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Home My WebLink About20083355.tiff MEMORANDUM '_ate,gipiv\t DATE: December 18, 2008 1'�� William H. Jerke, Chair, Board of Cou ty Comm' sio r IlDTO:O FROM: Judy A. Griego, Director, Human Se es Dep meet Vi W • COLORADO RE: Addendums to Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements between the Weld County Department of Human Services and Various Providers to be Placed on the Consent Agenda Enclosed for Board approval are Addendums to the Individual Provider Contracts for Purpose of Foster Care Services and Foster Care Facility Agreements between the Weld County Department of Human Services and Various Providers. These Agreements are to be placed on the Board's Consent Agenda. Type of Facility No. Provider Location Daily Rate Foster Home 1 Reed, Matthew and Brooke Greeley, Colorado $16.32 - $40.11 Foster Home 2 Reyna, Ali and Jessica Greeley, Colorado $16.32 - $40.11 Foster Home 3 Montez, Joseph and Alexis Greeley, Colorado $16.32 - $40.11 The term for these Agreements is July 1, 2008 through June 30, 2009. If you have questions, please give me a call at extension 6510. f'k&C7 3�� 2008-3355 Cc11C�,14 ,�lC}E�,i�ci 1 �3( . _ -2 :1.7 _ 0 ns ce4 DEPARTMENT OF HUMAN SERVICES P.O. BOX A 1 GREELEY, CO. 80632 �l Website: eld.co.us 2 Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 lURe COLORADO MEMORANDUM TO: Judy Griego — Director FROM: Lesley Cobb- Child Welfare Rate Negotiator DATE: December 12, 2008 SUBJECT: Weld County Addendum to the Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement. Attached please find the Weld County Addendums to the Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreements for the following County foster care providers: 2008-2009 SIGNED CONTRACTS FOR COUNTY FOSTER CARE PROVIDERS ^fit.'- ' i �, .. r:� f c, i?7.. .. G e ` .... ']er B a 1°)'kik ''9af Reed, Matthew and Greeley, CO 1 Brooke 1537242 6129 W 6`h St 80634 Greeley, CO 2 Reyna, Ali and Jessica 1502220 3304 Syrah St 80634 These contracts have been presented for consent approval to the Board of County Commissioners however; I am requesting your signature along with the Boards to complete these contracts for the FY 2008-2009. If you have any questions please call me at Ext. 6441. WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Reed, Matthew and Brooke and the Weld County Department of Human Services for the period from July 1, 2008 through June 30,2009. The following provisions,made this c27day of " z;2008, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement,based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1537242. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall be submitted to and approved by the appropriate County staff as set forth in the Foster Parent Handbook. Reimbursement for placement services shall be paid from the date of placement up to, but not including the day of discharge. All billings by the Provider must be in a format approved by the County and may be returned unpaid if submitted in an unapproved format or inadequate documentation is provided. All billings are to be submitted by the 4th of each month following the month of service. If the billing is not submitted within twenty-five(25) calendar days of the month following service, it may result in forfeiture of payment. t Weld County Addendum to the CWS-7A 6. The Director of Human Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Human Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Human Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Human Services and the Provider, or by Human Services as a debt to Human Services or otherwise as provided by law. 7. Provider shall promptly notify Human Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Human Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. This review team convenes every Monday morning, excluding holidays but may hold emergency staffings as needed. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Home Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Human Services or Weld County Department of Human Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. To schedule physical and dental examinations within 48 hours after a child is placed in provider's care. Medical examinations need to be completed within 10 days of the child being placed with Provider and dental examinations need to be completed within 14 days of the child being placed with Provider. All documentation of these examinations will be placed in the Foster Child's Placement Information Management Binder or as indicated in the Foster Parent Handbook. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 2 Weld County Addendum to the CWS-7A 6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB M F I I WORKER COMPLETING ASSESSMENT HH# 'DATE OF ASSESSMENT AGENCY NAME 'PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan? ❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week ❑2) 3-4 round trips a week. 02%)5 round trips a week 03) 6 round trips a week ❑3%z)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑Basic Maint.)No participation required ❑1)Once a month 01%)Two times month 02)Three times a month 02%)Once a week 03)Two times a week 03%)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑Basic Maint.)No educational requirements 01)Less than a '/:hour per day 01%)%hour a day 02) 1 hour a day 02 %) 1''/-2 hours per day 03)2'/-3 hours per day 03%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 0 Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week ❑2) 8 to 10 hours per week 02%) 11 to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedin, bathing,grooming,physical, and/or occupational therapy? ❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'%x) 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. ❑1%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County Addendum to the CW S S WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) BEHAVIOR ASSESSMENT Please rate the behavior/mtenstty of conditions which create the need for services that apply to this child „rat}sa,/,' s w` } as * - F' yK i } } "' - I e}r ...v�..,.r.:.'*..w...a..�.�.. ,y..B . ,a�..�. Aggression/Cruelty to Animals ❑ ❑ 0 ❑ Verbal or Physical Threatening ❑ 0 0 ❑ Destructive of Property/Fire Setting 0 0 0 ❑ Stealing ❑ O 0 ❑ Self-injurious Behavior ❑ ❑ 0 ❑ Substance Abuse ❑ ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ O 0 ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ 0 0 Sexual Offenses ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CWS-7 • BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) '5,. Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child. ". •: ' 5."` ""Ikt-7 •d p u2 t°'1'y � � :� . �. v=.v�, s'yk a ° �gvary " ' Sip r r# r 18tl ';(1:411:f, hagM� ..4..%5"sa°.rs. .:Itt ' ' °°`� 4 cf ,� a w...v3'4kY'x.`'t.. �""ax'�t'�':'�:`�+.-h#�'t:x,o'.....wi i*7w..tw.k ...ate;w< ..a .tda.,in Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ 0 Medical Needs (If condition is rated"severe",please complete ❑ ❑ ❑ ❑ the Medically fragile NBC) Emancipation ❑ ❑ ❑ ❑ Eating Problems ❑ ❑ 0 0 Boundary Issues ❑ 0 ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ 0 Involvement with Child's Family ❑ 0 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS-'. WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) e, A•e0-10...$16.32/da $496/month County Basic Ot A•e 11-14...$18.05/da $549/month Maint. A.e 15-21...$19.27/da $586/month +Res•ite Care$.66/da $20/month $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) 144, -444 $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 +$.66 Respite Care Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$,66 Respite Care Total Rate=($30.25 day/$920 month) 13/44.1:r; $32.88 3 +$.66 Respite Care Total Rate=($33.54day/$1020 month) $36.16 3 112 +$.66 Respite Care Total Rate=($36.82 day/$1,120 month) 4 $39.45 TRCCF Drop Down 4.66 Respite Care Total Rate=($40.11 day/$1220 month) Assessment Rate $30.25 day/$920 month(Includes Respite) (30 day max) 7.174 Effective 7/1/2008 7 Weld County Addendum to the CWS- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: �� ' " " ""'r Weld County Clerk to the Board fl : WELD COUNTY BOARD OF HUMAN SERVICES, ON BEHALF OF THE WELD COUNTY TI ID sei ` DEPARTMENT OF HUMAN SERVICES s. if By: i By: '2.5 cz✓ Deputy erk o the Board Chair Signature DEC 2 2 2008 PROVIDER: Reed, Matthew and Brooke 6129 W 6th St Greeley, CO 80634 1 By: ' '' Q Q G_ ( ign ture) WELD COUNTY DEPARTMENT / OF HUMAN SERVICES 1 By: (D' ector Sig9a re) 1 8 Weld County Addendum to the CWS-7A olaa— 385 WELD COUNTY ADDENDUM To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Reyna, Ali and Jessica and the Weld County Department of Human Services for the period from July 1, 2008 through June 30, 2009. The following provisions, made this 30 day of , 2008, are added to the referenced Agreement. Except as modified hereby, all terms o he Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement,based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1502220. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall be submitted to and approved by the appropriate County staff as set forth in the Foster Parent Handbook. Reimbursement for placement services shall be paid from the date of placement up to, but not including the day of discharge. All billings by the Provider must be in a format approved by the County and may be returned unpaid if submitted in an unapproved format or inadequate documentation is provided. All billings are to be submitted by the 4th of each month following the month of service. If the billing is not submitted within twenty-five (25) calendar days of the month following service, it may result in forfeiture of payment. Weld County Addendum to the CWS-7A 6. The Director of Social Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term"litigation"includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. This review team convenes every Monday morning, excluding holidays but may hold emergency staffings as needed. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Home Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Social Services or Weld County Department of Social Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. To schedule physical and dental examinations within 48 hours after a child is placed in provider's care. Medical examinations need to be completed within 10 days of the child being placed with Provider and dental examinations need to be completed within 14 days of the child being placed with Provider. All documentation of these examinations will be placed in the Foster Child's Placement Information Management Binder or as indicated in the Foster Parent Handbook. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 2 Weld County Addendum to the CWS-7A • • 6. To read,be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) DENTIFYING INFORMATION :HILD'S NAME STATE ID# SEX RAILS CASE ID DOB M F YORKER COMPLETING ASSESSMENT 1FIH# rATE OF ASSESSMENT IGENCY NAME PROVIDER NAME I PROVIDER TRAILS ID 1NSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. ['HE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: ' 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ['Basic Maint.)Less than one round trip a week 01)One round trip a week ❑1' )2 round trips a week 02)3-4 round trips a week. ❑2%)5 round trips a week 03)6 round trips a week 03%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑Basic Maint.)No participation required ❑1)Once a month ❑1'h)Two times month 02)Three times a month 02%)Once a week 03)Two times a week ❑3'/)Three times a week or more P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑Basic Maint.)No educational requirements ❑1)Less than a%hour per day 01%) 'A hour a day 02) 1 hour a day 02%) 11/2-2 hours per day 03)2%:-3 hours per day 03%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week 02%) 11 to 14 hours per week ❑3)Constant basis during awake hours 03%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding bathing,grooming,physical,and/or occupational therapy? O Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 01%) 5 to 7 hours per week ❑2) 8 to 10 hours per week ❑2'/) 11 to 15 hours per week ❑3) 16 to 20 per week 03%)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e. mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 01%)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 02%)Face-to-face contact three times per month with child and occasional crisis intervention. 03)Face-to-face contact weekly with child and occasional crisis intervention. 03%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination of multiple services. **Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one County foster child is with the same provider. T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)Not needed or provided by another source(i.e. Medicaid) 01)Less than 4 hours per month 02)4-8 hours per month 03)9-12 hours per month 4 Weld County Addendum to the CWS-7. • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) BEHAVIOR ASSESSMENT Please rate the behavior/intensit of conditions which create the need for services that a.•1 to this child. Aggression/Cruelty to Animals ❑ O ❑ ❑ Verbal or Physical Threatening ❑ ❑ O ❑ Destructive of Property/Fire Setting O O O ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ O Substance Abuse O O ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ O O Sexual Offenses O O O O 5 Weld County Addendum to the CWS-7. • BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Please rate the behavior/intensit of conditions which create the need for services that a..1 to this child. Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ 0 ❑ Medical Needs (If condition is rated"severe",please complete ❑ ❑ ❑ ❑ the Medically fragile NBC) Emancipation ❑ ❑ 0 ❑ Eating Problems ❑ ❑ 0 ❑ Boundary Issues ❑ ❑ ❑ ❑ Requires Night Care ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ 0 ❑ CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CWS-7. WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) Age 0-10...$16.32/day ($496/month) County Basic Age 11-14...$18.05/day ($549/month) Maint. Age 15-21...$19.27/day ($586/month) +Respite Care$.66/day ($20/month) 1Y $19.73 1 +$.66 Respite Care ry Total Rate= ($20.39 day/$620 month) ' $23.01 1 1/2 +$.66 Respite Care Total Rate=($23.67 day/$720 month) $26.30 2 c-=. +$.66 Respite Care `s'z? Total Rate=($26.96 day/$820 month) $29.59 2 112 `'- ' +$.66 Respite Care Total Rate=($30.25 day/$920 month) $32.88 3 " w +$.66 Respite Care Total Rate=($33.54day/$1020 month) 1Xi'a $36.16 3 1/2 n 4.66 Respite Care •:1 Total Rate=($36.82 day/$1,120 month) fix.. $39.45 4 `'' +$.66 Respite Care TRCCF Drop Down =:1 Total Rate=($40.11 day/$1220 month) Assess Rate $26.96 day/$820 month(Includes Respite) (30 day max) 4E�h's , Emergency Placement Rate $30.25 day/$920 month(Includes Respite) (30 day max) s4=„ S7u Effective 07/01/2008 7 Weld County Addendum to the CWS-7 IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: iiteiS"""'r Weld County Cl tilt q�J C- - .,: 4-;' r WELD COUNTY BOARD OF o _ SOCIAL SERVICES, ON BEHALF 1861 � OF THE WELD COUNTY DEPARTMENT OF SOCIAL Uigf � SERVICES By: .9 By: 'T'7�G,--- Deputy rk to the Board Chair Signature DEC 2 2 2008 PROVIDER: TitSSiCcc e'VeL «NAME» «MAILING ADDRESS» «CITY_STATE_ZIP» By: _P (Signature) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: )0,th, 0( [Director i tur i ) 8 Weld County Addendum to the CWS-7e --. N. • WELD COUNTY ADDENDUM F To that certain Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (the "Agreement") between Joseph and Alexis Montez and the Weld County Department of Human Services for the period from July 1, 2008 through June 30, 2009. The following provisions, made this 29th day of September, 2008, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. GENERAL PROVISIONS 1. County and Provider agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Provider unless the child is placed in a County certified kinship foster care home or if the child is placed in a County foster/adoption home as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will be reimbursed at the County Basic Maintenance level on the Needs Based Care Rate Table, designated as Attachment C, regardless of the child's level of need. 2. County agrees to purchase and Provider agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the Weld County Certified Foster Care Home identified as Provider ID#1582735. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. All bed hold authorizations and payments are subject to a 3 day maximum for a child's temporary absence from a facility, including hospitalization. Bed hold requests must have prior written authorization from the Department Administrator before payment will be release to Provider. 4. Any additional costs for specialized services, which may include but are not limited to; Co-pays, deductibles, or services not covered by Medicaid, will need to be authorized, in writing by the Department Administrator, prior to the service being performed. Any payment for specialized services not authorized in writing may be denied. 5. All reimbursement requests shall be submitted to and approved by the appropriate County staff as set forth in the Foster Parent Handbook. Reimbursement for placement services shall be paid from the date of placement up to, but not including the day of discharge. All billings by the Provider must be in a format approved by the County and may be returned unpaid if submitted in an unapproved format or inadequate documentation is provided. All billings are to be submitted by the 4th of each month following the month of service. If the billing is not submitted within twenty-five (25)calendar days of the month following service, it may result in forfeiture of payment. 1 Weld County Addendum to the CWS-7A 02©408- 6. The Director of Social Services or designee may exercise the following remedial actions should s/he find that the Provider substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Provider as outlined in the State Department Staff Manual Volume VII and/or County Department Policy and Procedure Manual. These remedial actions are as follows: A. Withhold payment to the Provider until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Provider cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; C. Recover from the Provider any incorrect payment due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Provider, or by Social Services as a debt to Social Services or otherwise as provided by law. 7. Provider shall promptly notify Social Services in the event in which it is a party defendant or respondent in a case, which involves services provided under the agreement. The Provider, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. PROVIDER AGREES: 1. To attend or participate, if requested by the Department, in staffing a child's placement with the Utilization Review Team. This review team convenes every Monday morning, excluding holidays but may hold emergency staffings as needed. 2. To request a staffing if considering giving notice to remove a child, except in emergency situations. These requests shall be made through the child's caseworker and/or the provider's Foster Home Coordinator. 3. To cooperate with any contractors hired by Weld County Department of Social Services or Weld County Department of Social Services staff to preserve placement in the least restrictive placement appropriate and to comply with the treatment plan of the child. 4. To schedule physical and dental examinations within 48 hours after a child is placed in provider's care. Medical examinations need to be completed within 10 days of the child being placed with Provider and dental examinations need to be completed within 14 days of the child being placed with Provider. All documentation of these examinations will be placed in the Foster Child's Placement Information Management Binder or as indicated in the Foster Parent Handbook. 5. To attend all necessary school meetings and support any plan that is developed regarding the child in order to promote educational success. 2 Weld County Addendum to the CWS-7A 6. To read, be familiar with and agree to the terms and conditions as set forth in the Foster Parent Handbook. 7. To report to the County Department and/or local law enforcement any known or suspected child abuse or neglect as set fourth in Section 19-3-304, C.R.S. 8. To maintain/access information on the Foster Parents Internet Database On-line System (FIDOS) as indicated in the Foster Parent Handbook. 9. To maintain/update information in the Foster Child Placement Information Management binder. The binder may be reviewed on a monthly basis and signed off by child's caseworker and/or the provider's Foster Home Coordinator. 10. To maintain behavior observation notes as required by the level of care assessed for each child as indicted in the Foster Parent Handbook. EXHIBITS: (Please refer to pages 4-7) 3 Weld County Addendum to the CWS-7A WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (Exhibit B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX TRAILS CASE ID DOB M F WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT • For each question below,please select the response which most closely applies to this child. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan? ❑Basic MainL)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%z)5 round trips a week 03)6 round trips a week ❑3%)7 round trips or more P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions? ❑ Basic Maint.)No participation required ❑l)Once a month 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 ❑1) Less than a %z hour per day 01%) '/ hour a day ❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/-3 hours per day 03%)More that 3 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week ❑2)8 to 10 hours per week ❑2%z) 11 to 14 hours per week 0 3)Constant basis during awake hours 03%)Nighttime hours P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feedini bathing,grooming,physical,and/or occupational therapy? 0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week 02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week ❑3'/z)21 or more hours per week A 1. How often is CPA/County case management required?(Does not include therapy) ❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention. (i.e.mutual care placements.) ❑1)Face-to-face contact one time per month with child and minimal crisis intervention. 011/2)Face-to-face contact one time per month with child and occasional crisis intervention. 02)Face-to-face contact two times per month with child and occasional crisis intervention. 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 I. How often are therapy services needed to address child's individual needs per NBC assessment? 00)Not needed or provided by another source(i.e.Medicaid) ❑l)Less than 4 hours per month ❑2)4-8 hours per month ❑3)9-12 hours per month 4 Weld County Addendum to the CWS-7 WELD COUNTY NEEDS BASED CARE ASSESSMENT (Exhibit B) BEHAVIOR ASSESSMENT ate the behavior/intensity of conditions which create the need for services that a..1 to this child. p �ydx ._r N4� Y Please y.'OSjittfil sott3 itvetN xl r '�v � s�!! � 5.3 `tu�c ��* ' ' .%;:115 y s dc �! v+ f�u )! a >+3 ,� i ! it .�' m �5f≤Sl l AV:PT •TIL..�.:,. ''� ..la�'F .!�l rem i..r .... TAP . Aggression/Cruelty to Animals ❑ 0 ❑ ❑ Verbal or Physical Threatening ❑ ❑ 0 ❑ Destructive of Property/Fire Setting 0 ❑ 0 O Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ 0 0 Substance Abuse ❑ ❑ 0 0 Presence of Psychiatric Symptoms/Conditions ❑ O ❑ O Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Sexual Offenses ❑ ❑ ❑ ❑ 5 Weld County Addendum to the CW S-i BEHAVIOR ASSESSMENT CONTINUED (Exhibit B) Please rate the behavior/intensity of conditions which create the need for services that as.ly to this child. 4 'PIP.. alphi Sxv. y ,: vs N az,�x '1'4,:',/n-lar-r.tr. . f , li 'Q{ 7lf1J �_• U Yt E'!i Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ Li ❑ or Delinquent Behavi ❑ ❑ O O Depressive-like Behavi r o ❑ ❑ ❑ O Medical Needs (If condition is rated"severe',please complete El ❑ 0 ❑ the Medically fragile NBC) Emancipation ❑ ❑ O ❑ Eating Problems ❑ ❑ ❑ 0 Boundary Issues O ❑ 0 0 Requires Night Care ❑ ❑ 0 0 Education ❑ 0 ❑ 0 Involvement with Child's Family ❑ 0 ❑ 0 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT: (check level of need) ❑ 0 111 1 ❑ 2 ❑ 3 6 Weld County Addendum to the CW S WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE RATE TABLE (Exhibit C) fit `£�ti}:r i r i - x , ':f "' ''..4: Age 0-10...$16.32/day ($496/month) x County Basic ya is Age 11-14...$18.05/day ($549/month) Maint. `_ OE Age 15-21...$19.27/day ($586/month) r +Respite Care$.66/day ($20/month) iar= $19.73 1 +$.66 Respite Care Total Rate= ($20.39 day/$620 month) $23.01 1 1/2 +$.66 Respite Care ==" Total Rate=($23.67 day/$720 month) ilb �yFe $26.30 +$.66 Respite Care 2 vi. Eni Total Rate=($26.96 day/$820 month) $29.59 2 1/2 +$.66 Respite Care ulx'.- Total Rate=($30.25 day/$920 month) "ti"2 $32.88 3 z , +$.66 Respite Care Total Rate=($33.54day/$1020 month) qvw $36.16 3 112 A`: +$.66 Respite Care yw1y Total Rate=($36.82 day/$1,120 month) Tt ra. $39.45 4 i. +$.66 Respite Care TRCCF Drop Down = Total Rate=($40.11 day/$1220 month) Yid • iiiit Assessment Rate 1 $30.25 day/$920 month(Includes Respite) (30 day max) a Effective 7/1/2008 7 Weld County Addendum to the C W S- IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: �"'�" 14 " _"_"""'t Weld County Cler0. t-. WELD COUNTY BOARD OF e• SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY ', a DEPARTMENT OF SOCIAL a to SERVICES By: By: ' 2, z�✓ Deputy Cl z to the Board Chair Signature DEC 2 2 2008 PROVIDER: Joseph& Alexis Montez 3660 W. 25th St. #1102 Greeley, Colorado 80634 By: ". ,7 (Sigre) WELD COUNTY DEPARTMENT t OF SOCIAL SERVICES )J Q— By: (Di t ector Sign [tre) 8 Weld County Addendum to the CWS-7A w&8-335 E Hello