HomeMy WebLinkAbout20072846.tiff 0
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
I GREELEY, CO. 80632
Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
OFax Number(970)353-5215
COLORADO MEMORANDUM
TO: Judy Griego - Director
FROM: Lesley Cobb - Child Welfare Rate Negotiator
DATE: August 23, 2007
SUBJECT: Weld County Addendums to the Agreement to Purchase — State
SS-23A
Attached please find the Weld County Addendums to the Agreement to Purchase Child
Placement Agency Services for the following providers:
1) Adoption Options—Provider ID 45078
2) Ariel Child Placement Agency—Provider ID 90205
3) Bethany Christian Services Provider ID - 45514
4) Bridges Inc. —Provider ID 1980
5) Children's Network—Provider ID 77512
6) Commonworks DBA Synthesis—Provider ID 104085
7) Dungarvin— Provider ID 98960
8) Griffith Centers for Children Inc.—Provider ID 1531601
9) Hope and Homes—Provider ID 29867
10)Hope Family Services—Provider ID 42942
11)Imagine—Provider ID 21369
12)Loving Homes Inc.—Provider ID 72767
13)Lutheran Family Services of Colorado —Provider ID 45080
14)Maple Star Colorado—Provider ID 90967
15)Smith Agency Inc. —Provider ID 44882
16)Special Kids Special Families—Provider ID 43184
These contracts have been approved for consent by the Board of County Commissioners
however; I am requesting your signature along with the Boards to complete these contracts for
the FY 2007-2008. If you have any questions please call me at Ext. 6441.
SS 0031
2007-2846
witI dct ee,'SS'
cnlr< -aoo7
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Options and Weld County Department
of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of S/ , 2007, 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, 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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
• (Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F I'TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# I DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑l)One round trip a week 01%)2 round trips a week
❑2)3-4 round trips a week. ❑2%) 5 round trips a week 03) 6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
❑2)Three times a month 02%)Once a week 03)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a 'h hour per day ❑1'/) '/2 hour a day
❑2) 1 hour a day 02 %) 1%-2 hours per day 03)2%z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 011/2)5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑l)3 to 4 hours per week ❑1'/) 5 to 7 hours per week
❑2) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑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.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%:)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e. Medicaid) ❑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
W COUNTY
•
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.
_row96 i a'
N �r ki•!y, I 1 1:0tt ' f { 1 ::5 s �,,
s?l�.a i'+'' +' . 1.. X444..lecauffallek 6 ,akki i x is rte.; - p y
6
...m:'';, .,.--A.., tru-i:v:l+�I,. IL. ...... .. tea .;°r .,.ra4i , 4 kti .`.'iu t„ ..
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
0 0 0 0
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ O O
Enuresis/Encopresis
❑ ❑ 0 0
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ 0 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.
�� e7w�a :t xy� t� a
err -diti �.
F:i .: 5 e 'f.. 3 >e x a c In' �y, t 1�A„
.,,. .,:,-.;air ,! H,. Y�� ,. ,3:3 '". .r.._.r 4.44,-.- ._q„i¢ .R, + .. ..��_,. s .�.._ s as :.,�._.J m:.≥a'" ., ....
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
O 0 0 0
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete O 0 ❑ ❑
the Medically fragile NBC)
Emancipation
O 0 0 0
Eating Problems
O 0 0 0
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ 0 0 0
Education
❑ 0 0 0
Involvement with Child's Family
O 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
x
' i.x1r. 6 d 'b 6
it
'' x 1 ',>a vs y A'+aav"�`;,',, `� :v+r,�3: t' y *,,x '�y. a •h,�wu 4 * •'5,''i . a".; ,n �t :a` ry
Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo Level 0 $0
County
r61 Age 11-14...$18.05 3' 14
.. Therapy not needed or provided
Banc ihn
($549) : No crisis intervention, Minimal CPA , .. by Level 0...$0
Maint Age 15-21...$19.27 =piti • (None)
' +$,66($ 8 Respite Care rl,r involvement,one face-to-face visit another source,i.e.mental health.
• •
($20) 1-g--` with child per month.
$19.73 '.. Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo •
+$.66 Respite Care Minimal crisis interention as needed, Regularly scheduled therapy,
1Level 1 ...$2.99
one face-to-face visit per month with =
• ($20.39 day/$620 mo) litil child, up to 4 hours/month.
' 2-3 contacts per month ,.
$23.01 `
P
1 1/2 ' • +$.66 Respite Care a.7. Level 1 1/2 $9.86 day/$300 mo It,_
.a:• ($23.67 day/$720 mo) _.; _
$26.30 ari Level 2 $11.51 day/$350 mo a- Level 2 $9.86/$300 mo
•
r ii' +$.66 Respite Care Occasional crisis intervention as needed, ..-,4.•;:.,,k Weekly scheduled therapy,
2Level 2..$4.47
`' '3iu' two face-to-face visits with child, 5-8 hours a month with 4 hours of
' t ($26.96 day/$820 mo) 1
2-3 contacts per month t:,;2 group therapy. •
'
$29.59 �:o:,
tha::i . ,
2 1/2 ';i3' +$.66 Respite Care E Level 2 1/2.........$13.15 day/$400 mo (::{q
•
($30.25 day/$920 mo) �r
$32.88 ,- Level 3 $14.79 day/$450 mo ' Level 3 $14.79/$450 mo
+$.66 Respite Care ..;W:-. Ongoing crisis intervention as needed, Regularly scheduled weekly
3 x+ t multiple sessions,can include Level 3..$6.02
_ weekly face-to-face visits with childx more
($33.54day/$1020 mo) k.Ei and intensive coordination of Al than 1 person,i.e.family therapy,
y a
multiple services. ",„; for 9-12 hours/monthly.
$36.16 i, -�,
31/2 • +$.66 Respite Care T7A�_, Level 3 1/2 $16.44 day/$500 mo n
Ei('I ($36.82 day/$1,120 mo) is" "4-'
PI
$39.45 '`I Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, •4 Regularly scheduled weekly
4 •z ' multiple sessions,can include
U op '` which includes high level of case more Level 4....Neg.
x
Down :31' management and CPA involvement with than 1 person,i.e.family therapy,
($40.77 day/$1220 mo) _,. ',,,`,
t'::• child and provider and 2-3 face-to-face ict for 9-12 hours/monthly.
contacts •er week minimum.
v Bag
Ai qhith MI,:
Assess 0. $26.96 day/$820 mo ?a i tH+c
oi•
Rate f: (Includes Respite) 'mil $11.51 day/$350 mo ! ;N
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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: a" N.
Weld County eC
r
1861A iJ' '� WELD COUNTY BOARD OF
pSOCIAL SERVICES, ON BEHALF
� u 0�� OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
_r_ SERVICES
By: /a-Iiiftl.1/4,ea By: �Deputy Clthe Board David E. Long, Ch
P 0 5 2001
CONTRACTOR
Adoption Options
13900 E Harvard Ave, Suite 200
Aurora, CO 80014
By: Cl UY
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D rector
8 Weld County SS-23A Addendum
.-9nO7- .V.PS//
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency,Services
(the "Agreement") between Ariel Child Placement Agency and Weld'County
Department of Social Services for the period from /0
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of J.; 1/ , 2007, 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#90205. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2_ All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
o?oo 2-a85/ec,
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term"litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
• (Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX 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 ❑1)One round trip a week 01%)2 round trips a week
❑2)3-4 round trips a week. ❑2' ) 5 round trips a week 03) 6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month 01%)Two times month
02)Three times a month 02%)Once a week ❑3)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a'h hour per day Dv A) '/z hour a day
❑2) 1 hour a day 02 %) 1',4-2 hours per day 03)21/2-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week 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.
O 11/4)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0) Not needed or provided by another source(i.e.Medicaid) 01)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 DSS
••
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
ti r tt. ' a a t a5, , I
tNi 35q 3` �ti d } '�`-i'Waiya�j'
-9'.
vi/ ...e... -..,—_..r; ICe�kt� .A .'� ' s.,.t,' s—. u ,a-�r:� xaNeititatotrigaikar
ri !ixr ITIEISMNP Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ 0 0
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
O 0 ❑ 0
Self-injurious Behavior
O 0 0 0
Substance Abuse
O 0 0 0
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ 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.
i
v
ti
k xl �aiaii 1 < x ,ess ;irk i ¢ $1 X5
s .. .- .. ' +SS `:...._ :. _ - ..i ,a•, (* + -.,uv, tu,._,.w yay„ 1 4" ^1 a ti
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
O ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
O 0 0 0
Requires Night Care
❑ ❑ 0 0
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
. • WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
liglialjg, t a.'ice' ` '"z 'a ≥ a a r rt. 1 6
1,1
` .w ,�s i. v 4 y,..+. , , .- s y .l , ° eaih y'ye°: d °� ma p •. `�t '.z ;,.
5 4 oontoo I 1 .. �Ti4R '.5 k'g�V„ ift'°i iaii. i iq y,'*v'R,ilailla ""-- Y4,-
..,i
'.:'�- � e.e �b. �'�'� .,g.��4._°......�5� f�r.s "°ak `�"e:°�•ez..a�•�'.hyANS ��zv'. 'ki �tatiMgitafi �
.. .tea: .., Div. ..:, u`a,�...dm, t ... "� .'•w'# en.y
4444444 7444;4444 444 4404g4,44444444.4
EA ' a
Age 0-10...$16.32($496) ''� i Basic Maint $4.93 day/$150mo T.% Level 0 $0 •1t
l
County gas�' -_Age 11-14...$18.05 :_: Therapy not needed or provided
County
=ip ($549) ;`r"'§i? No crisis intervention,Minimal CPA by Level 0...$0
Maint. it
Basic Age 15-21...$19.27 •; 44
(None)
($586) . involvement,one face-to-face visit another source,i.e.mental health. -(
+$.66 Respite Care
($20) '- ' with child per month.
$19.73 _ Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo '0
r,i II
i
+$.66 Respite Care Minimal crisis interention as needed, sei Regularly scheduled therapy, 4:r
1 one face-to-face visit per month with Level 1 ...$2.99
($20.39 day/$620 mo) child, up to 4 hours/month
rlia
2-3 contacts per month „ °l
$23.01 lit.,
1 1/2 'Lrt,. +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo
($23.67 day/$720 mo)
' $26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo
.11
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy __> Level 2..$4.47
two face-to-face visits with child, 5-8 hours a month with 4 hours of la
n ($26.96 day/$820 mo) ha O
ilPi_: 2-3 contacts per month group therapy.
't' $29.59Ti0
2 1/2 , +$.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo
°'a ($30.25 day/$920 mo)
i
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo SS h
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly Si
lip 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 than 1 person,i.e.family therapy, 5,,:
multiple services. for 9-12 hours/monthly.
$36.16 as+F$
gym,
3 112 : $.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo „i:,,:
($36.82 day/$1,120 mo) =4'ss4i
' le
fir
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo ?4-
A
4-$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly '
4 if multiple sessions,can include
RTC which includes high level of case more tiliiiF Level 4....Neg.
Drop .l
Down j ($40.77 day/$1220 mo) • management and CPA involvement with than 1 person,i.e.family therapy, ii i
al
• child and provider and 2-3 face-to-face for 9-12 hours/monthly.
contacts °er week minimum. 8, wlr
Assess *4;'+a., $26.96 day/$820 mo "t•+
Rate ;: (Includes Respite) -,„ $11.51 day/$350 ma zy
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 month
7 Weld County SS-23A Addendum
1. IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld Cou 1 t
ssi `t r iffc
WELD COUNTY BOARD OF
'lc',- SOCIAL SERVICES, ON BEHALF
� :' OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: /_� ?t at 2 By:
Deputy erk to the Board David E. Long, Chai
S 0 5 2007
CONTRACTOR
Ariel Child Placement Agency
2938 North Ave, Suite G
Grand notion, COE� 8115504 gj�� 0- n
By: "vet a ("v't�"'I.C, 1-4-Yj
WELD COUNTY DEPARTMENT 81210
OF SOCIAL SERVICES
By:
irector
8 Weld County SS-23A Addendum
_1 AA 7 -.2.Pyti
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services '''.,
(the "Agreement") between Bethany Christian Services and Weld County /�
Department of Social Services for the period from +;
July 1, 2007 through June 30, 2008. /a
The following provisions, made this / day of 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the 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#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.
] Weld County SS-23A Addendum
0007-O7,'596
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [ RAILS CASE ID IDOB
M F I I
WORKER COMPLETING ASSESSMENT HH# IDATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1%z)2 round trips a week
02)3-4 round trips a week. 02%) 5 round trips a week 03) 6 round trips a week
❑3%)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
❑2)Three times a month ❑2%z)Once a week 03)Two times a week
D31/2)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements 01)Less than a% hour per day 01%) %:hour a day
02) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2%r3 hours per day
❑3'/)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2'/z) 11 to 14 hours per week
❑3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
03%)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑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?
❑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 SS-23A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
4
aras,irek
E 1 t 1
3£ otttp .e cs[`o Fit # t ,:$ pl
'� _ t
� p �.:'� . -: u
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
�'y� Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.,491 4 '� tdm i4til ! I '!. S
4 'F�rN . P a x.�
Inappropriate Sexual Behavior
❑ ❑ 0 0
Disruptive Behavior
❑ 0 ❑ 0
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ ❑ 0 0
Medical Needs
(If condition is rated"severe",please complete El 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 ❑
Eating Problems
❑ 0 0 ❑
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ 0 0
Education
❑ ❑ 0 ❑
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
. . ' WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
Milr c 1tt ra. - , an: r S
�w �, p' °y�e I j �_� � - � o .� a, r * 7; - � v,:a Y . �`
z 1�y� . e c `e %I i1`iWineli 1 �r�z h- � l � ,,. i 3.r p'ei i t,},„ 1m i�,x x '24O,
IA tlq
Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo iciii Level 0 $0 is
County Pi Age 11-14...$18.05 va Therapy not needed or provided ,
ddd ($549) No crisis intervention,Minimal CPA Age y j by Level 0...$0
Basic „4 15-21...$19.27 a d= '_`=`
�> (None)
Maint s `t•=
($586) involvement,one face-to-face visit v. another source,i.e.mental health. .dig !
iddii +$.66 Respite Care s _
($20) with child per month. rii '4m
$19.73 Level 1 $8.22 day/$250 mo VI Level 1 $4.93/$150 mo miff
i444i 4444 4.4
1 +$.66 Respite Care Minimal crisis interention as neededs Regularly scheduled therapy "? Level 1 ...$2.99
:biniiiiiir
one • 4...".face-to-face visit per month with
($20.39 day/$620 mo) child, up to 4 hours/month. _
2-3 contacts per month .'. °,.
'1 $23.01 1";
1 112 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo ` ------ ---------
ar P
($23.67 day/$720 mo) ,EZ
.;:'
$26.30 Level 2 $11.51 day/$350 mo 1 Level 2 $9.86/$300 mo tig
+$.66 Respite Care Occasional crisis intervention as needed, 2 Weekly scheduled therapy
2 „3a; .;fix. Level 2..$4.47
a ($26.96 day/$820 mo)
two face-to-face visits with child, '°°" 5-8 hours a month with 4 hours of
'
1k d:
Mil. 2-3 contacts per month : , group therapy. erd.
s4'> $29.59
2 1/2 idiiiiii
lid4 +$.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo !i hi . iiiiid
big ($30.25 day/$920 mo) hr:
mP 4
E;x $32.88 Level 3 $14.79 day/$450 mo ddid Level 3 $14.79/$450 mo yid
LiMt st, +$.66 Respite Care Ongoing crisis intervention as needed, muRegularlyltiple scheduleednweekly i
3 sl:: Level 3..$6.02
E:i weekly face-to-face visits with child, more si,
ar
din ($33.54day/$1020 mo) q§
and intensive coordination of -+ than 1 person,i.e.family therapy,
multiple services. a for 9-12 hours/monthly. ::
L„ � :
$36.16 •did did
"Ed-
-did
3112 iiididl +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo ,r rs =
($36.82 day/$1,120 mo) ,gym 4 s`
rvo ro
$39.45 Level 4 $18.08 day/$550 mo !did. Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly timS,
4 `idailii multiple sessions,can include lip4
RTC which includes high level of case more i's'.: Level 4....Neg.
Down ($40.77 day/$1220 ma) management and CPA involvement with than 1 person,i.e.family therapy,
{
is E4:41,5
i; i child and provider and 2-3 face-to-face for 9-12 hours/monthly.44,44
46
contacts .er week minimum. d
lb
a9Nxt�''ti .�u„m(a .��a.,.,,,,.,iiXrta .,..r..,.�„, :.. .,.,...,.. .,,.• ... r �t`x.4..�rvti�.
c i
Assess pil $26.96 day/$820 mo d dad
Rate Pmit
(Includes Respite) r $11.51 day/$350 mo •N didiiid
to IIiil
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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: a t4
Weld Count '2' Board
\%� WELD COUNTY BOARD OF
'— SOCIAL SERVICES, ON BEHALF
fc. OF THE WELD COUNTY
� 01 DEPARTMENT OF SOCIAL
SERVICES
By: By: c_J _ O
Deputy Cl to the Board David E. Long, Chair
SEP 5 2007
CONTRACTOR
Bethany Christian Services
4820 Rusina Rd, Suite C
Colorado Springs, CO 80907-8127
`
BY: ��o q. \"j\x`n Cloy I k
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
JIA,dBy:
)ctor
/ I)
J
8 Weld County SS-23A Addendum
—7M9 '2. _7,P[//
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Bridges Inc. and Weld County Department of
Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of (j u , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#1980. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum 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 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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
• 14. • Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs;etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑l)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%z)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%z)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements 01)Less than a'/z hour per day ❑1'/z) '/z hour a day
❑2) 1 hour a day 02 'A) 1'/z-2 hours per day 03)2'/z-3 hours per day
031/2)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑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 ❑1%)5 to 7 hours per week
02) 8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'A)21 or more hours per week
A 1. How often is CPA/County case management required? (Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
O 11/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
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?
DO)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 DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
+ 3L 9 I L6h Hs.i,t y,. ^qv F '4+tai'PIP's+l+�'t , it yRqq+lu. a . ,a ,..n. rp a Oat
i lFSr a.'t i! +at�9u' a 'Fw tci5 � g 3; ' c � ° �;
Aggression/Cruelty to Animals
❑ O ❑ O
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting O O O ❑
Stealing
❑ ❑ ❑ O
Self-injurious Behavior
❑ O O ❑
Substance Abuse
❑ ❑ O ❑
Presence of Psychiatric
Symptoms/Conditions O ❑ O O
Enuresis/Encopresis
❑ ❑ O O
Runaway
❑ O O O
Sexual Offenses
❑ ❑ O ❑
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.ly to this child.
fi (Ky rsThlh 91'v'+x'Sx i xi�_:k u• _
tT�'Stid ry � at�
"IXh mow- i i E i_ t i
toss i a }t i ..•„ •: .
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ 0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
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 SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
m "t 1 '* + '.s r. 'b ^.s ' to i +' h," l '4§5�� �. v.�
tw x�"r si + a VIII '� .. � '� a � "- t �a �q`"�"3 �.'�" �'`�a � zu ,,�s�h 't .,;k
� ase.+ : via '0 i a x 's'v * m w..:
� - .��,4 SCI tx � :>. .� � 't� ���. ni � .:
r "�"� . a&y *, "H :''a. ig'�at °%tr°a.T. Pa '§ ,.h a t
,I'i, T"s- s ' t s,r, k ::>. avr 5_l. a. �` + -*�I#�'' t ts' r .
gI �k .a ti ads s c man' rv€ "�,,*+,.' ,� +1.° ';c°
..._.�.r.�� ,� tea, t...��. . '".1_'r -_... r.>t� �. _ ���& a�. .,�, _' .'+,''+, ..E'#=�-s,�.�i .?, ,.,, ,�'+,_::...._r"
sac Age 0-10...$16.32($496) Basic Maint $4.93 day/$15omo • Level 0 $0
Count M Age 11-14...$18.05 3 :k Therapy not needed or provided
Y ($549) No crisis intervention,Minimal CPA by Level 0...$0
Basic Age 15-21...$19.27 . (None)
Maint E.≥a. .l
in: ($586) involvement,one face-to-face visit another source, i.e.mental health.
es +$,66 Respite Care �_'';4 i�,��
_.:} ($20) at: with child per month.
.`-" $19.73 ' ' Level 1 $8.22 day/$250 mo fr, 1 Level 1 $4.93/$150 mo
rL' 4.66 Respite Care , Minimal crisis interention as needed, Regularly scheduled therapy, 3i
1 Level 1 ...$2.99
PI II one face-to-face visit per month with
($20.39 day/$620 mo) sNW child, up to 4 hours/month.
,
{qL
. itd
2-3 contacts per month 'ar'
v v $23.01 'y ;a
.. Level 1 1/2 $9.86 day/$300 mo 1 1/2 -4.66 Respite rt r"`�e Care
($23.67 day/$720 mo) 1`-=' OM
kip
ilk
IIIII $26.30 0:1 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo
Vidkii.:
2 r- +$.66 Respite Care I'3 Occasional crisis intervention as needed, y Weekly scheduled therapy, '''t Level 2..$4.47
Ti.d ($26.96 day/$820 mo)miu, t ` two face-to-face visits with child, ` 5-8 hours a month with 4 hours of G
2-3 contacts per month group therapy.
$29.59 Via'.'
2 1/2 +$111k. .66 Respite Care „:.k.,
- Level 2 1/2 $13.15 day/$400 mo ..X
4i ($30.25 day/$920 mo) .rte-
.x $32.88 Level 3 $14.79 day/$450 mo t Level 3 $14.79/$450 mo
it
'r E't +$.66 Respite Care 41'x' Ongoing crisis intervention as needed, Regularly scheduled weekly
multiple sessions,can include
3 ` e' Level 3..$6.02
1,1 a= weekly face-to-face visits with child more
m ($33.54day/$1020 mo) ti ,a :I
Mill ; ;, and intensive coordination of than 1 person,i.e.family therapy,
1it
I t, ';E multiple services. '4 for 9-12 hours/monthly.
wit $36.16 `'r,
3 1/2 a +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo
Tat ($36.82 day/$1,120 mo) "44, ':n,:
,x:11W It
11;55 $39.45 ,, Level 4 $18.08 day/$550 mo Level 4 $14.791$450 mo
M
+$.66 Respite Care V' Ongoing crisis intervention as needed, twi Regularly scheduled weekly
4 i multiple sessions,can include
RTC ISIII, 1411F which includes high level of case more
Level 4....Neg.
Down 1 ($40.77 day/$1220 mo) ,,' management and CPA involvement with ,
than 1 person,i.e.family therapy, ..
,j-:4 iSt$
:I;V T!I; child and provider and 2-3 face-to-face TX4 for 9-12 hours/monthly.feie
'e'
contacts •er week minimum.
68
Assess MN $26.96 day/$820 mo n j! x
Rate (Includes Respite) -:jir
ha.N $11.51 day/$350 mo
IV Zii
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld Cou Cl to'td oaa
1861 -" ,r"`..
ivicw) a WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
°(1- 4 OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
BY: 44-7let._4 )1eiticai BYDeputy Crk to the Board Davi E. Long, Chai
S 0 5 2007
CONTRACTOR
Bridges Inc.
1225 N Main Street, Suite 102
Pueblo, CO 81003
By
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: \._/ C
Dire or
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Children's Network and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of Oa , 2007, 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#77512. 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
. 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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
•
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
• 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%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
❑3%z)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required 01)Once a month ❑1yz)Two times month
02)Three times a month ❑2'/z)Once a week 03)Two times a week
❑3%z)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a'h hour per day 01%) %hour a day
02) 1 hour a day 02 %n) 1'/z-2 hours per day ❑3)2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑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 O1%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
O Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
011/2)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
02%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
DO)Not needed or provided by another source(i.e.Medicaid) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
BASED• LED COUNTY CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child.
vX' t3 �R3Nkl4 `./i fr�C�, x
h� M "`'�v��i 4.
k' 3 �9� 9..E 8 . ..
s 4
d� �ti
§ x'''
.�tm2ata vAj. a+v�,.ti -5 tiZtiit�� ,� a c r= + f -r • 49
!. a - - .4
ti 3 fa ?e� T t.a-u: a a.:. �.. t�x c
' , x:t; e g.,. 1 s} a u_ - ra i �
a fi �'^xfr ��• qh 4h yd, Ff19
ti3. ,§4 3L a 4 il nut?t 1_1,-_3 ._ m.,_.v 4 x `Y�'E4:va_ ._ .. - < ...x,a�4k'i i ' rE.+ �7 uii�;
Aggression/Cruelty to Animals
❑ ❑ 0 0
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ 0
Runaway
❑ ❑ ❑ ❑
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.
f%d ° ( dE #341 ( - iii
�� I L 5 I �e f — i 4✓_ 3 �✓— `` t
... ....... i stay.
Si x .S• • ; �: �_ a :_:.s..: 3 a " �. s qty
410 641i4 0,2111r17 StQaftelre..rtagg..XCit4445.4YPI}
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 ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ 0 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 SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
:+ +��,, (Exhibit C)
kk `' '.sAI ', as a. i ; 4 £ e c s""�,_.` .gy IZEfr rk .6�;; ' `4w a.m��' +i' 4 ₹. :,'
n 114. aT+ ,y ' rte. s+, .s,i'ir5 '* ,,, 4 *s .
iiiiinte lift a, 4a 'is k° 'a t ��Z.t �, a tr, p ". .• '' ' .
.= Age 0-10...$16.32($496) p. , Basic Maint $4.93 day/$150mo Level 0 $0
uti Age 11-14...$18.05 Therapy not needed or provided
County
Basic ;;<',','T ($549) No crisis intervention,Minimal CPA by Level 0...$0
Manicint. i,€ Age 15-21...$19.27 (None)
.„ ($586) involvement,one face-to-face visit another source,i.e.mental health.
N +$.66 Respite Care
($20) with child per illt $19.73 ta Level 1 Pei
$8.22 day/$250 mo to Level 1 $4.93/$150 mo
+$.66 Respite Care Minimal crisis interention as needed, filti
1 ,i'7,5, Regularly scheduled therapy, Level 1 ...$2.99
one face-to-face visit per month with •
I"" ($20.39 child, •;, up to 4 hours/month.
day/$620 mo)
2-3 contacts per month •
, T $23.01
1 1/2 irk, +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo
im
($23.67 day/$720 mo)
$26.30 Level 2 $11.51 day/$350 mo A
rta Level 2 $9.86/$300 mo
2 t +$.66 Respite Care '' Occasional crisis intervention as needed, Weekly scheduled therapy, Level 2..$4.47
to k. two face-to-face visits with child, 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) 11
(",4G` ,, 2-3 contacts per month group therapy.
„` $29.59
2 1/2 ^i( +$.66 Respite Care r! Level 2 1/2 $13.15 day/$400 mo
"1i ($30.25 day/$920 mo)
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
gi
r q +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
u ; multiple sessions,can include
3 13eie Level 3..$6.02
;, weekly face-to-face visits with child, more
'1 ($33.54day/$1020 mo)
�:;; and intensive coordination of than 1 person, i.e.family therapy,
')� ffi multiple services. Kt for 9-12 hours/monthl .
$36.16 - };w
31/2 ,�; +$,66 Respite Care Level 31/2.........$16.44 day/$500 mo
i ($36.82 day/$1,120 mo) I,'=ik _*.
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo +�
4 i.: +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
multiple sessions,can include I?
RTC which includes high level of case more ,ti=' Level 4....Ne
Drop _ 9
Down Tiki ($40.77 day/$1220 mo) management and CPA involvement with .ik: than 1 person,i.e.family therapy,
'a[{a ^ child and provider and 2-3 face-to-face for 9-12 hours/monthly. I[
contacts .er week minimum k, s..
II ,:
Assess t $26.96 day/$820 mo 7 I x v
Rate ,r (Includes Respite) $11.51 day/$350 mo l�:S. x.a n
l
::mot iF„, .34.
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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: Ate,
Weld Co � - sd
y , a WELD COUNTY BOARD OF
+'Oft',`'�� SOCIAL SERVICES, ON BEHALF
O Fels �,I OF THE WELD COUNTY
Oultl� DEPARTMENT OF SOCIAL
SERVICES
By: 414(.et— By:
Deputy Clefk to the Board David E. Long, Chair
SEP 5 2007
CONTRACTOR
Children's Network
7651 W 41st Ave, Suite 96
Wheat Ridge,
C�O_80033
By: O Jst &Bit
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
I
By:
Dir ctor
5 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Commonworks D.B.A. Synthesis and Weld
County Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this , day of ow/ , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Afrieement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#104085. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
9. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
10. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
11. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. 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.
12. 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
gi'
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
gn
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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
•
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX F I TRAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1'/z)2 round trips a week
❑2) 3-4 round trips a week. ❑2%z)5 round trips a week 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 Du Once a month ❑1'/z)Two times month
O2)Three times a month O2%)Once a week ❑3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1) Less than a '/z hour per day ❑1'%) %z hour a day
❑2) 1 hour a day O2 %) 1'/r2 hours per day ❑3)2'/2-3 hours per day
O 3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑l)Less than 5 hours per week ❑1%) 5 to 7 hours per week
O2) 8 to 10 hours per week ❑2'%z) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1%)5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 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.)
01)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.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'%z)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) 01)Less than 4 hours per month
O2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/in of conditions which create the need for services that apply to this child.
t t�rfia a,st ,l� t a r o e . t li '
! keN .,x= 3�x'`Sr v t t t w.. .. t . ;:..,, ,,a
t .¢
ffi
, Roweere:,tit;
i I t
s �. 's s.L ts ���:.. ' 1 i,At! 0+ 'yn9 i
44 ii 2;40ivSlttavq . i .74,aa - ' ii.'Sr.:.:. !'..`�' '" '4+ }�'A. ." ..�.al=.. �`� �:.� 7�r i .....+?g
..3631 .. .......,. w. ... ...... .. .�.aks :r,Y:� e..
ls
Aggression/Cruelty to Anima
❑ 0 0 0
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting ❑ 0 ❑ 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ ❑ 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 tigilikA-L 4 t$d ayag'v k'4t' 'v�5k s 3Y i e s r ! : ., ! � t5'-
T w L
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ 0
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C) ;P
j;i - +� :ti etwt.
'PIA ,400,:pirilligi : +. � „ `'t+� 77 ;k 7 I't's. 2a$'mow" ) &°' ,, `ci s. o y s J.441, S tit ift �.. .,
i.. < .: �. t° ,m. `i ' . "gad ,tits,a�i,i_. ar i,1.4w .kshid4 me 5wv y,(,,. "''».. Heir,,. ;.,dart r
Sir' Age 0-10...$16.32($496) /n4. Basic Maint $4.93 day/$150mo Level 0 $0
Age 11-14...$18.05 'T` Therapy not needed or provided
,'
County -°�Y ($549) -,}''�._`._.: No crisis intervention,Minimal CPA by %. . Level 0...$0
BasiMaint Age 15-21...$19.27 . 1E, (None)
($586) a,;: involvement,one face-to-face visit another source,i.e.mental health. . s„
10; ' +$.66 Respite Care .:.r;.
47=`; $20 ,1,111t.- with child .er month. El `;
•
$19.73 't,l.; Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo '"`
+$.66 Respite Care ' Minimal crisis interention as needed, Pia WI
Regularly scheduled therapy Level 1 ...$2.99 1
;I:; one face-to-face visit per month with
($20.39 day/$620 mo) ? child, up to 4 hours/month.
i. lii
2-3 contacts per monthEN
.
$23.01 sx
1 1/2 +$.66 Respite Care t Level 1 1/2 $9.86 day/$300 mo ..
($23.67 day/$720 mo) y„ aLt.
$26.30 .( Level 2................$11.51 day/$350 mo - Level 2 $9.86/$300 mo 't'`
2 +$.66 Respite Care v Occasional crisis intervention as needed, Weekly scheduled therapy, ,a;" Level 2..$4.47
i MI 1I
df
ri1 ($26.96 day/$820 mo) '"� two face-to-face visits with child, ~r 5-8 hours a month with 4 hours of ,
11
L=.
2-3 contacts per month group therapy. 'a°':
In: I15
$29.59
2 1/2 +$,66 Respite Care $,. Level 2 1/2.........$13.15 day/$400 mo "
($30.25 day/$920 mo) "=li
$32.88 ;rr Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo Y_
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly '
multiple sessions,can include �dta
3 -I. - Level 3..$6.02
weekly face-to-face visits with child, more -h:
($33.54day/$1020 mo) ,, �;
a'.. and intensive coordination of than 1 person,i.e.family therapy ..,.:
r,:, °
,multiple services. for 9-12 hours/monthly.
,:
M1 z d
.
$36.16
31/2 +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo
($36.82 day/$1,120 mo) AR, s=F:
$39.45 ▪ Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care 5( Ongoing crisis intervention as needed, Regularly scheduled weekly tit,,,
",'4 -1 " multiple sessions,can include „,Y:'
RTC '1•"1 �
▪4' which includes high level of case more lip;: Level 4....Neg.
Drop RF
Down ($40.77 day/$1220 mo) �[:= management and CPA involvement with than 1 person, i.e.family therapy, f- _
° s child and provider and 2-3 face-to-face for 9-12 hours/monthly. rT
A
; contacts •er week minimum. lit :_
P.
Assess a 41 $26.96 day/$820 mo „gym.. 14: _
Rate (Includes Respite) (,.RA- $11.51 day/$350 mo ,?_. ta
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld County Clerk to the Board
yg )1111.1.? WELD COUNTY BOARD OF
:t, r, SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
r SERVICES
By: / 1llL . By:
Deputy CI to the Board David E. Long, C air
SE 0 5 2007
CONTRACTOR
Commonworks D.B.A. Synthesis
3000 Youngfield Street, Suite 155
Lakewood CO 80215 J
By: l Bats_
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Lti ector
8 Weld County SS-23A Addendum
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Dungarvin Colorado, Inc. and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30,2008.
The following provisions, made this / day of DT; , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the*cement 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#98960. 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
4(52)2-078%
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
•
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX tTRAILS CASE ID DOB
M F
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 ❑1'%)2 round trips a week
❑2)3-4 round trips a week. ❑2%) 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 ❑1/)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
❑3'/z)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements 01)Less than a'/ hour per day ❑1'%) hour a day
❑2) 1 hour a day O2 %) 1'/r2 hours per day O3)2Yr3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1%:)5 to 7 hours per week
O2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2'%z) 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.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%)Face-to-face contact one time per month with child and occasional crisis intervention.
O 2)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2' )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?
DO)Not needed or provided by another source(Le. 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 DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child.
'' 21141 x^-d , ; ? d i M Y r411 t,-.; tr,...j.htt,"tkt44411-ii24ANXit;45:::42a6:Filt!;:RiNtiliA5alial
Att$t: t .
t+ .�.
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ 0
Stealing
❑ ❑ 0 ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ ❑ ❑ ❑
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 a..ly to this child.
13f� � t € tl
xC i!!. i4,4 IgiNEW^
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ 0 0
Delinquent Behavior
❑ ❑ 0 0
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ 0 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ 0
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ 0 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
.�Y li z 9 ""'y"'v*"°'!a" "s"}:"° �4 `r`# § f"n 'i5. -*-u.& yy'+�R 3 S'4."t'ia g,�',G.=' 3Y°t T y ''„ '+" , e
.r ':31 ,i'#a�x 4Itqt 00 4 0"ti k qtr .�}c'�'3, 'a'y tbre"s i',' 7 +� s ��sw °� N
r a "s"v,. s * 4 a 4.§t* v.'� 'g` x• i -wti` snt gill x tie ~�,: t`
$tli
iit iP tau+ , a, . it lgi °n'+, t Tiifi: Ki 7 .s,y, 4'`r }e'.& ,a'C asc%. i3 ara a.� x kaanialligirlitkirmisreinirte
wigirtifzi$Al,t,,�'.bliff., :. z sa� •n n.We'LE '.v" s� arx.:.:,.t,.....o..�,u°...�a� . .u.
{,v fi Age 0-10...$16.32($496) kw,'} Basic Maint $4.93 day/$150mo Level 0 $0 al
'i,`i Age 11-14...$18.05 1,14 Therapy not needed or provided in
County f >t ($549) No crisis intervention, Minimal CPA by Level 0...$0
Basic : ,.v_==.
Maint. Age 15-21...$19.27 °" (None)
($586) 1 involvement,one face-to-face visit ( another source,i.e.mental health.
Mi. +$.66 Respite Care r$+9: .$7A1 ti
uI' ($20) 7z,' with child per month.
�y;yr
$19.73 .'" Level 1 $8.22 day/$250 mo Irt Level 1 $4.93/$150 mo iiii e +$.66 Care Respite ,
p' all Minimal crisis interention as needed, Regularly scheduled therapy,
1 - to one face-to-face visit per month with Level 1 ...$2.99
rAt ($20.39 day/$620 mo) II child, up to 4 hours/month.
dill
`( 2-3 contacts per month
' $23.01 ,„i.
1 1/2 r'? +$.66 Respite Care ..i'.. Level 1 1/2 $9.86 day/$300 mo
isi ($23.67 day/$720 mo) ,
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo
2 +$.66 Respite Care 14 Occasional crisis intervention as needed, Weekly scheduled therapy, Level 2..$4.47
($26.96 day/$820 mo) .a two face-to-face visits with child, t.t 5-8 hours a month with 4 hours of
rtil 2-3 contacts per month group therapy.
$29.59
21/2 +$.66 Respite Care n Level 2 1/2 $13.15 day/$400 mo
($30.25 day/$920 mo)
3!`)' $32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
i=_ 4.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
3 ' , multiple sessions,can include Level 3..$6.02
_ weekly face-to-face visits with child, 0 more
Eilli ($33.54day/$1020 mo) th, , and intensive coordination of 4 than 1 person, i.e.family therapy,
tittl IC Vii,^':; multiple services. for 9-12 hours/monthly.
a43I
vii, $36.16
3 112 - .66 Respite Care . Level 3 1/2 $16.44 day/$500 mo
f_ +$
a? ($36.82 day/$1,120 mo)
a: rii
;' $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
>xs
fs" 4.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly •
4 multiple sessions,can include •
RTC it which includes high level of case more • Level 4....Neg.
Drop W.
Down u_ ($40.77 day/$1220 mo) .• management and CPA involvement withthan 1 person, i.e.family therapy,
t..
child and provider and 2-3 face-to-face hF1 for 9-12 hours/monthly.
Si deit
contacts .er week minimum. „
r•
Assess t $26.96 day/$820 mo 1: u .
Rate „.£ (Includes Respite) :, ,.' $11.51 day/$350 mo d":
IIH,F. blit Pitt PP
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld Count� 1 to . _ ar'
:Sol ,
WELD COUNTY BOARD OF
*O
( SOCIAL SERVICES, ON BEHALF
$ OF THE WELD COUNTY
` ��✓ DEPARTMENT OF SOCIAL
SERVICES
4
By: By: WA C.
Deputy C c to t e Board David E. Long, Chair
SE 0 5 2007
CONTRACTOR
Dungarvin Colorado, Inc.
4704 Harlan St., Suite 200
Denver CO 80212-7417
By: Lc /14A-3
/�, ,
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dire for
8 Weld County SS-23A Addendum
_7 n/J___h.Pi/Z
WELD COUNTY ADDENDUM RECEIVED AUG 16 1007
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Griffith Centers for Children and Weld County
Department of Social Services for the period
July 1, 2007 through June 30,2008. '7 J�
l.,.:/h. S'
The following provisions, made this / day of v u/ , 2007, 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#1531601. 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
02067-
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# IEX F RAILS CASE ID DOB
WORKER COMPLETING ASSESSMENT HH# }DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week 01)One round trip a week ❑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 ❑1)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
O3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑ Basic Maint.)No educational requirements 01)Less than a''1 hour per day 01%) Y 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 ❑l) Less than 5 hours per week 01%) 5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
❑3)Constant basis during awake hours O3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week 01%) 5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
O3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
['Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
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) 01)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 DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
"r. " ' , E R i i Ai . C- t iE
, �
, t te pie P-
a
"C z I
9 �R aYY tt d 'ti 8_ sL ...xig , u zi , 5 , , `
a 3 �
k. Ai %s. 'yk.h , 4
Aggression/Cruelty to Animals
❑ 0 0 ❑
Verbal or Physical Threatening
❑ 0 ❑ ❑
Destructive of Property/Fire
Setting ❑ 0 ❑ ❑
Stealing
❑ 0 0 ❑
Self-injurious Behavior
❑ 0 0 0
Substance Abuse
❑ ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions 0 0 0 ❑
Enuresis/Encopresis
❑ ❑ 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.
k s a r i�ysd40.
� . --r.''''W
liM:5i.kajEllat2V4 1;271.7nta4c.::..41'-, ::,:lc-.:31-1/4,1,-:',I.e,, p.,„,,...„,..„,„,,,.,,,Ix:i,;:lit4ci
igiftige4Yr� -
.:a_ a - k,-_ �= a m.�_3§e.;u ' 'rnn? ,h : 3�4'i =�..:,ri,,s..N
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ 0 ❑
Medical Needs
(If condition is rated"severe",please complete O 0 0 ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ 0 ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ 0 0 ❑
Education
O 0 0 ❑
Involvement with Child's Family
❑ ❑ 0 ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
' . WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
' i{ .d,i u ".,h' P"`s' s,.;.�'- xa $*^:�v. xro 5 a ag s. ^i +:. °, >ia• a -
.c:�_ `�, � +,r� i > ' . �'4 y' s_.q; ' > -.r5 4'k.. �r'� r;�" " 'w,a s�se � x
' t .' a,.+>r.�,. ,.a.., a..:{�+,a'`'aa "$' lia a 4Ova '£'v bti nz"'``". +'
a -:,k L L ,'"=."�' r`'"' .` a` _ gl o why �„ M, "i t• t fi
L' - ova^. ,a. 5 a:cat 4w y 'a sq ,�
Age 0-10...$16.32($496) 'i,„= Basic Maint $4.93 day/$150mo Level 0 $0 v,i.
h t Age 11-14..$18.05 " ' L. Therapy not needed or provided }�
County
($549) No crisis intervention, Minimal CPA by a', Level 0...$0
Bac Ma nt Tgn Age 15-21...$19.27 A . v 3:i (None)
anp ($586) Via involvement,one face-to-face visit -! another source,i.e.mental health.
.$.66 Respite Care 1;
r ($20) tT. with child per month. ak
'F r
$19.73 : Level 1 $8.22 day/$250 mo �,; ' Level 1 $4.931$150 mo tipr
i;.kr iaii:
1 +$.66 Respite Care ,'' Minimal crisis interention as needed, r Regularly scheduled therapy, "
r g Level 1 ...$2.99
i1- one face-to-face visit per month with h.i
of ($20.39 day/$620 mo) ;+ child, Any up to 4 hours/month. -I
it ...
,:; 2-3 contacts per month
m. $23.01 l ' '_--
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo :4".,Z; -u'`
=: .
__ ($23.67 day/$720 mo) Via: :�:
i lift.
a $26.30 y Level 2 $11.51 day/$350 mo P , Level 2 $9.86/$300 mo ;u
'a av
+$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, *F
2qiim �'' _, Level 2..$4.47
; two face-to-face visits with child, O% 5-8 hours a month with 4 hours of t
($26.96 day/$820 mo) c.� ..s*
w
i`'' 2-3 contacts per month .' group therapy. =R`
r' $29.59 ..'' ryx s r`
2112 .t:" 6lt. ,."t +$.66 Respite Care ' Level 2 1/2.........$13.15 day/$400 mo �'1
si."k ili
�._ ($30.25 day/$920 mo) : . ,-s1
li,im $32.88 - is Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo fa
Illifi ' "
F +5.66 Respite Care Ongoing crisis intervention as needed, °' Regularly scheduled weekly :loss
3 mi multiple sessions,can include a."'ka', Level 3..$6.02
weekly face-to-face visits with child, :qinf more
lnii ($33.54day/$1020 mo) "
ik�y and intensive coordination of than 1 person, i.e.family therapy,
3,,;;,s multiple services. °wI: for 9-12 hours/monthly. S,a
$36.16 ,,.rre„ g Wiall f.
31/2 € +$,66 Respite Care r:;'" Level 3 1/2 $16.44 day/$500 mo U'-.4,f' 11O
($36.82 day/$1,120 mo) b;l:;.
P.
St
4 $39.45 p Level 4 $18.08 day/$550 mo 3_ 1,Level 4 $14.79/$450 mo
t.* +$.66 Respite Care (: a Ongoing crisis intervention as needed, Regularly scheduled weekly 1.71,
4 .': -r- ' multiple sessions,can include . "
RTCiliwri ttv which includes high level of case ",,; more -.Big Level 4....Neg.
x : a ;i 35= 9.
Down ($40.77 day/$1220 mo) •1t management and CPA involvement with 54O than 1 person,i.e.family therapy,
RT ,N Vii"
i; child and provider and 2-3 face-to face for 9-12 hours/monthly .a
contacts .er week minimum. ' ; .irk
fry'
Assess .f $26.96 day/$820 mo
Rate tilII Iw (Includes Respite) P`? $11.51 day/$350 mo �` ,,:ahr
hp
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld Cou Sal and
s'' eh: WELD COUNTY BOARD OF
te
inJ SOCIAL SERVICES, ON BEHALF
. -.t OF THE WELD COUNTY
`� . DEPARTMENT OF SOCIAL
.� ;� SERVICES
By: By:
Deputy C c to e Board David E. Long, h
S P 052007
CONTRACTOR
Griffith Centers for Children
14142 Denver West Pkwy, Suite 225
Lakewood, CO 80401
By.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
8 Weld County SS-23A Addendum
n ..-A 1 rob///
WELD COUNTY ADDENDUM
•
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope and Homes and Weld County Department
of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this C day of 3 G , 2007, 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#29867. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold authorizations and payments are subject to a 3 day
maximum for a child's temporary absence from a facility, including hospitalization. Bed
hold requests must have prior written authorization from the Department Administrator
before payment will be release to provider.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Section III, Paragraph 5. Contractor additionally agrees to have appropriate personnel
available for staffing current placements with the Utilization Review Team. This review
team convenes every Monday morning, excluding holidays.
8. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
1 Weld County SS-23A Addendum
aoo7-aeye
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
' exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# PATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week ❑1) One round trip a week ❑1%)2 round trips a week
❑2)3-4 round trips a week. 02%) 5 round trips a week 03)6 round trips a week
❑3%z)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month ❑1%)Two times month
02)Three times a month ❑2%)Once a week 03)Two times a week
❑3%:)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements 01)Less than a%z hour per day 011/2) '/z hour a day
02) 1 hour a day 02 %z) 1'/-2 hours per day 03)2'h-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed O1)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?
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%) 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 timejer 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.
❑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 DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a..ly to this child.
!: tiaj o . 0 i ! d # 6 € 9 t
t pf
� ?.. E it `1 # L2a
���''iv.t:. r` y
f
5 -.�� ! tv of raitmaim. - ,a E,. yE s ;
e' 4 2 Ott lY 1+ 4t i i�(�."lltlilie%em , llt k .
Aggression/Cruelty to Animals
❑ ❑ 0 ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ 0 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis
❑ ❑ 0 ❑ •
Runaway
❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
(Exhibit B)
Please rate the behaavior/intensity of conditions wh�i�ch create the need for services that apply to this child
-�'-x r t to-�� . �a 2 �z �p 1 s ¢ .,...s . ..r t 7 '� r�tlic��
:" �- } S lit 5# S tit t i 2 p .L,
. .y pnpf r� '�'�tls,`� v. `� om. � a ra,� t q fi.
:, {x.O,1- toy v li= nt iix ° at as t r t t t o t ( i yrs 414 ''aa 71 t>k,cr t t ti i it el,-;,_::. a s, t ',, t srt :ii,
ti-' -e � 6� 5 °�aNY
� F. tR 'i& I °I t s Es. "'L t 3. t � a sa
%1:240:,w •Fv,. _.„. , e.._ Ma.ris':...fl ... ,Is.., ₹i , . r t,rr'.cs {.: .`N:'r ,t ,. s F).... _
Inappropriate Sexual Behavior
❑ ❑ ❑ 0
Disruptive Behavior
❑ ❑ ❑ 0
Delinquent Behavior
❑ ❑ 0 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
❑ 0 0 ❑
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ill 2 ❑ 3
6 Weld County SS-23A Addendum
- WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
iI S y k A P
,
'. Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo y, Level 0 $0
County Age 11-14...$18.05 4 Therapy not needed or provided ,''
($549) No crisis intervention,Minimal CPA by .' . Level 0...$0
Basic Age 15-21...$19.27 t +1L (None)
Maint w"! Pa;
43 .
yl;. ($586) involvement,one face-to-face visit i another source,i.e.mental health.
, ,`. +$,66 Respite Care
($20) with child per month. y1 -
y
i $19.73 Level 1 $8.22 day/$250 mo 7'44' Level 1 $4.93/$150 mo
lr:
+$.66 Respite Care Minimal crisis interention as needed, F = Regularly scheduled therapy, Level 1 ...$2.99
1 )1*: one face-to-face visit per month with !''
:! ($20.39 day/$620 mo) child, up to 4 hours/month.
t
2-3 contacts per month V.
:i: e
$23.01 ,1.
1 1/2 :, +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo 'r
:-! ($23.67 day/$720 mo) .
.F::'
$26.30 Level 2 $11.51 day/$350 mo tli Level 2 $9.86/$300 mo
m:
• +$.66 Respite Care Occasional crisis intervention as needed, P.N. Weekly scheduled therapy,2 _,r 4.Vi i. Level 2..$4.47
two face-to-face visits with child, t. 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) k``°
2-3 contacts per month irg group therapy.
$29.59
2 1/2 +$.66 Respite Care = Level 2 1/2 $13.15 day/$400 mo 1_
($30.25 day/$920 mo) a '3{v(
$32.88 Level 3 $14.79 day/$450 mo 4 n 1, Level 3 $14.79/$450 mo y'"!
,_F;.. +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly T,
*
3 . multiple sessions,can include r'"' Level 3..$6.02
weekly face-to-face visits with child, more
TM
($33.54day/$1020 mo) and intensive coordination of r` than 1 person,i.e.family therapy,
!i *Al
,114' multiple services. = for 9-12 hours/monthly.
`"
• $36.16
m .: iiEli
31/2 _,r. +$.66 Respite Care Level 31/2.........$16.44 day/$500 mo F r,'!!
($36.82 day/$1,120 mo)
3 .r
.. $39.45 1 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
Pic,a; +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly )':
4 - multiple sessions,can include
RTC '' which includes high level of case !'T more ?'C''
9 i'; Level 4....Neg.
Drop
Down ($40.77 day/$1220 mo) management and CPA involvement with & it than 1 person,i.e.family therapy, t_r-
child and provider and 2-3 face-to-face _ for 9-12 hours/monthly. _
, contacts •er week minimum. '.,
Assess - $26.96 day/$820 mo
Rate (Includes Respite) 3,-7,=�rgS', $11.51 day/$350 mo if?!.
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld County fierk
elm A.4
WELD COUNTY BOARD OF
P'' s; SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
- y SERVICES
By: ZalLt&f— By: J
Deputy Cl to the Board avid E. Long, Chair
SEP 5 2007
CONTRACTOR
Hope and Homes
1925 Dominion Way, Ste 200
Colorado Springs, CO E 80918
/
By: //to �(WO2 r
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dir ctor
a Weld(`nmty CC_9;A Addenda m
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope Family Services and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of J u y , 2007, 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.
] Weld County SS-23A Addendum
aas a8%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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term"litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
•
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX TRAILS CASE ID DOB
F I
WORKER COMPLETING ASSESSMENT HH# 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS I ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week ❑1)One round trip a week 011/2)2 round trips a week
❑2) 3-4 round trips a week. ❑2%z)5 round trips a week 03)6 round trips a week
❑3'%z) 7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month Eli'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 01)Less than a Yz hour per day Pi%) %hour a day
❑2) 1 hour a day 02 %z) 1'/z-2 hours per day 03)2'/z-3 hours per day
❑3%z)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of lime
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 021/4) 11 to 14 hours per week
❑ 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%)5 to 7 hours per week
❑2) 8 to 10 hours per week 021/4) 11 to 15 hours per week ❑3) 16 to 20 per week
O 3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%x)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?
DO)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 DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that apply to this child cisiertiea, . ° o e a t •s 'is'
oo
4R'itti 3i' y i§
t� ,t d,o m1/4 s72 v k;�e,
-a
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting ❑ ❑ ❑ ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ O
Sexual Offenses
❑ ❑ ❑ ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSMENT CONTINUED
•
(Exhibit B)
ninga.rmteitl":7*Iiltr,+4:on
Please rate the behavior/intensity of conditions which create the need for services that ap r ly to this child.
3�' ,..�1`t',fs 'b � 75v. ti lE w � i�r d a 3
.Fry' pct h (' tv`is p !e zf�
a b/
�. I t131 aw $ik"! xry&sw
;.101rC b ,S 4 e !_t. 4 a to it c a xa t , u �... �'a' .s.:
r �-ralittta m,t..,7s f:,._ _ '���,� .a. g"�'�.: .w'= _,�"S..'sas ,3'" .�..,.,� ,;a.�, ,. ..n �' t.9_�c b....,.,' cii fii'!�' .._�:.:S, wi lla [,,.. iE• , a :t._._
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
El El El ❑
Depressive-like Behavior
❑ 0 ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
❑ 0 ❑ ❑
Boundary Issues
Requires Night Care
El ❑ El El
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 SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
um ¢ r '�t i:. a w __ .. 0: .. .sr }t; S err;' h' .,a
�` ; �a d za c 12.E 14 od # r`f i 'N'', 4,{k
SERVICE2 f•'i' iSd ir i,, u,: [[-�. 6 y D - > E
rA 8tvv i ,SRS:k !ahSiG,ti 4 c i _aThi,h t a^4iltetal 3litif�r Wearill
r-0 r i"."1 ry, a „F. 41.x. d z < : ,. .u`i
c 4 'fy�t h. I i �' �:'r,,� ��r4 l�r6Yht...� 1 F {{ tyy ni �� �. �_.. F 4 � :. A,
..�ti i � 'Ya`?.' 1'��n .5. 'Iu`c
ti Age 0-10..$16.32($496) i Basic Maint $4.93 day/$150mo 4{ Level 0 $0 WI
Age 11-14...$18.05 Therapy not needed or provided tli:
County ! ($549) No crisis intervention, Minimal CPA by z.[ ; Level 0...$0
Basic w#
Maint. :la Age 15-21...$19.27 lit (None)
3`'"L ($586) involvement,one face-to-face visit be" another source,i.e.mental health. O.,'
+$.66 Respite Care I;
IF ($20) with child per month.
$19.73 b, Level 1 $8.22 day/$250 mo s. Level 1 $4.93/$150 mo '_'
li
, : +$.66 Respite Care Minimal crisis interention as needed, r: Regularly scheduled therapy,
Level 1 ...$2.99
one face-to-face visit per month with ;.
($20.39 day/$620 mo) child, up to 4 hours/month.
li2-3 contacts per month IN
$23.01 y; i'''.
1 1/2ify. +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo k
($23.67 day/$720 mo) "
$26.30 eft Level 2 $11.51 day/$350 mo ,„ Level 2 $9.86/$300 mo mi+$.66 Respite Care Occasional crisis intervention as needed, Ti Weekly scheduled therapy, ',h r
2 , hh;! Level 2..$4.47
OH two face-to-face visits with child, re' 5-8 hours a month with 4 hours of i4
($26.96 day/$820 mo) IM ,j..
2-3 contacts per month ,$} group therapy. RiP
$29.59 ''
30
2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo r• : ------------------
($30.25 day/$920 mo)
$32.88 I. Level 3 $14.79 day/$450 mo Hreh Level 3 $14.79/$450 mo irri i4:'.gN
iiiiii +$.66 Respite Care Ongoing crisis intervention as needed, ;>,',try` Regularly scheduled weekly 2tli
multiple sessions,can include
3 " Level 3..$6.02
weekly face-to-face visits with child, Arg
moreit
($33.54day/$1020 ma)Uiiiii and intensive coordination of . ` than 1 person,i.e.family therapy, v= •
multiple services. for 9-12 hours/monthly.
$36.16
3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 mo ,#L,'^,,-
7,4
($36.82 day/$1-rrim ,120 mo) :#.#:#1`'
$39.45 • Level 4 $18.08 day/$550 mo c Level 4 $14.79/$450 mo cc'.'.
+$.66 Respite Care Ongoing crisis intervention as needed, • Regularly scheduled weekly sirE
4 vo multiple sessions,can include
RTC LUE which includes high level of case #, more Level 4....Neg.
Drop
Down ($40.77 management and CPA involvement with ,,• than 1 person,i.e.family therapy, If
day/$1220 mo)
child and provider and 2-3 face-to-face for 9-12 hours/monthly. 7,'
LW
contacts .er week minimum .,
<'2'. .r
YAII N
ii
Assess I q:. $26.96 day/$820 mo I ;
Rate (Includes Respite) $11.51 day/$350 mo y
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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.
7
ATTEST:
Weld Count/ 1er
\,1i. WELD COUNTY BOARD OF
,, p'' SOCIAL SERVICES, ON BEHALF
r ` , & j 4, OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: /LA`/1�/GGC. � ��/fl By: e
Deputy Cl rk to the Board David E. Long, C aii
SE 0 5 2007
CONTRACTOR
Hope Family Services
1610 29th Ave Place#100
Greel; CO�8,0634
By: ' /''� 701
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
6 By:
Dire for ( J
c
8 Weld County SS-23A Addendum
n.,f).— - ,P//L.
WELD COUNTY ADDENDUM
. . 4'
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Imagine and Weld County Department of Social
Services for the period from
July 1, 2007 through June 30, 2008.
nd
The following provisions, made this 02'day of U' , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of th �greement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#21369. These services will be for
children who have been deemed eligible for social services under the statutes, rul s and
regulations of the State of olorado. �� ; 6 d G � �.`I i 1 rQ-� c?-4-12,
w t 11 *do- P,�"1' y'C2 - „� t,� � `''�' $/°3l °7
3. Section I, Paragraph 2. All bed hold a orizations and payments are subject to—2 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
ape 2-a(Py6
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.
11. 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.
12. 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.
13. 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.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
2 Weld County SS-23A Addendum
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
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX TRAILS CASE ID jDOB
M F I I
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week 01%)2 round trips a week
O2) 3-4 round trips a week. ❑2%z)5 round trips a week O3)6 round trips a week
O3%) 7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required 01)Once a month 01%)Two times month
O2)Three times a month O2%)Once a week O3)Two times a week
❑3Yz)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements 01)Less than a Yz hour per day 01%) '//hour a day
O2) 1 hour a day O2 %) 1'/z-2 hours per day ❑3)2'h-3 hours per day
O3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed 01)Less than 5 hours per week 01%) 5 to 7 hours per week
O2) 8 to 10 hours per week O2%) 11 to 14 hours per week
0 3)Constant basis during awake hours ❑3'/z)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑Basic Maint.)0-2 hours per week 01)3 to 4 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week O2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'%z)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
O2%)Face-to-face contact three times per month with child and occasional crisis intervention.
O3)Face-to-face contact weekly with child and occasional crisis intervention.
O3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
O0)Not needed or provided by another source(i.e. Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD(Exhi COUNTY DSS
NEEDS BASED CARE ASSESSMENT
bit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensit of conditions which create the need for services that apply to this child.
rry 'tJ.. eem :m:
' Cii ! P t i d o f is
#ti
s� ':f fie .. biit
n:.
t
CM Sixr1 d i a...5.' a,��t s_ u,e..�.c °,mss i ! to"s1
Aggression/Cruelty to Animals
❑ ❑ 0 ❑
Verbal or Physical Threatening
❑ ❑ 0 ❑
Destructive of Property/Fire
Setting ❑ 0 0 0
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ 0 ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ 0 ❑
Runaway
❑ ❑ ❑ ❑
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 a..1 to this child.
—44r40174101rs,vi.,1 .i,' 'fin. C '�a 6 ' ! - i
f ,�w'i ern 'lj l
$ 1 3 .»Tip~
,.....,�, iM
�� ° ..F xr�%E3�: 4 .;a�'. ;1 .3.w.k#..d.. .k� v �� ! >Lxm- ..a + �-' km— c ._ 5 ,aNi dv ,;:tt..rS}L
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ 0 ❑ ❑
Delinquent Behavior
❑ 0 0 ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ 0
Eating Problems
❑ ❑ 0 0
Boundary Issues
❑ ❑ 0 0
Requires Night Care
❑ ❑ ❑ ❑
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 SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
• .. ! -% Y -• 455a 51 ht '.'.t a :ti 4,. ti fin% W.`u l - 1 et p w G 5iV.�'tiM a i '"� ,a 't ca'lat 4X'b"�''`... �,al.T.�,' te° ' S�.f x .,�^5-ry acct
i ill A,,% yt +. �'Lh�' b. 9 . yy6 � 4' ,,,A �'4}R LY'ilia :'
JA.,,,c4 .µ x°; ,a i w b f , +,::!:: f tad'*, iE :.
arcis
'r '' t+ a�ai ' ✓ "';Ai -t "51."E ,"..y i; i i `a"� 'at y$ ro iittlaMp ,� .,w "' v,p ..vp.atarititiPa aiiginkiiiaalY
_ �" e '*;m,. m....n: .'u. ,{sws. ?,p�,s.:w°v+.- a.k._ac._c' '....:.u.... . tir'4.'
Age 0-10...$16.32($496) '° Basic Maint $4.93 day/$150mo �.~�: Level 0 $0 1;1.
Age 11-14...$18.05 Therapy not needed or provided . '
County 91
Basic ($549) No crisis intervention,Minimal CPA by t?: Level 0...$0
Basic Age 15-21...$19.27 t'"° (None)
($586) involvement,one face-to-face visit a another source, i.e.mental health. Rit
AM
+$.66 Respite Care MI
Afilu ($20) with child per month.
RI $19.73 • Level 1 $8.22 day/$250 mo 7 Level 1 $4.93/$150 mo ;ta
',`
+$.66 Respite Care Minimal crisis interention as needed, Regularly scheduled therapy, Level 1 ...$2.99
1
one face-to-face visit per month with ,.' 'I
($20.39 day/$620 mo) child, up to 4 hours/month. i
03
.6 42-3 contacts per month001
yL'`
$23.01 ^a,
1 1/2 i. I 4.66 Respite Care Level 1 1/2 $9.86 day/$300 mo ° I ________--------------- .'
($23.67 day/$720 mo) 1!
$26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo 2a
•
4.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therm
2P therapy,
Eel(:; 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) L
2-3 contacts kr, per month group therapy. 'i
$29.59 '- '
2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo 4 ,
($30.25 day/$920 mo) f'?
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo a
4.66 Respite Care F. Ongoing crisis intervention as needed, iffitv.I Regularly scheduled weekly lc
multiple sessions,can include 'I' Level 3..$6.02
3 more
weekly face-to-face visits with child, (ha,
($33.54day/$1020 mo) and intensive coordination of than 1 person,i.e.family therapy,
multiple services. ail-
for 9-12 hours/monthly. I,-
F ii4
� ia
$36.16 N
3 1/2 .'/9 4.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo ""
x� ($36.82 day/$1,120 mo) fir;,
LISI It
$39.45 4. Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
y,a -
' +$.66 Respite Care ,irtOngoing crisis intervention as needed, Regularly scheduled weekly ';.
4 `` tot multiple sessions,can include +,
RTC which includes high level of case ,- more t i, Level 4....Neg.
Drop
Down = ($40.77 day/$1220 mo) • management and CPA involvement with tte than 1 person,i.e.family therapy v '
• } child and provider and 2-3 face-to-face for 9-12 hours/monthly. 441
YSft
A0
contacts .er week minimum ;4,,; ,„.
MI i!
itui
Assess $26.96 day/$820 mo ia, wiaix:.
Rate (Includes Respite) ay. $11.51 day/$350 mo ',t'.
t.
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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.
r
ATTEST: / t�,�I, •'f�
Weld Count R' a 00,4s,
96 e?(d
- 1 � WELD COUNTY BOARD OF
� SOCIAL SERVICES, ON BEHALF
Om ' OF THE WELD COUNTY
U lki DEPARTMENT OF SOCIAL� SERVICES
By: /// lL� � ��� By:
Deputy Clerk to the Board David E. Long, Chai
SE 0 5 2007
CONTRACTOR
Imagine
1400 Dixon Ave
Lafayett CO 8026
By: Dde\
WELD COUNTY DEPARTMENT $(j 3(°7 OF SOCIAL SERVICES '
By:
Dire for
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 Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of D y , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
I. 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 famished 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 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 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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation"includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX [TRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# 1DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.)Less than one round trip a week 01)One round trip a week 911/2) 2 round trips a week
❑2)3-4 round trips a week. ❑2'/z)5 round trips a week ❑3)6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required Eli)Once a month 01%)Two times month
02)Three times a month ❑2'/)Once a week 03)Two times a week
03%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a '/z hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 %) 1%:-2 hours per day 03)2'/z-3 hours per day
031/2)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week 01%) 5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2'%) 11 to 14 hours per week
0 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑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.
❑PA)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) 91)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 DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
lai t3, ;._44 Y '. i ate n.�s!i _ .
Aggression/Cruelty to Animals
❑ 0 0 0
Verbal or Physical Threatening
O 0 0 0
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
O 0 0 0
Substance Abuse
❑ ❑ 0 0
Presence of Psychiatric
Symptoms/Conditions O O O O
Enuresis/Encopresis
❑ 0 0 0
Runaway
O 0 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.
f ,a, h }tit fit lgal i A s s w5�ax
:!.;;;;Ilittitte!traliftlitalritTilitc677:rt
un vaq- %
�,. _� i ii'
. .0 .., c „ 5ti 3 f++� . ,:,,' 1 mom „•„ A 41 :tr ui t-�, n a. ... �.,, �:m � s,. ..�..'P,f... . w,.:..:
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ ❑ ❑ ❑
Delinquent Behavior
❑ 0 ❑ ❑
Depressive-like Behavior
❑ 0 ❑ 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ 0 ❑ 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 SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
- {{ftu n ,x �',,. ,+.�4Y%vry ..&,.°�.�•,xma -�'' 4;'a' 4n d'+. A '+ +'ta�lita
il ilk :a, aR , 3t � y7 1
MitVL .14
'41,1?"-1*Lt,-kka'4''".'iarailltemmtlibenoseve,;•14=40SSioger,:':. ....22t-,na.ngwelrir,tisko,swiazti.i.FtMvIVea gilri,lAWK3Ilgiitial,. It 3337
. ,. _ a4" .. s. _......_.,�'f.�_r,i.::r-1se. $e ,�. . _..s_ 't ,i �5aa ., �., .i. ., ,`. _ u;.'i_' �w a .,i.i ..
Age 0-10...$16.32($496) • Basic Maint $4.93 day/$150mo ::- Level 0 $0 Si
Age 11-14...$18.05 • _ Therapy not needed or provided y,
County '»?` Li
Basic ,, ($549) No crisis intervention,Minimal CPA by :y Level 0...$0
Age 15-21...$19.27 y
Maint • (None)
($586) ms, involvement,one face-to-face visit u1 another source,i.e.mental health. s
I +$.66 Respite Care _ a
($20) with child per month. ''``i
FI $19.73 Level 1 $8.22 day/$250 mo ` Level 1 $4.93/$150 mo I!
non
+$.66 Respite Care Minimal crisis interention as needed :i? Regularly scheduled therapy, ':1=i
1 - 444 one face-to-face visit per month with ' ;3 tie! Level 1 ...$2.99
($20.39 day/$620 mo) child, up to 4 hours/month. _
IiiI4Fera2-3 contacts per month wi1�`
ETts: $23.01 ,•=+a
1 1/2 $a +$.66 Respite Care Level 1 1/2 $9.86 day/$300 moKttE
-;-�3 ($23.67 day/$720 mo) _ -
rK ;
ON $26.30 Level 2 $11.51 day/$350 mo - Level 2 $9.86/$300 mo
+$.66 Respite Care Occasional crisis intervention as needed, ji; Weekly scheduled therapy, Level 2..$4.47
two face-to-face visits with child, 3. 5-8 hours a month with 4 hours of 'I°`
MI ($26.96 day/$820 mo) _ ail
2-3 contacts per monthIm5, Phi group therapy. _
li St
$29.59
aiNii •
2 1/2 #tai ($O 25 Respite day/$920 mo) Level 2 1/2 $13.15 day/$400 mo
h1Flryy e
_
$32.88 a Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
3 multiple sessions,can include ion Level 3..$6.02
weekly face-to-face visits with child, more
-. ($33.54day/$1020 mo) and intensive coordination of than 1 person, i.e.family therapy, r'tilat
' • multiple services. for 9-12 hours/monthly. At
:.i $36.16Inri
31/2 f, +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo ::
($36.82 day/$1,120 mo) ,•-
KZ $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo .111/4+,.
Level
ifill +$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly `ii '
4 multiple sessions,can include
RTC Frg$t?, •
which includes high level of case more _ Level 4....Neg.
Drop u •
Down 4,1 ($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. ti�E,
sti..4 contacts •er week minimum. -
iAl
Assess $26.96 day/$820 mo ,r ;
Rate i (Includes Respite) $11.51 day/$350 mo tu' Fill.�4m " a y
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld Co 1�
s5 i
fJ
WELD COUNTY BOARD OF
{ y SOCIAL SERVICES, ON BEHALF
ft f)1/4-71P A OF THE WELD COUNTY
211pj DEPARTMENT OF SOCIAL
SERVICES
By: By: (1,J eDeputy Cler to the Board David E. Long, Chai
S 0 5 2007
CONTRACTOR
Loving Homes Inc.
125 S Union Ave
Puebl O 81003
I n q
By: ,/1- �`� VI , 2)��' c@
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dir c or
8 Weld County SS-23A Addendum
')/OAh_ not/L
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Lutheran Family Services and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of 4 , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Areement remain unchanged.
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
020407- CUM
' 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.
11. 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 Depaittttent of Social Services Policy and Procedure Manual.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
• 14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
• failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
•
• NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX TRAILS CASE ID DOB
M F I
WORKER COMPLETING ASSESSMENT HH# 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%n) 2 round trips a week
❑2) 3-4 round trips a week. ❑2'%)5 round trips a week 03)6 round trips a week
03%) 7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
❑Basic Maint.)No participation required ❑1)Once a month ❑1'%)Two times month
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 91)Less than a% hour per day 01%) 'h hour a day
❑2) 1 hour a day 02 %) 1'/-2 hours per day 03)2%r3 hours per day
031/2)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed ❑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 ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical,and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week ❑2%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.
01%)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
❑3)Face-to-face contact weekly with child and occasional crisis intervention.
❑3%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑1)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DSS
. . NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that at lily to this child.
irt�'��' i � w t t + € c a • s i�.
s e��,q t" _ <
..FY.Vim'
Aggression/Cruelty to Animals
❑ ❑ 0 ❑
Verbal or Physical Threatening
❑ ❑ 0 ❑
Destructive of Property/Fire
Setting 0 0 0 0
Stealing
❑ ❑ 0 0
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
O 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ 0 ❑ 0
Runaway
O 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 ap.ly to this child.
. } . Fvn
,z .,� t i ° t a . e f a
e
iiezv
6 e
P i ar .a•i Y yI s �3 A
.1..... ..nn...t,..,�Y'R.!sc`.^a:a.aJ rat__. ' $1,1:=11-_.. a._. ,;^t:: x*F.F ... a.u_s,_.m i a4`2 t,e.'.:.P.)
Inappropriate Sexual Behavior
❑ ❑ 0 ❑
Disruptive Behavior
❑ 0 ❑ 0
Delinquent Behavior
❑ ❑ ❑ 0
Depressive-like Behavior
❑ 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ ❑ ❑
the Medically fragile NBC)
Emancipation
❑ 0 ❑ ❑
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ 0
Requires Night Care
❑ ❑ 0 ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
' NEEDS BASED CARE
•
. RATE TABLE
(Exhibit C)
!t sL ! a E^ v q to S -. ys:_ :•4'r ;s�„
IL
'(!.k« "yam J �{$ � as a trlg5. ra, L ry ��y �y,�3R �
`' i - a1`'�'hv tl1 ti a _ .� '1��4'k' '�v'e- e i vY�Yc
yy 4 � !i
� �vv 3 '+- .. _AAg--•'` 4$?�N 'G s »,y.T . e ,k s a t i
1107.97404a1440:041140111::10 :4.011L111;211Skittliabitlatkaanal'ejel10011M01-0:
,. Lsk ! „0 11��x„ru O.... 13• , 0.: t ;a ..'.m, a 0. ^!001PI,i .' �r110.. .L"0z.• .
Sii Age 0-10...$16.32($496) L Basic Maint $4.93 day/$150mo * Level 0 w $0 ,�*;�
County Age 11-14...$18.05 AlTherapy not needed or provided ,i
($549) vy,
Basic •11."
No crisis intervention,Minimal CPA by14'61Level 0...$0
aint Age 15-21..$19 27 1,1,/!: y b (None)
M ($586) iiiii9 involvementlik, ,one face-to-face visit .: another source, i.e.mental health.
+$.66 Respite Care y rhp�,,($20) MA with child per month.
WI -PT
OS
$19.73 my Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
::
+$.66 Respite Care in Minimal crisis interention as needed, , r, Regularly scheduled therapy,
1 ' Level 1 ...$2.99
one face-to-face visit per month with($20.39 day/$620 mo) a ig
child, 41 1 up to 4 hours/month.
�- 2-3 contacts per month �.) '(=
$23.01 1 IMF
1 1/2 4;r +$.66 Respite Care t�., Level 1 1/2 $9.86 day/$300 mo 1,371, k�"
45.O ($23.67 day/$720 mo) 1,,5 T:a � ?
$26.30 ' Level 2 $11.51 day/$350 mo L'.,, Level 2 $9.86/$300 mo ,114,1:
A +$.66 Respite Care ' Occasional crisis intervention as needed, Weekly scheduled therapy, g
2 :,. `5 on, Level 2..$4.47
iiiyr E two face-to-face visits with child, z; 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) 11
,arA 2-3 contacts per month N group therapy. (1
$29.59 10110
2 1/2 _ >i+$.66 Respite Care Level 2 1/2 $13.15 day/$400 mo ':' 'ir
($30.25 day/$920 mo) )
!` $32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo
illigfib
4.66 Respite Care r Ongoing crisis intervention as needed, k:' Regularly scheduled weekly =i
multiple sessions,can include Level 3..$6.02
3 II weekly face-to-face visits with child, more
($33.54day/$1020 ma) S ,0•.:
� and intensive coordination of r. .- than 1 person,i.e.family therapy,
l
Sil nS multiple services. vk: for 9-12 hours/monthly. 4`"
$36.16 °�:'
3 1/2 .G +$.66 Respite Care 3+ 3t Level 3 1/2.........$16.44 day/$500 mo "' 'ig::.
($36.82 day/$1,120 mo) i.i mat, 4112
$39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo ,8itlil 8;
+$.66 Respite Care Ongoing .41. Regularly weekly On oin crisis intervention as needed, Re ularl scheduled
4 II:,IMIII . 'a multiple sessions,can include
ROro which includes high level of case ,; more Level 4....Neg.
mnn
Down i : ($40.77 day/$1220 mo) Ni management and CPA involvement with than 1 person,i.e.family therapy,
'pip
2." aZ child and provider and 2-3 face-to-face ids. for 9-12 hours/monthly.
'4 'n S contacts .er week minimum. 1
33i._.
ithi
i
Assess t $26.96 day/$820 mo l: IT s`=
Rate 1- (Includes Respite) ^1 $11.51 day/$350 mo iasr. E i
ASA r'11
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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: Li
Weld County e`
a6I t ���IP
�� WELD COUNTY BOARD OF
` SOCIAL SERVICES, ON BEHALF
c(,3 OF THE WELD COUNTY
c'egf7 IF At Th> DEPARTMENT OF SOCIAL
e,v_J k\ , SERVICES
BY: 4-Ititet- 92q i� �� By: aG
Deputy Clem toe Board David E. Long, Chair
SEP 2007
CONTRACTOR /
Lutheran Family Services iF G�rtaO
3800 Automation Way, Suite 200
Fort Collins, 80525
By:
WELD COUNTY DEPARTMENT I
OF SOCIAL SERVICES
. l�. ?
By: 5/O
Dir ctor
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Maple Star Colorado and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this 1 day of U u I , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Xgreement 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
.7407-a 896
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term"litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE IDN ISEX F I ID
OB
CASE ID DOB
WORKER COMPLETING ASSESSMENT HHN [DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy;Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week ❑1)One round trip a week ❑1'%)2 round trips a week
02) 3-4 round trips a week. 02%)5 round trips a week ❑3) 6 round trips a week
03%)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
0 Basic Maint.)No participation required ❑l)Once a month 01%)Two times month
02)Three times a month 02%)Once a week 03)Two times a week
❑3%)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a%x hour per day ❑1%) '/ hour a day
❑2) 1 hour a day 02 %) 1'/-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 01)Less than 5 hours per week 01%)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑ 3)Constant basis during awake hours 03%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
❑ Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 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.)
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.
93%)Face-to-face contact weekly with child and ongoing crisis intervention which may include intensive coordination
of multiple services.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling group,or more than one
County foster child is with the same provider.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
00)Not needed or provided by another source(i.e.Medicaid) 01)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
4 Weld County SS-23A Addendum
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
ri . tit” a s t e a i � � iE`.
Opp
is . u.MILIPSASIWRIS
Aghilt-VII ,...1IY etaRiie;. lif,f il.�i':"3Y - i'l"b 1 IIIf <
......:'. L ......
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting O O O O
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ O
Presence of Psychiatric
Symptoms/Conditions O O O ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ O
Sexual Offenses
❑ ❑ ❑ O
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 a..ly to this child
} i ia6thigningine:!Please
R' e A ti i .�' w is "r air t r.! _ ':' a ,�
y�! '3.y :n£'�fi'dgA i 6 i R i f __ i '1eii a �t�x�
ta
..y, L V y..;•v t i !Y�
••• � ROAe use.� -
y q .R f i•alai E I
i q i t ffi F! i ti
. ,.,,,��'au. k 0I O,-;rAIRM uy Mi66iYlku, 1' *c3raw.l.-.,`�-- a�U r °;isa. ..s:�.�1.$x s _n�_≥.. d"ffi'v, 9' �..:a3AI' .s;w 'k'.- _.o .�F'M
Inappropriate Sexual Behavior
❑ ❑ ❑ ❑
Disruptive Behavior
❑ O ❑ ❑
Delinquent Behavior
❑ ❑ ❑ O
Depressive-like Behavior
❑ ❑ O O
Medical Needs
(Itcondition is rated"severe",please complete ❑ ❑ O O
the Medically fragile NBC)
Emancipation
❑ O ❑ O
Eating Problems
❑ O ❑ O
Boundary Issues
❑ ❑ ❑ O
Requires Night Care
❑ ❑ ❑ O
Education
❑ O ❑ ❑
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 SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
to , v ...... _:a,gh _ f. s m-,nm,7w :y
i,:Ri . :4 . :1 a A x,.a a tet x 1 3. - f. i s r 2 3
', e x' rte ' a lik 1 �'��1
l�. 4, �.4 �� �'-�' �� Any . u: ,� l
{� r c�a t 4 �� f. .lfb,A .. "1
:1��4,Lnkz 'leri ' 5 ,0,-9!—, 1077th :., i S r _::+ ' .>4:. 4,. ,:AA2.,;.A a"wu ;JIIrrainIrrthielIII
Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo t';'<„' Level 0 $0 cc.
County Age 11-14...$18.05 ;. Therapy not needed or provided irt
($549) No crisis intervention, Minimal CPA �`' by /Ii',`.. Level 0...$0
Basic - Age 15-21...$19.27 a : ,*. (None)
Maint. i
9i$ ($586) involvement,one face-to-face visit another source,i.e.mental health. li
,A,g +$.66 Respite Care = ITEE
E ($20) with child per month. t
$19.73 Level 1 $8.22 day/$250 mo (: Level 1 $4.93/$150 mo
iimy
`dii" irt `
' +$.66 Respite Care Minimal crisis interention as needed, ; Regularly scheduled therapy, =i'
1 : 3 6::„...., Level 1 ...$2.99
Sill
�f one face-to-face visit per month with s r
($20.39 day/$620 mo) child, q up to 4 hours/month. rt
2-3 contacts per month .` l's
kr $23.01
IIIilhWs
1 1/2 +$.66 Respite Care Level 1 1/2 $9.86 day/$300 mo
+, _ ($23.67 day/$720 mo)
"
$26.30 Level 2 $11.51 day/$350 mo 1:2„:"3, Level 2 $9.86/$300 mo `'
+"i + �-,i Weekly scheduled thera
2 fgf $.66 Respite Care Occasional crisis intervention as needed, pY Level 2..$4.47
r=
L' two face-to-face visits with child, Al* 5-8 hours a month with 4 hours of
ViT ($26.96 day/$820 mo) ?
lye" •• 2-3 contacts per month `. group therapy.
ut $29.59
S v
2 1/2 ,tit +$.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo `S
($30.25 day/$920 mo) 3;
ilihill $32.88 Level 3 $14.79 day/$450 mo lr, Level 3 $14.79/$450 mo 1.2 et'
+$.66 Respite Care Ongoing crisis intervention as needed, ! Regularly scheduled weekly
3 multiple sessions,can include Level 3..$6.02
weekly face-to-face visits with child, `"r;. more
($33.54day/$1020 mo) > '
and intensive coordination of +-Ei s than 1 person,i.e.family therapy, 1j t.
multiple services. for 9-12 hours/monthly. ,0!".
$36.16 ..Pi
3 1/2 +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo aati': :[,,,1'
illiiiii ($36.82 day/$1,120 mo) l
i $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, ,:, Regularly scheduled weekly
r 4 mot. multiple sessions,can include
RTC ill which includes high level of case , more 'l.
Drop 1 Level 4....Neg.
Down hi ($40.77 day/$1220 mo) management and CPA involvement with la: than 1 person,i.e.family therapy,
t�arg'rF child and provider and 2-3 face-to-face �'. for 9-12 hours/monthly.
contacts .er week minimum. i?;
Assess r, $26.96 day/$820 mo a, liP
Rate `s (Includes Respite) (33; $11.51 day/$350 mo r1i
;1 ' : £iii ':Ti:
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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: at
Weld County
so: .9 WELD COUNTY BOARD OF
a s,, ;•,/ SOCIAL SERVICES, ON BEHALF
\3?---:)
I`;w. OF THE WELD COUNTY
i f VI DEPARTMENT OF SOCIAL
_ -- SERVICES
By: / By: 67
Deputy Clef= to the Board David E. Long, Chair
SEP 0 5 2007
CONTRACTOR
Maple Star Colorado
2785 Speer Blvd, Suite 340
Denver, CO 80211
By: LJ'1 (,;(ye,
ict l`-
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: lib c
Dire for
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Smith Agency Inc. and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of v u t , 2007, 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#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.
1 Weld County SS-23A Addendum
ate9-as".96
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX ITRAILS CASE ID DOB
M F
WORKER COMPLETING ASSESSMENT HH# !DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
['Basic Maint.) Less than one round trip a week 01)One round trip a week 011/2)2 round trips a week
❑2) 3-4 round trips a week. ❑2Yz) 5 round trips a week 03) 6 round trips a week
031/2)7 round trips or more
P 2. How often is the foster care provider required to participate in child's therapy or counseling sessions?
0 Basic Maint.)No participation required 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?
0 Basic Maint.)No educational requirements 01)Less than a''/z hour per day 01%) Yz hour a day
02) 1 hour a day 02 Yz) 1'/z-2 hours per day 03)2'/z-3 hours per day
03%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
0 Basic Maint.)No special involvement needed ❑I)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 feeding,
bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week 01%) 5 to 7 hours per week
02) 8 to 10 hours per week 02%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%z)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑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) 01)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 DSS
• NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
n m � °�� ekt ' k
R i,a 5 s �`� `` `v`.E1—e:- 9 P e t f ! ° $p (' ` j >5 10 fr t
445 1 ,,.* ' , y{�y� i > m• $ S :+.Fv riship �'r ki:
'a ti Ja
it .BAs°5.W(5 ,, t 43Ingillealt :'Y9 iii It t r -E 3 i iA-9Pt
..3 y >� r q „ m,w v v�. ,
hl as 5 n,,�i . mot:_ c �n pi_ a v ir, -yay sat m
Aggression/Cruelty to Animals
O 0 0 ❑
Verbal or Physical Threatening
O 0 0 ❑
Destructive of Property/Fire
Setting ❑ ❑ 0 ❑
Stealing
❑ 0 0 0
Self-injurious Behavior
O 0 0 0
Substance Abuse
❑ 0 ❑ ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ ❑ El
Sexual Offenses
O El 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.
" 'a;
_
tihfiyN i xxx xs t x & �i } ih5
MBYY$ is ,y hba ism
r s .4:aii 'i sa a '� x a 'c 4J•
iS v. t, A It rme1 'uJI'. i H It fi'� .i �tv-'M i $ � i
S �} i lk3} C�. i� i ,}ff i .
_m..., ,a`� ' �,
Inappropriate Sexual Behavior
❑ 0 0 ❑
Disruptive Behavior
❑ 0 0 0
Delinquent Behavior
❑ ❑ ❑ ❑
Depressive-like Behavior
❑ ❑ ❑ ❑
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ 0 0
the Medically fragile NBC)
Emancipation
❑ ❑ 0 0
Eating Problems
o
o
0
0
Boundary Issues
❑ ❑ 0 ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ 0
Involvement with Child's Family
❑ 0 0 0
CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑ 1 ❑ 2 LI 3
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
•
NEEDS BASED CARE
RATE TABLE
(Exhibit C)
.dsdrt v� z
1 Q A
R P& r 1 r°_ s _,t f .. k " i
lattsiti Is ' 1a raI t9;a`w i1dop €!t if 4 ° Nigh,
11
Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo illiiii Level 0 $0
Age 11-14...$18.05 = 4i Therapy not needed or provided itiiii.,
County fp ($549) ii.i. No crisis intervention, Minimal CPA i, by Level 0...$0
Basic Age 15-21...$19.27 '.3 i; (None)
Maint
($586) - involvement,one face-to-face visit liiiii. another source,i.e.mental health. 4
+$.66 Respite Care
($20) with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
1 a. +$.66 Respite Care .i Minimal crisis interention as needed,
Regularly scheduled therapy,
illligil k one face-to-face visit per month with d:,? Level 1 ...$2.99
t ($20.39 day/$620 mo) iIiiirii is child, up to 4 hours/month.
reig Ii t 2-3 contacts per month
iiinT $23.01
1 1/2 ifiiff +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo ".
iiiigg ($23.67 day/$720 mo) !` _
M:
$26.30 Level 2 $11.51 day/$350 mo "h Level 2 $9.86/$300 mo iiiiiin
2 +$.66 Respite Care ;r. Occasional crisis intervention as needed Weekly scheduled therapy ' Level 2..$4.47
i'I two face-to-face visits with child, 3.p 5-8 hours a month with 4 hours of
($26.96 day/$820 mo) r,=
2-3 contacts per month group therapy. iiiiibi
$29.59 _ ii,iii_N
2 1/2 ,, 4.66 Respite Care f 1` Level 2 1/2.........$13.15 day/$400 mo ;i.(
($30iiiiiii .25 day/$920 mo) u(l
".$32.88 S( Level 3 $14.79 day/$450 mo irilf Level 3 $14.79/$450 mo
iiiiiiiii
+$.66 Respite Care ciiiiii Ongoing crisis intervention as needed, Ali Regularly scheduled weekly
3 multiple sessions,can include Level 3..$6.02
.,: weekly face-to-face visits with child, iiiiiiii more iiiiiiii
($33.54day/$1020 mo) and intensive coordination of iiiii than 1 person,i.e.family therapy, IR
multiple services. fiiillil for 9-12 hours/month)
iiilli $36.16 ) IS
31/2 4.66 Respite Care Level 3 1/2 $16.44 day/$500 mo fir
($36.82 day/$1,120 mo) k.:41-,
$39.45 }). Level 4 $18.08 day/$550 mo a Level 4 $14.79/$450 mo
Tiiiii +$.66 Respite Care qs Ongoing crisis intervention as needed, liti Regularly scheduled weekly
4itini1-
itiliih multiple sessions,can include iiiiiiiii
RTC iiiiii, r;, which includes high level of case more:94E* di Level 4....Neg.
Drop Down ��i ($40.77 day/$1220 mo) ;m w;i management and CPA involvement with iiq than 1 person, i.e.family therapy,
child and provider and 2-3 face-to-face 1 n`, for 9-12 hours/monthly.
iiiiii :4111 " :ilk,
ag
contacts ier week minimum. Wit
,:+a ,_w, =ti65d�=2ee«.4Ar`± .`" ,4"a1��sE�t`4tau4a�,LmA`.:u1Iz9E;t>Yia>z ,�id3¢ ,,..S+i'.rHi=Lu„cx.,iui s+si 411 i,s c w 15Li k ..S, q} ss v, ae ,ji.::,_�.
}
gii-li 4.Assess $26.96 day/$820 mo �1 yo= �;,
Rate (Includes Respite) _ifh.i:- $11.51 day/$350 mo
.. t;i.'1 iii„
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 month
7 Weld County SS-23A Addendum
i
' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: _ ___ '� ✓
Weld Count t, 0,tfg d
afr P5'
WELD COUNTY BOARD OF
?- 725,0
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
BY: /�,�LtiL1at_Eck By:
Deputy Cl to the Board David E. Long, Chair
SEP 0 5 2007
CONTRACTOR
Smith Agency Inc.
7169 S Liverpool St
Centennial, CO 80016
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
te14)f‘ (
�}
1`J
S Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Special Kids Special Families and Weld County
Department of Social Services for the period from
July 1, 2007 through June 30, 2008.
The following provisions, made this / day of 7:y , 2007, are added to the referenced
Agreement. Except as modified hereby, all terms of the Ngreement remain unchanged.
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.
1 Weld County SS-23A Addendum
ace 7-aey6
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.
11. 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.
12. 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.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
2 Weld County SS-23A Addendum
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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 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 Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor 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 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
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Weld County SS-23A Addendum
NORTHERN CONSORTIUM OF COUNTIES
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# ISEX F TRAILS CASE ID (DOB
I WORKER COMPLETING ASSESSMENT HH# I PATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER TRAILS ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care provider for the following: Therapy; Medical Treatment;
Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.) Less than one round trip a week ❑1)One round trip a week ❑1%:)2 round trips a week
❑2)3-4 round trips a week. ❑2'%)5 round trips a week O3)6 round trips a week
❑3'h)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 Du Once a month ❑1%z)Two times month
O2)Three times a month ❑2%n)Once a week O3)Two times a week
❑3'/)Three times a week or more
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or
special education plan?
❑Basic Maint.)No educational requirements ❑1)Less than a Yz hour per day ❑1'%) Yz hour a day
❑2) 1 hour a day O2 %) 1'h-2 hours per day O3)2'/-3 hours per day
❑3%)More that 3 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time
and/or activities and/or crisis management?
❑Basic Maint.)No special involvement needed 01)Less than 5 hours per week ❑1/)5 to 7 hours per week
❑2) 8 to 10 hours per week ❑2%) 11 to 14 hours per week
❑3)Constant basis during awake hours ❑3%)Nighttime hours
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,
bathing,grooming,physical, and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1) 3 to 4 hours per week ❑1/) 5 to 7 hours per week
O2) 8 to 10 hours per week ❑2%) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3%)21 or more hours per week
A 1. How often is CPA/County case management required?(Does not include therapy)
❑Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e.mutual care placements.)
❑1)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1'/)Face-to-face contact one time per month with child and occasional crisis intervention.
O2)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)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 DSS
NEEDS BASED CARE ASSESSMENT
(Exhibit B)
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.eaiwy y ,4-46:1,41650.1141744:41 :74
" 14 ! a £ 8.Y tatiVRk_ i 9pS'v. 36 + , t { 3 '_ P
} `Wt •-ki rm
�svl igitiarillSIS t3H _._
: 8all!i 4Ll+ yj�Li` *magi 1 =i fi i
Aggression/Cruelty to Animals
❑ ❑ ❑ ❑
Verbal or Physical Threatening
❑ ❑ ❑ ❑
Destructive of Property/Fire
Setting 0 ❑ 0 ❑
Stealing
❑ ❑ ❑ ❑
Self-injurious Behavior
❑ ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ ❑
Presence of Psychiatric
Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis
❑ ❑ ❑ ❑
Runaway
❑ ❑ 0 ❑
Sexual Offenses
❑ ❑ 0 ❑
5 Weld County SS-23A Addendum
BEHAVIOR ASSESSENTB) CONTINUED
•
(exhibMit
• Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
�a _ rix l
al
w .F .,e yt ill 3 t _ 5.. ate ® . a ��
i:ctbittamtiatwat :fib St, r3.� g4 ' P .ha,li I
a.IPIREIRI'a Assess �sAre "'53'ihvR 3,. ti,�.t : ti u r u n iI3 i w g ti P. IS >zF
jj P, 7 {E , 7 rit ".:;:!2.,,. .z- P ''" ' x,1 no-az" do _ t .�FaN
'-` gg4„,.,,,‘,,„,4„,,„„
,.. ... �'. .dw..�` S°„?33`3fiv �'(,FL' ...F } .63}!i.azR2E.�d �'4S'C.m. sa 4..: .'V3 .. r ' ...S wd.c... �4
Inappropriate Sexual Behavior
❑ 0 0 0
Disruptive Behavior
O 0 0 0
Delinquent Behavior
o ❑ ❑ 0
Depressive-like Behavior
O 0 0 0
Medical Needs
(If condition is rated"severe",please complete ❑ ❑ O ❑
the Medically fragile NBC)
Emancipation
❑ 0 0 0
Eating Problems
❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑
Education
❑ ❑ ❑ ❑
Involvement with Child's Family
❑ 0 0 0
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 SOCIAL SERVICES
NEEDS BASED CARE
•
RATE TABLE
(Exhibit C)
a ese
D
- r s tm.
. _.. -440flat B ' + 5_t i 4 Y$5*:
; Age 0-10...$16.32($496) Basic Maint $4.93 day/$150mo @t' Level 0 $0 SO
Count Count Age 11-14...$18.05 F ' Therapy not needed or provided
y ($549) No crisis intervention, Minimal CPA 8:k byit Level 0...$0
Basic Age 15-21...$19.27 "
Maint. (None)
($586) involvement,one face-to-face visit 914 another source,i.e.mental health.
$.66 Respite Care ` '`
+ 3�i k�?
($20) with child per month.
$19.73 Level 1 $8.22 day/$250 mo Level 1 $4.93/$150 mo
+$.66 Respite Care Minimal crisis interention as needed, sue. Regularly scheduled therapy,
1 one face-to-face visit per month with Level 1 ...$2.99
($20.39 day/$620 mo) child, 5. up to 4 hours/month. `;
Int :
i( 2-3 contacts per month 1m• k .
$23.01
1 1/2 •
.,.L +$.66 Respite Care Level 1 1/2.........$9.86 day/$300 mo
`% ($23.67 day/$720 mo)
1• $26.30 Level 2 $11.51 day/$350 mo Level 2 $9.86/$300 mo �, .
t;r
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy, 1,!,!,: 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 r
rA
2-3 contacts per month group therapy.
$29.59
+u..
2 1/2 .. +$.66 Respite Care Level 2 1/2.........$13.15 day/$400 mo 1"=`
Pi ($30.25 day/$920 mo) _
$32.88 Level 3 $14.79 day/$450 mo Level 3 $14.79/$450 mo 1,:.
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly =_ "
multiple sessions,can include
t*473 weekly face-to-face visits with child, more Ili : Level 3..$6.02
($33.54day/$1020 mo) and intensive coordination of I than 1 person,i.e.family therapy, r0.
multiple services. for 9-12 hours/monthly. i.E.
$36.16 +
3 1/2 • +$.66 Respite Care Level 3 1/2.........$16.44 day/$500 mo "4
h. ($36.82 day/$1,120 mo)
e. $39.45 Level 4 $18.08 day/$550 mo Level 4 $14.79/$450 mo
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly , ,
multiple sessions,can include ',194'
=:
RTC ` ' which includes high level of case more 91ST,'
9 Leve14....Neg.
Drop
Down ($40.77 day/$1220 mo) management and CPA involvement with than 1 person, i.e.family therapy,
itS
4lAt1 child and provider and 2-3 face-to-face for 9-12 hours/monthly. ;ifs;
:I contacts .er week minimum.
$+t. . .S s._ - . r ar. ...s u'=, „ +. ..., "r, . . ... .:F +.,. ... '[ ... .. =t. .. + L,. u3.. wry 4, 7,`:,,�2" ia. ... ...
Assess Iiit $26.96 day/$820 mo it!.
Rate n (Includes Respite) %, $11.51 day/$350 mo k`�',
Admin.Overhead Rate: As of 7/01/07
$6.25 day/$190.00 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:
Weld Cou t C
J
j :-(i WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
BY: /.L ifyiJe SZeitti By:
Deputy Cl to the Board David E. Long, Chair
SEP 5 2007
CONTRACTOR
Special Kids Special Families
424 W Pikes Peak Ave 1
Colorado Springs, C 905
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: ,__//l,l lk
lire or
s Weld County SS-23A Addendum
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