HomeMy WebLinkAbout20082167.tiff DEPARTMENT OF HUMAN SERVICES
P.O. BOX A
GREELEY,
CO. 80632
Website �c�c�c.co.mcld.co.
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
•
COLORADO
MEMORANDUM
TO: Judy Griego — Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: July 29, 2008
SUBJECT: Weld Addendum to the Agreements to Purchase Out-of-home Placement
Services (SS-23A)
Attached please find the Weld Addendum to the Agreements to Purchase Out-of-home
Placement Services (SS-23A) for the following providers:
2008-2009 CONTRACTS FOR
CHILD PLACEMENT AGENCY SERVICES
FACILITY
CPA,NAME ID MAILINGADDRESS !' , CITY'STATE ZIP;
1 Loving Homes Inc. 72767 125 S Union Ave Pueblo CO 81003
2 Hope Family Services 42942 1610 29th Ave Place#100 Greeley, CO 80634
Lutheran Family Services of 3800 Automation Way, Suite
- 3 Colorado 45080 200 Fort Collins, CO 80525
- 4 Lost and Found Inc. 57351 6700 44th Ave Wheatridge, CO 80033
5 Adoption Alliance 71259 2121 S. Oneda St, Suite 420 Denver, CO 80224
6 Maple Star Colorado 90967 2785 Speer Blvd, Suite 340 Denver, CO 80211
Colorado Springs, CO 80907-
7 Bethany Christian Services 45514 4820 Rusina Rd, Suite C 8127
Colorado Springs, CO 80910-
8 Kids Crossing 79752 1440 E Fountain Blvd 3502
9 Savio House 37330 325 King Street Denver, CO 80219
13900 E Harvard Ave, Suite
10 Adoption Options 45078 200 Aurora, CO 80014
11 Special Kids Special Families 43184 424 W Pikes Peak Ave Colorado Springs, CO 80905
,q EDDY
C�9h pin,(�k Zoos.2167
rFs 0E/, =doe
f
f i:5 pis` SAM
r "' 4
F. S.. .., m . . ,;, .lam°. . ... _ it x '11
-12 Imagine 21369 1400 Dixon Ave Lafayette, CO 80026
-13 Smith Agency Inc. 44882 7169 S Liverpool St Centennial, CO 80016
These contracts have been presented for consent approval to the Board of County
Commissioners however; I am requesting your signature along with the Boards to complete
these contracts for the FY 2008-2009. If you have any questions please call me at Ext. 6441.
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Alliance and Weld County Department
of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions,made this U day of Q Ab , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms o he eement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#71259. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
t Weld County SS-23A Addendum
•
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# �,t I 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME IPROVIDER 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?
❑Basic Maint.)No participation required ❑1)Once a month 91%)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 '/2 hour per day 01%) /2 hour a day
❑2) 1 hour a day 02 %) P/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
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
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 ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that apply to this child.
L t
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ 0 0 0
Sexual Offenses
❑ ❑ 0 0
5 Weld County SS-23A Addendun
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that a..I to this child.
y Y.
Inappropriate Sexual Behavior
❑ ❑ ❑ 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
❑ 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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
;, Age 0-10...$16.32 °° ,
.. �; ($496) ;'g: Basic Maint $4.93 day/$150mo x Level 0 $0 :
County 7 Age 11-14...$18 05 5 Therapy not needed or provided -9.
Basic ($549) No crisis intervention, Minimal CPA ci.f• .?. by Level 0...$0
Maint '. Age 15-21...$19.27 k, (None)
= ($586) Ifit.i. involvement,one face-to-face visit ,"v another source,i.e.mental health. :,.1,::::i
�' +$.66 Respite Care . r n4
",,,;_ ($20) g: with child per month. (.`` "="
$19.73 ( Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
Ye
4.66 Respite Care Y Minimal crisis intervention as needed, Regularly scheduled therapy,
1 •` - at"' one face-to-face visit per month with r', ,;r Level 1 ...$2.99
($20.39 day/$620 mo) - child, y{^ up to 4 hours/month.
" 2-3 contacts ter month + ;' „.
"K : $23.01 _' . '"" a
1 112 -4.66 Respite Care :-T Level 1 1/2.........$9.86 day/$300 mo z al..4
---------
:4 ($23.67 day/$720 mo) ,;,_
$26.30 z" Level 2 $11.51 day/$350 mo -=.);:l Level 2 $9.86/$300 mo
2 = ; +$.66 Respite Care Occasional crisis intervention as needed, ' Weekly scheduled therapy, t Level 2..$4.47
�,'° ' ,- two face-to-face visits with child, 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) 4 {
2-3 contacts per month 4. group therapy.
-. $29.59 P...
2 112 .,i +$.66 Respite Care ,..':::',1`, Level 2 1/2 $13.15 day/$400 mo ; ------ ---------
_` ($30.25 day/$920 mo) e,
i' �
$32.88 Level 3 $14.79 day/$450 mo +'' Level 3 $14.79/$450 mo ;f,
55ncdak,
k'+ri +$.66 Respite Care Ongoing crisis intervention as needed,y.
N; Regularly scheduled weekly
a: multiple sessions,can include
3 �'" Level 3..$6.02
weekly face-to-face visits with child more
($33.54day/$1020 mo) : and intensive coordination of 771 than 1 person,i.e.family therapy,
,., multiple services. .fikli. for 9-12 hours/monthly. Fit.,
e wy i
t'S'3 $36.16 3 s' ii v :k
3 1/2 , -4.66 Respite Care 5°'£5 Level 3 1/2 $16.44 day/$500 mo ------ --------
�, ($36.82 day/$1,120 mo) ' .k,!
by `. +aw
; eV, nL;r
$39.45 Level 4 $18.08 day/$550 mo f; Level 4 $14.79/$450 mo a
"` �
-4.66 Respite Care ` Ongoing crisis intervention as needed 'y�`.: Regularly scheduled weekly
4 :.t.'7. '3',":!' t - multiple sessions,can include q
RTC
p °ii' ( a, which includes high level of case 3, more > Level 4....Neg.
DDown ($40.77 day/$1220 mo)el lin- management and CPA involvement with .,' , than 1 person,i.e.family therapy,
f ;
tiNj:, v t child and-itprovider and 2-3 face-to-face for 9-12 hours/monthly. xP
contacts ter week minimum. ° ;:„r;
Assess $26.96 day/$820 mo ;,,..-7,,, f 4 ' -_----
Rate 3 (Includes Respite) ' 1 $11.51 day/$350 mo ---- °
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4114/4S-44
Weld C. . ,ni?i�w�y�to the Board
E La
WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
OF THE WELD COUNTY
�. 7.41/47,9
DEPARTMENT OF HUMAN
% �� SERVICES
By: / LS _��/ ; � BY:
Deputy Cl: to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Adoption Alliance
2121 S. neda St, Suite 420
Denv O 802211`
By.
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dir ctor
8 Weld County SS-23A Addend
off', -a/6 ;
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Options and Weld County Department
of Human Services for the period from
July 1, 2008 through June 30, 2009.
12
The following provisions, made this /l day of 449a571., 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45078. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours,the
Contractor will make every effort to notify the assigned caseworker, supervisor,intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Confctor
will contact the Emergency Duty Worker at the pager number(970) 304-2749. o
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate perknnel
available for staffing current placements with the Utilization Review Team. ThlWreview
team convenes every Monday morning, excluding holidays. cn
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
a ."(9/62
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement,had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is t e
express intention of the undersigned parties that any entity other than the under ed
parties or their assignees receiving services or benefits under this Agreement s " I be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees rr≥y
posses, nor shall any portion of this Agreement be deemed to have created a dttif of care
that did not previously exist with respect to any person not a party to this Agreient.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s)to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
I
a
D
w
c
3 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# IEX F [TRAILS CASE ID IDOB
WORKER COMPLETING ASSESSMENT HH# 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 On 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%3 hour per day 01%) %hour a thy
02) 1 hour a day 02 %) 11/2-2 hours per day 03)2'/:-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑l)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 ❑21/) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention. rc
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
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 iensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,pq more than one
County foster child is with the same provider. t D
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 SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
� 4 i .4 F HTii
t e xzv.,ee. ax
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 ❑ ❑
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ 0 ❑ 0
Runaway
❑ ❑ ❑ ❑ fir,
0
Sexual Offenses
❑ ❑ ❑ ❑
cn
O
5 Weld County SS-23A Addendum
•
BEHAVIOR ASSESSMENTbitB) CONTINUED
(Exhi
Please rate the behavior/intensity of conditions which create the need for services that apply to thhil is cd.
LR 6 fl i Y"
{
x §�
YP� Y y
x1; �r ` c" -"
..v v.......0.°S.. a i..-...4 4 .a....f........... .. ._.m s'..:x...; e .._ i.'' .._.v.....
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ 0 ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family c,@
❑ ❑ ❑ ❑
O
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: >
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
� n
x: Age 0-10...$16.32 , .:
e }_ ($496) ,,,,. Basic Maint $4.93 day/$150mo Level 0 $0 +' i.
County :'. Age 11-14...$18 05 ° ,tee(: Therapy not needed or provided ,
Basic ($549) '-s No crisis intervention, Minimal CPA by ' :a Level 0...$0
Maint Age 15-21...$19 27 '. `' r : (None)
($586) `'„ : involvement,one face-to-face visit y+a' another source,i.e.mental health. 11:i
:.:Cr..-. +$.66 Respite Care L-,,,,.1 `�
($20) '.vk with child per month. ' t.`"Q.
'" $19.73 ' Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
1 i• 4 Respite Care ',L.,-. Minimal crisis intervention as needed, Regularly scheduled therapy, e!,:i
' one face-to-face visit per month with .4.1 Assn Level 1 ...$2.99
r.i child, t "'
($20.39 day/$620 mo) up to 4 hours/month. 4rif„;
2-3 contacts per month tl..• ,
$23.01 .'1g ' . ,,>
1 1/2 4.66 Respite Care . Level 1 1/2 $9.86 day/$300 mo ________--- ------
°e ($23.67 day/$720 mo) ,
1^i. $26.30 v'% Level 2 $11.51 day/$350 mo C'4a Level 2 s :/l-i7.:
Y $9.86/$300 mo »
2 4.66 Respite Care $ Occasional crisis intervention as needed, sw=. Weekly scheduled therapy, '4 Level 2..$4.47
rwc° ($26.96 day/$820 mo) SP}; two face-to-face visits with child, IFE. 5-8 hours a month with 4 hours of
L.
d 2-3 contacts per month ,. group therapy.
$29.59grd re`f
2 1/2 ) +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ---__________ __ '.
:4,8, ($30.25 day/$920 mo)
g :
$32.88 ; Level 3 $14.79 day/$450 mo g,m Level 3 $14.79/$450 mo
t ,I r
+$.66 Respite Care ') Ongoing crisis intervention as needed, '1, Regularly scheduled weekly `'
3 ... 1)' multiple sessions,can include
weekly face-to-face visits with child, ' more Level 3..$6.02
# ($33.54day/$1020 mo) s a '
, and intensive coordination of 1 than 1 person, i.e.family therapy,
'Y',, nM'" multiple services. #SL.;
iiz"a =xs for 9-12 hours/monthly. x.;,
e $36.16 `"t: c"n
3 1/2 .4".".;" 4.66 Respite Care 9t_ Level 3 1/2.........$16.44 day/$500 mo gg,..
- ---------
�.w ($36.82 day/$1 120 mo) j''. S
ti4•
/. $39.45 Level 4 $18.08 day/$550 mo !!,-2.,.: Level 4 $14.79/$450 mo
+$.66 Respite Care ,..„,..::1.-)
a.' Ongoing crisis intervention as needed, ‘ Regularly scheduled weekly )
4 ,'; ., multiple sessions,can include s
RTC , :, which includes high level of case } more
Drop ; s' t'',,'i i. Leve14....Neg.
Down , ,. ($40.77 day/$1220 mo) a=a management and CPA involvement with FN than 1 person,i.e.family therapy -.}e,14'4,
Down
rt? child andprovider and 2-3 face-to-face :4i.:1!.:
per, ?Si: for 9-12 hours/monthly. O e
1y
contacts .er week minimum. . k
Assess xr B $26.96 day/$820 mo ,, 7 , '.
Rate (Includes Respite) $11.51 day/$350 mo -----------_______ ___
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4.4'414
Weld Cou erk to the Board
.11 FE/L a WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
'cqC
�-s OF THE WELD COUNTY
fri DEPARTMENT OF HUMAN
' SERVICES
BY: % 1J7 By: 1-2---4-Gt�'
Deputy rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Adoption Options
13900 E Harvard Ave, Suite 200
Aurora,(CO 80014
� �
By: ( �1,� i�f uCtO4COS)SflA_
WELD COUNTY DEPARTMENT k/n P(' (Y ll�}�- ` C UV
OF HUMAN SERVICES
By:
Dir ctor
I^r
it
r
O
O1
O
8 Weld County SS-23A Addendum
• •
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency S rvlas
(the "Agreement") between Bethany Christian Services and Weld Conn*
Department of Human Services for the period from S9
July 1, 2008 through June 30, 2009.
The following provisions,made this//—day of4, 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of t e Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45514. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
j Weld County SS-23A Addendum
aoof- a/6
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement,had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
•
• WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX "TRAILS CASE ID 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 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
❑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 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 01)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'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?
❑Basic Maint.)No special involvement needed ❑1)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 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 On 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
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.)
❑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.
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 SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
a'.fr
' 5
:ate.....':�..... §...,.a.ain.. ..,.: .,. . ... .. I..,,. —.• r.,'" s ',. ..,...s :lfalg`:^P; err. . .: ,_. .......:. e,.a._.,.....a<..,_ a
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ 0 ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County SS-23A Addendum
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
ay �ti N k ti'
}-O v ..v�.e4. ,. ..¢. rr :m.
Inappropriate Sexual Behavior
❑ 0 ❑ 0
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Age 0-10...$16.32
.A`
($496) +,, Basic Maint $4.93 day/$150mo y„y Level 0 $0
Count * ' Age 11-14...$18 05 {i .n; Therapy not needed or provided U.,:;
Y
Basic ($549) : , No crisis intervention,Minimal CPA by Level 0...$0
Maint Age 15-21...$19.27 P` ' z s .1,, (None)
($586) ':' involvement,one face-to-face visit i ..-1 another source,i.e.mental health. ` a
+$,66 Respite Care °`' aq °'�;
($20) : with child per month. a i
y
4'9. $19.73 ,,ii°, Level 1 $8.22 day/$250 mo , Level 1 $4.93/$150 mo
'
s +$.66 Respite Care Minimal crisis intervention as needed, ' , Regularly scheduled therapy,
1 .ppi,.
Level 1 ...$2.99
/x one face-to-face visit per month with ;
4, ($20.39 day/$620 mo) child, t up to 4 hours/month „_*,
2-3 contacts per month ,ad. ,
1 1/2 +$.66 Respite Care , Level 1 1/2 $9.86 day/$300 mo t.;;;;',
' --------
($23.67 day/$720 mo) 4, .V
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo yw
2 4.66 Respite Care Occasional crisis intervention as needed Weekly scheduled therapy, Level 2..$4.47
ff
:§ °{'' two face-to-face visits with child, 4:::1:4 5-8 hours a month with 4 hours of °
ru; ($26.96 day/$820 mo) ii c: tom„ �}:'
2-3 contacts per month group therapy. •7•;;•‘
$29.59
2 1/2 H +$.66 Respite Care ',,.14i,, Level 2 1/2 $13.15 day/$400 mo iit,!. -------------------- It.,4 --------
°va ($30.25 day/$920 mo) Vs_,3 m
$32.88 . ".. Level 3 $14.79 day/$450 mo �i Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, ` . Regularly scheduled weekly ir k-'
multiple sessions,can include
3 ` s „o. Level 3..$6.02
weekly face-to-face visits with child, more
' ($33.54day/$1020 mo) " ``
L and intensive coordination of than 1 person,i.e.family therapy,
`
iti,t vxr§ multiple services. % for 9-12 hours/monthly tt
f!'� Al
:�•
$36.16 „>sil Al
3 1/2 °;. 4.66 Respite Care '" i. Level 3 1/2.........$16.44 day/$500 mo :;..#1,4;„1. ° ---------
•($36.82 day/$1,120 mo) *;i t0a
$39.45 Level 4 $18.08 day/$550 mo ,S.11 fla
I Level 4.........$14.79/$450 mo "r'
~v� +$.66 Respite Care `,r" Ongoing crisis intervention as needed, t Regularly scheduled weekly x.
4 A, °• ; r multiple sessions,can include .r;a:.
RTC il '. which includes high level of case ^ more ,° Level 4....Neg.
Drop .0.':•,
Down :, = management and CPA involvement with than 1 person, i.e.family therapy,
�,�, ($40.77 day/$1220 mo) ':.
r child and provider and 2-3 face-to face ,„. for 9-12 hours/monthly.
x '.
contacts ser week minimum. r r:*'
Y
Assess ' ,' $26.96 day/$820 mo ps %.4.:
Rate :41'.:', (Includes Respite) 'Ti'; $11.51 day/$350 mo 1. ii
.;, A Sill
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: iattliA024
Weld Count- `the Board
JEWELD COUNTY BOARD OF
.419$1: )� HUMAN SERVICES, ON BEHALF
]S61 ` fr 7� $ � OF THE WELD COUNTY
d ' DEPARTMENT OF HUMAN
SERVICES
By: Zit- , .1 •.I i'. � By: 1-rt
Deputy Cl- to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Bethany Christian Services
4820 Rusina Rd, Suite C
Colorado Springs, CO 80907-8127
6)BY4�is��S�R >,
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
D rector
8 Weld County SS-23A Addendum
Cag&— air ;
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope Family Services and Weld County
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this f day of Airwi , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#42942. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX F [TRAILS CASE ID !DOB
WORKER COMPLETING ASSESSMENT HH# M I !DATE OF ASSESSMENT
AGENCY NAME !PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation;Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1%)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 ❑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
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%x hour per day ❑1'%) '/z hour a day
O2) 1 hour a day O2 %) 1%-2 hours per day O3)2Yr3 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 Dl)Less than 5 hours per week ❑1%)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 ❑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
❑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.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
O2)4-8 hours per month O3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that a.81 to this child.
.-4-.i.&&m�!?:
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
❑ 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 ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ 0 0 ❑
5 Weld County SS-23A Addendum
• BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
7.177
. _ _. . ;.: .� ._ a �:. t
r.
fie.. : ..�..... .. ..... .ak. .. ..,.r ', ,.�, �: '');7a k. ui i .;� ", 5
Inappropriate Sexual Behavior
❑ 0 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
❑ ❑ ❑ ❑
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 SS-23A Addendum
• WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
x � • y �
'yyl�,,
.,a...nt...3 v
Age 0-10...$16.32 - .
($496) .} Basic Maint $4.93 day/$150mo );',..el Level 0 $0 ;',
County &t- Age 11-14...$18.05 ri 13x Therapy not needed or provided „ ?
Basic :: ($549) ' No crisis intervention,Minimal CPA §,i by : Level 0...$0
Age 15-21...$19.27 des . (None)
Maint �;.. y ,•
($586) involvement,one face-to-face visit Kili another source,i.e.mental health.
3 +$.66 Respite Care 4'!:.
($20) with child per month. za
a '!:
' $19.73 °(}' Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo .,°,
*TV +$.66 Respite Care • Minimal crisis intervention as needed Regularly scheduled therapy,
',Al ; one face-to-face visit per month with S,p) Level 1
($20.39 day/$620 mo) child, up to 4 hours/month. ,i.
2-3 contacts per month
J.::
$23.01 ; 7 i..,
1 1/2 : +$,66 Respite Care :-' Level 1 1/2.........$9.86 day/$300 mo
:::;ii
xj ($23.67 day/$720 mo)
i
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo ""r
2 r +$.66 Respite Care :. Occasional crisis intervention as needed, ; ' Weekly scheduled therapy -."`4e. Level 2..$4.47
` two face-to-face visits with child, 4.!;.!:,'` 5-8 hours a month with 4 hours of *"a;l
x.* ($26.96 day/$820 mo) 'x,: li
'° v 2-3 contacts per month group therapy. kit
w s,i
$29.59 " p.,"^ 114
2 1/2 .. +$.66 Respite Care n Level 2 1/2 $13.15 day/$400 mo
. : ($30.25 day/$920 mo) 1:t;:.:. IA!
VE:
,A $32.88 y Level 3 $14.79 day/$450 mo z Level 3 $14.79/$450 mo
+$.66 Respite Care ,a�" t r:',";;;
r':.:151,
p = -; Ongoing crisis intervention as needed, = Regularly scheduled weekly :b',s
3 rr ' multiple sessions,can include ,a
weekly face-to-face visits with child more ,, Level 3..$6.02
($33.54day/$1020 mo) 4"" ' ,. "
. "7( and intensive coordination of $1. than 1 person,i.e.family therapy, 4,...it
,,'�1 multiple services. s;: for 9-12 hours/monthly. 4;44.
!
'
$36.16 '3.' r. ma's
31/2 'a +$.66 Respite Care - q; day/$500 °** ; Level 3 1/2.........$16.44 mo 4 . --------------- —
,: ($36.82 day/$1,120 mo) .f "
` $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo .4'..=
6 ii,w +$.66 Respite Care yzr-
# Ongoing crisis intervention as needed a Regularly scheduled weekly 'z,
4
+t multiple sessions,can include
RTC
`.≥g' which includes high level of case f \ more `,v Level 4....Neg.
P
Down a-:° ($40.77 day/$1220 mo) ' management and CPA involvement with . , ' than 1 person,i.e.family therapy, b
4rtli= child and provider and 2-3 face-to-face ,,,, for 9-12 hours/monthly.
contacts .er week minimum. `' ,,,.
.... ..._.. tee'..
1 AA
Assess a, $26.96 day/$820 mo ,,, , --------
Rate z (Includes Respite) I s $11.51 day/$350 mo g..'
f
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: ia �� " """"4
Weld,9grty9crIc to the Board
� i,..1;
e� WELD COUNTY BOARD OF
HUMAN SERVICES, ON BEHALF
DEPARTMENT OF HUMAN
's4l Ai_" — OF THE WELD COUNTY
f'""ClIt\ � _•,, SERVICES
By: By: /Li k1,--e
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Hope Family Services
1610 29 ' ace#100
Greeley CO 80/
By: `
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dir ctor
8 Weld County SS-23A Addendum ll
t9/7)X— cnQ /lO ;
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Imagine and Weld County Department of
Human Services for the period from
July 1, 2008 through June 30, 2009.
ft
The following provisions, made this Gj day of 3-s , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#21369. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
d6kr—air '
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY MIS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# IEX F ['RAILS CASE ID IDOB
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
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
❑2)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?
0 Basic Maint.)No educational requirements ❑1)Less than a '/3 hour per day ❑1%) '%hour a day
❑2) 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 01)Less than 5 hours per week 01%) 5 to 7 hours per week
O2) 8 to 10 hours per week ❑2'/o 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 ❑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.)
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
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a I$1 to this child.
}
3 {
a <
dwiv v.. ... .t. r.n. . • .�.a.... ..�.. .& ... , .kn M.w�..vs.z... . anx %..Y�.."ux 3.. .. . .. .. .,v.. § ua. a. .. ... .n n n,�✓�tt§
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ ❑ 0
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ 0 ❑ 0
Substance Abuse
❑ 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ 0 0
Enuresis/Encopresis
❑ 0 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 ❑ ❑
5 Weld County SS-23A Addendum
•
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
b �
,i
.. ..v.-... ,.. .. .:. .. ` v......w... tt�c4..a..'. ..,a S° ) a?i' _.....i.... :xx
Inappropriate Sexual Behavior
❑ 0 ❑ ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ 0 ❑ 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O 0 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ 0 0 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ 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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
T Age 0-10...$16.32 .r °t
aaN ($496) -svy Basic Maint $4.93 day/$150mo ,' Level 0 $0
County Age 11-14...$18 05 1., Therapy not needed or provided
Basic ($549) No crisis intervention, Minimal CPA by Level 0...$0
Maint .a Age 15-21...$19.27 :b (None)
y„ ($586) ,:•: involvement,one face-to-face visit *,* another source,i.e.mental health.
+$.66 Respite Care f".3
($20) with child per month. *;Y
$19.73 e Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
r
+$.66 Respite Care .. Minimal crisis intervention as needed, Regularly scheduled therapy,
1
one face-to-face visit per month with a.:1 c4 1 ...$2.99
v ($20.39 day/$620 mo) :: child, up to 4 hours/month..itsm
s
s'va 2-3 contacts per month ask
.
$23.01 a
11/2 ,.' +$.66 Respite Care ` , Level 11/2.........$9.86 day/$300 mo °" ---------- --------
�) ($23.67 day/$720 mo) P7.1_ "'_�
v"*
$26.30 Level 2 $11.51 day/$350 mo = Level 2 $9.86/$300 mo .s.°
s
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, v'
- d
Level 2..$4.47
s ($26.96 day/$820 mo) • two face-to-face visits with child, k 5-8 hours a month with 4 hours of
E!`l 2-3 contacts per month group therapy.
t�fq .
$29.59 ;:e4"� a'
2 1/2 ;x +$.66 Respite Care rx, Level 2 1/2.........$13.15 day/$400 mo OA
,;: ($30.25 day/$920 mo) ' i `.
„ ;y
4 titi $32.88 ,; % Level 3 $14.79 day/$450 mo g Level 3 $14.79/$450 mo 5
+$.66 Respite Care ff 4 Ongoing crisis intervention as needed, °i Regularly scheduled weekly y
3 �`°� riV multiple sessions,can include
' weekly face-to-face visits with child, ° more Level 3..$6.02
($33.54day/$1020 mo) ;i and intensive coordination of Alt:, than 1 person,i.e.family therapy,
multiple services. .xb. for 9-12 hours/monthly.
$36.16Tti: ;.:
3 1/2 ` 4.66 Respite Care Level 3 1/2 $16.44 day/$500 mo ----------- ---
($36.82 day/$1 120 mo) F°` YY"
`! _-------
i: a ":: it S li, 'si A ill! 5n
N $39.45 „4;: Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo x`;
'2,7.4.i +$.66 Respite Care , 51 Ongoing crisis intervention as needed, Regularly scheduled weekly fee:
4 44.$1, k multiple sessions,can include
RTC "d. r i which includes high level of case ., t: more
Drop ;. �, Leve14....Neg.
Down fly; ($40.77 day/$1220 mo) management and CPA involvement with a,-- than 1 person,i.e.family therapy,
�,=M1:� child and provider and 2-3 face-to-face 1 for 9-12 hours/monthly.
t
.
.,...4 „_„ contacts ser week minimum.
^ `
Assess $26.96 day/$820 mo .1,4.2x '.
Rate a T (Includes Respite) ' z ° -----
%5b) $11.51 day/$350 mo 41 h ,
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: SIAL
Weld C .ty;; etiq the Board
)'ctn !c o/,i tie.
n. WELD COUNTY BOARD OF
i ;Si: .� \ - HUMAN SERVICES, ON BEHALF
861 OF THE WELD COUNTY
�1 .j
�,� I DEPARTMENT OF HUMAN
!FLU `S SERVICES
By: it VCS By: ,')L-
Deputy Cle to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Imagine
1400 Dixon Ave
Lafayette, CO 80026
By: 7d1"---->„_,
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Due for 1
8 Weld County SS-23A Addendum �'7
,-0/111?- O(- 9/6i
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Kids Crossing and Weld County Department of
Human Services for the period from
July 1, 2008 through June 30, 2009.
l 1
The following provisions, made this// 474/—day of ' c 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of tie Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#79752. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
ate- aleo;
, 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
•
•
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE lD# 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. ❑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 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
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2%-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%x) 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 a¢e 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
❑3%) 21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensi of conditions which create the need for services that a..l to this child.
,, ,..„.:!:,. ::::.11,;;E:1;1,,si)k.
a..
.,..u...=::. ... e. .:.:. .......ss... . '+:„ .. . ., _n.r._.�_:.vY..�vx+.,.,.�
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ O O
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ 0 0 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
• - (Exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
s w " y Y'5
x 33;!:.7:::.;":„,::.,..;.;;;;;;.;.;..t.,;;;';';
f .'1.,'-i:-.;;:;;;.?;;, ,,.,..,:.:,.,:: 'f.-h 5 t k k'> x Y;
a t t t $
Y ¢ S
.�,�_..>..:.. ... ....: :.. 5. ,k,d�tiAt „ e... _'«s.:' ,;:.'_v1..d..a..,P ,...R ...:. .d�.. .,z' .,ici.,,..Yt.Llit_ ..x._. .. .-. .. ?;7i....:,..-... ..,31..:•-. ._..._.:1,.....:_,.f,. ?;i
Inappropriate Sexual Behavior
El El El El
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ 0 El
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete El ❑ ❑ ❑
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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
l S. ... . . 't. ..----T-.7-;;E.-7, -.4:7;.E,7-17,77:7Z•:;427..:1;
�' a S did
y5 � d
'aC*kv b" ',�� , . .:� ',.. 4 ...^'�, i
ar '''::::',,'.k2-,e.''''
f L i } - • - 4
ry s d 2 e*
sr„a; .r..rN..V Ww,ti m
" ^ Age 0 10...$16 32 .. . .,. s.. �.
($496) Basic Maint $4.93 day/$150mo ," Level 0 $0
County " Age 11-14...$18.05 ' Therapy not needed or provided I
Basic7:7/.r ($549) r No crisis intervention, Minimal CPA w? by Level 0...$0
MaintAge 15-21...$1927 �.,e, ,: (None)
($586) involvement,one face-to-face visit another source,i.e.mental health. :
4 +$.66 Respite Care ..T. ''>
($20) with child per month. rit
aa $19.73 • = Level 1 $8.22 day/$250 mo iii," Level 1 $4.93/$150 mo
+$.66 Respite Care :•;4.,';'..! Minimal crisis intervention as needed Regularly scheduled therapy,
1
si, one face-to-face visit per month with ^'`,r`; .,,,,Iii..
Level 1 ...$2.99
($20.39 day/$620 mo) * child, up to 4 hours/month.
fix. 2-3 contacts per month
,?.;
.:t $23.01 .•e S. wzd
1 1/2 +$.66 Respite Care °"i , Level 1 1/2 $9.86 day/$300 mo �`.��` ------------------- w" ----------
'", ($23.67 day/$720 mo) fsv%(� ..
$26.30 Level 2 $11.51 day/$350 mo },•s Level 2 $9.86/$300 mo -A
til
2 r s. ,'s1+$.66 Respite Care a's Occasional crisis intervention as needed,TsPe Weekly scheduled therapy °Ar
Level 2..$4.47
($26.96 day/$820 mo) a two face-to-face visits with child, '. 5-8 hours a month with 4 hours of
2-3 contactsper month i '
ili
;, group therapy. ^+:,.
s $29.59 $;
21/2 ; +$,66 Respite Care4. Level 2 1/2.........$13.15 day/$400 mo a:
f ($30.25 day/$920 mo) -t - --------
S $32.88 `': Level 3 $14.79 day/$450 mo :11 Level 3 $14.79/$450 mo
.4 +$.66 Respite Care ' Ongoing crisis intervention as needed, a Regularly scheduled weekly
3 z multiple sessions,can include Level 3..$6.02
t weekly face-to-face visits with child, �a more
7.:3, ($33.54day/$1020 mo) .~~
.t; c.*; and intensive coordination of n.0 than 1 person,i.e.family therapy, 11
fit rk a^
"�;: multiple services. !'}1 for 9-12 hours/monthly. may,
liti $36.16 y#d 11 ?,pii
3 1elie
12 +$.66 Respite Care - Level 3 1/2 $16.44 day/$500 mo t ? -----------.......—
($36.82 day/$1,120 mo) #'� t
y aa
:Via
::
ji $39.45 it, Level 4 $18.08 day/$550 mob Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4 s multiple sessions,can include4'
DrRop ‘S:41,
* which includes high level of case & more Level 4....Neg.
rso
Down ($40.77 day/$1220 mo) h“
management and CPA involvement with ' y than 1 person,i.e.family therapy,
child and provider and 2-3 face-to-face 'r5?;; for 9-12 hours/monthly. 1'`�
7z.
,,.. )gl: contacts ler week minimum. k;5i ";T
rei
Assess ,'€tS $26.96 day/$820 mo w )
Rate till (Includes Respite) $11.51 day/$350 mo
ig
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4te#12aLal
Weld CouW'lrF& to4the Board
Fr WELD COUNTY BOARD OF
`4 A,'� ‘ , '1 ` HUMAN SERVICES, ON BEHALF
s i_ OF THE WELD COUNTY
O tJ')3/4,
I J DEPARTMENT OF HUMAN
�i, '; --�". �,7 SERVICES
By: By: �-'�=rr frG..—i
Deputy CI tot e Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Kids Crossing
1440 E Fountain Blvd
Colorado Springs, CO 80910-3502
By: 43
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dir ctor
8 Weld County SS-23A Addendum
ata-a/6;
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Lost and Found Inc. and Weld County
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
tom'
The following provisions, made this // day of A , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms ofement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#57351. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
half-O/6
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement,the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F tTRAILS CASE ID IDOB
WORKER COMPLETING ASSESSMENT HH# �y 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. 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 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 ❑1)Less than a''/3 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
03%)More that 3 hours per thy
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours 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.)
❑l)Face-to-face contact one time per month with child and minimal crisis intervention.
O 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.
O 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
02)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that ap.l to this child. y
n Y3 14".S
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ 0 0 ❑
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 0
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(exhibit B)
Please rate the behavior/intensity of conditions which create the need for services that ap.l to this child.
v a )° 2s " ( ?s 's xs a s is r b " P
�a. ....,._,v°'_s , . . , ee . . _ .... . ...... ... ::. .s. �._, ..:....,,i�.9w
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ 0 0
❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
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) El ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
4
_„y A
rve
+y: Age 0-10...$16.32
4,44-). ($496) . ' Basic Maint $4.93 day/$15omo Level 0 $0
County §r,' Age 11-14...$18.05 k a Therapy not needed or provided ,'
Basic g ($549) '' No crisis intervention,Minimal CPA , by Level 0...$0
Maint �'14 Age 15-21...$19 27 ,. , (None)
ten ($586) 'e +. involvement,one face-to-face visit tv15 another source,i.e.mental health a,,z{
+$.66 Respite Care . .;
($20) with child per month.
FS $19.73 Level 1 $8 44444:44 .22 day/$250 mo 4r Level 1 $4.93/$150 mo
`t, +$.66 Respite Care I Minimal crisis intervention as needed, 2 Regularly scheduled therapy
' ., _; one face-to-face visit per month with ,'. Level 1 ...$2.99
1
414,
($20.39 day/$620 mo) t„ii child, up to 4 hours/month
is M1 ₹ 2-3 contacts per month 'N
x r,', $23.01 r"� ,t
1 1/2 r, 4.66 Respite Care .::•�. Level 1 1/2 $9.86 day/$300 mo �e 3. ,
3
($23.67 day/$720 mo) q sg.' ;.
'ill $26.30 Level 2 $11.51 day/$350 mo { i4 Level 2 $9.86/$300 mo ..:
2 , +$.66 Respite Care 'r`,' Occasional crisis intervention as needed, Weekly scheduled therapy,
4€"=
I tn=�. Level 2..$4.47
littel f11,44,:. two face-to-face visits with child, ¢ 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) ,gip
q �z 2-3 contactsper month group therapy.�'.' 'f4v #
$29.59 i P.
2 1/2 a +$.66 Respite Care _zv. Level 2 1/2 $13.15 day/$400 mo iti‘k --_------------------- +ti
($30.25 day/$920 mo) '4.%,
* f
$32.88 $' Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mox,
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly s,
ilrf
3 n multiple sessions,can include Level 3..$6.02
weekly face-to-face visits with child, -4* 4.1141 more
($33.54day/$1020 mo) and intensive coordination of - than 1 person,i.e.family therapy,
tTii
' 4i
multiple services. xw for 9-12 hours/monthly. a
y'( 6Tx
;' $36.16 ;',e" k' '
3 1/2 t 4.66 Respite Care :,:ri Level 3 1/2 $16.44 day/$500 mo cj33.,14 i•y 1
if:f ($36.82 day/$1,120 mo) .r 7`3'
T.,*"
nii!it,
v $39.45 s' Level 4 $18.O8 day/$550 mo Level 4 $14.79/$450 mo ',x(
4.66 Respite Care ` Ongoing crisis intervention as needed, Regularly scheduled weekly ';-,444.
4 Rer r 7x multiple sessions,can include
RTC ,s, >t which includes high level of case :. more xs'ia
Drop ) ,. ;,. Leve14....Neg.
Down ($40.77 day/$1220 mo) management and CPA involvement with :. than 1 person,i.e.family therapy,
: child and provider and 2-3 face-to-face for 9-12 hours/monthly
44.4t.
& = Pa.x: contacts 'er week minimum. "";
Assess $26.96 day/$820 mo ;4.4.,!:‘,4
Rate (Includes Respite) iB " $11.51 day/$350mo —
Pt4 741
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 4144/41'�/""'"""'r
Weld Cou_d.�At,«� r he Board
,I 1 ).n;/, / :\�
WELD COUNTY BOARD OF
c:11,47,4: CHW."5.
\ HUMAN SERVICES, ON BEHALF
issi 1 OF THE WELD COUNTY
DEPARTMENT OF HUMAN
O 4,4:1? �k,
.r r• - _ SERVICES
/ 7
By: •/. i .f/ 4% 2 By: "\—Lc �1,_-/
Deputy CI tto the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Lost and Found Inc.
6700 44th Ave
Wheatridge, CO 80033
B /
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
D. ctor
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Loving Homes Inc. and Weld County
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this 1/—day of 4144'q , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#72767. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
] Weld County SS-23A Addendum
&OAP— aid'
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT IHH# 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. 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 ❑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 01)Less than a%z hour per day ❑1%)1/2 hour a day
❑2) 1 hour a day 02 'A) 1'/r2 hours per day 03)2%r3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%) 5 to 7 hours per week
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 01)3 to 4 hours per week ❑1'/)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑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.
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
O 2)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions whichcreate the need for services that a..l to this child.
% Y
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ 0 ❑ 0
Presence of Psychiatric
Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ 0
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that a..ly to this child.
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O O O
❑
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 ❑ I ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
r a
"- Age 0-10...$16.32 ::
($496) ,v,; Basic Maint $4.93 day/$150mo : Level 0 $0
County ` ,, Age 11-14...$18.05 7/ . ..--, Therapy not needed or provided
Basic ($549) 27,-40.:.'i No crisis intervention,Minimal CPA a x:, by Level 0...$0
Maint a Age 15-21...$19.27 ,. . ; (None)
($586) involvement,one face-to-face visit another source,i.e.mental health.
`;. ; +$.66 Respite Care �f
($20) with child per month. :il.f.
$19.73 a: Level 1 $8.22 day/$250 mo ri,p, Level 1 $4.93/$150 mo F;;
`
+$.66 Respite Care Minimal crisis intervention as needed, ' Regularly scheduled therapy, *
1 Fk -t4'4i one face-to-face visit per month with -.,!,,,:,;.31' �+ Level 1 ...$2.99
t ($20.39 day/$620 mo) `1 child, �,' up to 4 hours/month.
�,: -, j 2-3 contacts per month `�
$23.01 ' ,1 :,:::
1 1/2 ,',.•,•:... +$.66 Respite Care !•,i':',°. Level 1 1/2 $9.86 day/$300 mo ,1 ---------------------
($23.67 day/$720 mo) ' .fie
•,{
. $26.30 vA Level 2 $11.51 day/$350 mo Level 2..........$9.86/$300 mo s'
+$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy,
2 ta? y Level 2..$4.47
ate
($26.96 day/$820 mo) two face-to-face visits with child, ';' 5-8 hours a month with 4 hours of =x.
2-3 contacts per month ' group therapy. i;≤
w
$29.59 t.1' '�`%
2 1/2 -4.66 Respite Care . Level 2 1/2.........$13.15 day/$400 mo ,,,_� -----------------— v
+."+21 ($30.25 day/$920 mo) _. if
$32.88 ,� Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
4.66 Respite Care Ongoing crisis intervention as needed, t as Regularly scheduled weekly xa
3 , `- multiple sessions,can include y; Level 3..$6.02
mot. weekly face-to-face visits with child, At more
� ._".
:ii i.4.2, mo) and intensive coordination of than 1 person,i.e.family therapy,
a multiple services. ,.w for 9-12 hours/monthly. ;4
a
r, $36.16 {. §` 'r
3 1/2 +$.66 Respite Care :r1,a.. Level 3 1/2 $16.44 day/$500 mo " ---------- ----- ! ------
($36.82 day/$1,120 mo) V., f,
w3
$39.45ifi, Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo > A
+$,66 Respite Care & Ongoing crisis intervention as needed, ti Regularly scheduled weekly .:;
4 ?4,t+ A multiple sessions,can include
't
RTC ';',4".- }1,a which includes high level of case :; more Level 4....Neg.
Drop : ; °, ,#.4i
Down ,x d ($40.77 day/$1220 mo) CM management and CPA involvement with than 1 person,i.e.family therapy, o e
v. child and provider and 2-3 face-to face for 9-12 hours/monthly. "ray;
iWx i ,,.t '-'
,, v,`' contacts •er week minimum. ar'. „" ,
Assess a $26.96 day/$820 mo 2 ,iVtil
Rate (Includes Respite) R. $11ai, .51 day/$350 mo ,"
Wail
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L"`f Alli
Weld Coy . he Board
by > WELD COUNTY BOARD OF
r� ` 'Aq„ ' HUMAN SERVICES, ON BEHALF
-----1 OF THE WELD COUNTY
%b kc; 3 DEPARTMENT OF HUMAN
+ _
4,�' ,,;-_ F; SERVICES
�'.�'fir
i
By: By: ti-±
Deputy C to the Board Chair Signature
William H. Jerke
AUG 1 1 2000
CONTRACTOR
Loving Homes Inc.
125 S Union Ave
Pueblo CO/� 81003 J
By:/�^„4 / ?"4 /12O
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dire for
8 Weld County SS-23A Addendum
owe- ai4,7
WELD COUNTY ADDENDUM
•
To that certain Agreement to Purchase Child Placement Agency Services JUL 8 2008
(the"Agreement") between Lutheran Family Services and Weld County'
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this // -day of /h491/s/ , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45080. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
aooe- a 1 2
9r Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
• exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s)to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID 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%)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 01)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 On Less than a %3 hour per day ❑1'%) %z hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day ❑3)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 ❑l'A)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 ❑1%)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2'/4 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.
❑l'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 SS-23A Addendum
•
•
WELD COUNTY DHS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
+ a ac a=
•,.:.5_:+.x�:e xivccrt§�:. � ...G.�..rw_r,,._,,.s_!k'.:_ '....st,..3r. +� +;.x.
y e by
Aggression/Cruelty to Animals
❑ ❑ ❑ 0
Verbal or Physical Threatening
❑ ❑ 0 0
Destructive of Property/Fire
Setting 0 0 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ 0 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 ❑ ❑
Enuresis/Encopresis
❑ 0 0 ❑
Runaway
❑ 0 0 ❑
Sexual Offenses
❑ ❑ 0 0
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
' r x
t'-
w
Y.% • w
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
❑ ❑ ❑ ❑
Boundary Issues
❑ 0 0 0
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 SS-23A Addendum
•
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
. f
n
.
%Age 0-10...$16.32
($496) Basic Maint $4.93 day/$150mo v Level 0 $0 '
County ?..,!€.,2,;. Age 11-14...$18 OS ,yi . ,? Therapy not needed or provided ''
Basic ^'& ($549) . No crisis intervention,Minimal CPA . by Level 0...$0
Maint Age 15-21...$19.27 _ . (None)
aye ($586) e ` involvement,one face-to-face visit another source,i.e.mental health
&3: +$.66 Respite Care 7r
I N ($20) =t f with child per month. ''
. ,',„,:;:‘,..,,...;.:.;
l',1 ry a.�<' $19.73 Level 1 $8.22 day/$250 mo11:11!:‘:
Level 1 $4.93/$150 mo
r.
- +$.66 Respite Care Minimal crisis intervention as needed Regularly scheduled therapy
1 )' one face-to-face visit per month with t'; Level 1 ...$2.99
w6 ($20.39 day/$620 mo) child, -,,,,.......w
up to 4 hours/month '
° w` 2-3 contacts per monthL.*' ;�
r` $23.01 q` i.-4•t.; '
t Level 11/2.........$9.86 day/$300 mo #x, "�-
1 112 `,'x +$.66 Respite Care --------
d a ($23.67 day/$720 mo) "T '
s $26.30 r Level 2 $11.51 day/$350 mo • Level 2 $9.86/$300 mo ir.R
2 "4::::! +$.66 Respite Care `7` Occasional crisis intervention as needed, ' Weekly scheduled therapy Level 2..$4.47
?;•,,,"-,.: I. two face-to-face visits with child s` 5-8 hours a month with 4 hours of ')„-
($26.96 day/$820 mo) :,,,,,,t.„,,
T1` �:�" 2-3 contacts per monthigroup therapy.
$29.59 ;.< '
21/2 Yv� +$.66 Respite Care :. , Level 2 1/2.........$13.15 day/$400 mo
mi� ($30.25 day/$920 mo)
v.`,. ',4 l.
$32.88 4a Level 3 $14.79 day/$450 mo i Level 3 $14.79/$450 mo }
i'k +$.66 Respite Care Ongoing crisis intervention as needed Regularly scheduled weekly +
3 t? ` ' multiple sessions,can include
weekly face-to-face visits with child more Level 3..$6.02
($33.54day/$1020 mo) and intensive coordination of than 1 erson,i.e.family therapy, ':!�'"' r.. P PY
�.a multiple services. for 9-12 hours/monthly �%
:.I0 $36.16 +' ')
31/2 y, +$.66 Respite Care a Level 3 1/2.........$16.44 day/$500 mo 4 '
#�' ti,'t "u4 5",.d
($36.82 day/$1,120 mo)
S
$39.45 =:- Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo ;.
q1 +$.66 Respite Care `A Ongoing crisis intervention as needed Regularly scheduled weekly xis
RTC f".:• twz.i; multiple sessions,can include �'
E which includes high level of case more Level 4....Ne
Drop g
Down a'. ($40.77 day/$1220 mo) '�,: management and CPA involvement with + • than 1 person,i.e.family therapy
h$ ::'s T.tiq child and provider and 2-3 face-to-face 1,2.• for 9-12 hours/monthly. r�`
• contacts .er week minimum. `'; `
A Assess ?}It:" $26.96 day/$820 mo ' ;.
Rate (Includes Respite) ;!,'..a.;: : > l
a� ar ; $11.51 day/$350 mo ` =
Pe
Admin. Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: is ay/1'!/7/ 1j
Weld County Clerk to the Board
a I., (.\ WELD COUNTY BOARD OF
; HUMAN SERVICES ON BEHALF
�, �A \ OF THE WELD COUNTY
�" �p _ t DEPARTMENT OF HUMAN
tk r \ / './ SERVICES
_
By: 7 4.. By: 71,-t—:7c. �✓
Deputy Clevl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR �
Lutheran Family Services OP 6;Pf-ADO
3800 Au i e
Fort Collins, CUzUb23 / ,T
30.3 .5. 461.L.y.\/,, 5:-.,/A
By #VV1/Ceerir eSfae
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
N jel7
Di ector
JUL 8 ?@[18
8 Weld County SS-23A Addendum
O70g-- ovel
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Maple Star Colorado and Weld County
Department of Human Services for the period from
July 1, 2008 through June 30,2009.
The following provisions, made this ft day of 4144-, i, 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of tlfe Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#90967. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
t Weld County SS-23A Addendum
n /
Q42e` cQ/(O
• 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
• exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
• WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX !'RAILS 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'%)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month 01%)Two times month
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'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?
0 Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 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.
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
02)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..l to this child.
_ -.
X°�..n: .•.,: ..4.. . . ...a, .... .._ 4.�v, ... ...�.' ♦.s. ._.�:. ..anMrv. x....vY..aa7a';,tx,tv vE l.e n . .. � .. Yv�.v_.._.:.. . .✓.,.v �`.. ,;1`t
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ 0
Destructive of Property/Fire
Setting 0 0 ❑ ❑
Stealing
❑ ❑ ❑ 0
Self-injurious Behavior
❑ 0 0 0
Substance Abuse
❑ 0 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ 0 ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Plea rate the behavior/intensity of conditions which create the need for services that a..l to this child.
dY l 5 4R, se s' ^` d'�" ' }1 M :"'3
-,.. ro £
e'„,
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Age 0-10..$16 32 .
($496) - a Basic Maint .., ;n$4.93 day/$150mo r,, Level 0 $0 ,. .a
County �* Age 11-14...$18.05 9+ , ') Therapy not needed or provided r`
Basic ,� ($549) No crisis intervention,Minimal CPA by Level 0...$0
Maint ' •, Age 15-21...$19.27 - (None)
�, ($586) kZ.1 involvement,one face-to-face visit ..411!..:1,., another source,i.e.mental health. is
'y +$.66 Respite Care 'd:�.
('r�' ' �° '* M ($20) n:,4, with child per month. ,h°
`
$19.73 ',Dili Level 1 $8.22 day/$250 mo i2.V. Level 1 $4.93/$150 mo
E :; S.j +$,66 Respite Care kj Minimal crisis intervention as needed, Regularly scheduled therapy,
1 +' ' °� s„,,......4Level 1 ...$2.99
�, ; one face-to-face visit per month with ,':;,
` child, { up to 4 hours/month.
($20.39 day/$620 mo) ,alt; ,�
&t:i 2-3 contacts per month
$23.01 X3a' S
1 1/2p :)+$,66 Respite Care . Level 1 1/2 $9.86 day/$300 mo `E.%
($23.67 day/$720 mo) '1',„'; * �;.
-t�` $26.30 Level 2 $11.51 day/$350 mo " Level 2 $9.86/$300 mo , ,-
`* +$.66 Respite Care 71, Occasional crisis intervention as needed, Weekly scheduled therapy, .4„.„
2 a,4,. , *._` Level 2..$4.47
t,i two face-to-face visits with child, t 5-8 hours a month with 4 hours of w
:t, ($26.96 day/$820 mo) :.magi4w R
2-3 contacts per month taggroup therapy.
ae,k $29.59 °
2 1/2 1 +$.66 Respite Care ` Level 2 1/2.........$13.15 day/$400 mo �` ---------
($30.25 day/$920 mo) e 9 ' 4: ti_
$32.88 �''3 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo a
+$.66 Respite Care vilij, Ongoing crisis intervention as needed, `P'r, Regularly scheduled weekly °y
3 $ multiple sessions,can include `'
sn ... Level 3..$6.02
weekly face-to-face visits with child, more •aa7
($33.54day/$1020 mo) and intensive coordination of f `) than 1 person,i.e. therapy, . `
ra
is a,. family .e-,
,ya a) multiple services. ( for 9-12 hours/monthly.
21 $36.16 9` h' ''
3 1/2 is +$.66 Respite Care .,�"'�; Level 3 1/2 $16.44 day/$500 mo °) ---- s.- --------
($36.82 day/$1,120 mo) '"tj ,-
A.
rl $39.45 c5 Level 4 $18.08 day/$550 mo i;i1 Level 4 $14.79/$450 mo .
i 1 +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly s
4 }' , ,+ multiple sessions,can include
RTC iii..Drop s> ` '�'..°.rn. which includes high level of caseos
more ' Level 4....Neg.
Down ham; management and CPA involvement with ' than 1 person,i.e.family therapy, ilia
&: ($40.77 day/$1220 mo) �,, ;��
l child and provider and 2-3 face-to-face for 9-12 hours/monthly.
,. go
@At 09
" contacts •er week minimum. ;TM, 'N;
Assess yi $26.96 day/$820 mo t" +fr,sm
c,
Rate i asre: (Includes Respite) $11.51 day/$350 moL"
thfll
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: MailaAil
Wel * ark) he Board
e '\i4,..„,,j` WELD COUNTY BOARD OF
s') 1t. `; d ,_ J HUMAN SERVICES, ON BEHALF
�, 1. f OF THE WELD COUNTY
' V >/ DEPARTMENT OF HUMAN
`t` Fl V f✓ SERVICES
By: __ By: 'I-1T et-- (��
Deputy C rk to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Maple Star Colorado
2785 Speer Blvd, Suite 340
Denver, CO^^80211
-
By:7)0,121
2'1
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
erector
K
8 Weld County SS-23A Addendum
awe-air
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Savio House and Weld County Department of
Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this J/—day of 2008, are added to the referenced
Agreement. Except as modified hereby, all terms of t e Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#37330. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum r/
nt02—, ?irl>
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five (5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term"litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE IDN 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?
0 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 Du Less than a '/z hour per day 01%) '/z hour a day
❑2) 1 hour a day 02 %) 11/2-2 hours per day 03)2%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
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
❑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.)
❑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 SS-23A Addendum
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
tee •
. . .. . , ,
i
e ,
�
Aggression/Cruelty to Animals
❑ 0 ❑ ❑
Verbal or Physical Threatening
❑ 0 0 0
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ 0 ❑ ❑
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 0 ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
rp C
1 ti. A3
„ .a.+s .�.._.,,.s`w�,..s=�1w9.ix.S..C.m:'aw ., .a aa'.a•-_ ...._. , ._..x. ... .. ,.. '. :. ,. .0
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ ❑ 0 ❑
Delinquent Behavior
❑ 0 0 0
Depressive-like Behavior
❑ ❑ ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ 0 0 El
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ 0 0 0
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) D 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
x ..
4zt
u"tu xtit
Age 0-10...$16.32 D:::,:: a�= 0
'z` ($496) ,"5:!(').!:. Basic Maint $4.93 day/$150mo Level 0 $0 'a
County Age 11-14...$18.05 a,�p '�', Therapy not needed or provided
Basic ,^"¥�"°. ($549) No crisis intervention,Minimal CPA t`A' by r�„ Level 0...$0
Maint • Age 15-21...$1927 ;.a +`, (None)
($586) involvement,one face-to-face visit t another source,i.e.mental health
r,`°0. +$.66 Respite Care or{
$20 with child .er month. w"
e:
g $19.73 Level 1 $8.22 day/$250 mos Level 1 $4.93/$150 mo
•`'( +$.66 Respite Caretr`p ( Minimal crisis intervention as needed, Regularly scheduled therapy,
1 ,m,r #". Level 1 ...$2.99
•Pu one face-to-face visit per month with ,^
Ymo) child, : up to 4 hours/month.da /$620 ;t. x "-.
^' 2-3 contacts .er month ., ,
SI
.. , $23.01 n' ti '.
1 1/2 +$.66 Respite Care :-"�7' Level 1 1/2 $9.86 day/$300 mo a'„ ------ ........._____
:;; ---------
+r $23.67 da /$720 mo f k
$26.30 `. Level 2 $11.51 day/$350 mo µ' Level 2 $9.86/$300 mo
2 , 4.66 Respite Care ' Occasional crisis intervention as needed, ' Weekly scheduled therapy, �� Level 2..$4.47
` ($26.96 day/$820 mo) ;' two face-to-face visits with child, .. 5-8 hours a month with 4 hours of
` .
T.1 LTA
2-3 contacts .er month .rou. them. . ;;x**°
s 'iti
$29.59 ga .' k'� ema
2 1/2 +$,66 Respite Care `� Level 2 1/2.........$13.15 day/$400 mo
($30.25 day/$920 mo) Kutx, : x
$32.88x'5 Level 3Zia
$14.79 day/$450 mo Level 3 $14.79/$450 mo
s"9 +$.66 Respite Care il ,a Ongoing crisis intervention as needed ', Regularly scheduled weekly °P
3 V. AVIP
ar *,aa. multiple sessions,can include Level 3..$6.02
weekly face-to-face visits with child, more
AL ($33.54day/$1020 mo) x ' and intensive coordination of than 1 erson,i.e.family them
c x ?>};„ multiple services. * for 9-12 hours/month) ''
$36.16xt:
3 1/2 i , +$.66 Respite Care k,'° °' Level 3 1/2 $16.44 day/$500 mo h: --------
($36.82 day/$1,120 mo) 1k ,,, +`�# -
: $39.45 Level 4 $18.08 day/$550 mo ,rm.4 Level 4 $14.79/$450 mo
+$.66 •Respite Care Ongoing crisis intervention as needed ;;' Regularly scheduled weekly
t' t; ' multiple sessions,can include '
RTC ,: a• � which includes high level of case �y more ) Level 4....Neg.
Drop
Down ($40.77 day/$1220 mo) x�h management and CPA involvement with !..0s.„:.
than 1 person,i.e.family therapy `„
','•' y child and provider and 2-3 face-to-face for 9-12 hours/month) §
p°, rs.Y: Y :e
K.
,'? �.,#. contacts •or week minimum. rv;°:; ^.�^
Assess ,, $26.96 day/$820 mo e)$ o f
Ittr
Rate x �a Respite) '°" -------
(Includes P ) 8`s¢ $11.51 day/$350 mo ''
gee
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: iata 1 ��"�"
Weld County Clerk to the Board
IA ' ' ' WELD COUNTY BOARD OF
n/F' J HUMAN SERVICES, ON BEHALF
` p ;4;V OF THE WELD COUNTY
14 ! DEPARTMENT OF HUMAN
4 ' SERVICES
By: / By:
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Savio House
325 King Street
Denver, CO
80219
By:l%2 /"/j4
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dire or
8 Weld County SS-23A Addendum a/�
aaa8
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services 7
(the"Agreement") between Smith Agency Inc. and Weld County �1 02
Department of Human Services for the period from
July 1, 2008 through June 30, 2009.
The following provisions, made this // ay of/ /f5,L , 2008, are added to the referenced
Agreement. Except as modified hereby, all terms oYthe Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#44882. These services will be for
children who have been deemed eligible for social services under the statutes,rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
Weld County SS-23A Addendum
02/9a-07/6 -
, 9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation" includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
WELD COUNTY DHS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID jDOB
M F I I
WORKER COMPLETING ASSESSMENT 1HH# (DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME I 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 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 ❑2%z)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%)1/2 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?
❑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?
❑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
❑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.)
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
02)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DHS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
t m _ t�. x k s
'�` st° x
:` �, dry ....` +a v ro w kt i JiL
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
❑ 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ 0
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
y�vx"' t ��'x
'a' *# "t{'hA Vy S 55
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ 0
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
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
,is:-L7:-.,y-c.
! y Gt . •-
L:,Y q!T
3 iq � � p.. 1 I.
J 6 tpP
3 $ P a
.. Age 0-10...$16.32 ';
a$ ($496) '3 Basic Maint $4.93 day/$150mo ' Level 0 $0
Count Age 11-14...$18.05 ,:, x Therapy not needed or provided
Basic" ($549) x,` No crisis intervention, Minimal CPA -. by Level 0...$0
Age 15-21...$19.27 >_? >'a'7 (None)
Maint x:;
($586) 6a involvement,one face-to-face visit :,. another source,i.e.mental health.
+$.66 Respite Care `1;
($20) 7, with child per month.
$19.73 ;h:'� Level 1 $8.22 day/$250 mo �' Level 1 $4.93/$150 mo
'`x:"' +$.66 Respite Care :r Minimal crisis intervention as needed, Regularly scheduled therapy,
1 w? Level 1 ...$2.99
one face-to-face visit per month with p '
c1 ($20.39 day/$620 mo) °.. child, M!l4 up to 4 hours/month.
2-3 contacts per month >'
vs>'i$23.01 ₹-
1 1/2 4.66 Respite Care .),,,:',.$. Level 1 1/2.........$9.86 day/$300 moi. ------- ----------
A- --------
($23.67 day/$720 mo) 3r a;r '�°
$26.30 . ' Level 2 $11.51 day/$350 mo at Level 2 $9.86/$300 mo
2 : +$.66 Respite Care dt Occasional crisis intervention as needed, t Weekly scheduled therapy, Level 2..$4.47
d
($26.96 day/$820 mo) =i; two face-to-face visits with child -° 5-8 hours a month with 4 hours of Vii''
;'x,: 2-3 contacts per month group therapy. �n
$29.59 'E;w.. f3 5'";
2 112 .1.,.'., 4.66+$,66 Respite Care ''≥a Level 2 1/2 $13.15 day/$400 mo =a --------------------- 4 m�
($30.25 day/$920 mo) x#v !-a
TA :
$32.88 .`y Level 3 $14.79 day/$450 mo k Level 3 $14.79/$450 mo ,
r
+$.66 Respite Care s a Ongoing crisis intervention as needed, ,iii.,::,:; Regularly scheduled weekly .
3 .`,:. multiple sessions,can include `'..
weekly face-to-face visits with child, more Level 3..$6.02
($33.54day/$1020 mo) > .- `-
. : and intensive coordination of liy.'. than 1 person,i.e.family therapy,
"b fir' multiple services. :1€ for 9-12 hours/monthly. t:).
„%k- .z'
n.; $36.16 g`. :..
_,
3 1/2 r„ +$,66 Respite Care z,; Level 3 1/2 $16.44 day/$500 mo , -------------------
($36.82 day/$1,120 mo) ,>.,,1 ,i3.„!
:ac
'`^" $39.45 of Level 4 $18.08 day/$550 mo ;)f. Level 4 $14.79/$450 mo j,„
+,r ,, 4ri.
' +$.66 Respite Care 's Ongoing crisis intervention as needed, ° ' Regularly scheduled weekly
4 Pa multiple sessions,can include
Drop ; ` which includes high level of case t'' more Level 4....Neg.
Down 5' ($40.77 day/$1220 mo) Poi?,A«3 management and CPA involvement with r,('% than 1 person,i.e.family therapy !bt,
fps child and provider and 2-3 face-to-face ,I for 9-12 hours/monthly. "`'7
t sir R.aea '.; ^{.
.:.. 9 it contacts 'er week minimum. °;wk
Assess $26.96 day/$820 mo vg's ,,,..,,
Rate '-p (Includes Respite) ate- ' ---------
IP M yy $11.51 day/$350 mo ay5a
i x. .� �;,:,f4 '43:n'.
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
4,1441401/4
ATTEST:
Weld rk to the Board
it. EN
WELD COUNTY BOARD OF
7 HUMAN SERVICES, ON BEHALF
r OF THE WELD COUNTY
`r °° / DEPARTMENT OF HUMAN
SERVICES
By: / lk By: -)-v—e sE o
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Smith Agency Inc.
7169 S Liverpool St
Centennial, CO 80016
c----------7-----
BY: . y%%` -
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
Dire for
8 Weld County SS-23A Addendum
aaP8--al/, i
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Special Kids Special Families and Weld County ` o
Department of Human Services for the period from fie
July 1, 2008 through June 30, 2009.
Tt *
The following provisions, made this if day of Autr/,i5f, 2008, are added to the referenced i/
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. p�
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#43184. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
t Weld County SS-23A Addendum
p
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section W. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public(federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records,making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
12. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
13. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
14. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
15. Add Paragraph 9 to Section VI. The Director of Human Services or designee may
2 Weld County SS-23A Addendum
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Human Services as a debt to Human Services or otherwise as
provided by law.
16. Add Paragraph 10 to Section VI. The contractor shall promptly notify Human Services
in the event in which it is a party defendant or respondent in a case, which involves
services provided under the agreement. The Contractor, within five(5) calendar days
after being served with a summons, complaint, or other pleading which has been filed in
any federal or state court or administrative agency, shall deliver copies of such
document(s) to the Human Services' Director. The term "litigation"includes an
assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or
foreclosure.
17. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX !TRAILS CASE ID 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 ❑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 ❑1'A)Two times month
02)Three times a month ❑2%z)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
02) 1 hour a day 02 %) I'''A-2 hours per day 03)2'A-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%) 5 to 7 hours per week
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 ❑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
O 3 Y2)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) Di)Less than 4 hours per month
02)4-8 hours per month 03)9-12 hours per month
4 Weld County SS-23A Addendum
•
WELD COUNTY DHS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..1 to this child.
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ 0 0
Destructive of Property/Fire
Setting ❑ ❑ 0 ❑
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ 0 0
Sexual Offenses
❑ ❑ 0 ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behavior/intensit of conditions which create the need for services that ap•ly to this child.
Z a:. a 4 k n
v e a ..
M •
n ......xu.
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ 0
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ 0 0
Education
❑ ❑ ❑ El
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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
§:i
iSM&IIr v, v...._%-'-'"°t
�4 Age 0-10...$16 32 .,
}'a ($496) Basic Maint $4.93 day/$150mo .kkvii
D4 Level 0 $0 ,
County ' ' Age 11-14...$18.05 Therapy not needed or provided I
Basic t� ($549) a No crisis intervention,Minimal CPA by �y Level 0...$0
Maint 641 Age 15-21...$19.27 (None)
($586) involvement,one face-to-face visit + � another source,i.e.mental health.
YS: +$.66 Respite Care `xR.
slia ($20) .�ryr: with child per month.
ry $19.73 ` Level 1 $8.22 day/$250 mo . Level 1 $4.93/$150 mo ••-•::,!..:.
1 x, +$.66 Respite Care Minimal crisis intervention as needed, '°�.x Regularly scheduled therapy,r ,k Level 1 ...$2.99
v�1 ri1 = one face-to-face visit per month with -
($20.39 day/$620 mo) rvi.g child, +* up to 4 hours/month. ;M
t
ill
�='' 2-3 contacts per month rkt
N $23.01 12 ` ,P
1 1/2 c +$.66 Respite Care :a vi Level 1 1/2.........$9.86 day/$300 mo N:m ------------------ '"
. 0 Via.
AI ($23.67 day/$720 mo) .!.ITS �r l °��,
.a -n< "`°
°�-` $26.30 " Level 2.. ... . ...$11.51 day/$350 mo t Level 2 $9.86/$300 mo ..,
sritt
�' +$.66 Respite Care " Occasional crisis intervention as needed, Weekly scheduled therapy,
2 : : F;.. k 'y* Level 2..$4.47
'_` ,,-ii two face-to-face visits with child, 5-8 hours a month with 4 hours of 4.0
� ($26.96 day/$820 mo) a� �y`w,
3duskg 2-3 contacts per month t group therapy. `r W
:n4 Yy VIES
$29.59
ff, LIZ
2 1/2 ; +$,66 •Respite Care e w Level 2 1/2 $13.15 day/$400 mo
"�,t'.i ($30.25 day/$920 mo) ,_ k -
z I ., 1y
y% $32.88 f`, q Level 3 $14.79 day/$450 mo 'v Level 3 $14.79/$450 mo
'iS
+$.66 Respite Care p ;,, Ongoing crisis intervention as needed Regularly scheduled weekly ,
~, multiple sessions,can include '
,f', Level 3..$6.02
weekly face-to-face visits with child, FA put
more
($33.54day/$1020 mo) " " -
_-_., and intensive coordination of 1„'; than 1 person,i.e.family therapy.A
a multiple services. • for 9-12 hours/monthly.
cl
v,g $36.16 , tp,
3 112 yam.'; +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo At!
t.
---- a"� --------
'"�= ($36.82 day/$1,120 mo) 9iaN
y '
t" ligi
$39.45 Level 4 $18.08 day/$550 mo z,-.y Level 4.........$14.79/$450 mo Iv
t +$.66 Respite Care k" Ongoing crisis intervention as needed. '.= Regularly scheduled weekly '1.
4 a ,. s } multiple sessions,can include
RTC pzf` which includes high level of case v^ t more Level 4....Neg.
Drop4,5t, tiM
Down "k ($40.77 day/$1220 mo) management and CPA involvement with 5;111than 1 person,i.e.family therapy,{ aill
til i_ , child and provider and 2-3 face-to-face t for 9-12 hours/monthly. .i
i.contacts .er week minimum. , . 5-F
in kiki
Assess ,W4' ' , .e
$26.96 day/$820 mo mil
Rate w @ (Includes Respite) a $11.51 day/$350 mo 1
KA
gioti ,44.
Admin.Overhead Rate: As of 7/01/08
$6.91 day/$210.00 month
7
Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: 14 ��'�""� ""'f
Weld County Clerk to the Board
'
WELD COUNTY BOARD OF
.. ,•,. HUMAN SERVICES, ON BEHALF
I� f OF THE WELD COUNTY
ei_ 11 / DEPARTMENT OF HUMAN
��'���� SERVICES
By: 4 A By: 7 td-G,.,,
Deputy Cl to the Board Chair Signature
William H. Jerke
AUG 1 1 2008
CONTRACTOR
Special Kids Special Families
424 W Pikes Peak Ave
Colorado Spri 09 it
By: �/
WELD COUNTY DEPARTMENT
OF HUMAN SERVICES
By:
rector
8 Weld County SS-23A Addendum
Hello