HomeMy WebLinkAbout20061679 RESOLUTION
RE: APPROVE REVISIONS TO OPERATIONS MANUAL, SECTION 2.000, SOCIAL
SERVICES DIVISION POLICIES AND PROCEDURES
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with revisions to Section 2.000,Social Services
Division Policies and Procedures,for the Department of Social Services Operations Manual, and
WHEREAS,after review,the Board deems it advisable to approve said revisions,a copy of
which is attached hereto and incorporated herein by reference.
NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services,that the revisions to Section 2.000, Social
Services Division Policies and Procedures for the Department of Social Services Operations
Manual, be, and hereby are, approved.
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 26th day of June, A.D., 2006.
BOARD OF C NTY COMMISSIONERS
E�+�`� WELD COU Y, COLORADO
ATTEST: 4 ; '.,• 43? ,pi� —
�� M Bile, Chair
Weld County Clerk to t{te r P .0 C
q;. G
David E. Long, Pro-Tem
BY: A (1-1 ) I 11 R-
De ty Cler o the Board '1.- z ,,,_if
Willi H. erke
AP V AS TO FO x - L ?
���- _ Robert D. Mas n
my Attorney
I Glenn Vaa
Date of signature: I1H f
2006-1679
SS0033
64.4.3/41 , DEPARTMENT OF SOCIAL SERVICES
P.O.BOX A
GREELEY,CO. 80632
Website:www.ce.weld.co.us
I
Administration and Piddle Assistance(970)352-1551
Child Support(970)352-6933
C.
COLORADO
MEMORANDUM
TO: M.J. Geile, Chair Date: June 21, 2006
Board of County Commissioners
FR: Judy A. Griego,Director, Social Services - 0`, ?LAT
jtklul
RE: Revisions to Section 2.000, Social Servicesivision
Policies and Procedures,Weld County Department of
Social Services Operations Manual
Enclosed for Board approval are revisions to Section 2.000, Social Services Division Policies and
Procedures, Weld County Department of Social Services Operations Manual. These revisions
were reviewed at the Board's Work Session held on June 19, 2006.
The purposes of these revisions are to:
1. Provide a 2% cost of living(COLA)increase to Child Placement Agencies. The 2%
COLA will result in an additional estimated cost of approximately$44,000 per year to
the Child Welfare Block. Concurrently, the Department is transitioning therapeutic
services,by June 30, 2007,to Medicaid through Northeast Behavioral Health
Organization,which will result in a savings of$93,000 per year. Reference: Sections
2.327 through 2.327.1.
2. Reflect Department rate negotiation practices and methodologies for
reimbursement with out of home placement facilities. These rate methodology
practices will be used by the Department with child placement agencies, group care
homes, therapeutic residential child care facilities,and other associated facilities.
Reference: Sections 2.320 through 2.320.1 and Exhibits A through G.
If you have any questions,please telephone me at extension 6510.
2006-1679
Social Services Division Policies and Procedures
2.327 Child Placement Agencies
Added 1/02
Revised 10/29/02 The Department has established and will reimburse the Child Placement
Agencies (CPA) by the method in this manual as outlined in Section
2.320.1.
2.327.1 Reimbursement Rate
Revised 10/29/02 A child specific Needs Based Care Assessment, designated as Exhibit B
Revised 6/06 shall be used to determine levels of care for each child placed within a
CPA. The assessment will be filled out by the county caseworker that is
placing the child. The specific rate of payment will be paid for each level
of service as recorded by the Needs Based Care Assessment. The
reimbursement rate for these levels will be indicated by the Needs Based
Care Rate Table, designated as Exhibit C. Once rates have been
established, the Needs Based Care Addendum, designated as Exhibit D,
will be completed by the County Rate Negotiator to outline the total rate
of reimbursement for the out-of-home care of the child. This addendum
will be effective from the time of placement until the end of the Colorado
fiscal year, June 30, unless otherwise negotiated. The Needs Based Care
forms have been adopted from the Northern Consortium of Counties.
Effective October 1, 2001, all providers received a 2.5% to 3% increase in
administrative overhead rate. Effective July 1, 2006, CPA providers
received a 2% COLA to the administrative overhead rate.
2.327.2 Rate Re-Evaluations and Adjustments
Added 10/29/02
A. The rates that are established in the Needs Based Care addendum
will be re-evaluated and/or adjusted as outlined in the
Department's Operations Manual, Section 2.902.2, or
B. The rates may be negotiated at any time based upon the changing
service needs of the child.
Social Services Division Policies and Procedures
2.320 Out-of-Home Placement Reimbursement
Effective 1/1/01 The Department establishes rates to be paid to providers for out-of-home
Revised 6/02 placements at the beginning of every state fiscal year. These rates are
similar to the State determined reimbursement for specific types of facilities.
2.320.1 State Licensed Provider Reimbursement
Added 6/02
Revised 6/06 A. The Department will reimburse a state licensed provider if such provider
meets the State reimbursement requirements of Colorado State Rules,
Section 7.405, Volume VII, Social Services Programs, and the State
requirements for State Licensed Providers of Colorado State Rules,
Section 7.417.2, Volume VII, Social Services Programs.
B. As required by C.R.S. 26-5-104, the Department will negotiate rates,
services, and outcomes with providers as outlined in the submitted Rate
Setting Methodology, Exhibit A, that has been approved by the State.
C. The Department will enter into yearly contracts with each State Licensed
Provider that the Department utilizes. The Contracts will be in force from
July 1, the start of the state fiscal year, to June 30, the end of the state
fiscal year.
D. The Child Welfare Rate Negotiator will initiate and mail out to providers,
both the State prescribed SS-23A, Agreement to Purchase, contract
Exhibit B, for Providers as outlined in Colorado State Rules, Section
7.304 and Section 7.304.661 of Volume VII, and the Weld County
Addendum to the Agreement to Purchase SS-23A, Exhibits C-G. The
county specific addendum will reflect the daily rate to be paid for each
child placed with the contracted provider for the state fiscal year, as
outlined in paragraph B. Rates reflected within the yearly contracts, will
be determined by the State and may include a cost-of-living increase the
county has approved. Rates may also be negotiated to reflect additional
services that the department has approved.
E. Once signed contracts have been received from providers, the State
prescribed SS-23A Agreement to Purchase contracts will be approved and
signed by the Director and All Weld County Addendums to the State
prescribed SS-23A will be approved and signed by the Director and the
Board of County Commissioners, Weld County, sitting as the Weld
County Board of Social Services.
F. Once Placement Contracts are approved and signed by the Director and/or
the Board of County Commissioners, each provider will be mailed fully
Social Services Division Policies and Procedures
executed copies of the Agreement to Purchase Services, SS-23A and Weld
County Addendum for their records.
G. All original contracts will be filed in the Business Office. The Business
Office will notify the Social Services Administrator, or designee, if a
provider is requesting reimbursement and does not have a current signed
contract. Payment cannot be authorized to the provider until the required
contract is provided to the Business Office.
v. Exhibit A
♦
Aill.%.414C(S
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY, CO. 80632
Website:www.co.weld.co.us
' Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
O
•
COLORADO
RATE SETTING METHODOLOGY
For
Out-of-Home Placements
SFY 2004-2005
Adoption —Negotiations are based on the special needs of the adoptive child and the
circumstances of the adoptive family. Maximum monetary payment for an adoption
subsidy is the Weld County Basic Child Maintenance rate. (See Table I)The $.66/day respite
allowance is not allowable under this program.
Foster Family Home Care
Regular County Homes—Reimbursement for foster care services in regular
county foster care homes are based on the Weld County Basic Child Maintenance Rate.
(See retie I) A respite allowance of$.66/day is also added as shown in Table 1.
Critical Care County Homes—Reimbursement for foster care services in county critical
care homes are based on the Weld County Basic Child Maintenance Rate established in
2000, in addition to a difficulty of care rate, which equaled a critical care base rate of
$800.00/mo. Cost of living increases have been added to the child maintenance portion of
the critical care base rate since 2001, as noted below in Table 1. The critical care county
home rate has been calculated as $28.38/day for 2005. A respite allowance of$.66/day is
also added to all critical care county homes.
RTC/Foster Care Transition Program* —The base rate for the RTC/foster care
transition homes consist of the Weld County Basic Child Maintenance rate (Table 1), in
addition to a difficulty of care rate, which equals a transition program base rate of
$1,500.00/mo. A respite allowance of$.66/day is also added to all county foster care
homes.
*This is a new program yet to be approved by the Board of Weld County Commissioners and is subject to
change.
Updated January,2005
Weld County DSS Exhibit A
• Rate Setting Methodology
•
Continued...
Child Placement Agencies* - Utilization of the Need Based Care assessment tool and
rates developed by the Northern Colorado Consortium of Counties and as approved by
the Board of Weld County Commissioners.
*Please note that the Northern Colorado Consortium of Counties has made minor changes to the assessment tool
and the rate table effective August 2004. Due to Weld County being bound by provider contracts until June
2005,we will not be utilizing these changes. Attached please find the amended assessment tool and rate table
that will be utilized for the state fiscal year 2005-2006,subject to approval by the Board of Weld County
Commissioners.
Kinship Foster Care-Reimbursement for kinship foster care services are based on the Weld
County Basic Child Maintenance Rate. (See Table 1)A respite allowance of$.66/day is also
added as shown in Table 1.
Group Center Care(CPA)* -Utilization of the Need Based Care assessment tool and rates
developed by the Northern Colorado Consortium of Counties and as approved by the
Board of Weld County Commissioners.
*Please note that the Northern Colorado Consortium of Counties has made minor changes to the assessment tool
and the rate table effective August 2004. Due to Weld County being bound by provider contracts until June
2005,we will not be utilizing these changes. Attached please find the amended assessment tool and rate table
that will be utilized for the state fiscal year 2005-2006,subject to approval by the Board of Weld County
Commissioners.
Group Home Care
County Homes—Reimbursement for county group home care services are based on the
Weld County Basic Child Maintenance Rate (see Table 1), plus the Weld County Direct
Care and Services Allowance. (see Table 2) The basic child maintenance rate is based on the
age range that the group home accepts, the direct care and service allowance is based on
the number of paid full-time equivalent staff. Currently, the department has two group
homes with a total of four reserved spaces per month.
Child Placement Agencies*- Utilization of the Need Based Care assessment tool and
rates developed by the Northern Colorado Consortium of Counties and as approved by
the Board of Weld County Commissioners.
*(Please note that the Northern Colorado Consortium of Counties has made minor changes to the assessment tool
and the rate table effective August 2004. Due to Weld County being bound by provider contracts until June
2005,we will not be utilizing these changes. Attached please find the amended assessment tool and rate table
that will be utilized for the state fiscal year 2005-2006,subject to approval by the Board of Weld County
Commissioners.
Receiving Homes
County Homes - Reimbursement for county receiving home care services are based cm
the Weld County Basic Child Maintenance Rate (See Table 1), plus the Weld County Direct
Care and Services Allowance. (seeTable3) The basic child maintenance rate is based on the
age range that the receiving home accepts, the direct care and service allowance is based
on the number of paid full-time equivalent staff. Currently, the department has four
receiving homes with one reserved space per month.
2
Updated January, 2005
Weld County DSS Exhibit'A
Rate Setting Methodology
Continued...
Residential Child Care Facility-Utilization of State determined rates plus approximately a
2.5% increase to the child maintenance rate, which was effective July 1, 2001.
Residential Child Care Facility(Shelter) -Utilization of State determined rates plus
approximately a 2.5% increase to the child maintenance rate, which was effective July 1,
2001. The department may negotiate rates with providers to reflect additional services
that the department has approved.
Residential Treatment Center—Room and Board Rates Only. Utilization of State
determined rates plus a 2.5% increase to the maintenance/room and board rate, which was
effective July 1, 2001. The department may negotiate room and board rates with
providers to reflect additional services that the department has approved.
Children's Habilitation Residential Program(CHRP) - Utilization of the Level of Need
Worksheet (COPAR), in conjunction with the Needs Based Care assessment tool and
rates developed by the Northern Colorado Consortium of Counties and as approved by
the Board of Weld County Commissioners.
*(Please note that the Northern Colorado Consortium of Counties has made minor changes to the assessment tool
and the rate table effective August 2004. Due to Weld County being bound by provider contracts until June
2005,these changes we will not be utilizing these changes. Attached please find the amended assessment tool and
rate table that will be utilized for the state fiscal year 2005-2006,subject to approval by the Board of Weld
County Commissioners.
Placement Contracts
Agreement To Purchase Services (SS-23A)—Effective July I, 2002, Weld County changed to
annual Agreement to Purchase Services contracts (SS-23A). The annual agreements
replace the process of individual contracts being generated per child. Child specific
information is now reflected in an attachment A to the annual agreement. This
•
attachment A is designated as the Placement Referral form, which is completed by
caseworkers at the time the child is placed at a facility. The referral form includes the
initial treatment plan, estimated dates of accomplishing goals for the child and anticipated
living arrangements once the child completes the treatment plan. These agreements and
forms are subject to change upon approval of the Board of Weld County Commissioners.
3
Updated January, 2005
Exhibit A
Weld County DSS
Rate Setting Methodology
Continued...
Table 1
Weld County
*Basic Child Maintenance Rate
Age Daily Respite Care
Of Maintenance Daily
Child Rate Allowance
0 months
To $15.20 $.66
10 years
11 years
To $16.82 $.66
14 years
15 years
To $17.97 $.66
21 years
• Established from the standard rates set by the Colorado Department
Of Human Services,Division of Child Welfare Plus Weld County
Department of Social Services cost of living increases as follows:
1999-2003—Approximate 4%increase each year
2004—Approximate 3%increase
2005—Approximate 2.5%increase
Table 2
Weld County
Group Care
*Direct Care and Services Allowance
Number of Paid Payment per Month
FTE Staff Per Child
2.0 $11.11
2.25 $11.87
2.50 $12.56
2.75 $13.22
3.0 and above $13.91
• Established from the standard rates set by the Colorado Department
Of Human Services,Division of Child Welfare Plus Weld County
Department of Social Services cost of living increases as follows:
1999—Approximate 4%increase
Table 3
Weld County
Receiving Home
* Direct Care and Services Allowance
Number of Paid Payment per Day
FTE Staff Per Child
1.0 $11.11
1.5 $11.87
2.0 $12.56
2.5 $13.22
3.0 $13.91
• Established from the standard rates set by the Colorado Department
Of Human Services,Division of Child Welfare Plus Weld County
Department of Social Services cost of living increases as follows:
1999—Approximate 4%increase
Note: Cost of living increases are effective January 1st of each year upon approval by the Board of
Weld County Commissioners.
4
Updated January,2005
Exhibit A 1
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE ASSESSMENT
IDENTIFYING INFORMATION
CHILD'S NAME 'STATE ID# SEX RAILS CASE ID 'DOB
Sex
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 CHILDREN
AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for the following: Therapy; Medical Treatment; Family
Visitation; Extraordinary Educational Needs; Etc.,as outlined in the treatment plan?
❑0) One round trip a week or less ❑1)2-3 round trips a week
O2)4-5 round trips a week O3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0) Once a month ❑1)Two times but less than weekly
O2) Once a week ❑3)2 or more times a week
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) Less than a 'A hour per day ❑1) 'A hour a day
O2)More than 'A hour per day, up to 2 hours per day O3)More than 2 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)Less than 5 hours per week ❑1)5 to 10 hours per week
O2)At least daily O3)On a constant basis
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) Less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0)No crisis intervention,minimal CPA involvement, one face-to-face visit with child per month.
❑1) Minimal crisis intervention as needed,one face-to-face visit with child,2-3 contacts per month.
O2) Occasional crisis intervention as needed, two face-to-face visits with child,2-3 contacts per month.
O3) Ongoing crisis intervention as needed, weekly face-to-face visits with child, and 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
Exhibit A 2
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE ASSESSMENT
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
LEVEL#
Comments:
LEVEL OF CPA CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (TI)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
Exhibit A 3
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE ASSESSMENT
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE
SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ORe-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING.
3 - zlxrC' Std �f
�^ �
*-'d-� -- 'a.-.
°a.0 ^mot i4!) e'7°'x> is Y� 11 "fit- lze1f s T [. ir yf 5 1. 11EL'" 1:12;;e - Fls
tel r" ,�za,..,_ :. '' s., t z .� k Si .�'i'� .�wi bvt : F i 4- kY m in,
stu/' ,. a�i.s&es�......ve 44. �.' 4..:5 3b.""* 4y� fi..''fY Sae '°" nl .43�P'
Aggression/Cruelty to Animals 0 0 0 ❑
Verbal or Physical Threatening 0 ❑ 0 0
Destructive of Property/Fire Setting ❑ ❑ ❑ 0
Stealing ❑ 0 ❑ 0
Self-injurious Behavior ❑ 0 ❑ ❑
Substance Abuse ❑ ❑ ❑ 0
Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis 0 0 ❑ ❑
Runaway 0 ❑ ❑ ❑
Inappropriate Sexual Behavior 0 ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ 0 0 ❑
Depressive-like Behavior ❑ 0 0 0
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ 0
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) 0 0 ❑ l ❑ 2 0 3
Exhibit A
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE
RATE TABLE
C t rxd sYs1e �.--iv —iy,, -712` * " #r "iti 'I 'x Y fFt y ,
r ez <
--"✓.,' -t tir ss ra ' .e y1t,IJ & -- L€ �
Age 0-10...$11.47($349) ` Level 0 $4.93 day/$150 month Level 0 $0
0 ' Age 11-14...$12.89($392) . No crisis intervention,Minimal CPA ',. Therapy not needed or provided by Level 0........$0
111
Age 15-21...$13.91 ($423) involvement,one face-to-face visit 1 another source,i.e.mental health. (None)
+5.66 Respite Care($20) t with child per month.
$15.78 st
1/2 +$.66 Respite Care Level 1/2 $6.58 day/$200 month —
($16.44 day/$500 month) 0 !1.
$19.07 .' Level 1 $8.22 day/$250 month ' Level 1 $4.93/$150 month
1 +$.66 Respite Care Minimal crisis interention as needed, Regularly scheduled therapy,
Level 1 $2.99
($19.73 day/$600 month)
one face-to-face visit per month with child, ;; up to 4 hours/month.
01
2-3 contacts per month
$22.35
1 1/2 0 +$.66 Respite Care ( Level 1 1/2 $9.86 day/$300 month s
($23.01 day/$700 month) ..
"$25.64 Level 2 $11.51 day/$350 month . Level 2 $9.86/$300 month
2 +$.66 Respite Care Occasional crisis intervention as needed, Weekly scheduled therapy,
Level 2 $4.47
($26.30 day/$800 month) two face-to-face visits with child, 5-8 hours a month with 4 hours of Is
2-3 contacts per month group therapy.
$28.93
2 1/2 +$.66 Respite Care Level 2 1/2 $13.15 day/$400 month s —_ --
($29.59 day/$900 month)
5 $32.22 Level 3 $14.79 day/$450 month z Level 3.........$14.79/$450 month
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
3 weekly face-to-face visits with child, �• multiple sessions,can include more Level 3 $6.02
($32.88 day/$1000 month) and intensive coordination of than 1 person,i.e.family therapy,
multiple services. for 9-12 hours/monthly.
$35.50
3 1/2 +$.66 Respite Care Level 3 1/2 $16.44 day/$500 month ''
($36.16 day/$1,100 month)
$39.45 Level 4 $18.08 day/$550 month Level 4 $14.79/$450 month
+$.66 Respite Care Ongoing crisis intervention as needed, Regularly scheduled weekly
4
RTC Drop ' which includes high level of case multiple sessions,can include more
Level4 Neg.
Down ($40.11 day/$1200 month) management and CPA involvement with than 1 person,i.e.family therapy,
child and provider and 2-3 face-to-face for 9-12 hours/monthly.
contacts per week minimum.
MTgSiYAY.2Su" )r'oa. a- -ik4 $5 t*it{�&N.-i41'u x1 r36-,J3i41.a .f.'d:zitM'ibut¢iWY\W% �.rvm p eA:.
Assess
Rate $19.73 day/$600 month
Children (Includes Respite) $8.22 day/$250 month --___________-_
0-10
Assess
Rate $26.30 day/$800 month
Children (Includes Respite) $11.51 day/$350 month ---_--_____-.-__-__
11-18
Admin. Overhead Rate: As of 7/1/05
$4.56 day/$138 month
Exhibit B
AGREEMENT TO PURCHASE
® CHILD PLACEMENT AGENCY SERVICES (CPA)
❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF)
❑ THERAPEUTIC RESIDENTIAL CHILD CARE FACILITY (TRCCF)
❑ RESIDENTIAL CHILD CARE FACILITY (RCCF)
0 FOSTER FAMILY HOME CARE
❑ KINSHIP CARE
❑ RECEIVING HOME CARE
❑ GROUP HOME/GROUP CENTER CARE
❑ SUBSIDIZED ADOPTION
❑ SHELTER CARE
❑ INDEPENDENT LIVING
❑ TRANSITION/HOME BASED AFTER-CARE
❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM
THIS AGREEMENT, made this day of , 2006 between the Board of Weld County
Commissioners, sitting as the Board of Social Services, on behalf of the Weld County
Department of Social Service hereinafter called "County" and«CPA_NAME»,
«MAILING ADDRESS», «CITY STATE_ZIP», hereinafter called "Contractor."
THIS AGREEMENT, shall include all children placed by Weld County Department of Social
Services and «CPA NAME».
A child specific addendum, identifying individual service needs, must be completed and attached
to supplement this agreement for each child being served by the facility. If this is a CPA
placement, the child specific addendum should also address how administrative services will be
provided in the event the child is placed for adoption in a foster home supervised by the CPA.
WHEREAS, the Colorado State Department of Human Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social/Human Services and,
WHEREAS, the County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, the County wishes to provide these services by purchasing them from Contractor,
and,
WHEREAS, the Contractor is licensed as a Child Placement Agency, Residential Child Care
Facility, certified Psychiatric Residential Treatment Facility, or Therapeutic Residential Child
Care Facility.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the
County and the Contractor agree as follows:
This Agreement shall be in force from the date of the agreement, July 1, 200, until the
end of the Colorado fiscal year, June 30, 2007. Any child may be removed from the
facility prior to the end of the fiscal year by the county department. The contractor may
1 State SS-23A(6/2006)
Exhibit B
also seek approval in writing from the county to terminate the agreement prior to the end
of the fiscal year.
This Agreement may be renewed only by entering into a new written Agreement such as
this Agreement signed by the authorized representatives of the parties. Except as
otherwise provided above, either party shall have the right to terminate this contract by
giving the other party thirty(30) days notice by registered mail, return receipt requested.
If notice is so given, this contract shall terminate on the expiration of the thirty(30) days
or until the eligible child can be placed elsewhere, whichever occurs first, and the liability
of the parties hereunder for further performance of the terms of this Agreement shall
thereupon cease, but the parties shall not be released from the duty to perform their
obligations up to the date of termination.
This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION I. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The total rate of payment for care and services under this Agreement shall not exceed the
established rate: for the Psychiatric Residential Treatment Facility(PRTF) on the
approved vendor list, for CPA placements the negotiated rate or the approved vendor
rate, for TRCCF or RCCF placements the negotiated rate or the approved vendor rate,
and for the Children's Habilitation Residential Program (CHRP) placements on the
agreed upon service proposal rate.
The amount paid for purchased care and services for less than a full month will be based
upon the daily rate.
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 F.
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County has responsibility for the decision to return the child to the facility,
with input from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/service plan.
5. Any transportation costs to be incurred on behalf of a child in placement, which are to be
borne by persons, or agencies, which are not a party to this contract, shall be specified in
the treatment/service plan, and those persons shall acknowledge their responsibility by
signing the treatment/service plan.
2 Stale SS-23A(6/2006)
Exhibit B
SECTION II. LEGAL STATUS AND AUTHORIZATIONS
• 1. Such permission as is held by the County is hereby granted to the Contractor to authorize
routine or emergency medical and dental treatment except for the following:
a. Medical or dental care shall be provided by personnel duly licensed by law as
required by the State of Colorado. It is mutually understood hereto that hospital
expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other
unusual expenses are not included in the monthly rate. The cost of any items not
covered by Medicaid will be negotiated between County and Contractor.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and
Periodic Screening, Diagnosis and Treatment Program.
3. It is agreed and permission is granted for the child(ren) to participate in planned
recreational and social activities of Contractor, including supervised off grounds
excursions and extended trips within the State, provided that Contractor has written
permission from County and legal guardian for any trips out of Colorado for any reason
and any planned absence from the facility of over seven (7) days within a consecutive
30—day period. Such written permission may be in the treatment/service plan. Further,
Contractor and County will also secure, where possible, permission from parents or
guardians of the child placed with the Contractor.
4. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status which comes to their attention.
SECTION III. REASONS FOR REFERRAL, TREATMENT PLAN, AND PROGRESS
REPORTS.
1. County and Contractor agree and understand that the reasons for referral, which
necessitate purchasing services for children are specified in the attached child specific
addendum and Family Services Plan. Any other relevant information concerning these
children that does not necessitate purchasing services is also included in the addendum.
2. County and Contractor shall formulate an initial individual plan of care within 60 days
for children in TRCCFs, RCCFs, or CPAs. The initial individual plan of care must be
completed within 72 hours for children in PRTFs. For children in PRTFs a
comprehensive individual plan of care must be completed by the multidisciplinary team
within 14 days from placement date. The placement date is that date noted in the
attached child specific addendum included with this contract. The child's Family Service
Plan may be utilized for this purpose for facilities other than PRTFs. Modifications to
this plan shall be agreed to in writing on the plan or as a supplemental document.
3. The treatment/service plan shall be goal oriented and time-limited and include:
a. Anticipated psychological/behavioral changes and dates for accomplishing those
changes;
b. Involvement of the child's family or significant other persons in the treatment of
the child;
c. Anticipated living arrangement for the child at the date of discharge;
d. Anticipated educational arrangement for the child at the time of discharge;
e. Anticipated date for discharge from treatment purchased for the child.
f. A permanency goal for the child.
3 State SS-23A(6/2006)
Exhibit B
4. Quarterly, Child Placement Agencies, TRCCFs and RCCFs, and every 14 days for
PRTFs, shall provide the County with written reports which address changes to the
child's physical condition, psychological and social functioning, changes in the child's
family situation, educational progress, significant incidents or disciplinary actions, and
progress made to achieve goals specified in the treatment plan. Further, the Contractor
agrees to sequence reports to be received by the County fifteen (15) days prior to judicial
or administrative hearings or reviews when provided with thirty(30) days advance notice
of such dates by County.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the State Department, the
Department of Health Care Policy and Financing (if appropriate), the State of Colorado
and any federal laws and regulations, as such, which may be amended from time to time,
and shall be binding on Contractor and control any disputes in this Agreement.
2. Maintain a current license and maintain license requirements as specified under State law
and rule.
3. Not charge any fees to children or families of children referred by county for any services
provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Director of the County Department or his/her
appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child.
6. Maintain during the term of this Agreement a liability insurance policy of at least
$25,000 for CPAs and $400,000 for PRTFs, TRCCFs, and RCCFs for property damage
liability, $150,000 for injury and/or damage to any one person, and $600,000 for total
injuries arising from any one accident.
7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)
months gross receipts, whichever is greater, covering the activities of any of its officers,
agents or employees responsible for the implementation and/or administration of this
contract in order to make reparations for any wrongful acts, omissions, or any other
defalcations of the Contractor.
8. Indemnify County, State Department and the State of Colorado against any and loss
against all claims and actions based upon or arising out of damage or injury, including
death, to persons or property caused or sustained in connection with the performance of
this contract or by conditions created thereby, or based upon any violations of any statute,
ordinance, or regulation and the defense of any such claims or actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
4 State SS-23A(62006)
Exhibit B
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado State Department.
10. Bill the County for services rendered, using the required form. This form is to be mailed
to the County department by the last day of the month of care. Billings for PRTFs,
TRCCFs, RCCFs, CPAs and CHRP placements shall be made to both the MMIS System
and the County Department. Provider will not be paid by the county when billing is not
received by the County within 30 days following the billing due date.
11. Attend and participate in Administrative Reviews for children in placement with the
Contractor pursuant to two (2) weeks written notice by the County. The Contractor shall
encourage children (over the age of twelve) to attend their Administrative Review.
Participation may be in person or by teleconference.
12. The Contractor shall pay the foster parent the amount identified by the county as the child
maintenance or room and board. Any payment to the foster parent in excess of the child
maintenance or room and board amount shall be treated as income to the foster parent.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the children under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Human Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate when billing is submitted as described in Section IV, Number 11(above).
4. Abide by all the rules and regulations of the State Department, federal rules and
regulations and the laws of the State of Colorado, any of which may be amended from
time to time.
5. If this agreement covers an initial placement for a child, the Contractor may receive an
"initial clothing allowance: in accordance with State Department rules and regulations, as
they currently exist in 7.406.1 (W) and such may be amended.
6. Monitor children's progress in accordance with the treatment/family services plan and the
requirements of State Department Staff Manual, Volume VII, and provide consultation to
Contractor in relation to the services purchased under this Agreement.
7. Invite Contractor to Administrative Reviews.
8. Involve Contractor in planning for the child and give the Contractor a copy of the Family
Services Plan at time of placement or as soon as completed and when updated or revised.
9. The county shall seek recovery from the PRTF, TRCCF, RCCF or CPA for any payment
amounts that have been misused (as defined in Volume VII). The county may withhold
subsequent payments to recover any funds misused by the CPA. The county shall seek
recovery of any remaining funds as a debt due the county for the benefit of the state. The
5 State SS-23A(6/2006)
Exhibit B
• CPA may appeal the decision to recover or withhold subsequent payments (as defined in
Volume VII).
10. The county shall identify the amount to be paid to the foster parent for the child's room
and board. Such amount will be the same as shown in Trails for the child's maintenance.
11. Reimbursement rates that are negotiated between County departments and the Contractor
shall be for allowable costs in one or more of three primary components: child
maintenance, administrative services, and administrative maintenance (7.418.1-7.418.3).
Provider type will determine which of these three components will be included in the
reimbursement rate.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub—contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Children, Contractor will be
released from responsibility for loss or damage to such personal items.
4. This Agreement is intended to be applied in conjunction with the child specific
addendum and family services plan as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other amendment
hereto shall have any force or affect whatsoever, unless embodied herein in writing. No
subsequent notation, renewal, addition, deletion, or other amendment hereto shall have
any force or effect unless embodied as a part of this written Agreement.
5. The contract shall permit the State Department to monitor service program, fiscal books
and other records sufficiently to assure the purchase services in this Agreement are
carried out for the benefit of the aforementioned client through program reports, on site
visits where applicable and other contracts as deemed necessary. The Contractor
understands that the State Department may provide consultation to Contractor to assure
satisfactory performance in the provision of purchased services under this Agreement.
a. All reimbursement requests shall be submitted to and approved by the appropriate
County staff. Reimbursement for placement services shall be paid from the date
of admission up to, but not including, the day of discharge. Furthermore,
Medicaid payments for PRTF and TRCCF treatment services or CHRP
placements are not permitted on the day of discharge. Medicaid funds shall not be
limited to funds encumbered in this contract and shall also include Medicaid
funds for PRTF and TRCCF treatment programs and CHRP placements paid by
the Department of Health Care Policy and Financing. Payment for placement
services will not be provided for clients on "runaway" status unless the County
6 State SS-23A(6'2006)
Exhibit B
has previously approved it. Reimbursement requests for treatment costs for
clients enrolled in PRTF, TRCCF and CHRP programs shall be submitted to the
Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal
Agent. The Contractor shall forward copies of such billings to the County on a
monthly basis.
In the event that a Contractor receives payment for a discharge day, regardless of
funding source, the Contractor shall refund those dollars forthwith.
b. The purpose of these requirements is to provide minimum assurance the
Contractor has adequate accounting and budgeting information available to allow
management to maintain a financially viable enterprise and to demonstrate
financial accountability to the County departments of human/social services and
State Departments of Human Services for the use of public funds.
1) The Contractor must have in place a double entry accounting system and
all financial transactions must be posted to this system. Financial
statements, prepared from information provided by this system, shall be
presented in conformity with U.S. generally accepted accounting
principles (GAAP). The Contractor must also have adequate time
keeping and cost allocation systems to allocate salary cost and indirect
cost to appropriate cost centers. The Contractor must also comply with
cost principles pursuant to (a) OMB Circular A-122, Cost Principles for
Non-Profit Organizations or (b) Title 48—Federal Acquisition
Regulations System, Chapter 1—Federal Acquisition Regulation, Part
31—Contract Cost Principles and Procedures for contracts with
commercial organizations or OMB A-87, Cost Principles for State,
Local, and Indian Tribal Governments, whichever is applicable. Books
and records of the Contractor shall be subject, at any reasonable time, to
inspection, audit or copying by appropriate Federal, State or county
personnel, or such independent auditors or accountants as may be
designated by these personnel.
2) All billing by the contractor must be in a format approved by the fiscal
agent or county. Contractors must bill the fiscal agent and county at
least once a month. Contractors may bill twice a month, on the 15th and
last day of the month, for services rendered. Bills will be returned
unpaid if the bills do not conform to the approved format or the
documentation is inadequate.
3) All Contractors whose total annual expenditures are $100,000 or more
shall submit an annual audit of their financial statements by an
independent certified public accountant. Contractors with total annual
expenditures less than $100,000 may submit an audit as described above
or may submit compiled or reviewed financial statements, prepared in
accordance with generally accepted accounting principles. If the
Contractor is a government agency that has an independent audit done
by another agency of that government, their audited financial statements,
prepared in accordance with generally accepted accounting principles
for state and local governments meet this requirement. The audited,
compiled or reviewed financial statements of PRTFs, TRCCFs, RCCFs,
and CPAs must be completed and a copy provided to the Colorado
7 State SS-23A(6'2006)
Exhibit B
Department of Human Services (Attn: RTC Administrator for PRTFs,
TRCCFs and RCCFs and Attn: Audit Division Director for CPAs)
within 180 days after the contractor's fiscal year end. The audited
financial statements and supplementary information defined in
regulation for various agencies shall be presented as described in Section
VI B-1 above and must contain sufficient detail to provide evidence of
financial accountability under the terms of this contract and controlling
state regulations. Contractors that are a subsidiary of a parent
organization must submit separate financial statements for the subsidiary
that detail each of the Contractor's facilities and/or programs that
provide services for the Department and also must provide a
reconciliation of these financial statements to the consolidated financial
statements of the organization as a whole. When applicable, the
Contractor must comply with the audit requirements found in the Single
Audit Act of 1984 and the Single Audit Act Amendments of 1996 and
U. S. Office of Management and Budget (OMB) Circular A-133, Audits
of States, Local Governments, and Non-Profit Organizations including
subsequent revisions, and appropriate audit and financial reporting
requirements as defined in State laws and regulations.
4) If Contractors do not submit their annual audit or refuse to disclose
financial information regarding the operation of the program in a timely
manner, the Fiscal Agent may withhold payment until the audit and/or
requested information is submitted. If the provider is a CPA, then
sanctions of the provider may occur for failure to submit. If the provider
is a PRTF then the rate may be reduced in accordance with Volume 8
rules.
5) In cases where documentation does not exist to support audit
information or services provided, providers will be required to repay all
funds received for which documentation does not exist.
6) In cases where audit deficiencies are noted, a plan of corrective action
shall be submitted to the Department Audit Division for approval within
four(4) months of the date of the audit.
7) Failure to comply with any of these requirements, including items on the
addendum is justification for the County to impose fiscal sanctions,
penalties, or cancel the contract.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at the discretion of the County until final audit. Incorrect payments to the Contractor due
to Omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
of Colorado, Colorado Department of Human Services and the County. The waiver of
any violation shall not be construed as a waiver of any other or subsequent violation of
this contract or appropriate statutes and regulations.
8 Slate SS-23A(6/2006)
Exhibit B
WHEREFORE, the parties have herein set their hands and affixed their seals the day and date
first written above.
COUNTY PROVIDER
County Department of Social/Human Services Name
Address Address
City, State Zip City, State Zip
County Director's Signature/Date Director's Signature/Date
9 State SS-23A(6/2006)
Exhibit C(CHRP)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between «CENTER_NAME» and Weld County
Department of Social Services for the period from
October 1, 2005, through June 30, 2006.
The following provisions, made this day of , 2005, 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#«FACILITY_ID». Rates outlined
may be negotiated based on the child's CHRP application and the COPAR assessment.
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. Add Paragraph 14 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.
4. Add Paragraph 6 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) 350-8389.
5. Section V, Paragraph 5. Children in Residential Treatment 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.
6. 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.
7. 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.
8. 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
Exhibit C(CHRP)
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, 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.
10. 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.
11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunities the parties or their officers or employees may
possess, 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.
12. 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;
2
Exhibit C(CHRP)
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.
13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
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.
14. Add Section VII-ATTACHMENTS:
Exhibit C(CHRP)
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX trails Case ID DOB
Sex
WORKER COMPLETING ASSESSMENT I HH# IDATE OF ASSESSMEN
AGENCY NAME PROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for one of the following: therapeutic or
medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the
caseworker?
DO)one trip a week or less ❑l)2-3 trips a week
❑2)4-5 trips a week ❑3)6 or more trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
DO)one a month ❑1)twice a month D2)once a week ❑3)2 or more times a week
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?
DO)less than a'h hour per day ❑l)%3 hour a day
D2)more than %hour per day,up to 2 hours per day D3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorin of time and/or activities and/or crisis management?
D0)less than 5 hours per week ❑l)5 to 10 hours per week
❑2)at least daily ❑3)on a constant basis
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)less than 5 hours per week ❑l)5 to 10 hours per week
❑2) 11 to 20 hours per week ❑3)21 or more hours per week
A I. How often is CPA case management required?
DO) Minimal CPA involvement per month and/or no crisis intervention
❑1) 2-3 contacts per month and/or minimal crisis intervention
❑2) l face to face contact per month and/or occasional crisis intervention
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention
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
D2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ D
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A I Case Management ❑ ❑ ❑ ❑
T I Therapeutic Services ❑ ❑ ❑ ❑
4
Exhibit C(CHRP)
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(CONT.)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
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r_4� 111 tS it;I. ! i {i 1 a;4rsuii Iii ` t11�S1 71 R }y{}i,;y�y N� �! � ill ' N'.ililf�,l,� .'l�f �t :j' t) �}qI #@ t, lid 1{ s}i};, ,:ah { ` u vi.fi 1 1- i FI 7 sl E�It. I ut'll. E t it l {l'; i11 is . � . l�l; ; ) { E •
y[3 ,. :a
., tf .1.::,� „' ��� ���r� • f �1'E ;'1j.�:� 2'],I�,I,,I t4 i��(1t i t °�I s{�+'r�A'}+t���`,t(�l�..S } r t) �. i
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis ❑ 0 ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ 0
Disruptive Behavior ❑ 0 ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ 0
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
5 Ui..l.i r nunlu cc-11A A.I,h„.i...11
Exhibit C(CHRP)
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
•
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
EVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
ERIOD 1: LEVEL#
omments:
EVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
EVEL #
omments:
EVEL OF THERAPY SERVICES NEEDED (T1)
EVEL #
omments:
PECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
omments:
EXT SCHEDULED RATE REVIEW: Initial Date:
maximum of 6 month intervals)
6 weld County SS-23A Addendum
Exhibit C(CHRP)
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
' b.�, rj( (F a i it ` i::,.3n, ppi,�yyr,l t I rt i{ t, " t y'I ^ C? €' ti 1A ii
i tl S 1 `� i' ; a) , tifi ,0 a:,1A� V s1:"P
w v ''C'1110
7A110 , �� - P l i p�7 �
� r ., 4,tc titbit! I. 1Ii. ht44Itfl #t,L.�� �) Al, iir.'e '3 t� I,
11
w 6 ��I� i Wit t. n 1t 1�}i 4 v w , t tq t I i£.
e is �1 v Pr r u t ,(I Ij 3't i i i3' .A n t
t x E I rr v i
k °.}' :rh K t I`t'''r:'''','i Elio � I I i7 • 1 g t" ,,g y
AY3 §t" ,5$" i'["I n4 '$ t I pit�9(' t, d7Pt it I ti t,+� ',',',11,411,r,,
lt+y¶ lt't r'l' ( ilt
+,fi
t ) t i Nmy 'vt. ,liriglr'� ,k ' t (Ca4 M'NI{ ) 4 d t It t I ii 4' t i,X 11 a"f) .i iw
:P{ t t4� t 4 !+ ,111E +t it, t i' a
i ! a s Piro"(AdV t I' i A
kkgg 4((s(( :; i v rt ki
°s'�'Fr' ,. ft _ cf& tr t �, a v i f4 =,lk6�� . ��I=t ltlt(AQp11i1)it� � ,�t � 3;, PI' E� a it,i:i� !� (I A:� . t . f .
p 0-10...$11.47'III 1
Level 0...$5.60 Le Id III l l ] h.�tli 1 . ° , 1 .,
Age vet 0 $4.93 re Level 0 1h, $0 Level 0 $0
3 Age 11-14...$12.89 . i
o '' D. (Minimal CPA involvement,no '�. (Therapy not needed or provided (None)
j1 Age 15-21...$13.91 ' A crisis intervention. Only doing rA`" by another source,i.e.mental
o }„. }- what is necessary to maintain `.it;!
health.) 4z
! +$.66 Respite Care I r ii monthly responsibility.) I
(, 9 tfil
4,II rIl I.
Level 1 $8.22 II Level 1 $4.93 I
1i $19.07 `"' S, Levell $2.99
01.4(LowIII level of case management,. (Regularly scheduled therapy, .II:
+$.66 Respite Care Level 1...$5.60 minimal crisis intervention,2-3 t. g 4 hours/month.) py
($19.73) • contacts/month,minimal crisis
41 I intervention,
kit
₹, 2-3 contacts/month.) nil:
hi
4 by
it ir
'$Level 2 $11.51 I`i Level 2
(( $9.86 III
2 ;:: $25.64 . , (Moderate level of case (Weekly scheduled therapy, •
( + Respite 1v III
Management including t Level 2 $4.47
$.66 Care Level 2...$5 60 :s. 9 4-8 hours a month with 4 hours of
g ($26.30) i ( Weekly support services, t, Group therapy.)
i
t, Occasional crisis intervention, ih}'.
if, ₹` Face to face contact 1 time ,ii` •
•i
� i4 Per month.) < t.
kr k: III 114
u; "
k44
r�Level 3 $14.79 Level 3 $14.79
"IIti` . ``'(High level of case management (Regularly scheduled weekly (n"
$32.22 k1, and CPA involvement with child 1t*{ multiple sessions,can include t;= Level 3 $6.02
3 `« +$.66 Respite Care ,I ' Level 3...$5 60 ,
.,; t FIB and provider including ongoing ( more than 1 person,i.e.family
" ($32.88) , crisis intervention and face to therapy,for 8-12 hours/monthly.)
11 1.1 r{t face contactl-2 time per week
'+J h I1 minimum.)
73 t,
hp ' Level 4 $18.08 Level 4 $14.79 IY
4 • t
RTC $38.79 t (High level of case management (Regularly scheduled weekly Level 4 Neg.
+$66 Respite Care Level 4 $560 ' and CPA involvement with child multiple sessions,can include
Drop , 4...$5.60 and provider, including on-going more than 1 person,i.e.family
ti
Down ($39.45) I,li I. crisis intervention and face to therapy,for 8-12 hours/monthly.) ,
face contact 2-3 times per
week minimum.)
till
Assess. Assessment t .
Period Period $26.30 •' Assessment Assessment Assessment Period $0
(Includes Respite) ' Period $560 Period $11.51
Effective 07/01/2006
7 Weld County SS-23A Addendum
Exhibit C(CHRP)
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
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCL&L
SERVICES
By: By:
Deputy Clerk to the Board William H. Jerke, Chair
CONTRACTOR
«CENTER NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
8 Weld County SS-23A Addendum
Exhibit D(CPA)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between «CPA_NAME» and Weld County Department of
Social Services for the period from
October 1, 2005, through June 30, 2006.
The following provisions, made this day of , 2005, 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#«FACILITY_ID». 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. Add Paragraph 14 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.
4. Add Paragraph 6 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) 350-8389.
5. Section V, Paragraph 5. Children in Residential Treatment 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.
6. 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.
7. 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.
8. 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
1 AF/cld rnunio cc?IA Ad.b.,.6,m
Exhibit D(CPA)
the County.
9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, 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.
10. 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.
11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunities the parties or their officers or employees may
possess, 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.
12. 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
2
Exhibit D(CPA)
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.
13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
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.
14. Add Section VII-ATTACHMENTS:
Exhibit D(CPA)
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT IHH# IRATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for one of the following: therapeutic or
medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the
caseworker?
❑0)one trip a week or less ❑1)2-3 trips a week
❑2)4-5 trips a week ❑3)6 or more trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0)one a month ❑1)twice a month ❑2)once a week ❑3)2 or more times a week
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)less than a''A hour per day O1)1/4 hour a day
92)more than '/ hour per day,up to 2 hours per day O3)more than 2 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)less than 5 hours per week ❑1)5 to 10 hours per week
9 2)at least daily ❑3)on a constant basis
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?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
DO) Minimal CPA involvement per month and/or no crisis intervention
01) 2-3 contacts per month and/or minimal crisis intervention
O2) 1 face to face contact per month and/or occasional crisis intervention
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention
T I. 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 93)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P I Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ - 0 ❑
P 3 Educational Intervention 9 9 _ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ 0 ❑ 0 A 1 Case Management ❑ ❑ ❑ 0 —
T 1 Therapeutic Services ❑ ❑ 0 ❑
Exhibit D(CPA)
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(CONT.)
RATE TI-IE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
$F X icy 'hhaa.. kyzyiqµµ. 19{ $irli " Kln if' G}i h,top + FpF i.'
� 1 �� i. PT...:)v, t ' ,TIr t Oog li t� Nlaw p a
�"& t�'$y�j�4 'tr( ��I v 1111 �y, 4, � f it,,I,',;!?-,:.'',�{�f� ! ��6v� I �.
t i " ia�.` iit n., iiie �i 9 I fib FF'A41.9; d fh,
at'' *.ix a`Lkuz'3�m.� 1 La d.,..i, wa
t �y y w nr Nitp 'f7 ^ i at HtE rig,,,„„,„,„,„,„,„,,,,,,,,,,,,„.,,,
l'111Y 7 S ;40)4
0 ) L� �r� fF �' �lTi , e ?;,0,,e0,;;ti,',,,
1(I,'
§ f iy.. re Pto, �' 4:,tin:,} ttlit, I �t .I h ' :PIP�' �: ItI dt th
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ O
Enuresis/Encopresis ❑ ❑ ❑ O
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
5
Exhibit D(CPA)
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of Pl through 135)
PERIOD I: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
Exhibit D(CPA)
• WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C),Acipiii.tiiiiiglf(0.8iIiiiIIII:iliii(154iiiIililliliiiiiiiiiilliiipligtlii) (\Tril,' -r a s -( ulliliili e . e c ('"a - i. `�"i la ;,,t a I
y )�E t�« 14 1 �gae a Yr-r
(
",g: gIiiip l.p H�� ri l{ ai' ka �14 iy
tlit lta r iyy - as ai' ti
t ', h $t u. .i aMtii (n Ari I «:� ICWI� �,�it,li
C, 9 3* i t ��{ « tit, g1 p a
§ cursirtgRifiiiiiigir; ramcoN a�
.. ��«; °`• �' 1'- }{ a silk. (I ,,1 •" tlii
{pN$����`' mil a r a
Age 0-10...$11.47 t
oPi
Level 0...$5.60 Level 0 $4.93 Level 0 $0 k„ Level 0 $0
0 PO Age 11-14...$12.89 k- (Therapy not needed or provided F (None)
la (Minimal CPA involvement,no linby another source,i.e.mental
Age 15-21...$13.91 crisis rvtn Oy ong ) fit:',
0iiii
what ii iory.to nl maintaindiill" health.ii+$.66 Respite Care monthly responsibility.)
1-42 iii,la
Level 1 $6.22 =I Level 1 $4.93
1
$19.07 Level 1 $2.99
+$.66 Respite Care iii Level 1...$5.60 (Low level of case management, (Regularly scheduled therapy, ,ii
($19 73) 1;�; minimal crisis intervention,2-3 a 4 hours/month.) ssl
NI pla r,# contacts/month,minimal crisis • f4.
intervention,
liiii ,`r 2-3 contacts/month.) ,
y'',3 r
al
il,
`� Level 2 $11.51 ii Level 2 $9.86a1i
2 ill $25,64kr=, (Moderate level of case (Weekly scheduled therapy, i&
+$.66 Respite Care Level 2...$5 60 i Management including '; 4-8 hours a month with 4 hours of a i Level 2 $4.47
($26.30) ail ai3 Weekly support services, Group therapy.)
Occasional crisis intervention
'i;j I Face to face contact 1 time iki
ili a fi Per month.) 1
iii;! 4i i11i.
'k
� ... rYt, Level3 $14.79 !Level 3 $14.79
a
a - h_} (High level of case management�(a(;; (Regularly scheduled weekly I`;
3 $3222 tl` and CPA involvement with child Mi multiple sessions,can include 1: Level 3 $6.02
iii +$.66 Respite Care Level 3...$5.60 .��
($32.88) i and provider including ongoing ,r more than 1 person,i.e.family
), it ! crisis intervention and face to therapy,for 8-12 hours/monthly.)
' face contact1-2 time per week (?f.
N minimum.) I
r
'II
Level 4 $18.08 r.Level 4 $14.79
4 $38 79 ,''v;(High level of case management bli.. (Regularly scheduled weekly Level 4 Neg.
RTC +$.66 Respite Care Level 4...$5 60 • and CPA involvement with child multiple sessions,can include
Drop ($39.45) and provider,including on-going `'; more than 1 person,i.e.family
Down crisis intervention and face to k therapy,for 8-12 hours/monthly.)
face contact 2-3 times per
week minimum.)
i;
Assess. Assessment Assessment Assessment
Period a Period $26.30 ` Assessment Period $0
t, (Includes Respite) Period $5.60 Period $11.51
Effective 07/01/2006
7 Weld County SS-23A Addendum
Exhibit D(CPA)
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
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By:
Deputy Clerk to the Board William H. Jerke, Chair
CONTRACTOR
«CPA NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
8 Weld County SS-23A Addendum
Exhibit E(Group Care)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Group Center Care Services
("Agreement") between «CENTER_NAME» and Weld County Department
of Social Services for the period from
October 1, 2005, through June 30, 2006.
The following provisions, made this day of , 2005, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider ID
#«FACILITY_ID», agrees to provide:
A. Care and services, which are listed in this Agreement at a rate of
«PROVIDER_RATE»per day for children placed within the Group
Home/Center.
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.
2. Add Paragraph 12 to Section I. The services purchased under this Agreement for Group
Home/Center services may include,but are not limited to: Basic 24-hour care and child
maintenance (food, shelter, clothing, educational supplies and allowance), Direct Child
Care, Transportation, Administrative Overhead, Support Overhead, Service delivery
Staff, which may include but are not limited to: Parent Training for Teens, Independent
Living Training, Mentor/Advocate, and Supervised Visitation.
3. Add Paragraph 6 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) 350-8389.
4. Section V, Paragraph 5. Children in Residential Treatment 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.
5. 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.
6. 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.
7. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
i Weld County SS-23A Addendum
•
Exhibit E(Group Care)
(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.
8. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. 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 immunities the parties or their officers or employees may
possess, 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
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
2 Weld County SS-23A Addendum
Exhibit E(Group Care)
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 that the Contractor learns of any actual litigation in which it is a party defendant
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.
3 Weld County SS-23A Addendum
Exhibit E(Group Care)
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
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By:
Deputy Clerk to the Board William H. Jerke, Chair
CONTRACTOR
«CENTER NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
4 Weld County SS-23A Addendum
Exhibit F(RCCF/CHRP)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Treatment Center
Services and Residential Child Care Facility Services (the "Agreement")
between «RCCF_NAME» and Weld County Department of Social Services
for the period from October 1, 2005, through January 1, 2006, unless sooner
terminated by the Department of Social Services upon the provision of 30
days prior notice.
The following provisions, made this day of , 2005, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider
ID#«FACILITY_ID», agrees to provide:
A. Care and services, which are listed in this Agreement at a rate of
«PROVIDER_RATE»per day for children placed within the Residential Child
Care Facility unless the child is eligible for the CHRP program.
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.
2. Add Paragraph 12 to Section I. The services purchased under this Agreement for
Residential Child Care Facility services may include, but are not limited to: Basic 24-
hour care and child maintenance (food, shelter, clothing, educational supplies and
allowance), Direct Child Care, Transportation, Administrative Overhead, Support
Overhead, Therapeutic Recreation, Service delivery Staff, Direct therapy and evaluation,
which may include but are not limited to: Psychological, Neurological Medication and
follow-up, Family Therapy, Individual Therapy, Group Therapy, Sex Offender
Evaluation and/or Sex Offender Treatment as prescribed by the Sex Offender
Management Board Policy, Polygraph, Plethysmograph, Parent Training for Teens,
Independent Living Training, Mentor/Advocate, and Supervised Visitation.
3. Add Paragraph 14 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.
4. Add Paragraph 6 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) 350-8389.
5. Section V, Paragraph 5. Children in Residential Treatment 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.
i Weld County SS-23A Addendum
Exhibit F(RCCF/CHRP)
6. 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.
7. 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.
8. 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.
9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. 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 immunities the parties or their officers or employees may
possess, 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
Exhibit F(RCCF/CHAP)
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 that the Contractor learns of any actual litigation in which it is a party defendant
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.
3 Weld County SS-23A Addendum
Exhibit F(RCCF/CHRP)
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
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By:
Deputy Clerk to the Board William H. Jerke, Chair
CONTRACTOR
«RCCF NAME»
«MAILING ADDRESS»
«CITY STATE ZIP»
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
4 Weld County SS-23A Addendum
Exhibit G(RTC/RCCF)
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Residential Treatment Center
Services and Residential Child Care Facility Services (the "Agreement")
between «RCCF_NAME» and Weld County Department of Social Services
for the period from October 1, 2005, through January 1, 2006, unless sooner
terminated by the Department of Social Services upon the provision of 30
days prior notice.
The following provisions, made this day of , 2005, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County agrees to purchase and Contractor, identified as Provider
ID#«FACILITY_ID», agrees to provide:
A. Room and Board services, which are listed in this Agreement at a rate of
«RTC RATE»per day for children placed within the Residential Treatment
Center.
B. Care and services, which are listed in this Agreement at a rate of
«RCCF_RATE» per day for children placed within the Residential Child Care
Facility.
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.
2. Add Paragraph 11 to Section I. The services purchased under this Agreement as Room
and Board services for Residential Treatment Center facility services include, but are not
limited to: Child Maintenance (food, shelter, clothing, personal needs and allowance),
Administration, Administrative Overhead, Support Staff, Support Overhead, and Sleep-
over Staff The anticipated minimum percentage for each item is as follows and will be
subject to County monitoring as outlined in Section VI of this contract:
A. Food, including meals and snacks (35%);
B. Clothing (3%);
C. Shelter, including utilities and use of household furnishing and equipment and
daily supervision, including those activities that a parent would normally carry out
to assure protection, emotional support and care of the child (20%);
D. Personal items and grooming care for the child, such as toothpaste, toothbrushes,
soap, combs, haircuts, and other essentials (2%);
E. Other/miscellaneous items considered usual in the care and supervision of the
child, include, but are not limited to, transportation, recreation and overhead
(40%)
3. Add Paragraph 12 to Section I. The services purchased under this Agreement for
Residential Child Care Facility services may include,but are not limited to: Basic 24-
hour care and child maintenance (food, shelter, clothing, educational supplies and
allowance), Direct Child Care, Transportation, Administrative Overhead, Support
Overhead, Therapeutic Recreation, Service delivery Staff, Direct therapy and evaluation,
which may include but are not limited to: Psychological, Neurological Medication and
follow-up, Family Therapy, Individual Therapy, Group Therapy, Sex Offender
Evaluation and/or Sex Offender Treatment as prescribed by the Sex Offender
Management Board Policy, Polygraph, Plethysmograph, Parent Training for Teens,
Independent Living Training, Mentor/Advocate, and Supervised Visitation.
] Weld Count y SS-2 IA Addendum
Exhibit G(RTC/RCCF)
•
4. Add Paragraph 13 to Section I. Residential Treatment Center services for children that
are deemed in need of rehabilitation will be assessed by the Colorado Client Assessment
Record (CCAR) to determine the appropriate level of care. These services are
reimbursable by Medicaid under this Agreement, as outlined in the Department of Health
Care Policy and Finance, Staff Manual Vol. 8.
5. Add Paragraph 14 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.
6. Add Paragraph 6 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) 350-8389.
7. Section V, Paragraph 5. Children in Residential Treatment 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.
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.
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, 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;
2 Weld County SS-23A Addendum
Exhibit C(RTC/RCCF)
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
12. 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 immunities the parties or their officers or employees may
possess, 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
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 that the Contractor learns of any actual litigation in which it is a party defendant
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.
3 Weld County SS-23A Addendum
Exhibit G(RTC/RCCF)
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
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
By: By:
Deputy Clerk to the Board William H. Jerke, Chair
CONTRACTOR
RCCFNAME»
«MAILING ADDRESS»
«CITY_STATE_ZIP»
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director
4 Weld County SS-2?A Addendum
Hello