ 0
0 0
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 0 O
Stealing
❑ O 0 0
Self-injurious Behavior
El 0 0 0
Substance Abuse
El 0 0 0
Presence of Psychiatric
Symptoms/Conditions O ❑ ❑ O
Enuresis/Encopresis
❑ 0 0 0
Runaway
O O 0 0
Sexual Offenses
0 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSM(ExhibitEB)NT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that a.ply to thn.is child.ymizmausza
cLe,2411Paill,)'14 lii-F"Yii 1 3
I ti 6f I cpPabsinatilizt t §4 a 9'x3".- .. 4 1 mx
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ El ❑
the Medically fragile NBC)
Emancipation
O ❑ ❑ 0
Eating Problems
❑ ❑ ❑ 0
Boundary Issues
O ❑ ❑ 0
Requires Night Care
O ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 Ill 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
g
i .> ' It4+N ° 4u' .vv.Kx r
A.e 0-10...$16.32/da $496/month
County Basic
A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
+$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
Vie $23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
;x
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
TRCCF Drop Down *$�Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
ty Clerk to the Board
itaLa WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
lrsi cD
OF THE WELD COUNTY
r-. h DEPARTMENT OF SOCIAL
• { �y SERVICES
By: ✓ - L% By: -
Deputy Cle z to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Maronek, Dennis and Patricia
4860 Eagle Crest Blvd
Firestone, CO 80504
By: Patted-ILL, \(flc /l&ta V
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Di ector Signat)h e)
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
McCreery, James and Tammy
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this day of 1 , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#40215. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4`h of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F 'TRAILS CASE ID IDOB
WORKER COMPLETING ASSESSMENT HH# 'DATE OF ASSESSMENT
I
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'/z)2 round trips a week
02)3-4 round trips a week. 021/2)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 ❑1`/z)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 01)Less than a '/z hour per day 011/2) '/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?
0 Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑ 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?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1Yz)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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
t a # t t`NalittleStV,SOC941:4-LV:1;C:. t"'
-CCI :._� + o. o VON:'-i;471,17
. B .,.,._'...41 $ pax' �_-i- .
ii v§c � 4` tx My �''
—� et & A 4'b di _ 6s1Wi�
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
' Please rate the behavior/intensity of conditions which create the need for services that abpi to this child.
Ph 'e �xi $, �'" ,+"' — F a-'d��?�^>xn,,. .� *„ e# r �a ,, 3 4 '1 t 1 tt i�p , tn'i R
} � �b %4 � Ft $ H l4 s.,.,„
� rt
yf 4
ltn ash STud irk?" 4 • t E
. ��s t:,........� rte t
icolirWierict.
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ El
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ 0
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ 0 ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
` '&';a 5 "x. ° k
nl 8
.1L x >t w..iv3n.
�_:5i:.x"•� 5a�f.�k;�:h S, .
Ase 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
.l $19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
4141
$23.01
1 112 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate ±, $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ,tL.4/ i1
iadAl
Weld Co he Board
IA L
WELD COUNTY BOARD OF
1451 1- SOCIAL SERVICES, ON BEHALF
j�`y`� + OF THE WELD COUNTY
A ; DEPARTMENT OF SOCIAL
� fy,,p1�T�Fl 1 SERVICES
By: c By: G\v;o (—G,,.✓
Deputy C c to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
McCreery, James and Tammy
120 Maple Ave
Eaton, CO 80615
B 2 6
c ,
(Si nature)
WELD COUNTY DEPARTMENT / r
OF SOCIAL SERVICES L 42A-0 417/
By: rect igt ure) fr
Cti(Y
8 Weld County Addendum to the CWS-7A
a1DOd'- ai&'9
WELD COUNTY ADDENDUM
RECEIVED JUN 16 2008
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
McGee, Donna
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1539853. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
i Weld County Addendum to the CWS-7A
WeP— a/4
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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%)2 round trips a week
02) 3-4 round trips a week. 02'/z) 5 round trips a week 03)6 round trips a week
❑3%z) 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
❑2)Three times a month ❑2%)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 01%) '/z hour a day
❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/z-3 hours per day
❑3'%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed Du 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
0 3) Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
0Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
O1v2)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?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CRE ASSESSMENT
(ExhibAit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
rf>ra,.. ° c a w a t a - cat
4 r� �! IniWieardirtritaf 7.04 6 t �1 $ 3 } t mtraiitairsift h
>K r i a S= � .
t! 'ntA u ;s t .. aL. st . :: ter
i
'f�}
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ O O O
Destructive of Property/Fire
Setting O El O O
Stealing
❑ O O O
Self-injurious Behavior
❑ O O O
Substance Abuse
❑ O O O
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ O
Enuresis/Encopresis
❑ O O O
Runaway
❑ O O O
Sexual Offenses
❑ O O O
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
4t h = f.p ' 1 k 1 u EJ
stet
na 'fk
44:1141Sbireaitaitir.1” 'art'veyL��?� aSF + t {41 ,i,. a
titaistaaalltigna
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
O 0 0 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 0 ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 0 0
Requires Night Care
❑ 0 ❑ ❑
Education
❑ 0 0 ❑
Involvement with Child's Family
O 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
S f F Na
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
fre
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 -4.66 Respite Care
174 Total Rate=($33.54day/$1020 month)
1,471
$36.16
eztt
3 112 k +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
•
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 144414 ' " a ,r
Weld Cou the Board
'41 �1 WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
s' , A OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
(!1
�� SERVICES
By: By:
Deputy j c to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
McGee, Donna
1649 31st Ave
Greeley?CO 80634
di
By: k).--)07q6 /l 19 cL
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
( irec or St g t lure)
8 Weld County Addendum to the CWS-7A
ao%t- a/a
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreemenp;between
Mellmen,Jeffrey and Letha %
and the . Cl/
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
•The following provisions, made this I Ipl*day of W^( , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547484. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
��i C>74)
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A S-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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
❑2)3-4 round trips a week. ❑2'/)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 ❑1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'/:)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?
0 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'/z-2 hours per day 03)2'1-3 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 feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week
02) 8 to 10 hours per week 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.
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?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Ry m+vs cS"�'�tt ro �FsY"ng
x.
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
O ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
°aat = -v tr -� x. �A. d @", v'^ s<. +:..a` s, : .4,er
rsY ri+ Ors A+O. z4$ � tliq tt�� �'' '4 ? `b "'r7Ti°S.js i.e: 'a5a.4'y,',: :',:-' "i :::;''14:9'7:::r:"-.
'' :: " %, . k'
- :, y n w x �r_ x Sci ..r°� T :: to „ "'a T�`va v'w z '.,,,,.-3„..,
omL4i� �t".`c `�.,.t ..:.$E§,.": ,itti.m..°� .r_ - a. ..'�E'+'�..' . ma..... .:.xrave.. ....,..,.,,,. .. .. _ ..< ... �.°
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O 0 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ 0 ❑ ❑
Education
❑ ❑ 0 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
v ro •
A.e 0-10...$16.32/da $496/month
County Basic As 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1.120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
iv
41 Assessment Rate it $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: fia-4"o'r
Weld Co` 9 � �o the Board
v" WELD COUNTY BOARD OF
n`,y�� SOCIAL SERVICES, ON BEHALF
sal �< OF THE WELD COUNTY
vim :
DEPARTMENT OF SOCIAL
SERVICES
By: By: A-C7 6---74....i
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Mellmen, Jeffrey and Letha
352 Laurel Ave
Eaton, CO 80615
By:
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
c\a,tr)
By: C (Diretjsinature)
&Dar- a/6;
8 Weld County Addendum to cc—ry lc'9 A
i
WELD COUNTY ADDENDUM L 1j '
Cw \
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the"Agreement") between
Mena, David and Marie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this day of 1-2 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the eement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1510691. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CW5 7AA J /4
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX TRAILS CASE ID DOB
F 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 ❑1%x)2 round trips a week
O2)3-4 round trips a week. ❑2%:)5 round trips a week O3)6 round trips a week
❑3'%z)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 ❑1%)Two times month
O2)Three times a month ❑2'h)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 Du Less than a %2 hour per day D1%) v2 hour a day
O2) 1 hour a day O2 'A) 1'h-2 hours per day O3)2'A-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑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?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'A)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑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.
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.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
i rI' 3 :
��rvy 9-vi_ 9LJ :"..t rlkf S. gg
, ,n al, f=f a a ray
iiilgaiii
Aggression/Cruelty to Animals
❑ ❑ 0 ❑
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
AntiriAttriRL rt. t' ! B C e 3 i
e" i o t 1 ... i.
m
F
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ 0
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ 0 ❑ ❑
Involvement with Child's Family
❑ 0 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
S-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
t { y
A•e0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
Lit $19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
rat $36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ""(
Weld Count he Board
/' WELD COUNTY BOARD OF
if ! , r
(-I Y i SOCIAL SERVICES, ON BEHALF
' �Y OF THE WELD COUNTY
4 / w
DEPARTMENT OF SOCIAL
���' = SERVICES
By: By: t t—G�
Deputy C1e ' o the oard Chair Signature
William H. Jerke
AUG i 1 2008
PROVIDER:
Mena, David and Marie
2905 41st Ave
By eley�d34
(JR/`I Signsl'Atel
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: U.4
( ' ctor Sign t re)
8 Weld County Addendum to the CWS-7A
o?oS 0≥J6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Middleton, Brian and Deborah
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this day of ,}L / , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of thiAgreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1537851. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
ch //
�G'�'J �(
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX 'TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 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?
O 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 01)Less than a %z hour per day 01%) 1/2 hour a day
02) 1 hour a day 02 'A) 1'/z-2 hours per day 03)21/4-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond aae 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) 01)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that as sly to this child.
.i.. . . ..
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 0 ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a'ply to this child.
a sz
,tr t t t Ys r z r "
1*,; 4x)!�# 3...... : �,.,,..�;°s ..;. � .w *�,„. : ,,.,x�_� a��,�z � dif.lr�.zt3..� 'is.r.�....a:Y�_ _ .__.. .:.5 . ._.
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
714
$29.59
2 112 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: M" %
Weld o the Board
' WELD COUNTY BOARD OF
>F ' HUMAN SERVICES, ON BEHALF
,;
1 OF THE WELD COUNTY
k .• v- t7/i DEPARTMENT OF HUMAN
SERVICES
By: By: ..)..,.-7.4-74.--,---c
Deputy Cl tot e Board Chair Signature
William H. Jerke
AUG 1 1 7008
PROVIDER:
Middleton, Brian and Debo
2418 W. 24th St
Greeley, CO 80634 l � --
BY: 1'�:Jlai i/da��E{'aLln
(Signatu
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By: C tutrAi r Sig tture)
i
8 Weld County Addendum to the CWS-7
C2Md — <9/b Ed
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Moore, Earl and Patricia
and the cS
Weld County Department of Social Services �U,
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this•22_ day o , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1517579. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CW S-7A
aat ‘, /&
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Social Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F I I
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 ❑1/)2 round trips a week
02)3-4 round trips a week. ❑2'/)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 ❑I)Once a month ❑1%z)Two times month
02)Three times a month ❑2%)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 ❑l)Less than a''/z hour per day ❑1%) %z hour a day
❑2) 1 hour a day 02 A) 1%-2 hours per day 03)2'/z-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1/) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑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 01)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.)
❑l)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.
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?
❑0)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
^� �n
eS F 3 E B A E f
%4,..�.;
_
ijlcgk
I P r b c. is y ,,,,yYpi i ht"-r qSy n
-y dye' fib €t i !ht, 3' yf, _ ' ,. !T-,-...;,,..',..:41-4,L,
t B'• 1 n " t i
"a re
v ..-t.,3'5 � ��-y a a�4 ;x 3. "x - .,. :: su �.tt7 L 1. �'� .� +S ,w
Aggression/Cruelty to Animals
I: ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
O 0 0 ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions 0 ❑ 0 0
Enuresis/Encopresis
El ❑ 0 0
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASS(ExhibitESSMEB)NT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
rw a E ; 3 �•: €al;4 174iyin " . If __ t ..., , .; r ,:aairr
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ El ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 III 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
xG.
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
tent
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 ):. +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
iSa
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
44 Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS S
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: "' a (
Weld ( Clerk to the Board
./#:44 1 e.y
WELD COUNTY BOARD OF
* p �; 7'a' SOCIAL SERVICES, ON BEHALF
i ihItrAp OF THE WELD COUNTY
f DEPARTMENT OF SOCIAL
7 ,. SERVICES
2-
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Moore, Earl and Patricia
135 Poplar St
Lochbuie,/ CO 80603
BY. c A- ar, J
c J��//77
/(Sgnalu�
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Di ector Signal e)
8 Weld County Addendum to the C3/S- 02/6 9
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Murrell, Nicholas and Terri
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this \p day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C,regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1547183. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A J a/o,,
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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'%)2 round trips a week
02) 3-4 round trips a week. ❑2'/)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 ❑1'%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3''/)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 %x hour per day ❑1'%i '/z hour a day
❑2) 1 hour a day 02 %) 1'/r2 hours per day ❑3)2'h-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 Di%) 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 ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%) 21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
0Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1/)Face-to-face contact one time per month with child and occasional crisis intervention.
O 2)Face-to-face contact two times per month with child and occasional crisis intervention.
021/2)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
m u�Gtm%iii ` F""a "'t p ki ufE°° ,ei k h. ,�,� ,w "x eus. ,.
5 R '�',. yi aruro y�:. tom: �yEit
�'' sn ' " t' � � i iglu � i{n r o-t� �" , „itit � .
b 4 .:�.ip,�N���t, p6t7 is t� StYY 'ri.: w b
6R
10141:.;,,A roggw„iii, -414 nisi elf;12,..e.,,Arnfrgestioameimitamprvitt:: .41-m
Aggression/Cruelty to Animals
❑ ❑ ❑ O
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting O ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ O O ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ O ❑ O
Runaway
❑ ❑ ❑ O
Sexual Offenses
❑ ❑ O ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
•
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Fsn Ww. -7':.. k o- t o a s ��''`2n..vt
a 4:74 ttle4t n t .� yt - ' tom", ICI«, s ..
',4I3 k b A .A '' ''�,:. nr„ t ) .i .k SfrM vriggted, , +1 r,19Pifin, �M`x* -_ t4 u n
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete El El ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ 0 0 0
Boundary Issues
O 0 ❑ 0
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
O 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ l ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
5�x ;
A.e0-10...$16.32/da $496/month
pi
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
01
+Res site Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
!:: $29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
4O. $32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Ratelot $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 1414" M
Weld County Board
4 r. WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
O\ ��
DEPARTMENT OF HUMAN
SERVICES
By: 4.'/L�14 C l By: 72-271,4„,
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Murrell, Nicholas and Tern
812 Scotch Pine Dr
Windsor, CO 80550
By: \Q_)`17lS_
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(Dir ctor Signa e
8 Weld County Addendum to the CWS-7A y 9/6
;
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Newbold, Scott and Monica
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this t(e day of OT.A,let t. , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1549222. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX [TRAILS CASE ID DOB
IM F I
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
❑2)3-4 round trips a week. ❑2'%2) 5 round trips a week ❑3)6 round trips a week
93%)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
❑2)Three times a month ❑2%)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 '/2 hour per day 01%) '/2 hour a day
❑2) 1 hour a day 02 %) 1''A-2 hours per day ❑3) 2'/2-3 hours per day
❑3%2)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 ❑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 ate appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
9 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week ❑1%) 5 to 7 hours per week
❑2) 8 to 10 hours per week 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.)
91)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.
❑2)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a:sly.to this child.gaSnil'�,. .t sn k tir '3eEi r .� "l v,.`j -s1..„ ,a'ta x 4�s q r
It:fri +° aU'F 3 "4'3 sS 3a.�5? �����+lyy??"„„'2 ' 3g ii
� >7 5rs biz 1411 it
in bTl t y i ti ¢re:"}R�33Rii } y
.���yy{ ��� qa n is y �� 3h w�14
......................
a j i�i,i �v4�'4IR� '4.i°dhSA.
._.... ..,w. .-�_..a. 3 ..,u� .=:acs.. r RPM"
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting ❑ ❑ 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
m.. . v � -:in 4C ^v 7 t : a:'ltli ' n .t.4 ,...a m t6F
-E' � t `} d4 ;�,�T'h!_$l f 3 i A k ` i yEyt
zit'' . g-r7 6 t� al t ug t1 e r : -fh—�, _tca
x{t.y k# .3 - '$' °w' 4.4t,a. : t['tee ? 5 a
_: #, ;^"t ���
ssw a v 0J: : z i t tIRT
qt+
tSfi t t t;v�guY, v 3 c n � 't,-; `y, -a 1pgaiNegtInappropriate 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 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
•
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
Witz
$23.01
1 1/2 +$.66 Respite Care
TIP Total Rate=($23.67 day/$720 month)
$26.30
2 ek1f. +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
• Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
epfsl
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
.74
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
tta
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L414/1-444
Weld County Clerk the Board
44 }i" 4 r
j� WELD COUNTY BOARD OF
- HUMAN SERVICES, ON BEHALF
- - ; i OF THE WELD COUNTY
4t.1 .te 2I DEPARTMENT OF HUMAN
yr ' SERVICES
BY: 2 1L1lit LI By: � _ r
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 7008
PROVIDER:
Newbold, Scott and Monica
4324 Silverview Court
For Co MI.CO 8052
By:
en (Sig re)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By: a G O
( hector Signa a e)
8 Weld County Addendum to the CWS-7A
S-7A
a'Vf- (9)69
r
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Parker,Brian and Beryldell
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this y day of 7ttir1 , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1538709. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and maybe returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
a/6 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Social Services'
Director. The term"litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A S-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. ' To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 ❑1)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
❑3%i 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'/2 hour per day ❑1%) '/z hour a day
O2) 1 hour a day O2 %) 1'/2-2 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 ❑1)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?
O Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 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?
❑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 Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child.
�'x °'` �u ' * v. '`�- c Gpxb' ""a h". r"4"' m x ;S�tt" a.aSz % this.
s +' 2"i '�` �` 4
'� g� .,` 'a, � �� + 's 4 +t ,$ .' rt +x .a,4,r2x 5
Aggression/Cruelty to Animals
❑ 0 ❑ 0
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting ❑ 0 0 0
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ 0 ❑ 0
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ 0
Enuresis/Encopresis
❑ 0 0 ❑
Runaway
❑ ❑ 0 ❑
Sexual Offenses
❑ 0 ❑ 0
5 Weld County Addendum to the CWS-7A
S-7A
BEHAVIOR ASSESSMENT CONTINUED
•
(Exhibit B)
Please rate the bbeehavior/intensit of conditions which create the need for services that apply to this child.
14
a . �'—nnv` a , �u rb�g�'4 'e n,nmsw aps e.t a;8 ,�a`�`;*. '.t""s
u , r, ''tF ti, a
5.a, fyu a.l=,. ,.va.' ` ` `t�" s . C'pL_
. ,^.'. '+ '� . # �� .
kqt. .. .,-"4* Wr„.;aily ti s .k^y;. .4O ,„ 5 -„9
• +c�` a sr, t t » x •; 11 n 7„a+ E; ,r avh•k�. t a'" ' ,.,.aa ° Ra'
t. ..s :�' a.re tx l• '�r b
v6.. tot..s °'2...m. a,+t .se:.i.'k±rcs... _,. .F..e. .$r...s. ...._.mva
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
R tV
tint
im � ka iI
•.- 4-14...$1.. /.- $4•./month
County Basic rat, Age 11-14...$18.05/day ($549/month)
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
04
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
flt
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
lei Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) mil
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: e"integ�'//'�
Weld Co Clerk tithe Board
WELD COUNTY BOARD OF
Yea SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By: i��
Deputy erk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Parker, Brian and Beryldell
3001 50th Ave
Greeley, CO 80634
By: l L�r'J a jar �2
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Direct r Signature)
8 Weld County Addendum to the CWS-7A
aaoi .7/65
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") better
Pluma, Mike and Annette Cwt
and the C,�3D Qlu 8.
Weld County Department of Human Services /a
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o th Agreement remain unchanged.
GENERAL PROVISIONS
County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#35126. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
j Weld County Addendum to the CWS-7A
0201 02/69
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX !TRAILS CASE ID IDOB
M F I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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'/z)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 ❑l'/)Two times month
❑2)Three times a month 02%)Once a week 03)Two times a week
❑3'/z)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 Du Less than a '/ hour per day 01%) 'A hour a day
❑2) 1 hour a day 02 'A) 1'/z-2 hours per day 03) 2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 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 ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two timesper 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
02)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
s*
� B
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ 0 ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child
�..
;§ `per x
& :k;„ . .... ..as.: . .,r _n .a. ,'ilk �._.. .r• :�...
d-05;4-0241: 7
te .va Y ° it
1:1:30.20;;;;;:irz„sa,� '� ,n+s;�a4..s.z* ,tr...� ...is"� k+:�w��.i v. .yal. .ws a 's +#As.n.:ke ;: ' ` sa._.,_ • E ''
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ 0 ❑ 0
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete O 0 0 0
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ 0 0 0
Requires Night Care
❑ 0 0 0
Education
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4"/S-444
Weld County C1er oard
Si,/,f j WELD COUNTY
,44jF ' HUMAN SERVICES,BOARD ON BEHALFOF
is€1 l It-a OF THE WELD COUNTY
DEPARTMENT OF HUMAN
>` .�� SERVICES
� r: I .
BY: 40-11/1,-- Gf/L/ By: -e/22—.,
Deputy Cleft to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Pluma, Mike and Annette
PO Box 34
Kersey, CO 806 /
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(D ector Sign e)
8 Weld County Addendum to the CWS-7A
& 6d'- 917o
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Preston, Daniel and Lisa
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this /9 day of /,., ) , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1548050. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
a49f-07/69
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX F TR[ AILS CASE ID jDOB
I WORKER COMPLETING ASSESSMENT HH# I (DATE OF ASSESSMENT
I AGENCY NAME PROVIDER NAME PROVIDER TRAILS I 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%z)2 round trips a week
02)3-4 round trips a week. ❑2'/z)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
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 '/2 hour per day 01%) %z hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2%z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 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 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 ❑1'%z)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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
D11/2)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.
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) 01)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
+'at:e `� � t 'hi", ₹� �t z,'b.ii'+ t a aa4 t #.' k sxa-,
4Fr : 't;WIWI vv ' ra' �, 7: }S _5 ;per ," vkt. r k a i ` s, x
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 0 ❑
Destructive of Property/Fire
Setting ❑ ❑ 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ 0 0 ❑
5 Weld County Addendum to the CWS-7A
• BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
# ',sue .. "r .r `�*a '#'; h ,'t" �:'v �. z s w. . + x
�,a • r �, akp 7 r. s "k,ys� ,,°° a,to x+''`# .s '` ° . °`, a ...44
•R'y`a. t a a ri: `s.t« -. " Fait` ", . i a A �,�' '* s. , v
VMS: .� 3, :. a v—a' q ;a �ti s'+ . *!Ae a i �t'x its a4
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
�saa t E1 t,h aat ,� .� `tisfi s tv
Ase 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
$39.45
4
4.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
Assessment Rate 11 $30.25 day/$920 month(Includes Respite)
(30 day max)
dsi
Effective 7/1/2008
7 Weld County Addendum to the CWS .
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gl4/147144
Weld County Clerk to the Board
`µ )ra %Lx
i�- J WELD COUNTY BOARD OF
�c
SOCIAL SERVICES, ON BEHALF
v 1 OF THE WELD COUNTY
lw ': DEPARTMENT OF SOCIAL
_t SERVICES
By: a tit/ By: ��(�/ ..✓
Deputy erk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Preston, Daniel and Lisa
611 Cornerstone Dr
Windsor, CO 550
By: _/ �'�"V -
WELD COUNTY DEPARTMENT �� r(�ignam b.
OF SOCIAL SERVICES
By:
(Dire to Signatur
8 Weld County Addendum to the CWS-7A
4.9,0a- &/�
WELD COUNTY ADDENDUM
t
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Purcella, Denise
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms t Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1551571. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
S-7A
arid'- a/6 9
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he,find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child. except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook. •
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CIIILD'S NAME STATE IDt/ SEX TRAILS CASE ID IDOB
M F I J
WORKER COMPLETING ASSESSMENT 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 ❑1)One round trip a week ❑1'/)2 round trips a week
92)3-4 round trips a week. ❑2Y:)5 round trips a week ❑3)6 round trips a week
❑3%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
9 Basic Maint.)No participation required ❑l)Once a month ❑1%)Two times month
92)Three times a month ❑2'/:)Once a week ❑3)Two times a week
❑3'/:)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?
9 Basic Maint.)No educational requirements ❑1)Less than a'/z hour per day ❑1'/) 1 hour a day
❑2) 1 hour a day 92 1/2) 1'/2-2 hours per day 93)2'/a-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?
9 Basic Maint.)No special involvement needed ❑l) Less than 5 hours per week O1%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2''/) 11 to 14 hours per week
9 3)Constant basis during awake hours ❑3'/)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding.
bathing,grooming,physical, and/or occupational therapy?
9 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/:)5 to 7 hours per week
92) 8 to 10 hours per week ❑2%,) 11 to 15 hours per week ❑3) 16 to 20 per week
93'A)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑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.
❑2)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%z)Face-to-face contact three times per month with child and occasional crisis intervention.
93)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%) Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
90)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
w Check one box for each cat o; :: . ::
.............. ....• s .. _. :... : Moderate Se •
p 1. 2 3 - ...
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ El
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
Rating of Conditions
-
Check one box for each es .._...
. .)`.`';: ; . ;_:' :. �_�:s-��`_::-isaa':-i; :=: : .:.:::..,_ >:
.' tcsr iid Moderate sib:.:::: ...:,: ::-..::..-.........: .:.:. .:Comm' ::: .:::::::-::..:::. .:: ,...._.._..
........::
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ El
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ O O O
Education
❑ ❑ ❑ O
Involvement with Child's Family
El O ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 n 1 n 2 ❑ 3
6 Weld County Addendum to the CWS-7P
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
LEVEL OF
ROIwMANENFI:C3 ;>::;::
SERVICE
Leven .R
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2\ +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
/
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 112 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
+$.66 Respite Care
TRCCF Drop Down Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: i ,dd
Weld C to the Board
E
,�n i7, ., \
WELD COUNTY BOARD OF
r
FF ' -%\ SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
.\ > �x yr. '` +�l DEPARTMENT OF SOCIAL
r- ^ - , ,? SERVICES
•". r) 11,:;;
By: / By: '1-CrleG.../
Deputy Cle to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
«NAME»
«MAILING ADDRESS»
«CIT(YSTATE ZIP» �
BY: 1G./ (l�C.t.(_e:� Fit
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES Demise, A PueccLC r9
loco Sea 6fito CAtCE Cz2.
rieeiroNE, Co Soso*
By:
(Di ctor igna e)
8 Weld County Addendum to the CWS-7A
a0 orGP- oR/�
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Rael, Charles and Carmen
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms t Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1526232. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
t- a/t'9&a
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID IDOB
M F 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
❑2)3-4 round trips a week. 02%)5 round trips a week 03)6 round trips a week
031/2)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
02)Three times a month ❑2%)Once a week 03)Two times a week
❑3%)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
02) 1 hour a day 02 %) 1'/r2 hours per day 03)2/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week 011/2)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 I71 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.
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 ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the rvi That apply to this child.
�.. 2 needfor se ces
2^N p���
�y � knd ' 6 430 q3 ¢x ��.
�i T� 1 ' iY : f i iIk
4 :rwgxk,� 4s ₹ m i ru aat„,:i u .!
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 ❑ 0 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County Addendum to the CWS-7A
• BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
a � A c i i t l fi s t
{ t 'L y
tAle it 410C /P. 2'
4let"
}" i, t} ,,;_
x..�� 3aJ a is=E: t�;a i
Mgr" *PAN
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ 0 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A zs
> i"q
A•e 0-10...$16.32/da $496/month
County Basic Ave 11-14...$18.05/da $549/month
Maint.
Erz Ase 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
0.51
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 112 ' 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
5.4
$32.88
3 t 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) r
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: iaa-Mil
Weld County C to the Board
4.1 y°ii.dt WELD COUNTY BOARD OF
)' SOCIAL SERVICES, ON BEHALF
�a —� OF THE WELD COUNTY
fl6 I
✓' ,th- DEPARTMENT OF SOCIAL
et(Th, ,; SERVICES
;r
y thBy: By: '‘--1.--e k
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Rael,,harles and Carmen
431 W 1 St Ln
G e: ey, CO
B :
I/ (Si
WELD COUNTY DEPARTMENT
^
OF SOCIAL SERVICES ( (, CL/6
C
By:
(Du cc or Signal e)
8 Weld County Addendum to the CWS-7A
rand' au
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the"Agreement") between
Ramos, Julian
and the
Weld County Department of Social 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 th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#37631. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7Ay ��,
6: The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CW S-7A
6: To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
• (Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID jDOB
WORKER COMPLETING ASSESSMENT HH# I [DATE OF ASSESSMENT
I
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
❑3%)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 ❑1'/2)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
❑3%2)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 %2 hour per day 01%) '/2 hour a day
❑2) 1 hour a day O2 %) 1'h-2 hours per day ❑3)2'/2-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours 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?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week O2%) 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.
O 1%)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.
❑2A)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 Addendum to the C W S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
ices
Please rate the behavior/intensity of conditions which create the need for sery that apply to th s child.
, ! f ore O�
:a
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
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
O 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
O 0 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
O 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of condisamartions which create the need for services that apply to this child.
iR;!�y4F�y" r! a t i a a t e
a
' F s i v t u. her.
t Haas :k: 4'.I"b '.v. R E?,-kkil
.:; C _ it Y a 'at;W. , :; s__: a r �� . a_
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
3� R uY`C
d5Y 4i ' � fasx 4�y'`..a
•
Poe 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/de $586/month)
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
eltNi
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down *$66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
ads
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: utailah
Weld CounSaygcrk to the Board
f" q A
�� i?J'..✓''� WELD COUNTY BOARD OF
' .- SOCIAL SERVICES, ON BEHALF
ti;6i : v OF THE WELD COUNTY
,ion
Fi; ) DEPARTMENT OF SOCIAL
S�c: k, SERVICES
40; 1 V
By: By 7\-17, tE'Gw
Deputy erk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Ramos, Julian
2604 49th Ave
Greele CO 80634
ig
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: _
�u U
(Di ect r Signature)
8 Weld County Addendum to the CWS-7 /62
WELD COUNTY ADDENDUM
•
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Christcipher & Mary Ransome
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I5 day of u , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of th Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
1552605 These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
0
5. All reimbursement requests shall be submitted to and approved by the appropriat`�-County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement *vices
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may beTeturned
unpaid if submitted in an unapproved format or inadequate documentation is prodded.
All billings are to be submitted by the 4th of each month following the month ofservice.
If the billing is not submitted within twenty-five (25) calendar days of the month_
following service, it may result in forfeiture of payment. N
1 Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five(5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of SociServices
or Weld County Department of Social Services staff to preserve placement in7ie least
restrictive placement appropriate and to comply with the treatment plan of thy-child.
4. To schedule physical and dental examinations within 48 hours after a child ispnlaced in
provider's care. Medical examinations need to be completed within 10 days if the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
epN
fT
Pia
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX !TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HEW 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?
0Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1%)2 round trips a week
02)3-4 round trips a week, 02%)5 round trips a week 03) 6 round trips a week
❑3Y:)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
❑2)Three times a month ❑2''/)Once a week 03)Two times a week
031/2)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%) 'h hour a day
❑2) 1 hour a day 02 %) 1'/z-2 hours per day 03)21/2-3 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 ❑2%) 11 to 14 hours per week
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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
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.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2'/)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a••ly to this child.sogookioomofg:k i os 't yso v. ¢1 ( tis,za�je a ! �� a �,r
ittaitehttskliviblik
'Itraktaitte.:f!;
Et e, i R rant
4 yli' p i"i' R T.. , n !s 1
�' ,.. a,, 9R,33� g" .eP R"- : s t e ails `i i t k ! ° :. ! 'd5t .
.. ....... .. ......:..'.t... L .� ... . .' '.
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ 0 0 ❑
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
•
❑ 0 ❑ 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ 0 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apptn
ly to this child.
w atn_
• W� C adF z;:•:1, ,'-..! 1 + t E I . . .. s
� '� p ,, ,c
t {i14''� i
v Cb R• `�Y.ji'IH ylea v�'i. t. 4 ) i N-trti,,lisstirtt yJ� 'vi�2 a y.'7.:lititratkillkifrt in--, 4 a v �. ft$"It
s di:ux 2a u i ' •3 � rGa.
S
il 3R '�� 9 , a it h-e}- l 44 k J -:.t.-..2:401441,404.ai S,e _ '^ti3 tL
':. ..., r...: ....., ..a l a __..-...;•-xu ..... : ,,..c: _ i ,:« ..x r,n.,:.F..�t..:�.`5`n.:. +v�a/�.t . .7,. � ..a.. "_....'li`,,.:
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0
CI
Delinquent Behavior
El 0 CI El
'or
Depressive-like Behav
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete El ❑ CI CI
the Medically fragile NBC)
Emancipation
❑ El CI CI
Eating Problems
❑ ❑ El 0
Boundary Issues
❑ El El CI
Requires Night Care
❑ ❑ CI 0
Education
❑ 0 0 0
Involvement with Child's Family
❑ CI 0
0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
''a s s°,ti r s I } i c s ' err
T :ii • vu a c:tt is w ..y d tr
-Fr'�s ' �!�5,r. .... ' + : , :�� :a=_ z,°d:� ' . Rite 4
a 'Fa r tlia, L))0aallUt .0042 FR may
" . iri1141._ : ="'>;v1'br_°; '. 0I° - ..l ;l_.
Age 0-10...$16.32/day ($496/month)
County Basic `� Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
64,
- -- +Respite Care$.66/day ($20/month)
$19.73
1 =i3= +$.66 Respite Care
!...111,1'
!'' Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 `_ - +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
=11i $26.30
2 +$.66 Respite Care
=€il Total Rate=($26.96 day/$820 month)
y
' $29.59
;(ti'
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
5,55
5555 $32.88
,19
3 ?: +$,66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 n`;;;} 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
:i $39.45
4 x
TRCCF Drop Down -555 +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
i 4 i . •
Assessment Rate % $30.25 day/$920 month(Includes Respite)
(30 day max)
015
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: li a""a/
Weld County Clerk to the Board
/ '. ' ' WELD COUNTY BOARD OF
f (s.....r `ti SOCIAL SERVICES, ON BEHALF
f OF THE WELD COUNTY
.. IDEPARTMENT OF SOCIAL
c� '� SERVICES
By: By: A..,-/rA..--,'
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 7008
PROVIDER: n
«NAME»Chri5 iansome, Mani f24nsarnz,
«MAILING ADDRESS» 1103 2.44% Ave
«CITY_ST TTE_ZZIIP» &reelcy to 1001
By:
(Signature)(,
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: `,-
(Dir ctor Signa e)
c
r-
cr
F.
8 Weld County Addendum to the CWS-7A sear-a/,,
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Rasmussen,Dennis and Diane
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this /O day of ) L , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms f the greement remain unchanged.
GENERAL PROVISIONS
County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#104555. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
&m1- a//9
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
1 0. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F I I
WORKER COMPLETING ASSESSMENT 1HH# (DATE OF ASSESSMENT
AGENCY NAME !PROVIDER NAME I 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 Dl)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
❑3%:)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 ❑l)Once a month ❑l'/)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 01)Less than a%l hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03) 2Y:-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 ❑1%)5 to 7 hours per week
02)8 to 10 hours per week ❑2%) 11 to 14 hours per week
O 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
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%i 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) ❑l)Less than 4 hours per month
02)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that ap•ly to this child
y
.r t`h b u++
J l4 is
ns'r::n�i.�` �e�.�'a`9:4c ?.x °e,.+A.��.. +. .v4.n.}'ae°a4s°S"LY °' ••.t '� � 1
{. ...svvv.,. .. �'. "� ..........•
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ 0 ❑ ❑
Self-injurious Behavior
❑ 0 ❑ 0
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ 0
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ 0 ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ 0 ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
s T
�' ' =
•
trtd
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/de $549/month
Maint.
A•e 15-21...$19.27/da $586/month
-41
+Res•ite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) Eiri
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: MA/2/4L47
Weld C crow,the Board hki �- WELD COUNTY BOARD OF
iF a�, HUMAN SERVICES, ON BEHALF
861 � � � OF THE WELD COUNTY kg.v
DEPARTMENT OF HUMAN
SERVICES
tr
/
By: ' By: n-, ' k z —
Deputy Cl c to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Rasmussen, Dennis and Diane
345 Gypsum Lane
Johnstown, CO 80534
By: S:Izi.A.-„ C, "n-a_,--
(S7 re) '
---CiTtlin'ue-ii-av-Yu.)
WELD COUNTY DEPARTMENT P
OF HUMAN SERVICES /t4- ex,,, �` " 1
By:
(Dire tor Signatur
8 Weld County Addendum to the CWS-7A
GOOd' -02/
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Pu,posP et Care
Services and Foster Care Facility Agreement(the"Agreeme ' between
Redding, Christopher and Sonja
and the
Weld County Department of Social 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 th greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1524128. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
mod'- 02/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
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 01)One round trip a week 01%)2 round trips a week
02)3-4 round trips a week. ❑2'/:)5 round trips a week ❑3) 6 round trips a week
❑3%:)7 round trips or more
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 01)Once a month ❑1%:)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%:)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''/3 hour per day 011/2) '/2 hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2%-3 hours per day
031/2)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑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 feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/x) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
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) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
r
a}i � 3 444, Wd i a i +'{
,214.44itit4::!;igega#daPartaTa NUS
b.' s
nurawriodreptvit
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
O ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ 0 0
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
O 0 0 ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
. BEHAVIOR ASS(ExEShibitSMEB)NT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
s:Y .r"
Std
iabl
R f
ky Y H Ptglign
`\§ :47:0...r,PS " .:x14
ty "� R T i ty'' 1 A:.#_ 11�.i�. ll x 3C`. LS- 4,1 fI *. 3 R
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
0 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete O 0 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
0 0 0 0
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ 0 0
Education
❑ ❑ 0 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 El 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
r r�
� Lb{�.. �`�c�.r a. v 3'+,&x.�x�- t �� c �... �a �' , �s�4�k s, 'S➢en�:.._9a.
A•e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
Poe 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
elM
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
21/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31(2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
114 $39.45
4
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
414
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L /gaii __'""'
Weld County Clerk to the Board
M �~x;;i WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
a61(.---
Far 1-` OF THE WELD COUNTY
Fx , _ IDEPARTMENT OF SOCIAL
r � ✓ /k f , SERVICES
i!
By: / /1 BY: " '-1 (1---A-.A
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Redding, Christopher and Sonja
2305 42nd Ave
Greeley, CO 80634 �✓J
By: /� igna[ure) -
WELD COUNTY DEPARTMENT /C�
OF SOCIAL SERVICES fer /7
01(
By:
(Di ector Signa e)
8 Weld County Addendum to the CWS-7A
S-7A
at7r ...07/1
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Ripka, Gary and Jennifer
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 21 day of' U 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of tlAgreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1538429. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
ateg-C/O
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
• A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX [TRAILS CASE ID DOB
F I
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 01)One round trip a week ❑1%:)2 round trips a week
❑2)3-4 round trips a week. ❑2'/i)5 round trips a week ❑3)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 ❑1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
O 3%)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%) 1/2 hour a day
O 2) 1 hour a day 02 %1) 1'h-2 hours per day 03)2'/r3 hours per day
93%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 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 feeding,
bathing,grooming,physical,and/or occupational therapy?
O Basic Maint.)0-2 hours per week ❑l) 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
O 3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
O 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?
❑0)Not needed or provided by another source(i.e. Medicaid) 01) Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 weld County Addendum to the CWS-7A S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�'x fr r`'� i'xvy:=r7 vmr x' a EFk xs t !�'s` ";t't�' ThirgrnSfisaliggiifint7 MallialleallESSVIESPry v r + * 'tc'-ate° r x : �{ r�a !
::'v nn d4x vd :-t"i i ww key L xgh xg i ... q w*.
J t +w 5e. 4 i�3 I L .
tr 2z vvaT xx,: Sri uJal vi g it cttf •Friu at Nx tt Biwa a4gi`r'Ssw
Px#
:v- B 'R'.` x' E v - a ar r' igai °niacrx
OO7;::;CA,,EWIfilF3.-1.kij.h.heiM`HUP'AiM24.,RIq'MIP v
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ O
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
v r " ��rVW0 :�4.7vn, t t i i t er i e • :
age
aiRigila �5. yr a .s F a . ,v. o-5 c. u F f F as .y:t_'4� \y �e- ' E4
iciataltialial lin........................[st t 3 as x .. aa'ar
"a s t : ,` H`(fi-5 4 It v
s *1/40 hr ��d''(` A �c �' ' I .. rvc v a n .. �.'�-`' Flr0,i• .i ...
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
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 ❑ ❑
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
atii5.a -ti S' -ciPiN1.3"�"}.t ,�,3& da a a sac lr,
4 #. ii a 5 .N
,.al,p s t` amp 4 .'�3 . _„ w i:+
F7 ,ane=y)4 'y� �" � y$ ii �;. +
hi tt �- i —�°� as s :Fars
l2
iii c .. �ekt ihiit...:..: i,. "i fir..,. . .. .m.......
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 ghtt +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
zi
yip_,
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
1x K
$29.59
2 1/2 g4p 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
.._.. $32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down .::;r:f 4.66 Respite Care
- Total Rate=($40.11 day/$1220 month)
Assessment Rate n a}. $30.25 day/$920 month(Includes Respite)
(30 day max) pit
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A S-7A
. IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4 4d'l/7
Weld Co o the Board
41 rc
). WELD COUNTY BOARD OF
' y f ta
SOCIAL SERVICES, ON BEHALF
-)� OF THE WELD COUNTY
O r` DEPARTMENT OF SOCIAL
SERVICES
By: bb By: ")-.-1 ll'J,,,,f
Deputy Cl tot e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Ripka, Gary and Jennifer
2113 74th Ave
Greeley, CO 80634
By:
�����(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Di etor Signs n e)
8
Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Jeffrey & Tami Rogers
and the
Weld County Department of Social Services
for the period from July 1,2008 through June 30, 2009.
The following provisions, made this_Is' day of July , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1550689These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS•7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
•
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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
02)3-4 round trips a week. 92%) 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 ❑1%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3'%)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?
0 Basic Maint.)No educational requirements ❑1) Less than a 'h hour per day 011/2) '/x hour a day
02) 1 hour a day 02 %) 1''A-2 hours per day ❑3)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?
9 Basic Maint.)No special involvement needed ❑l) Less than 5 hours per week ❑1'/) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
9 3)Constant basis during awake hours ❑3%i 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?
9 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/) 5 to 7 hours per week
❑2)8 to 10 hours per week 92%) 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.)
91)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.
92)Face-to-face contact two times per month with child and occasional crisis intervention.
92%)Face-to-face contact three times per month with child and occasional crisis intervention.
93)Face-to-face contact weekly with child and occasional crisis intervention.
93%)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) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for sen.ices that apply to this child.
a,„_ ?}_- } r(t- t v �kii��F�7: "'i.'"+rJ'r₹'PL'`+nr
Rating of Conditions�E6..n . s 00„11 t.Fy15 *,r�
(Check one box for each category) •
Assessment Areas None Had Moderate Severe Comn ei4s:
d 1 2 3
Aggression/Cruelty to Animals
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
..... ... ....
..SS Y.:'j ELLY: ,3,� •:JU: '� N • Ate4ult , }sating of Conditions
t 7t ;;. . (Check one box for each category)
Assessment Areas Nerve Moderate Severe Comments;
4 1 2 3
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) n 0 n 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
• • WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
NEP swc .. . s 4 3tL t jq #w, a.. .."OratTgatit,ifaiiiiii3A"PkUtEiaMt. liTh:"!IiigllitiONETL±...
MORTYMI-ZgatgeHaitINE . 2i I a, x.sa, 4x a`Nx.
ks�l.
a ll ,; .!n
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1(2 ''' 4.66 Respite Care
2 : Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
21/2 '� 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down "' +$.66 Respite Care
gti'
Total Rate=($40.11 day/$1220 month)
fv 1 fE�l ''�•1�,'.`^ty�iln.n i�, �"'���i �"+I� - �"r"f`i1,1 �`�k1VI� �' :•�� � 'Assessment Rate l $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
' • . . IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4^+ !/i'(/a-4f
Weld Count erk to the Board
WELD COUNTY BOARD OF
I fir
. � . SOCIAL SERVICES, ON BEHALF
1 itt � OF THE WELD COUNTY
e DEPARTMENT OF SOCIAL
' '•"c'
� SERVICES
By: / By: 71., f .-G„-i
Deputy CI tote Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
«NAME»
«MAILING_ADDRESS»
«CITY_STATE ZIP»
By: %z5K C.
(S�7ie
)
WELD COUNTY DEPARTMENT -Tva. \7-_t:36`z�
OF SOCIAL SERVICES
S .).-.)-\ &k,-iz✓Lg:x ?ks..k,
I�1Vt1 �raZ., Ci: Ye5—Oy
By:
( trector S nature)
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
ALAN & DIANE SEARS ZT,
and the <'0 A'l'l 10: qq
Weld County Department of Social Services
for the period from July 1,2008 through June 30, 2009.
The following provisions, made this I ) day of ( I1-( , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1551278. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F I I
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 01)One round trip a week ❑1%s)2 round trips a week
❑2)3-4 round trips a week. ❑2%) 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 ❑1%:)Two times month
❑2)Three times a month ❑2%)Once a week 03)Two times a week
❑3%)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) '/z hour a day
02) 1 hour a day ❑2 /) 1'/:-2 hours per day ❑3)2'/-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑I) Less than 5 hours per week ❑1'%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2/) I 1 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'%)5 to 7 hours per week
O 2) S 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.
O 11/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2/)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit 8)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a.,ly to this child.
x� a,ts.p i2i3c xgn,� a
2 EYnny. Y ^'k .i� - �. ? f £ ! . q t I t�.�y �'
t 4vi�i •�tM s4 g na
. ...%Rilli £: 2 �}R m2 f i P l it • 4 i !. { u
2 2 elx'§nF41 .4 .v' ,141 ayrri 4'
ilg
t'_u �a :.x wr..�
i 2Ir 3.,,, v 7 r,Y 2 e 21 f y!2 v aR �µl setr - y
t l ''t i . . >zt exit 't ° `',t^'r" 1 �yyp . i n. ` .'C}it4,)gqiiiS .....v ai. a..l „to__ ii:I i44i
Aggression/Cruelty to Animals
❑ 0 0 ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
❑ 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a ly to this child.
ydM,v �,r t:5v '4144 ed*Oil ` '`�. r 5 4 !'t i "r n
s t a ie �, 1v,s x '",44,4;14,• NelfillPtkligf•t
1/4 t.. �.t e'a'' t '"`eSs c"IS H l es w t ''��u s tG'`t�t 6ra tk
dag , ;r �idlifr AID !) tom F S ! i �.i9 �' a '5. 1rhv
' E i F'I"" "if 'A' r ezti
to cox �c S3n 4t ..�. . Tzjals ! ! c' 81l74111r#1.
.�r w"t °r' .p,�•I I ._ , ""c n!y v p�'>t tl p� 2 v! !
lo~ I £ it 1 Il h 'i! 4 r". Y 'v dgl�� d '! 4 .(jl
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
O ❑ 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
O 0 El 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
O 0 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 0 0
Education
❑ 0 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
T, 7. M F c rj' `1(iusm-.,: .w 9
ibianiattilinsilh t
Nginava
> > fa ` ��i k4Y '�°�'�3`"` Mn
Age 0-10...$16.32/day ($496/month)
County Basic - Age 11-14...$18.05/day ($549/month)
Maint.
`,, Age 15-21...$19.27/day ($586/month)
s-'
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
NEt
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
• -- Total Rate=($26.96 day/$820 month)
$29.59
2 112 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
PHIIF $32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 ";' +$.66 Respite Care
I[; Total Rate=($36.82 day/$1,120 month)
rs1
4 $39.45
TRCCF Drop Down _ +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
r .
° tl . ... ..htiq
..:.....:'.
Hy
Assessment Rate IV $30.25 day/$920 month(Includes Respite)
(30 day max) a,.
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
- ' ' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: iG �u
Weld Count ,C1erlc19 the Board
�~
' ,:%-t--, y: WELD COUNTY BOARD OF
nh (;;.,T.:/-"\--- SOCIAL SERVICES, ON BEHALF
iFt, d. ...: °;" ‘) OF THE WELD COUNTY
+'`�' � , DEPARTMENT OF SOCIAL
�,, _�, SERVICES
�Il �)�\\
By: 47 It , ►� I By: 'It l(---l.,--1
Deputy C1-rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Alan or Diane Sears
61 Westward Way
Eaton, C rado 80615
By: (,UKL,iA__,
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Di ector Signa e)
8 Weld County Addendum to the CWS-7A
a-67/2
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Sevestre, Lewis and Maureen
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this a.t day ofdi n , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C,regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1551169. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
C-9eni ale,
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations wit ??��••4 h urs after a child is placed in
provider's care. Medical examinations need to be within 10 days of the child
being placed with Provider and dental examinations need to be ttiledia within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
B
CHILD'S NAME STATE ID# ISEX F !TRAILS CASE ID bD0[MOW0RKER COMPLETING ASSESSMENT [MO DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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
❑2) 3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week
❑3%)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
02)Three times a month 02%)Once a week 03)Two times a week
❑3%)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 01%) '/z hour a day
❑2) 1 hour a day 02 %) 1'h-2 hours per day ❑3)2'/z-3 hours per day
❑31z)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 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 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
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
031/2)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
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 ❑3)9-12 hours per month
4 weld County Addendum to the CWS-7A
WELD COUNTY DSS
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
, Y +' :� �f. r, 4t anP .
-L '� '' s i ass Yt
• Jan:y.ri ..;:4:it <..3. 4 1 r.k.. fix..: 2&;:
Aggression/Cruelty to Animals
❑ 0 0 ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
❑ 0 0 0
Self-injurious Behavior
O 0 ❑ 0
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions 0 0 0 ❑
Enuresis/Encopresis
❑ 0 ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
O 0 0 ❑
5 Weld County Addendum to the CWS-'
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child.
•n i wa wx * :� r ,r '* 'act, 9. §g ,a r wag.'k z ey�r
•
.aa+a":ti¢,.t.•.h,:i a Th °"di&��*:c4 z`'t" . ,.a *....._ =4� : "^ xc _'
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑ 0
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
Pit
+Res•ite Care$.66/da $20/month
$19.73
Nit
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2ttt.11: 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
tra $26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 nr,,s +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.62 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$66 Respite Care
Total Rate=($40.11 day/$1220 month)
itA
Assessment Rate too. $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Liej���� `^"4
Weld Clerk to the Board
17(f 71 r�� WELD COUNTY BOARD OF
:`C Y' HUMAN SERVICES, ON BEHALF
t ' (` Astt, OF THE WELD COUNTY
\I ' '' 4, }' ' DEPARTMENT OF HUMAN
CF � SERVICES
l
BY: [�iti ./(J` le-teiki.YBy: ���1, -/
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Sevestre, Lewis and Maureen
1717 69th Ave
Greeley, CO 80634
l
BY: -/l (a,(af6,Y1 ,fill( a1c
(Signature)
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By: a
(Dire for Signatw
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Shindle, Danny and Andrea
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / day of / , 2008, are added to the referenced
re
Agreement. Except as modified hereby, all term f U Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1550177. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
I Weld County Addendum to the CWS-7A
& -02/69
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
•
• NEEDS BASED CARE ASSESSMENT
` (Exhibit B)
DENTIFYING INFORMATION
.HILD'S NAME STATE 11N1 SEX F 'TRAILS CASE ID bDOB
WORKER COMPLETING ASSESSMENT riffriff �.t 'DATE OF ASSESSMENT
LGENCY 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 Ibis 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 01)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
3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a%x hour per day 01%) '/2 hour a day
O2) 1 hour a day O2 %) 1'/r2 hours per day O3)2%r3 hours per day
❑3'%)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 O2%) II to 14 hours per week
❑3)Constant basis during awake hours O3%)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?
❑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 03) lb to 20 per week
O3%)21 or more hours per week
1 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.
' 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) 01)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that ap.ly to this child.
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting 0 ❑ 0 0
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ 0 0
Sexual Offenses
❑ 0 ❑ 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
... <. . v. ...,. a. .. . e.._ .... ..R a x.0 ...,..rk{$5..a.....S. .j.a . .. .. .. .. .., ..�.. .v. ._
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ 0 ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ 0 0 0
Involvement with Child's Family
❑ 0 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Age 0-10...$16.32/day ($496/month)
«i«
County Basic *#-,; Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
y s
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 ' '- 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$,66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate= y month)
($33.54day/$1020
$36.16
3 1/2 +$,66 Respite Care
) ; Total Rate=($36.82 day/$1,120 month)
$39.45
4 +$.66 Respite Care
TRCCF Drop Down . Total Rate=($40.11 day/$1220 month)
Assess Rate $26.96 day/$820 month(Includes Respite)
(30 day max)
Emergency s
Placement Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
ems,;
Effective 07/01/2008
7 Weld County Addendum to the CWS-7A
•
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ^ 12a"
Weld C to the Board
WELD COUNTY BOARD OF
% g SOCIAL SERVICES, ON BEHALF
II
#, I_, - OF THE WELD COUNTY
a ri<� DEPARTMENT OF SOCIAL
SERVICES
•
By: / , By:
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
«NAME»
«MAILING_ADDRESS»
«CITY STATE ZIP»
By/
re)
WELD COUNTY DEPARTMENT -
OF SOCIAL SERVICES //
By:
( ector Sign re) ✓t.wl
/(4 04 �QCY47-te-5 Re(
aa2J-air
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Skeldum, William
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o t Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#16666. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A ow". &//
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the Willis and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
DENTIFYING INFORMATION
:HILD'S NAME STATE ID# 4SE I IDOB
F TRAILS CASE ID DOB
NORKER COMPLETING ASSESSMENT HH# �yt DATE OF ASSESSMENT
\GENCV NAME PROVIDER NAME PROVIDER TRAILS ID
kNSWERS 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.
PHE 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
❑2)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?
0 Basic Maint.)No participation required 01)Once a month 01%)Two times month
❑2)Three times a month 02%)Once a week 03)Two times a week
❑3%)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 Y hour per day 01%) Y hour a day
02) 1 hour a day ❑2 %) 1%-2 hours per thy 03)2'A-3 hours per day
❑3Y:)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑1) Less than 5 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with 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
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) ❑1)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County Addendum to the CW S-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
+�y�Please rate the behavior/intensity of conditions whiic'h.c�r'ea�.te the needfor services that apply to this child.
r�"'y'e -hK.F{! zdeM3"w 'L�n"` x .. en it �c ?T'tions which, �? t. {°�I � 3� 4 i;
"x- ., Q'iz.d 'tin alt6P f t 3.,.. ..
G.�' i t i ;III
t i.4'4
. i `fir .W 4 }
,
757.4.
Ii rlt y 2 { SZ ➢.;_i: tL '. id: a Y' y1 ! { 'u.g. r
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ El El 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ o 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions O O El O
Enuresis/Encopresis
❑ 0 ❑ 0
Runaway
❑ 0 0 0
Sexual Offenses
❑ 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
iltirrebice:Marini .1T-Witt 11/4%, Mitartmajligeacirlatvingai
at,..4,41S12414Wrilge WW1
�3.1 ra���>Plf6fre4wirilia
td:h, :- ). "(u§ kf1; jc
4?,
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ 0 ❑
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
iat
�.vW.ui ..tS s o.'alsll4iae 1�"`' TzcF"Tr.-tiaJ�$��..Si� - hem
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
•
$19.73
4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 s +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
451
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7.
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: i"a"" 7 /�'I/� '1(
Weld C to the Board
WELD COUNTY BOARD OF
4,_ SOCIAL SERVICES, ON BEHALF
I'61 !a OF THE WELD COUNTY
OMEir 'f DEPARTMENT OF SOCIAL
SERVICES
By: By: 71---i r.(-1✓
Deputy Cl to t e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Skeldum, William
5113 Saguaro Ct
Johnstown, CO 80534
By:tV\ - L--
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(Dir ctor Signal )
8 Weld County Addendum to the CWS-7A
aaw-ai69
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Slaughenhaupt, Gary and Grace
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this a, day of Jvp. e, , 2008, are added to the refelenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 4
GENERAL PROVISIONS ,y/O
1. County and Provider agree that a child specific Needs Based Care Assessment, v6
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1544611. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
] Weld County Addendum to the CWS-7A
n/�
c2ZO --c
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID IDOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 ❑i)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?
0 Basic Maint.)No participation required ❑1)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 ❑1)Less than a %z hour per day 01%) '/2 hour a day
❑2) 1 hour a day O2 %) 1'/-2 hours per day O3)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?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%) 5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours 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?
0 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 O2%) 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.
❑3)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 Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which createth*e need for services that apply to this child.
'a 444.Variglitta,„!ntagatittU tit;:1'k �` vq .f "' k `4. ' S4,w�- t
d S. 4 0S' cti". �1ilikT p; ,:tt.' 'yS.,� 'h, ^Lk 3 i.._c,..."" R� 4
+� a"�'a ".'�'b"*'Fk ,+ ft t'�s ahn, xxapA , 8 a �,t
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ 0 0 ❑
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
•
• Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
��'� .er y k '�.. k s,.r.+.. �,k"*x�.�°v "�� spa�.xxv�.� *`���4 vs:e+s.
,,, 'v s r t s u'' 'ii °°°� s' t -+..I ''�. ti *av v
1 `�,. `":"'e .i4)4`a ki a`:Ilitie A r +'s +` Orr k F '' k, ``t,?'�C;. rl! Vi
" �.s'+ �. �''rf ., ti-° , ;�, ....................................................
S`a•: e e 3 ^k' • . v a r oaf � ` 5"ak .ti 1+r v c x- ,
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
❑ 0 ❑ 0
Delinquent Behavior
O 0 ❑ 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
O ❑ ❑ ❑
Involvement with Child's Family
❑ 0 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
• a�` �� '1� b 3' Y� � b7� 4(J � V� t43:v�
A.e 0-10...$16.32/da $496/month
urN
County Basic A.e 11-14...$18.05/da $549/month
Maint.
/toe 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
.44
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
.474
$36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
+$.66 Respite Care
TRCCF Drop Down
Total Rate=($40.11 day/$1220 month)
dp
Assessment Rateit CZ $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
• IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
•month, and year first above written.
ATTEST: ,at ms ji
Weld-County Clerk to the Board
WELD COUNTY BOARD OF
n <a SOCIAL SERVICES, ON BEHALF
c j OF THE WELD COUNTY
Tka ''r DEPARTMENT OF SOCIAL
= .N 9� SERVICES
0
By: By: /1"
Deputy Cle to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Slaughenhaupt, Gary and Grace
30633 CR 78
Eaton, CO 80615
By: e 9,I
(Sign re)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dire or Signatur
8 Weld County Addendum to the CWS-7A
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Slipka, Darrel and Ruby
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this 5 day of r✓l o-. , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of t e Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1525217. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to thaw of
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Depaitutent and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID ID
M F I I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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 ❑l)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 ❑l)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?
0 Basic Maint.)No educational requirements El)Less than a %z hour per day ❑1%) '/ hour a day
02) 1 hour a day 02 %) 11/2-2 hours per day 03)2%z-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%z)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
02) 8 to 10 hours per week ❑2%z) 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.
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) ❑l)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensgiitty of Condit ons which create the need for services that a 1 to this child.
iq tl axe ' ; `- s` { }r :f• a' 7F i ' 'i,,t>irrl!Ih i ;44 a y ` a...: "y "` 1. .10 t�l,.,.', }`�,'3S�• ° 5 -x- . o-x ''+t`r"* ti a
}T v i $".4 .ai a g,�' g 4Rizi i} §? }: 4a� S „0,.-;} ;ii
Aggression/Cruelty to Animals
❑ ❑ I: El
Verbal or Physical Threatening
❑ 0 0 ❑
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
El ❑ ❑ ❑
Self-injurious Behavior
❑ o 0 ❑
Substance Abuse
❑ O 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
El ❑ ❑ ❑
Runaway
❑ ❑ El ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
`'4 A.a 4 F_@ 5 4xt !(^ e' ; Y i ,�k' °6. 'r Y''i. 3�c % k' 3 x . ,.s,"4
`. '? 9R§x.. s tirAY 5 �, ''§ - $,saaa§'°e'da -x.§. Y% 4 rt LEEvrk 'v4 �
t S r a r` �..:$ § �. r'°"an'�i T +ft°'.,5 a,r ...rig'Ev. .w .�'+h Y...>a kg' .'tC£aSt% �P3i �y'+.�.t ri' '. ]eJ z:. �bk°..e nid' .e :a .m. P .x.a.a,mvna..xM{t
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ O
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
• NEEDS BASED CARE
RATE TABLE
(Exhibit C)
,+ h
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Res•ite Care$.66/da $20/month
$19.73
1 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)
efik
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
•. .. $39.45
4
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
--'�~ Assessment Rate
(30 day max) $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: gjeW jf
Weld Count rk to the Board
\F t^ :j WELD COUNTY BOARD OF
1/ �F`;.� SOCIAL SERVICES, ON BEHALF
'ss; OF THE WELD COUNTY
} 'Ct f� ��� DEPARTMENT OF SOCIAL
t"? 4, SERVICES
By: By: l j illitiJ
Deputy Cl to e Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Slipka, Darrel and Ruby
515 Shirley Ct
Platteville, CO 80651
By: ( /Z---
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
(D ector Signa e)
8 Weld County Addendum to the CWe
—air
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(the "Agreement") between
Steitz, Daniel and Natalie
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this 1ct day of 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1546930. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7
ate - a/6f
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# I PATE 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 ❑l)One round trip a week ❑l%)2 round trips a week
92)3-4 round trips a week. 92%) 5 round trips a week 03)6 round trips a week
93%)7 round trips or more
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 ❑1)Once a month Ell 1/2)Two times month
02)Three times a month 02%)Once a week 93)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?
0 Basic Maint.)No educational requirements 01)Less than a''/ hour per day 01%) '/z hour a day
❑2) 1 hour a day 02 %) 1%-2 hours per day 03)2%-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed 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 age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑l)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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to thi •
•
s child.
ihitts If 3i E t N_i
E YH 1 t !
*Wet �; 3 m x fit. ea .. .41
x•1 _... _.z.;;X * �` "�. .. „,.„4.„„„ i y �. '(�,'�,'" �. _.: t :i1> .I::s _:s 'k a+.
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
❑ ❑ O ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
of conditions which create the need for services that apply to this child.
Please rate the behavior/intensity
' - s.t=3,14.%:,r e a t
c
at - t t r
• jy ,s s
2..• t FF2:1 tr-u.:?_i it .,- u ..' �il_r ash- a 'l
„V 5 }} v
y,
lagratietmecta
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
� tyt ,s `' •
y is
�444444Y
A•e 0-10...$16.32/da $496/month
County Basic �x
A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 k 4.66 Respite Care
Total Rate= ($20.39 day/$620 month)tAt $23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 � 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 r. +$.66 Respite Care
Total Rate=($33.54day/$1020 month)k. $36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
•
$39.45
4 "74,i +$.66 Respite Care
TRCCF Drop Down Total Rate=($40.11 day/$1220 month)
Assessment Rate n. $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-
$ , ,
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Lat4
Weld County Clerk to the Board
_/G WELD COUNTY BOARD OF
*•'3v SOCIAL SERVICES, ON BEHALF
io OF THE WELD COUNTY
8
DEPARTMENT OF SOCIAL
SERVICES
By: / By:
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Steitz, Daniel and Natalie
1701 Elder Ave
Greeley, 0631
By: LYcQ
(Signature)
. )
e.
WELD COUNTY DEPARTMENT (' o±oc i
OF SOCIAL SERVICES
By:
(Di t ctor Sig re)
8 Weld County Addendum to the C WS-7A 7 e
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Sugden, Stanley and Lena
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this I day of , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o the greement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1537224. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
•
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID IDOB
M F I
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 01)Less than a''/z hour per day ❑1%) 1/4 hour a day
02) 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 ❑1)Less than 5 hours per week ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%z) 11 to 14 hours per week
0 3) Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑l)3 to 4 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2'%z) 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?
00)Not needed or provided by another source(i.e.Medicaid) ❑l)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting ❑ 0 0 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ 0 ❑ ❑
Runaway
❑ ❑ 0 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
e 8 behavior/intensity
:!fir +?°` p+,/'Sa '°'y+'4 , 'x m * '.rvn ry br qw,
X a• q:�` s. a`'^sm"�'¢}4y`ti x Asa - t E a `e;. �, ,�.`a174. *, 3
d'ia ' i°°
1k5'#3 w£'''''C '" e rr # p. '„
:. 4 v y ria;kattikLen r'd (.l: ,e ,� ` � s:;" ' litilft S S ? -4 s
a8�*. ' wa:� "' b:. .v.°a'im.n„s,.t.....::.,..�.ia.�.s..,�.s.,.__�....s. ., . .. ... x� :
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ 0 0 0
Involvement with Child's Family
❑ 0 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
tiai' a"Y
a _ v . ya at -,. h
P L- yn' rud}' a h y
,^ i • £ '`1 ! yNe" S
'.a�.*'h�s
_ .:itti,i.,,,,,I,;(.:::::,,,:rdl.,i,,,ri,. ..
1,2 A.e 0-10...$16.32/da $496/month
County Basic A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 FM
+$.66 Respite Care
Total Rate=($23.67 day/$720 month)
Pi
$26.30
2 Len +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
di
KM $36.16
3 1/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
lail
4 $39.45
TRCCF Drop Down +$_66 Respite Care
Total Rate=($40.11 day/$1220 month)
tie
Assessment Rate 14 $30.25 day/$920 month(Includes Respite)
(30 day max)
Keri
Effective 7/1/2008
7 Weld County Addendum to the CWS ',
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: �a
W :__lerk to the Board
"5 WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
" C i` OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
�� SERVICES
iw
I
By: By: 1.-z-7 PL,�
Deputy Clef c to the Board Chair Signature
William H. Jerke
AUG 1 1 2009
PROVIDER:
Sugden, Stanley and Lena
1251 51st Ave
Greeley, CO 80634
By:
(Signature) 0
WELD COUNTY DEPARTMENT j, _ � 7 ,
OF SOCIAL SERVICES i .9�_
By: a
(Di ctor Signat )
8 Weld County Addendum to the CWS-7A
&oa-G/6
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Trevino-Rivera, Irene
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this a day of Me, L, , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1506181. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7A
amp'- a/
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
DENTIFYING INFORMATION
:HILD'S NAME STATE ID# SEX !TRAILS CASE ID IDOB
M F I
YORKER COMPLETING ASSESSMENT HH# 1DATE OF ASSESSMENT
CENCY 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 01)One round trip a week 01%)2 round trips a week
O2)3-4 round trips a week. ❑2'/z) 5 round trips a week O3) 6 round trips a week
O3%)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
O2)Three times a month ❑2%)Once a week O3)Two times a week
O3%)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?
0 Basic Maint.)No educational requirements ❑1)Less than a '/z hour per day 01%) %z hour a day
❑2) 1 hour a day O2 '/z) 1'/z-2 hours per day O3)2'/z-3 hours per day
O3%)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?
0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1'/z)5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%z)Nighttime hours
'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
O2) 8 to 10 hours per week ❑2%z) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)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.
❑1%)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.
❑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.
C 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) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�,�'�,? • 1 ! i i i E o f k
�{��� � � 3 t I i t I S f
Nt`:l
R IB'= b . tl'1 " `.'§eY I, "..l
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ 0
❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ ❑ ❑ 0
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
O 0 0 ❑
Runaway
❑ 0 0 ❑
Sexual Offenses
O 0 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap.ly to this child
`5
Ti
. v,.. ' vdt� .,� :71 a t , s .sx.rw" yes �i F -tx•; *'
•
"ov Vicar . ¢ a :.x''.. r: v� 7 �;y,r
titi • a, .
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ 0 ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 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 Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
^" H G } tvyv
A•e 0-10...$16.32/da $496/month
County Basic A•e 11-14...$18.05/da $549/month
Maint.
A•e 15-21...$19.27/da $586/month
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 tr9 4.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
w,.
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
a._
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
.
$39.45
4 +$.66 Respite Care
TRCCF Drop Down Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-'
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: atakiai-Ali
Weld GihMit}E1Pri, k to the Board
./ :tilt. , A
�If NI > + WELD COUNTY BOARD OF
(I hs�r t1) SOCIAL SERVICES, ON BEHALF
kl,0,"k
OF THE WELD COUNTY
A DEPARTMENT OF SOCIAL
p,iq. SERVICES
By: _ By: "Iz-j C/..,..."
Deputy Cl rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Trevino-Rivera, Irene
4227 W 31st ST
Greeley, CO 80634
By: L
ignature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
•
AI
By: lit�tJ
(Dir ctor Signatu e
8 Weld County Addendum to the CWS-7A
• WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Van Den Elzen, Dawn
and the
Weld County Department of Social Services
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this / J;day of .,V{ , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#44282. These services will be for children who have been deemed eligible for social
services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to,but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five (25) calendar days of the month
following service, it may result in forfeiture of payment.
1 Weld County Addendum to the CWS-7
ass- a/6
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation"includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID jDOB
M F I I
WORKER COMPLETING ASSESSMENT HH# 1DATE 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'/z)2 round trips a week
❑2)3-4 round trips a week. ❑2%z)5 round trips a week 03)6 round trips a week
❑3%z) 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 ❑1%z)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 On Less than a%x hour per day 011/2) 1/2 hour a day
02) 1 hour a day 02 %) 1'/z-2 hours per day 03)2%z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 011/2)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 feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
0Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
O 1)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
02)4-8 hours per month ❑3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
ERA,z
tv. ! i ! k 6 q F i
£X ,c
�' '�-,�' R[:_ �,„�E a� i)i(� f k 1 i i
& b\ mod x v Vacs.�xam:s a _4�4 ,t"Y+�ae" , @'.fi `^ +,
.:11 � a ,� a ..
t 4tl d. ^Y"i � �' s. '� �S17:4' � e s;) Itilleggaatinf-atiniWk4
' m Ati2j'd r rr₹r,-
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
O O ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ 0
Stealing
O O ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions El 0 ❑ ❑
Enuresis/Encopresis
❑ O 0 ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County Addendum to the CWS-7A
• BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
yt. irfit air ,
�c '' aro t a' a a a i
'y`t Yom:'... ; I:a i '•. . _r. a
V
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
Or condition is rated"severe",please complete ❑ 0 El ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
A•e 0-10...$16.32/da $496/month
County Basic
A•e 11-14...$18.05/da $549/month
Maint.
Ase 15-21...$19.27/da $586/month
ka
+Respite Care$.66/da $20/month
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 4.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 f +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 (` 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 4.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
3 1/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max) t
Effective 7/1/2008
7 Weld County Addendum to the CWS-
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
/444
Li Il /
ATTEST: ,Y'
Weld County Cler the Board
/° WELD COUNTY BOARD OF
g5 r • SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
f1c DEPARTMENT OF SOCIAL
SERVICES
By: By:
Deputy rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Van Den Elzen, Dawn
7219 W 20th St Ln
Greeley, CO 80634
By: ,,fit.,, 1:0.),624;)
(Signature)
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: lJ�
(Direct r Signatur
8 Weld County Addendum to the CWS-7A
aoaP-a/e 5
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Walker, Kurt and Jennifer `V
and the .,
Weld County Department of Social Services �/A
for the period from July 1, 2008 through June 30, 2009.
The following provisions, made this ? ' day of c)unc. , 2008, are added to the referenced /4
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1546248. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator, prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4th of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
/‘?
1 Weld County Addendum to the CWS-7A
6. The Director of Social Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
•
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Social Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Social Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Social Services and the Provider, or by Social
Services as a debt to Social Services or otherwise as provided by law.
7. Provider shall promptly notify Social Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five (5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Social Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Social Services
or Weld County Department of Social Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY 1)55
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX F [TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# �ryt I ATE OF ASSESSMENT
I
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'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
❑3'/)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 ❑1%)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 %z hour per day ❑1%) %]hour a day
❑2) 1 hour a day 02 %) 1'/r2 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 ❑1)Less than 5 hours per week ❑1/)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑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?
O 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 ❑2'/z) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%:)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%i 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
03)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ 0 ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ 0 ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 ❑ 0
5 Weld County Addendum to the CWS-7A
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
❑ ❑ O O
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ O ❑ O
Medical Needs
(If condition is rated"severe",please complete O O O O
the Medically fragile NBC)
Emancipation
❑ O ❑ O
Eating Problems
❑ O O O
Boundary Issues
❑ ❑ ❑ O
Requires Night Care
❑ ❑ ❑ O
Education
❑ ❑ O O
Involvement with Child's Family
❑ ❑ O O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) 0 0 ❑ 1 0 2 ❑ 3
6 Weld County Addendum to the CWS-7A S-7A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
• RATE TABLE
(Exhibit C)
Age 0-10...$16.32/day ($496/month)
County Basic Age 11-14...$18.05/day ($549/month)
Maint.
Age 15-21...$19.27/day ($586/month)
+Respite Care$.66/day ($20/month)
$19.73
1 +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 4.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 +$.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down ' 4.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate
(30 day max) $30.25 day/$920 month(Includes Respite)
Effective 7/1/2008
7 Weld County Addendum to the CWS
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: la" eWa [
Weld CounC9TC-Ier the Board
„g`\J WELD COUNTY BOARD OF
c � `` a SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
k! `� SERVICES
By: By: ''.I
Deputy Cl to a Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Walker, Kurt and Jennifer
1901 15th St
Greeley, CO 80631
By: aa.- "
(Si tam)
WELD COUNTY DEPARTMENT vD jO i
OF SOCIAL SERVICES
By:
(Dlr ctor Signatu ) &er8 Weld County Addendum to theCW5�0?/4
WELD COUNTY ADDENDUM
To that certain Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement (the "Agreement") between
Willert,Melody D and Lee, Kimberly
and the
Weld County Department of Human Services
for the period from July 1, 2008 through June 30,2009.
The following provisions, made this 'Y--) day of tA. nR- , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms f the Agreement remain unchanged.
GENERAL PROVISIONS
1. County and Provider agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Provider unless the child is placed in a County certified kinship foster care
home or if the child is placed in a County foster/adoption home as a pre-adoptive
placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at
the County Basic Maintenance level on the Needs Based Care Rate Table, designated as
Attachment C, regardless of the child's level of need.
2. County agrees to purchase and Provider agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1540372. These services will be for children who have been deemed eligible for
social services under the statutes, rules and regulations of the State of Colorado.
3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's
temporary absence from a facility, including hospitalization. Bed hold requests must
have prior written authorization from the Department Administrator before payment will
be release to Provider.
4. Any additional costs for specialized services, which may include but are not limited to;
Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in
writing by the Department Administrator,prior to the service being performed. Any
payment for specialized services not authorized in writing may be denied.
5. All reimbursement requests shall be submitted to and approved by the appropriate County
staff as set forth in the Foster Parent Handbook. Reimbursement for placement services
shall be paid from the date of placement up to, but not including the day of discharge. All
billings by the Provider must be in a format approved by the County and may be returned
unpaid if submitted in an unapproved format or inadequate documentation is provided.
All billings are to be submitted by the 4`h of each month following the month of service.
If the billing is not submitted within twenty-five(25) calendar days of the month
following service, it may result in forfeiture of payment.
Weld County Addendum to the CWS-7A
& 'f- 0.2/6 2
6. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Provider substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Provider as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Provider until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the Provider
cannot be performed or if performed would be of no value to the Human Services.
Denial of the amount of payment shall be reasonably related to the amount of
work or deliverables lost to Human Services;
C. Recover from the Provider any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Provider, or by Human
Services as a debt to Human Services or otherwise as provided by law.
7. Provider shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
The Provider, within five(5) calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s) to the Human Services'
Director. The term"litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
PROVIDER AGREES:
1. To attend or participate, if requested by the Department, in staffing a child's placement
with the Utilization Review Team. This review team convenes every Monday morning,
excluding holidays but may hold emergency staffings as needed.
2. To request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
provider's Foster Home Coordinator.
3. To cooperate with any contractors hired by Weld County Department of Human Services
or Weld County Department of Human Services staff to preserve placement in the least
restrictive placement appropriate and to comply with the treatment plan of the child.
4. To schedule physical and dental examinations within 48 hours after a child is placed in
provider's care. Medical examinations need to be completed within 10 days of the child
being placed with Provider and dental examinations need to be completed within 14 days
of the child being placed with Provider. All documentation of these examinations will be
placed in the Foster Child's Placement Information Management Binder or as indicated
in the Foster Parent Handbook.
5. To attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
2 Weld County Addendum to the CWS-7A
6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook.
7. To report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S.
8. To maintain/access information on the Foster Parents Internet Database On-line System
(FIDOS) as indicated in the Foster Parent Handbook.
9. To maintain/update information in the Foster Child Placement Information Management
binder. The binder may be reviewed on a monthly basis and signed off by child's
caseworker and/or the provider's Foster Home Coordinator.
10. To maintain behavior observation notes as required by the level of care assessed for each
child as indicted in the Foster Parent Handbook.
EXHIBITS: (Please refer to pages 4-7)
3 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F [TRAMS CASE ID IDOB
WORKER COMPLETING ASSESSMENT [IIH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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'/) 2 round trips a week
O2)3-4 round trips a week. O2%) 5 round trips a week O3)6 round trips a week
❑3%)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
O2)Three times a month O2%)Once a week O3)Two times a week
❑3%)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'h hour per day 01%) '/ hour a day
❑2) 1 hour a day O2 %) 1'h-2 hours per day O3)2%r3 hours per day
❑3'%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%) 5 to 7 hours per week
O2) 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 feeding,
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 O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'h)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'/)Face-to-face contact one timeper 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) ❑l)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County Addendum to the CWS-7A
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a.ply to this child.
`. _, �• _.. ...... .. .... ..: ...
Aggression:Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
O 0 0 0
Destructive of Property/Fire
Setting 0 ❑ 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ 0 0
5 Weld County Addendum to the CWS-7A
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..l to this child.
� � 9
.. _ .}.....: . . '.."'. .. .. ....a. .. ..': ..... .> Vi'µ
r'.......
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O 0 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County Addendum to the CWS-7A
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
RCS �iY�g�
R F
P
Ase 0-10...$16.32/da $496/month
County Basic j. A.e 11-14...$18.05/da $549/month
Maint.
A.e 15-21...$19.27/da $586/month
+Res.ite Care$.66/da $20/month
$19.73
1 • +$.66 Respite Care
Total Rate= ($20.39 day/$620 month)
$23.01
1 1/2 +$.66 Respite Care
Total Rate=($23.67 day/$720 month)
$26.30
2 +$.66 Respite Care
Total Rate=($26.96 day/$820 month)
$29.59
2 1/2 rs +$.66 Respite Care
Total Rate=($30.25 day/$920 month)
$32.88
3 +$.66 Respite Care
Total Rate=($33.54day/$1020 month)
$36.16
31/2 4.66 Respite Care
Total Rate=($36.82 day/$1,120 month)
4 $39.45
TRCCF Drop Down +$.66 Respite Care
Total Rate=($40.11 day/$1220 month)
Assessment Rate $30.25 day/$920 month(Includes Respite)
(30 day max)
Effective 7/1/2008
7 Weld County Addendum to the CWS-7A
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld Count 4 qty ., oard
Af?)- WELD COUNTY BOARD OF
`'' HUMAN SERVICES, ON BEHALF
*" OF THE WELD COUNTY
(r , 3 r DEPARTMENT OF HUMAN
-C/ h ` `c • SERVICES
By 1 By: �l✓�
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
PROVIDER:
Willert, Melody D and Lee,
Kimberly
219 N 4th St
LaSalle, CO 80645
By:
(Si lure
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
(Dtr ctor Signal
8 Weld County Addendum to the CWS-7A
S-7A
&iVJ'—ai'
Hello