HomeMy WebLinkAbout20062391 RESOLUTION
RE: APPROVE ADDENDUM TO TWENTY-TWO AGREEMENTS TO PURCHASE CHILD
PLACEMENT AGENCY SERVICES AND AUTHORIZE CHAIR TO SIGN
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 Addendums to twenty-two Agreements to
Purchase Child Placement Agency Services between the County of Weld,State of Colorado,by and
through the Board of County Commissioners of Weld County,on behalf of the Department of Social
Services, and the following providers, commencing July 1, 2006, and ending June 30, 2007, with
further terms and conditions being as stated in said addendums, and
1. Adoption Alliance 12. Hope and Homes
2. Alpine Children's Environmental 13. Hope Family Services
Services, Inc.
3. Bethany Christian Services 14. Jacob Family Services
4. Bridges, Inc. 15. Laradon Hall
5. Children's Network 16. Loving Homes, Inc.
6. Colorado Family Services, Inc. 17. Lutheran Family Services
7. Carmel Community Living Corp. 18. Maple Star Colorado
8. Commonworks, dba Synthesis 19. Opportunity in Living
9. Dungarvin Colorado, Inc. 20. PATH
10. Frontier Family Services 21. Savio House
11. Griffith Centers for Children 22. Youth Ventures of Colorado
WHEREAS,after review,the Board deems it advisable to approve said addendums,copies
of which are 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 Addendums to twenty-two
Agreements to Purchase Child Placement Agency Services between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Social Services, and the above listed providers be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said addendums.
2006-2391
SS0033
; S-S oq-/9-off
ADDENDUM TO TWENTY-TWO AGREEMENTS TO PURCHASE CHILD PLACEMENT
AGENCY SERVICES AND AUTHORIZE CHAIR TO SIGN -VARIOUS PROVIDERS
PAGE 2
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 30th day of August, A.D., 2006, nunc pro tunc July 1, 2006.
BOARD OF COUNTY COMMISSIONERS
WELD COU , COLORADO
ATTEST: _/,N'I i ���"a4Ce"'7f� � 04 .4v $j4
1161 kV: G ile, Chair
Weld C unty Clerk to the o rd ` el ed 6
cir C
1 +i treavi. E. Long, Pro-Tern
BY: AU
/÷
Clerk t the Board "LI Yl J
Willia H. Jerke
APP AS TO F -h&--\\J`�,n`�W --�
Robert D. Masden
o ttor y EXCUSED
Glenn Vaad
Date of signature: Cr/l'204
2006-2391
SS0033
hea3/4.3/4...
rist ctit 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
Will O MEMORANDUM Fax(970)346-7663
•
COLORADO TO: M.J. Geile, Chair Date: August 28, 2006
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services✓ 41 Q Vw�
RE: Addendums to Agreements to Purchase Child Placement
Agency Services with 22 Vendors
Enclosed for Board approval are Addendums to Purchase Child Placement Agency(CPA)
Services between the Weld County Depai latent of Social Services (Department) with 22 vendors.
The Addendums were reviewed at the Board's Work Session held on August 28, 2006. The
Addendums are with providers for reimbursement during SFY2006-2007 (July 1, 2006 through
June 30, 2007).
A. Rates are based on Needs Based Care Assessment.
B. The vendors include:
Provider ID Number
1. Adoption Alliance #71259
2. Alpine Children's Environmental Services)1W#1519521
3. Bethany Christian Services #45514
4. Bridges, Inc. #1980
5. Children's Network #77512
6. Colorado Family Services, Inc. #26885
7. Carmel Community Living Corp #44383
8. Commonworks, dba Synthesis #104085
9. Dungarvin Colorado,Inc. #98960
10. Frontier Family Services #38041
11. Griffith Centers for Children #1531601
12. Hope and Homes #29867
13. Hope Family Services #42942
14. Jacob Family Services #71260
15. Laradon Hall #45200
16. Loving Homes Inc. #72767
17. Lutheran Family Services #45080
18. Maple Star Colorado #90967
19. Opportunity in Living #1511157
20. PATH #1502692
21. Savio House #37330
22. Youth Ventures of Colorado #1529601
If you have any questions,please contact me.
2006-2391
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Alliance and Weld County Department
of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this / day of , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th 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#71259. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
&n;-&39/
1 wpmr,.i,„n,cc_n e en
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 WPM("miter.,cc_ne
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.
16. Add Section VII-ATTACHMENTS:
3 WnmA rn„nh,CC_115 AAAnnA,,..,
. 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 I-IH# PATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment; Family visitation; Extraordinary educational needs;Etc.,as outlined in the treatment plan?
O0)one round trip a week or less ❑1)2-3 round trips a week
❑2)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?
DO)Once a month El Two times a month but less than weekly
❑2)Once a week O3)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?
O0)less than a'/z hour per day ❑1)'h,hour a day
O2)more than'/x 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
monitorinYY of time and/or activities and/or crisis management?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
O 2)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
O2) I 1 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
O0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e. Medicaid) On less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 0 0 0
P 3 Educational Intervention 0 0 0 0
P 4 Behavior Management 0 0 0 0
P 5 Personal Care 0 0 0 0
A 1 Case Management ❑ 0 0 ❑
T 1 Therapeutic Services 0 0 0 0
4 wpm rnnnh,CC-11A Addendnn.
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
a
t, ' .{= E i M}5s ,r 0 i9lM 1
�1I f b (Yi {i U.
' t iii
,li rvu x _ tl r � I •.. I ! S�
I at ppi l' .4'L : 11t '3a ILL dg' . ' ..
y�bil i „i p C t "Li I �3 it�„ ih. i,4 ill.
' i! �� � "v ST ' ^R � 'LIP I I � . li lhi C l�i 1 �{ �,I V �'f,�s ::::}-7)::;!'!I!"911!;11,111
Iv. '1 i al„ I,,, f;6/' ii uih� II� _
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting 0 ❑ ❑ ❑
Stealing ❑ 0 ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ 0 0 0
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis 0 ❑ ❑ ❑
Runaway ❑ 0 0 0
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) 0 0 ❑ 1 ❑ 2 ❑ 3
SU/p1.1 r,.,,.,,.,CC-11A AddP.,d,in,
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
•
P.
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
i i1ii I, I } it n 'I !14 •p ,i : 1 I' x , ,f° 11 nAG�aiPi( 11 , I '���'l�,I a y'
4414 i o- i i1P!a 111 ii 1i i t + '� 1 Ifn 1d I ,;;I iil91�10;p;i; li" yl-it'A ,'ill lu I ' ( 1 . Ili vim !G ,Fg� -J
i i H'il 1 1ri 'ITS thikt l' i 1 ( It -)Pr s , i ,C l ( g
1,�1 4o r� '! Al i )� ,pry) ! I, 41 �!' �
C!: )4)i 11 144: l I I '1 1; 11 N 11 ` 4 ('4.44 4•$!f'i ,Il ,, (-' }}r PGI i ' '>i•' 1 PIA: e t , t
ff 11) , , , ! r i '! ' a II14 IIi� 'N .41444,40v ( I 'I!If'6.G 1'at I' 1:Nifa 144 ill r,i 1p4,x , , i ry ;M i 1. 4 p nI! fh
4 . h II 41:ail 11,3 i y 1 414:144441'11 M'r 1+{p11iY� ( s 1 in> jo„k.,{.11 ,a 1�
gg�� �,�7 ,� , iv 34 � -GI I, f Ih I � I11 G 1 [INN G(l -�t .� H pp r ,j,�4�9Qr �f 10.144.122 f l.x'r fiY'r5 t1''.
9 1 f" ,. it:6 114:�N '' ,:6661 l r i"i r ( 1 R , :66tV+ It$1636'
i ('6 �'� i I ;'i,�' q I 6436 ¢N fi �xi a i I4
' )N ! f 1- 4!469664 643"'big 1(I' , 1 '6636661.6616i��SS441111 '�16 ' 5 ."6:1 11't,��11it f'i li cihil I 1)i , to ,I;L..,;.0.;,„:::.,44;.4,,,,,
;13' rg ,1, a uL i , : i W I , - b i ., 11, :, W 6 i, w Lui d„, timu, tii :1416:14126:61:136316614i
,h 66*, ( IBn rl f' ,I_., , (� " n 1 iI '''fIp , ,,,i1 n �,i _ ,; r if H ..
is * :::3461i66366;
Iri' u!44 1i t - !it'�',E ;;.';',;41::- 111 I i;;;.i ill,ii11I ) lc:1ril d1111IgIu11ni1I,1;19N1:'µ1 111 111 xd'� -� 'i n "1'',:411'G 6i r �'nd :;� i 'Ail 'iY
I f, ,dx , 1$ ! l l 1 3I 16 1616'n ! ,J,rl '1' I 4 ! I l 0.A 'Ii1i �,n i' I u6+) 'h"' A `' - ff P
j ( 4 ! , li 1 11 r111 I rai !• 4
I{ ,ii - � 1 - l iti 4 ,,I, It t Pa '4, "$t
GIN itl of � h, )
II 1 i:!' „ f I 1,1 PI y, ! 1, ! 6 1111`11! 1 Ui , r it, il:: n A.. l : 1 �I' s~ F.x h'n
r , II I
�..d:xn..}� ��;,;i,,,,i, 1 i ,.,.,�w1 .1I,,: IG!...ul .� ,)i,I11aa11J��d�lklil�711�1:9iML.�,,...,� �i�a,u'>i1'l�.w.',1,1:ll' ,f1;ICu�I.b,�;' "� �'�a, w� f,.IS,u,6,.m,...aL,W„.
Age 0 10...$11 47 , Level 0...$6.25 ' fIC Level 0 $0 Level 0 $0
o i I . Level0 $4.93 J,.
h+i
0 III Age 11-14...$12.89 I.I till' (Therapy not needed or provided III)) (None)
f- „ (Minimal CPA involvement It ill by another source, i.e.mental Ill
Age 15-21...$13 91 I
0 i and/or no crisis intervention i.e q� health.) x
4 l mutual care placements.) I
+$.66 Respite Care tilt I
r'
r•u III( 111 gli
Level 1 $8.22 F Level 1 $4.93 !
1 �f $19.07 II.:. (i, ,
n: wt ? Level $2.99
`I Pd.
(,,r +$.66 Respite Care It' Level 1...$6.25 I,' (Face to face contact one time I (Regularly scheduled therapy, itil
Ilk ($19.73) fl1 ( per month and minimal crisis Il, 4 hours/month.) .111
01 liti intervention)
), i!i Ii �I� l
i: .,) Ff:! 111
S a;i 'i :! JI',
11C ,) I I 1 El 11<
IFLYb 1� „Level 2 $11.511 Level 2 $9.86;III
H! 1 I i 4
2 G, $25.64 Ij (Face to face contact two times (Weekly scheduled therapy, 191 Level 2 $4.47
+$.66 Respite Care '11 Level 2...$6.25 , 1 per month and/or occasional Fill 4-8 hours a month with 4 hours of +.I
I ($26.30) I crisis intervention) V;I Group therapy.) 4'
-_, 4_u I,k *�3
1tia
iN
N I,'I
!, 1III ! 5 Level 3 $14.79 i )
' $14.791
p Level 3
64 I
.1 IrlIf
1 (Regularly scheduled weekly 141
i; $32.22 111
3 ' + Level 3...$6.25 (Face to face contact 1-2 times multiple sessions,can include i; Level 3.......$6.02
$.66 Respite Care 1 I more than 1 person,i.e.family
($32.88) 1 I per week and/or ongoing crisis { .1
1 ') therapy,for 8-12 hours/monthly.)
intervention.) iI.;
i
9 I�
:y '- L'.� I,.u) a1
1.
6 ti $14.79 i
y.
I Level 4 $18.08, l Level 4 ,(
4 )I ', (Face to face contact 2-3 times (Regularly scheduled weekly I1 Level 4 Neg.' Respite
,1,1' 9 Y
1•;1 +$.66 Respite Care �a Level 4...$6.25 per week minimum,High level 1 multiple sessions,can include Iiit
Drop I of case management and CPA - more than 1 person,i.e.family ,;,
Down 1` ($39.45) .; li. involvement with child and (' I therapy,for 8-12 hours/monthly.) tr
1;'i ,rl I'° provider,including on-going 1� s1i
crisis intervention.) III
r
1 r au1 11 a
Assess. I 1 Assessment 11 r. '
Assessment Assessment
Period Period $26.30 , i. 'Assessment Period $0 ;i
', (Includes Respite) ! Period $625 i = Period $11.51 1 ),i
la
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
E�a WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
ti F THE WELD COUNTY
1� EPARTMENT OF SOCIAL
ERVICES
By: fut' 1 11 By:
puty Cl to the Board M J. Geile, Chair
AUG 3 0 2006
CONTRACTOR
Adoption Alliance
2121 S. Oneda St, Suite 420
Denver, CO 80224
By: KJ04L4' A
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector
8 Weld County SS-23A Addendum
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Alpine Children's Environmental Services, Inc
and Weld County Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this ( day of j h� , 2006, 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#1519521. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
&Ca,-a! 1/
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 W Id Crumb/cc_ne ennann,,.,,
•
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.
16. Add Section VII-ATTACHMENTS:
3 Weld fnnnn,CCD1A Addendum
•
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 IEIH# PATE 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 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 ❑l)2-3 round trips a week
❑2)4-5 round trips a week ❑3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
DO)Once a month ❑l)Two times a month but less than weekly
02)Once a week 03)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'/:hour per day Ell)'/3 hour a day
02)more than%hour per day,up to 2 hours per day 03)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?
P0)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?
DO)less than 5 hours per week ❑1)5 to 10 hours per week
02) 11 to 20 hours per week 03)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 i.e.mutual care placements.
❑l) Face to face contact one time per month and minimal crisis intervention.
02) Face to face contact two times per month and/or occasional crisis intervention.
03) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is 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)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ 0 ❑
P 2 Therapy/Counseling ❑ ❑ ❑ 0
P 3 Educational Intervention 0 ❑ 0 ❑
P 4 Behavior Management 0 ❑ ❑ ❑
P 5 Personal Care 0 ❑ 0 0
A 1 Case Management ❑ 0 ❑ ❑
T 1 Therapeutic Services ❑ 0 ❑ ❑
4 Weld County CC-VIA AdAnnd,,.n
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
kiREINMIIRV:7:ir:iill'Briii;517C; s ; rr l iii M s ww�4 tin e, B
,w !Ili!'rc�"' i. � a � c e i i u r/ (� i t �1 �'Y '"i
r , llSiiii
� � "s'� z i i � ,a � ii�r i
"'�rc+"'::':.::}t:
> » t(-
1 '.1: '''''Y'
a it�i ' 41 r i�} 'H 111 �p$!!1:: � E Y..�
N t 11, i.A ' y,,s a p 'rii lax ,, � 'i I�r)p.p,T .. '
� I�, §s�"��.j i a Y Ih ttr�1 i��� I, 1A ' 41�34�1{� b i� i.e�� , '�
o o� .,t,# i�1' ` I('� n " d
6x 'LAi.lea Wads �&c1,,.L� ..i.� �,��i��li�i�ii��"SR � IltihilllM10l�w �
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ' ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ 0
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior 0 ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 0
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ 0
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ t ❑ 2 ❑ 3
5 wPu r,."ten,ccaae enAP.,n ,,,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (TO
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
•
(Atttachment C)
�i}., �� 4fNi+ � i �lY tilly,i ,1�� - '�I)i' trt ,P ':x��6,I'�I�4ir -li If ' , t ! • i'• h t - , y is E.
,§ 1, IB o. y � l Yl „ry���,}- i iili ( .Ii ul �) I � ol��� i rti 'i , Ii F P N Yu
A {P:. i„il, , , +.I I { 191!I 1 t � { iV re i l�, +i ( i, �'iu,,Ni a �,1 ik i,')i'rr+
:. ,, 9 t I ,- , i I I X ,PIP � a v syy,,F
RAi I � ( � + { Ii � i ,II I , i � y �I MOIL!,
YI ,C /' i'i rhh.
i yy",, Y P a I, i(l( I h i lit,
i I I I) �i yy ,I i i,!
{ ,M1! tl()i I ,i i I1 ,F i i i ' l� ,,, (� rtilP � t i ,{,C���`�1,,!)��„-%
k ., ..4{ a-. 3... .t„ ,,::Ai 1,� .,.,a., 8 r-t d , . II + ii ill y Ic, �41i ffl4alt ,,!Nl I 9999143 t��PuSttgbi
.II ( ' � � ' •� I t it lL Q14 I{I 1 4b.4 � +d3
µi, i �. 1 1 111 �� 1.1,;111111:.:11111F,11111,1101,141,0i ,i , ,II I, I ,P 111 r, , �N
I�Pi: II9i I �, t r9;9919,3 II Ib i i ' l,l �l• 17 !j i� I Ir• r1' i F rt.! :1 1114 tP it�t „ qay+ k If1'tt.,r.
i, t t I u5 3' s ,h { �nna4 1 "� I � q
I I I 11,,, i ! I I Vi I, T t l .,l '9 i'. Ci l lnl! i, I r�i�K
�'��', �I {!rFv �+11 i1 Ij P, 4GI{{;,:f �a I t, , {uI i {� ,un { tlt t� 4 ,���I , 1I d��{{i l+l �, ,�", , t ° +, wl,� , ' .:,
lix, 16 u a' , li (l{ I ki I ,TI, 'i, ,, n) {.l- ,, { :y 4i! ,-.A x '4ii
ili {:ii iiiiHtit hlv»' 9�+f {Gq �,,�.yy�t i. q , Ii h {i{, iu i'L 4,' l:,, y , R.:. ii4 t r. i n:9 {I+,i , {I I{i 1 (;
�i''Iill'.' W.« �i)IN,�,I.ndiauG,5q'iliLul4UN.d� t(k�,�ii'....t::�.l .,�-�.�id.u�il�'I'.', �n..iL!.,.I.,.,.,. ,u .,, MI -(` - 4 ,uI!'I�;�� in��w„iu���
fi Ill ,I'
I i` Age 0-10...$11 47 i�� i6 ..i
p Level 0...$6.25 �'f Level 0 $4.93 ;I Level0 $0 - Level 0 $0
ohi
Age 11-14...$12.89 ;!f (Therapy not needed or provided '• (None)
f (Minimal CPA involvement by another source,i.e.mental Ii:
o ,�i, Age 15-21...$13 91 ' and/or no crisis intervention i.e. l. health.) 1):
_{ 1
:a { mutual care placements.) t cit
1:: +$.66 Respite Care . )1,: F,
4ti ii ii I u
( r Level 1 $8.22 51 Level 1 $4.93 '
1 $19.07 (44 'I lC: Level 1 $2.99
a, +$.66 Respite Care i!I Level 1...$6.25 (Face to face contact one time di (Regularly scheduled therapy, jil
t ($19.73) + l iili per month and minimal crisis .. 4 hours/month.) I19
t�I intervention) II 1'.i.
;I it
,i;
Level 2 $11.51 Level 2 $9.86 a;'
5 `1 (Face to face contact two times I (Weekly scheduled therapy,
2 ;, $25.64 1 ,� Levell $4.47
+$.66 Respite Care , Level 2...$6.25 k per month and/or occasional i 4-8 hours a month with 4 hours of
($26.30) il,!_ ill crisis intervention) Group therapy.) ,4
5kJ 51,
I'' I
i
II
•r'i 99 Level 3 $14.79.4.
lii
,,Level3 $14.79 (Regularly scheduled weekly C.
$32.22 ' multiple sessions,can include r„
3 - P Level 3 $6.02
+$.66 Respite Care .I Level 3...$6.25 (Face to face contact 1-2 times more than 1 person,i.e.family ..
t ($32.88) , .ij per week and/or ongoing crisis therapy,for 8-12 hours/monthly.) '
i intervention.) I
F4
.41
�,:(Level 4 $18.08 1. Level 4 $14.79+I:
4 i (Face to face contact 2-3 times (Regularly scheduled weekly k Level 4 Neg.
RTC $38'79 € per week minimum, High level ,: multiple sessions,can include V.
+$.66 Respite Care 1 Level 4...$6.25 ii aI
Drop , i of case management and CPA '. more than 1 person,i.e.family
Down ($39.45) '`I' involvement with child and :_ therapy,for 8-12 hours/monthly.) ii
ii I provider,including on-going 41i
1 crisis intervention.) ;;j
ir
Assess. Assessment Assessment Assessment
Period Period $26.30 ; Period $6.25 Period $11.51 'Assessment Period $0
unAti (Includes Respite) ,
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
MA(1/4441
ATTEST:
Weld County Clerk to the B and
E1/4, WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
,est �
* OF THE WELD COUNTY
�
DEPARTMENT OF SOCIAL
SERVICES
°
1
By: {1 URI
4L.t.. '1(� By:
eputy rk to the Board M. J. Geile, Chair
AUG 3 0 aiue
CONTRACTOR
Alpine Children's Environmental
Services, Inc
301 N Cascade Ave, Suite C
Montrose, CO 81401
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D' ector
8 Weld County SS-23A Addendum
02°06-&,:69/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Bethany Christian Services and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this day of S\ . , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of thel Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45514. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
j
1 Wald('niint',cc_)ae e.ldrnA
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V,Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld r..,,.,n,QQ.»e AAd.„d....,
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.
16. Add Section VII-ATTACHMENTS:
3 WpmA Cn,,n..,cc ,1A AAden dn..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX I'Crails Case ID rOB
Sex
WORKER COMPLETING ASSESSMENT IHH# DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy;Medical
treatment; Family visitation;Extraordinary educational needs;Etc.,as outlined in the treatment plan?
DO)one round trip a week or less ❑l)2-3 round trips a week
❑2)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 a month but less than weekly
O2)Once a week O3)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'/2 hour per day ❑l)''/ hour a day
❑2)more than 1/2 hour per day,up to 2 hours per day ❑3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorinp_of time and/or activities and/or crisis management?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
O 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 ❑1)5 to 10 hours per week
O 2) 11 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
DI) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
Ti. How often is therapy services needed to address child's individual needs per NBC assessment?
DO)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month ❑3)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 ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A I Case Management ❑ 0 ❑ ❑
T I Therapeutic Services ❑ ❑ 0 ❑
4 Wald rn,,nn,ccalA Addpnd,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
i is ` si , ' �) n ` (,a'�t ,y ,1
;IWIli15
i t { � i�a �aa� 3 ��cw 1 I Po 1 ! �� I D � � U.
l'1VI:I i;Iit t9s i, a ,,.:. ,� � r I �� �� a ( ' ,' i 1.4 ii i i� '1
in. o., � l �, tine
q + ak t. �e �� 4 d t
J , $2i rn .i x , r,H w u.S u i.arc ,taw u,i,n urt mrluv.�
i kii't. `t 1 rv� 4 t k. .i , drW1 t ❑ iI, i7 * gi.,k
4: s t ,i � .i �i,�
r 0. st ., . ,::ii!.....:awc�,. t�" dh�I����1.1 s,i.n t�l� 'L�lili 'yeti ��S�
Aggression/Cruelty to Animals ❑ 0 ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting 0 ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ 0 ❑
Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway 0 ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ 0
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior 0 ❑ ❑ ❑
Medical Needs ❑ 0 0 0
Emancipation ❑ ❑ ❑ 0
Education ❑ ❑ ❑ ❑
Involvement with Child's Family 0 ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
5 WnlA r„u,nw cc-114 Addenn',n,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
1t I:IyIlt'I "i: h It r i It° -il it j1 116 ,II , , >r ll ~. i r [( 1 t�4u llylt,„Iz 7 r„ d 7 I
'p1 ti t W i , I d , h t 1 1 j( 1 eI; III RiNlIlli n 1 i {t Ili',11 t c t f) f , ,
i ,W t i {{i ' j to a"I l,1.z A:',1 I II�' , , i'I ` It ''',��;it., It t)(.;, 'otl i k n d04 to t ut II�
+E:_ Ili I I ICI,'! I t t ! IP B
' .ut I` i t j '':;141j'414'. I 1 (i, ,; i4t :„ . (1h1 'f AliF.94,44:1, ill j N �,t,1:t s rilig�f� °t - i Pt , t,,11 1 41
�%
. xpaa -P-Ili tl 1 ?!IIIIII II. ,!,_5 ll Ilftl M Ii y iI it : nInMl 1111: i Viic 0 it u a 114
i 1 i I II) 411ic I � n 1F��441! t i , '� aM
LI 11 i r. I I Iii It' I ( rl i 1+4'1 9n ( , I
'uillti P K I • • i I, 1 III t rmAIIA (Uri:' i, l I t A I II i , a ifji i!- I It ' ,4 i
aa{ ll aJ1�I ihR'i i t ll I i•AAA.:I .A:-,,,,i u jlta I, I trite; {4�+ 'd p i t ! '3 t ,4 I!e I !, to it e ii'rytj
i _ _ ., .) �#,uyl jell aj'j�it T81111t1{ t .�Pi tot ",I�it dm,iul, � w va�;.�..�r�' )
(- 1' 'i l j q 'It , li' 1 t I�I ii I I 12 1 y#61Ilti I, ItOP it irrrt 1 r - �i i � Ail,: y tt,: I 1,i't'" r
III TM 'je u , i ;a I dl j I. :;11.:,:p;t ( ,t C 1 4y imhi I i r1 I 4 i I Iii z i. I A ,i, 1 i aiAri
I1. I ( I ! ' 1 II ICi t I t it t ( itti t t 1III ') -id h�' 11 IF AAA;-µ''H' . Al jt . I ),{:tti
'�''; I t t 11 ii rr “Ii ,at,t���y1 '1 r Y t t '� ( jy��ig + i II,�L.(
It'. 9 Itti � t I ii ii �I i rl I ' i }.:; I' stet
t Y'a-nrr i'11j�11h1 1 1 I G „AAA. I {i{1 tif, , Nj.i
.''" xoaa::i II nisi t a„JIB a.I.Ia Lt...!,e 441 I i/1 dirk GI�n';d9k;..l.t,x'i AS.. 'Mt& lI i ilia t Q'2{ i l(7€��t t r .�k IUVuIre
0 }? Age 0-10...$11.47 7bi. Level 0...$6.25 ' i Level 0 $0 4 r Level 0 $0
kl Level 0 xi{ $4.93 Oill l Is.
In
1 Age 11-14...$12 89 i,
0 ��� ,1 iii; (Therapy not needed or provided ' (None)
,i ,, i., (Minimal CPA involvement by another source,i.e.mental ( ,
0 ril Age 15-21...$13.91 ;I ,j and/or no crisis intervention i.e t- health.)
I.. a mutual care placements.) I, .I
I;+$.66 Respite '�
�. .l) 1 it u„
Care
Ph f
1 , '{ . Level 1 $8.22 i; Level 1 $4.93 0
$19.07 I j Level 1 $2.99
1III +$.66 Respite Care ill Level 1...$6.25 j,; (Face to face contact one time I'° (Regularly scheduled therapy, "
($19.73) d per month and minimal crisis 1i 4 hours/month.) '
flilif "N intervention) :Ij '¢tt
Iii 1 d; l•b:
I;
gy :it
. ; Level $11.511,`:Level 2 $9.86 r F.
2 $25.64 I (Face to face contact two times I.
(Weekly scheduled therapy,
" +$.66 Respite Care Ilk per month and/or occasional 1; 4-8 hours a month with 4 hours of d lir Level 2 $4.47
p „ Level 2...$6.25
il ($26.30) 1 crisis intervention) Group therapy.) i
jll
I
ll
yl• ;e 11� III
to
is
Ai
49 Ay
' i
3i d t .)
!ii .i I 40
I ' II. .Level 3 $14.79 t'
3
fi $14'79 (Regularly scheduled weekly t-
3 !a + $3222 �� 14 multiple sessions,can include I„ Level 3 $6.02
VIII $.66 Respite Care Level 3...$6.25 (Face to face contact 1-2 times
($32.88) 1 ,I per week and/or ongoing crisis 's II more than 1 person,i.e.family
i t I. Ill! therapy,for 8-12 hours/monthly.) ;:
;( �t1 intervention.) (I;
r
i i �:'•;
iii
,'
,' ".Level 4 $18.08 '�,�Level 4 $14.79 rf
RTC $38.79 i 4 : (Face to face contact 2-3 times i k (Regularly scheduled weekly Level 4 Neg.
Drop .. +$66 Respite Care k Level 4...$6.25 !I of case managementer week minimum, h level 1,i
t',l moretle han 1 per on,,i ean lnfam family e y:
($39.45) ,.
Downth ;� j involvement with child and ',II therapy,for 8-12 hours/monthly.)
1, t , provider,including on-going I
rttis crisis intervention.)
Assess t Assessment y j t;
Period I ; Period $26.30 • Assessment Assessment '�Assessment Period $0
(Includes Respite) ' Period $6.25 Period $11.51 •,! ,
,1 r- Lit bill il;',
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
atellaVel-AT
ATTEST:
Weld County Clerk to the Board
IE La WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
1161 OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
. f SERVICES
y9
By: ^ C'L 1 . //1(-C " By:
puty Cl k to the Board M. J. eile, Chair AJt' Li
c b
CONTRACTOR
Bethany Christian Services
4820 Rusina Rd, Suite C
Colorado Springs, CO 80907-8127
•
By: S)A --�
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: a
Dir ctor
8 Weld County SS-23A Addendum
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Bridges Inc. and Weld County Department of
Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this \ day of , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#1980. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
f---Per-6-4289/
1 wad r„iinn,cc_ne ndda.,d..m
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Wald inn„nn,CC-114 AAArndnn,
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.
16. Add Section VII-ATTACHMENTS:
3 Wnl.l!Mimi-,CC-71A A,iA•wAnn,
•
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 IDATE 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 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
❑2)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 01)Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a'/:hour per day ❑1)'/x hour a day
O2)more than'/z 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?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)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
O2) 11 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
O0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
01) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month
O2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ 0
P 3 Educational Intervention 0 0 ❑ ❑
P 4 Behavior Management 0 ❑ ❑ ❑
P 5 Personal Care 0 ❑ 0 0
A 1 Case Management 0 ❑ ❑ 0
T 1 Therapeutic Services ❑ ❑ 0 0
4 Wald Cnuns,QQ-91A Addenda,,,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
t l h { iY r t} r ry rr r'Y lri
t o �. :,,,,(1,":'14,:':";i {rGY� r lr l r r� ; FM, ,Willi
I it rlr .)7 t ' k :i illi;ta a . ar yr� f w , �I ;.r in
��� fil fintii�{i H'( "J* S.} a t r Il f l� i! ;r
biq � N` (il •I Fi er lll�� f1.'•,',2.1:t'!1';;{�4Ar7 1
Its .� $ i ,#sh,,,J,,,,,,,,,,,,,,,,,F.,,{1,4;ia. Eli uw 1 ! wiS§ 1;1 6r,iiiii241&2:zialli
e iii ,",�
xi .,,. ,vV I �i�4d its .a 4 . w ` " a i t"IJr ti 1§I �p iillii ti ar kfa
i4 ,p I.
+et , f} o-''1 { h Ili �r1r.l rlil tr �F: .i
- 'td,wiWw ' 'f ' :St.�:,u i ..,...ib .. Lt.{rl.1Jt kill;.lU.� i i `i
Aggression/Cruelty to Animals 0 ❑ ❑ ❑
Verbal or Physical Threatening 0 0 0 0
Destructive of Property/Fire Setting ❑ 0 0 ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ 0 0
Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ 0 ❑
Inappropriate Sexual Behavior ❑ 0 ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ 0 0 ❑
Emancipation ❑ 0 ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 0 1 ❑ 2 0 3
5
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
., rli ,�"I :i `:':'f'I 101'Pr II o{�I� a Idl D II rgil afi , hill 111.,1 Nrill; In *IIlIA IPI r�lla I'i '"91•'s g
I irk �. ii y i ii t3 INII I t.,L is I IN i in #i4 L1l l I I ( IN l i :J 1 4
' il
' 1 e �, I�i i 1 � I a hip I Ii!l) t, Ia,',I i� ;���rr, Iu�,��� C9.1iII rk mho, �!�,�� {II� Ih� ,Iq ,W ��.; � 7
i .21yy 1I"d , I �, -11 1�f,,. 1 I I ij {;E I I I:!fillip,
. I'ip 1 I ( :I h ,� 1. 1,9O:11 ` „! !'-ti I I
.�"ys'�rH '�1�ik it Ii"In Ill ,,, I ( �f: , NII {IiNI (I lui j1, �N ��� .:!{!� II II,. ,1l Ia I !1 h� t , I II ,
:s, I'y41 S 41 - �,IIi ;,! . i' I i I,, }, !I,III k ,i) l,l it i' ! I I�1 'Iiili 4f�j'IV1it,,I r ml' i4 ,td iLa Iii III tili19Si,t dIIIh i ' "th'.I'n .u' ;tIN I I! -� {�{ III G - III t ,
I I I� I :I aI 7 u I - ' 'I � I { ' ,$Ilih�{I I, l I- 14 I Ill 4 II i z4•�l r`{r, I r r,1, , , l I I ml;. 11 ))I l AIiN {
.i , m 1 ' I I i Ili i ( ( _ h1 1 I ,,I III I'II I {' ') i , E (iii {t II,L L Iln!C y'�U I , " it 4 01 _I: , i "iti�
Ni �i .,w x 11 I jr i;.,0:::.-!):::,:;::I _ ,, !i i t litf x`111 l� ! 'I I (I1 II �Iil i4' ' �iiiit,'Gi: i g q to i
- 11111 t ih ., , I i, - Il h l l l 1 II Ii II ,xl wt I Ix,. d Ali I I .W
I 4 >t , i i I I ' 1 7 i ' . I IqI i ;; q I i i �r I 4 I III - ' , I
{ _k in�,M! ie Iii k 11 . N! I , 1, iI `i, y1 i{i!r Ip�1111I I'I ,i 1,!i -if I i-ani f.,�',�Ii s'; 4, 4.m � hu ,,..
�:i a III! I ,iiyAilih ail '°Noll ' 41 :t wr4t'i' p,,,i; i. 'I I{t!I
J III I I ' t i w 1 .�{� l i !113 m 4Nilfi { , t i ,
ili ;.i, 1�i1J.u�.�;�,Lmil,�I I,I � J,J + .:.�»..I 'o . 6 �$�..i.t_�il� tN.L�f�!�� {>I�S r.� ' r { �ji;I �ji, �s {Ni � I t
s .u..,J,v ueu.., ...h,�u.,l N._ , 16,. 6a,.n I ��_. tieAli,Lrl �x d,i�2,aa,Nn a.n6a6 ..'�,I,L,,,,,Lw.�.,...d,NtW:eu }
id, rlh'
0 Age 0-10...$1147 ro Level 0...$6.25 i1� I'i'I Level $0 .{ Level 0 $0
II!{ I Leve10 $4.93 �i6
Age 11-14...$12.89 '.i ',+
0 g �� �h: (Therapy not needed or provided { (None)
Off :ofol
,E (Minimal CPA involvement 1,!; by another source,i.e.mental .,
Age 15-21...$13 91 1 4
p I 9 } ,1 and/or no crisis intervention i.e OS; health.) i
Iiiii !i' ,i mutual care placements.) ',
NO +$.66 Respite Care :of a
0::: ,I!.I CL: Iii
i, h19 I{H PI
1 a ! Level 1 $8.22 Level 1 $4.93`t
j $19.07 ii 411 Level 1......$2.99
nN „
I ,,, '!;
' +$.66 Respite Care !I Level 1...$6.25 , iI (Face to face contact one time Eli (Regularly scheduled therapy, j,,i
($19.73) ({I 1:4 per month and minimal crisis r{' 4 hours/month.) 11'11
{I r,;I intervention) t&
00
0 i'i I,ll i{Ir,{
I 0., ! I
I
mC 5
r'IS r' II q 11
P:. !Level 2 $9.86 II
1., $11.51 ,.;,�Level 2
2 i $25.64 1 C i (Face to face contact two times ' (Weekly scheduled therapy, 1.�
I A +$.66 Respite Care � Level 2...$6.25 ( per month and/or occasional 1 4-8 hours a month with 4 hours of n Level 2 $4.47
r crisis
!1i{ ($26.30) I r , I intervention) 1 Group therapy.)
N! 14
l.i
h PU j it
fi' r '5 t
". h i<1 Level 3 $14.79,,1
'' - ..Level 3 $14.79
$32 22 1 (Regularly scheduled weekly '.1
3 I I multiple sessions,can include Level 3.......$6.02
+$.66 Respite Care I Level 3...$6.25 (Face to face contact 1-2 times
($32.88) '' r1, more than 1 person,i.e.family too,: 1 per week and/or ongoing crisis I therapy,for 8-12 hours/monthly.) !i '
O.I. intervention.) I.1
6. 'V La
�p'I"� II ,) l
ri ({I Level4 $18.08�'� Level4 $14.79
I
4 (-1 - 1 (Face to face contact 2-3 times ,d' l
$38 79 (Regularly scheduled weekly r Level 4 Neg.
RTC + i; r per week minimum,High level I. multiple sessions,can include
Drop $'66($39.45)espite Care '� Level 4...$6.25 ,;{ of case management and CPA more than 1 person,i.e.family o,
Down ..a N) :' involvement with child and l{ therapy,for 8-12 hours/monthly.) El
b
I-1 provider,including on-going I ; I ,i
do •l . crisis intervention.) I-:
Ft
!i COO ,.I s.n
ob
Assess F. Assessment ! +'
1 Assessment Assessment ' •
Period 1.4 Period $26.30 '' ' Assessment Period $0
I (Includes Respite) Period $6 25 'Oil Period $11.51 ! r $
I'', L e 6i ;:a=
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: L /��!/�GL
Weld County Clerk to the Board
E f� WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
r ;SSi ''"O• OF THE WELD COUNTY
sk x. DEPARTMENT OF SOCIAL
`\S 14 SERVICES
7
By: A rt.A. 1 ti( tiri By:
D uty Cler the Board M J. eile, Chair
AUG 3 0 2006
CONTRACTOR
Bridges Inc.
1225 N Main Street, Suite 102
Pueblo, 81003
By
WELD COUNTY DEPARTMENT p�
OF SOCIAL SERVICES
By:
'rector
8 Weld County SS-23A Addendum
&Gh6-a39/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Children's Network andj Weld County
Department of Social Services for the perio&&'
July 1, 2006 through June 30, 2007. G ,0
�' ?1
The following provisions, made this / day of sly , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#77512. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Add Paragraph 13 to Section W. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. 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.
1 wain�,.��.,..,CC-11A en&a*-435/
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Wahl Cn,,nh,CC_T1A 4ddnndn,n
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.
16. Add Section VII-ATTACHMENTS:
3 Wn1A rniint.,CC_J1A A'ld,,d,,n.
.........._. ...
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 HH# DATE 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 the following: Therapy;Medical
treatment; Family visitation; Extraordinary educational needs;Etc.,as outlined in the treatment plan?
O0)one round trip a week or less El)2-3 round trips a week
❑2)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?
O0)Once a month ❑1)Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a'/z hour per day ❑1) '/1 hour a day
❑2)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
monitorin$of time and/or activities and/or crisis management?
u0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)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 01)5 to 10 hours per week
O2) I 1 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
O0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ 0 ❑
P 2 Therapy/Counseling ❑ ❑ ❑ 0
P 3 Educational Intervention 0 ❑ ❑ ❑
P 4 Behavior Management 0 ❑ ❑ ❑
P 5 Personal Care 0 ❑ ❑ 0
A 1 Case Management 0 ❑ ❑ 0
T 1 Therapeutic Services 0 ❑ ❑ ❑
4 Wald rnnnt',cc-11A 4ddendnm
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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
.1:1PLANNING.
�t t'z ₹ CP! * i"v� s fY
jiff fltr�I'ry fa l{�r ltr �, - � y r 1!{ e i �"e { � 1 01 11 ₹�{Itn 1 r`'f #>�+' 1 tt +1
f r yr. 1 "� {.:. n ,.1 1 17 1₹t {e ,9 Iff�1 ₹I71 t₹if i)r Vi`�,`Ilsrs�'hPli
i7 r' § 3"' it °I i 11 Ilt I' 1 111 r 11 i ( �1 �� �t ie 1�� i (, Ip w1 3 .1; e
' ,li'e '# ` � 1 n Ii ' '' i �� 111 �i,l 7 1₹' rpI Is { 1I)' E if11i1� L ) S
ii
1 Il.- .. b.dr= r 1 i t N'�f
e t i j P -9�i �' I, {�1{ 1 1 S 1( I { {1 e1 i t' { 'ku� I
� n���k�ull,t t..u,. rtiC,� ' � � t i� S�w1) � �a.r �{k �. �,y dr�.6����t� I � uC1�LI§ t
ici J i 1 1 -s9:::/:;',x § 3 § yy+ s ,
j " i 1 11I 1 i 1 9:v It yp4 i _l tt « 11H _ll:x .A...w11.. . ik.i $
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ 0 0 0
Inappropriate Sexual Behavior 0 ❑ 0 ❑
Disruptive Behavior 0 0 ❑ ❑
Delinquent Behavior 0 0 ❑ 0
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs 0 0 0 ❑
Emancipation 0 ❑ ❑ ❑
Education 0 0 0 0
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
5 Weld(rennet cc-11,1 Addend".,,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
EVEL #
omments:
EXT SCHEDULED RATE REVIEW: Initial Date:
maximum of 6 month intervals)
6 Weld County SS-23A Addendum
/ WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
p G:= N@ 'ly ,Ilr' i ' r I Q `tii t dl'il dt INI 1 1 Vty , 1p 7 i i Iii III Il,l Ill
li ,l. , ; (,(j.1 'N•" `(,, i iii , I
I I9 "4�1'i l.. 1,t l i I i6[ { f Alvg- 1 ; 1, I II III) �p l 1jl n N.{i 'I i i J Ir � '.. ,ii ai9,r G
1 ,i ,. r I Ii ,i ul tl ' I�r1„ ,,?a -tn; . )IN, I pi, ii r n„ , p n ' 4 t
it Y{ ,..{,,q-i:03..., ., it I.t i It I'i : I 1 I .lb i(i(i.iI',4:55: l i ! n w+'�. I II Ir I +i I5 �pu m( r,-n" y U
i ,i (, ( , _ i ""i"fl�, ; iii i rt r , 1: it I'),�I1� . I d,I �.e. II�li i , Id, 1;. a. 1:r..to,tins i�'tyl, i t+;. r I ".,,i' i
{. i II(' Nl r , I) r ( (III III i I' t tl i �` lh ,air , ii Ia111i � ,i 1 f' 1�:h -_a
iC : ' ' i i I !i III i i! 14 ,'l , l' i i I iiill'i ili'pi ll 11..1'; r r ! {Ila5,;,I� bli 1{ fi:i µ t I`i i t r51,,":1,5;),,
.F.,., r 1 , ,I i II i;i a i i r q 1 i �- ,
k, I r , .1.,!;:,!.}.9, II u rtl IE I I I,Po Ill . it ,41, I,
6 V l , I i i i N x t ii'''fpili , I "i
i. n t I 6 II I 'I , i i) il, i51.1(,;''a I � ld F dig'tiN�2 ai rill
t N,:11;; Ga ,4,
I: I , , i 'i ti , , , �} i '4 i 4' , 'f, r611i II r sd -ser r i .:IP
i ht it Y.i II 1. rill , ' 'I y p F. �•i v. Ira la �, y { I m'{li t
G , I ( I. t 1 i A 1 r i pli O.a I.1, PIA
j, l�,lie'1!l �k I.7 , (.i, ,r`r.
,I. 'h ' i ,I - Ilitl ,- IJa M� .t t�, , ; , i ill
iii. i t ' i Ki �, l ,'P r ' 11iN l tf ,r K,+,., :iii(�a .LI..,.,....,.w i i I. . wll....ti..Y6n.A.:iL) 6;auRM > 4 1.� iit.,w..,.li,i .,
In
o 11 Age 0-10...$11.47 rill
ll Level 0...$6.25 ' Ii Level 0 $0�li' Level 0 $0
li
','E- 4i Level $4.93 e
0 q; Age 11-14...$12.89 II I I- (Therapy not needed orprovided ' (None)
Ili i
I'tl {III (Minimal CPA involvement by another source,i.e.mental
0 ill Age 15-21...$13 91 l; .. and/or no crisis intervention i.e health.) f'
:; mutual care placements.) i (I
+$.66 Respite Care w , G iii
1
' -ii Level 1 $8.22 ' Level 1 $4.93 "I
1 :it $19.07 I.I .. EIII Level 1 $2.99
iii +$.66 Respite Care i Level 1...$6.25 . (Face to face contact one time ' (Regularly scheduled therapy, 'rll.
($19.73) 'be per month and minimal crisis :� 4 hours/month.) fel
I ��f '1 intervention) it.
.01
rl I;u
H II t!
i, -i '8 Level 2 $11.51 a Level 2 $9.86 i::
; l i;.
•
$25.64 ?: (Face to face contact two times (Weekly scheduled therapy, ,
2 i ., Level 2 $4.47
f:a +$.66 Respite Care Level 2...$6.25 per month and/or occasional 14-8 hours a month with 4 hours of ill
:4'ii ($26.30) ale crisis intervention) I Group therapy.) is
II.1 it',
I a'
I , ,Y
G'1 ll'� ;r
' i ^Level 3 $14.79,'.
.Level 3 $14.79 ' (Regularly scheduled weekly
$32.22 "'
3 I ; j multiple sessions,can include , Level 3.......$6.02
ail +$.66 Respite Care I:, Level 3...$6.25 (Face to face contact 1-2 times more than 1 person,i.e.family 9-,
€:1 ($32.88) _ per week and/or ongoing crisis I thera for 8-12 hours/monthly.)I" intervention.) pY' :i:
is
' u.
a t.;
in
is I'N °
I!1
�_a !i is I,;;Level 4 $18.08 ::Level4 $14.79:
i°
4 ( il l (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
$38.79RTC ' per week minimum,High level multiple sessions,can include
t +$.66 Respite Care i,; Level 4...$6.25 g P ,;
Drop ; -- of case management and CPA more than 1 person,i.e.family r:
4.Down ,1l ($39.45) involvement with child and therapy,for 8-12 hours/monthly.) ;
11 .! provider,including on-going
l i :1
.i1 r.: crisis intervention.) ,
i
Assess. I,. Assessment I
Period C Period Assessment Assessment
$26 30 Assessment Period $0
Period $625 Period $11.51
ill a (Includes Respite) � ' l':
n.
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Letilialli
Weld County Clerk to the Board
Ef,4) WELD COUNTY BOARD OF
C ft qv I SOCIAL SERVICES, ON BEHALF
lit6i OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
SERVICES
`viii °`S
By: e'/ .4 t62a__. By:
puty Cle k to the Board . J. elle, Chair
AUG 3 0 2UUb
CONTRACTOR
Children's Network
7651 W'41st Ave, Suite 96
Wheat Ridge, CO 80033
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: CilAit
Dir for
•J
8 Weld County SS-23A Addendum
�, .
0a -.2:3".
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Colorado Family Services Inc. and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
•
The following provisions, made this 7b"day of J id/j' , 2006, 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#26885. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
t1 wPu ,.rii.,n,CC-71A cnn 4:12-9 //
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V,Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld('nnnhi QC-11 A Addendn.n
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.
16. Add Section VII-ATTACHMENTS:
3 Weld rn.,nn,CC-11A Addnndii.n
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX ITrails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT JHH# DATE 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 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 D1)2-3 round trips a week
❑2)4-5 round trips a week ❑3)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 ❑l)Two times a month but less than weekly
❑2)Once a week O3)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''/:hour per day ❑1)IA hour a day
O2)more than '/:hour per day,up to 2 hours per day ❑3)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?
00)less than 5 hours per week O1)5 to 10 hours per week
❑2)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 ❑I)5 to 10 hours per week
❑2) II to 20 hours per week O3)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 i.e.mutual care placements.
❑t) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is 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)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 ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 weld rnnnt.,CC-71A AddunAnn.
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
•
(Attachment B Continued)
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.
;',R f.9i11.rin7itI i llIMF 01 amIt`�'t1 ' s °`" °G , "`
o } w, n; 11 F11, 11 illII
.uil)u:q; 1N �itho N .
MT rdi {. i 1 y1Y Fv �� f*a � ° 43 : 14P .,x s
II r , .! ., I 1 a 1i,� '1'44
giali-II },Itil 14
I.dth I 6l.y ` i.�ll`a... ,N,.,., .. a'. .. a i uyt ` x 9l.w,l:1 uul }n 2lii
.l .R'� a`C`IS1t' N � '' e *, 1 k 4 x'�� 4�f�:'1 11'S Iii % , 6.10:ii ,.
a �7 ��ils-7
L-i I ax&a LILII;;I „f t aAdtai.4.8.: ...i. .
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting 0 ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ 0 ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis 0 ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ 0 ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ 0 ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ 0 0
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
5
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
A(9ti'y�i nRc, 'Iitii i""•'i"iiHB "::^ to flu 4n y,,-, F s _.,;p A+Qi=Uia f1![4 i 7 Ttaiiirli uiv5 srv�^�^ ,rauwl,wl muuutxf
h• 1I • % K 1� ',.1,•,',. .r.„':11.•,: � t� n.. .1 40 :%-", ii '1',!:•• t d .�,,I'''.1•,.•1". I -
-� t FifTrudl R 1Mi s ... • ,a.Y':
.j} }, i ' ' i` I t 1y( ,RATE MEDICAL.NEEDS-
r1 t i.K .p iiiwww 4,.+iv 1 i� � i,.:..4.. +E> r .�� i r .�{, , f,•+7 ti rL•r<wa au nvi, i •M n,'k4+'1 r i.- i• w �}�,+. i .qs
'd Y��pER _ r4 1 f i 1 df Ai --,,,..-.. ,,,,,,..,(:?F,,,,,;,,.., IN 9 p g, .AD M R
�r2 'ni t 44,I. ` '', i~ 4 d a '..7e .. fi �'F �" 'i' lir.f ,44I�,i14p IF�Nt
.,r!!,,.. • . ''s,!,PV,...,P s 1p f`i,- 4} ''•,'':'?`*.l' '14'', 1111,,.:".. t,74,:,..S $• ., '.: 106- iiPaP ;,
• i I I •1:,.. S y'.y'Sh . i b ' 4-t. 3� a t 7{iierq f,4t ad :i }.,$1•�M `1,
f1 •�� ,E 'Therapy g ,��
1•,Level . ,.',;...":,-,-••,-i-", 'ii r, • .RYti H : t• rc,ii , . I� nai GeT • i�ia'' ,i.i, c .t .;-,i 11'':;"''''''r.e'. '44'>I4
-
t' i' a , ..:0.•,:i; "•-•:!,„!:. pp I it itet 9, Ti, Admin.Services) ..? ,,h S'.
;ryKtj}tl� ';Iy' 1 . I.:, n:(Admin,IMilt]>)..�. , t,,Wt�il' In. Nl4j,1 i..y,i� q :li-il�h �.•. ,• ll� ZCI,
''I'l! Age 0-10...$11.47 qqyy
0 g Level 0...56.25 I� 1•1IrLevel0 $0 Level $0
Level 0 $4.93
Age 11-14...512.89
0 (Therapy not needed or provided (None)
'•' (Minimal CPA involvement by another source,i.e.mental t
0 Age 15-21...$13.91 a; and/or no crisis intervention i.e. health.) f�
mutual care placements.) &
+S.66 Respite Care y, r,,
fti 5,,i'''.
f I Level 1 $8.22 I !Level 1 $4.93
$19.07 . Level 1......$2.99
+$.66 Respite Care I I,,' Level 1...$6.25 (Face to face contact one time ':! (Regularly scheduled therapy, ll
( ($19.73) II' i• iI per month and minimal crisis 4 hours/month.)
intervention)
i .-Level 2 $11.51 a--Level 2 $9.86 Ilk
2 $25.64 (Face to face contact two times ' (Weekly scheduled therapy, ]]
+5.66 Respite Care Level 2...$6.25 pe
r month and/or occasional ;'' 4-8 hours a month with 4 hours of ,i Level 2 54.47
't ($26.30) crisis intervention) ., Group therapy.)
, Io
Level 3 $14.79
t Level 3 $14.79 (Regularly scheduled weekly ;
l,, 532.22 ,
3 , multiple sessions,can include Level 3 $6.02
+$.66 Respite Care I Level 3...$6.25 (Face to face contact 1-2 times dq'� more than 1 person,i.e.family
($32.88) :! per week and/or ongoing crisis 1I1 therapy,for 8-12 hours/monthly.)
intervention.) Ir
'Al
)`1
Level 4 $18.08 Level 4 $14.79:'
u
4 '' (Face to face contact 2-3 times ,.: (Regularly scheduled weekly i Level 4 Neg.
RTC • $38.79 per week minimum,High level 'y multiple sessions,can include
Drop ,; +$•66 Respite Care Level 4...56.25 of case management and CPA ° more than 1 person,i.e.family r."
Down '
($39.45) involvement with child and therapy,for 8-12 hours/monthly.) .;
provider,including on-going ';
crisis intervention.) "a'
h
.,-i !
Assess. Assessment ;
Assessment • ' Assessment
Period Period $26.30 Assessment Period $0 Iii
(Includes Respite) at Period $6.25 Period $11.51
IR
Effective 07/D1/06
7 Weld County SS-23A Addendum
•
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: /� �"'glka
Weld County Clerk to the Board
IE La WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
lwl , ? OF THE WELD COUNTY
, 1 DEPARTMENT OF SOCIAL
t "� - SERVICES
4'r
By: By: i A `
eputy CI to the Board I. J. Geile, Chair AUG 3 0 LUUt)
CONTRACTOR
Colorado Family Services Inc.
1200 S Wadsworth#300
Lakewood, CO 80232-5434
By: 4
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
8 Weld County SS-23A Addendum
t,Pere-a?3`1-/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Carmel Community Living Corp. and Weld
County Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this I day of 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th 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#44383. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate,will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2
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.
16. Add Section VII-ATTACHMENTS:
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 HH# JATE 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 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 El)2-3 round trips a week
❑2)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 01)Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a'''/ hour per day ❑l)%hour a day
O2)more than '/f 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
monitorin of time and/or activities and/or crisis management?
00)less than 5 hours per week ❑1)5 to 10 hours per week
❑ 2)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?
Do)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) II to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required? •
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑I) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e.Medicaid) El)less than 4 hours per month
❑2)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 ❑ ❑ O ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ O
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 woke r.,,,,n cc_nan
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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 Elite-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
. Rating of Conditions . _
' NuW� (Check one for each category)
, € ,`' 6r ,i r,
tj ,ASSESS ENTIAREl�.s AREAS **, None Mild Modernte Severe Comments•
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting El El ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ O
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ O O O
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway O O ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ O
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑ '
Depressive-like Behavior O ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ El ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family El ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
S U:Pin rn,.nt..CC_11 A Ad.-kmiinm
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD I: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
LEVEL OF RECOMMENDED t RECOMMENDED AGENCY RATE INTERVENTION RATE MEDIC NEEDS v. ":3.:,p i. +P&1� t 1 y as,iv -
•SERVICE PROVIDER RATE :'''''''L:14--
k�, ,•� ,•; . 4c. I ''iv % i dA ,,r Ti ,,w ADDENDUM'
;�i P1,-P5 - rr � $ ,Ark hk gL ,, • i!4'
t•Level .-,;.4w.7-,* -Rate' ' Admi Overhead Case Management • Therapy lr 41:5; :i * mss. ° 1 A
1 v< "'I 2 (Adorn.Services) }trl
(Admin.'Maint:) '(Adm(n.Maint.)
0 Age 0-10...$11.47 Level 0...$6.25 s Level 0
Level 0 $4.93 $0 Level 0 $0
Age 11-14...$12.89 )
0 (Therapy not needed or provided (None)
(Minimal CPA involvement r' by another source,i.e.mental
• Age 15-21...$13.91 `'
O,: {and/or no crisis intervention i.e. ,. health.)
+$.66 Respite Care it, -,
mutual care placements.) r
tr'
i
1 Level 1 $8.22 Level 1 $4.93 ; Level 1......$2.99
$19.07
., +$.66 Respite Care .'.' Level 1...$6.25 -, (Face to face contact one time (Regularly scheduled therapy,
($19.73) per month and minimal crisis 4 hours/month.)
z. intervention)
a ` ' ,Level 2 $11.51 '-: Level 2 $9.86
ii ' (Face to face contact two times Level 2 $4.47
2 $25.64 (Weekly scheduled therapy,
+$.66 Respite Care .¢'. Level 2...$6.25 ti. per month and/or occasional t" 4-8 hours a month with 4 hours of
($26.30) crisis intervention) 1,' Group therapy.)
5
1
U
a• t4,Level 3 $1479
r.; r„ Level 3 $14.79 ii
$32.22 i�` . (Regularly scheduled weekly
3 :ii'''' +$.66 Respite Care 1f Level 3...$6.25 (Face to face contact 1-2 times t' multiple sessions,can include Level 3 $6.02
($32.88) '' " per week and/or ongoing crisis 3 more than 1 person,i.e.family
y f, ;;: therapy,for 8-12 hours/monthly.) •
:{
�i intervention.)
Mt
ss
A Level 4 $18.08 Y'Level 4 $14.79 '•
ty G
4 $38.79 `` (Face to face contact 2-3 times ) (Regularly scheduled weekly Level 4 Neg.
RTC a; lit ` per week minimum,High level '-1 multiple sessions,can include
g +$.66 Respite Care Level 4...$6.25
Drop ' of case management and CPA ,•..c more than 1 person,i.e.family
($39.45)
�-}
Down , ;.4 involvement with child and therapy,for 8-12 hours/monthly.)
; , provider,including on-going Y
4 crisis intervention.)
Assess. Assessment y; -
Period Period $26.30 Assessment Assessment Assessment Period $0 •
(Includes Respite) • Period $6.25 Period $11.51
1 _
Effective 07/01/06
7 \Veld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: dati
Weld County Clerk to the Board
�� WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
is6t F OF THE WELD COUNTY
DEPARTMENT OF SOCIAL
-e,,7 9 SERVICES
nSPF
By: itt 1 C r2 . By:
putt'Cle to the Board M. J. Geile, Chair AUG 3 0 2U06
CONTRACTOR
Carmel Community Living Corp.
3030 Sterling Circle
Bo lder, CO 80301
By: /241fig
WELD COUNTY DEPARTMENT id, leg X-
OF SOCIAL SERVICES
By:
'rector
8 Weld Comity SS-23A Addendum 419/
• •
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Commonworks D.B.A. Synthesis and Weld
County Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this I day of ,Sul , 2006, 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#104085. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
1 wain rniint,cc_'zn e,inanr,,..,
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wau Q _)14 Addand,,,,,
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.
16. Add Section VII-ATTACHMENTS:
3 wpm rnnnn,CC-11A Addo..d,nn
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 IDATE OF ASSESSMEN
AGENCY NAME PROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment;Family visitation;Extraordinary educational needs; Etc.,as outlined in the treatment plan?
O0)one round trip a week or less ❑1)2-3 round trips a week
❑2)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?
O 0)Once a month ❑1)Two times a month but less than weekly
O2)Once a week O3)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?
O 0)less than a'A hour per day ❑1)'A hour a day
O2)more than '/2 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
monitorin of time and/or activities and/or crisis management?
IU0)less than 5 hours per week ❑1)5 to 10 hours per week
0 2)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?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
O2) I I to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
O 1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e.Medicaid) 01)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 ❑ ❑
P 2 Therapy/Counseling 0 ❑ ❑ 0
P 3 Educational Intervention 0 0 ❑ 0
P 4 Behavior Management 0 0 ❑ ❑
P 5 Personal Care 0 ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ 0
T 1 Therapeutic Services 0 0 0 0
4 Wald rn,,.,n,cC11A AdAand,,.n
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
y ..' . I 17,: 3 TApffi"4 I.I(' i^.,pi . N
fa trr+1 . 3at7F, I1.f ) tiil , D2 ! Yr:I'; P y�
' I
7... �; vr7i m ii 1@ .l..
I t7 a i I� 1 y 'L..a, � r ldl r d Y I .:ii i a '�₹ In i hk� � �y31��.� .
a � Ylti s - ip� y ,z 4 n �� ,i' l �,i I
T
d
�6V k hat.41 I„L L
n i i ' ,2it' �" �s 1 li � � q 5 l I ,u a�s
.�`) •w t 'A a s; ,rx i i a d ' Iii i t '''( 1} !h' '' a 4y�
a hST ,} { i .1-;:'''';'!1'';ci il I4 $ I. Ii 4zii,.SI l ..
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ 0 0
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing 0 ❑ ❑ ❑
Self-injurious Behavior ❑ 0 0 ❑
Substance Abuse 0 ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ 0 ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ 0 ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ 0 ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ I ❑ 2 ❑ 3
5
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
1,: 1 tl i Ii I_ rl' t ..':el:I}: I1,1 I i :li)itgil hl 1In Ii �IrfhH 1 .NtY'1 1:619 ig a I XiUI N i ,I; i TMli a
d i� L n i I 1 JL+ 1 f i II (rli lllrll , . it 1� r ildx Iii�ry 11 fi {'i I I
n r r t 1 I yy � 1 - '! i y r ry i
'f I r Ilse � r ' I 1 ( I I t ' � II �Y 1 r fr y , I�i r pF �I hl" '� yytn*f Fni (�I�rl'1111p�NIIy1r>'
,„ t ( f r ( IIfI t 1 �{� F Ir) i}t I,F 14 rl 'dl 4 tE4 t )1
h 11 ,,; i 1 III If 'tfi II 'If� Iiiil iltii;iii„ L1 �iH li Ii lql,i''i i"I r'III q} Iili ' it!'I
llea 1 '_.lYi. Ill L1'I IT it , I n. I1 illl,l �1 AO' III(irrr f{ ll' I ll'IdrilH :l'O rlk6 ( ' IR!�`ti lbi in ,rl. 1 r )
i rI ( ii tiii ll I t1�r {i : Ir a � n
1 ili'. .i 1 1 i j _' t 1'"it
I- If IiI f1I 'I!) ii a f hill Wi iI.�I! l:II )iii,1 I1' Ighl.II III : I4 ! ii
i lr� j t r r L Ir (l II r r i xil III irlrri: k If II PPP �� a`' N
ij,d,r { f i 1 - 'r W f r bred r Iddg il' II iI 11lP 1.1.r I P d Iy1l1111 S�i::"I I i!'il l.;kr r'pllii h'km# !UI Ilk(li:i l i!JI'u'IiG{' i�I
(lli1.:'p' .jlj r +• 1 1Ir r f r I r
li 1G( Ii � °, $IFr rill i 1 II 1{ II i-Ir i 1' I!,G�il�ir �r r I II'1G,GII a 1 e419:}l„�1 9i f I{w
II h 1lni J IF) ( r 1 if r Ii-it')�iir{' III:III Ihhl tlliu ' ,Id it r((:�. j91 r i i r ,}
x�a lil ", r JI :limp rl i i i 11 11.tIo :: f -:I;I ilia (r - ( 1 j 111 R :c III�I- O tai i1 III� i f III i 1 I 4p II� . %�1�II ) 'i'I ir:i I�IIII14 � , r) iir iu It ai ll,'lll lrl�)'a� '„i
.I,Ikc I f I I Iy Iff II U I 'jn Gr I r i I I I 11 I G l t.. I II -' r I ( CI r I ( JI 4IVI�� t �1i r
i r a f.l : 1 1 fi (f i)i i 1 III:Ii 1 1 1 1 1 : pt'L !W I y�(11""11��Si11{11 $ ( I,i�"r': r ,ryAyl'iFlY.l,i,�,r'I�`y( kI��g ("(rat y+;,rl�i�ft li i Vii)
II GGIv���rl i:l.&WH34i111I1(1 f11. �I:I� I .�i.I Ar+LIt�.«��X.r II rr L6:�JI�II���i....11�.1.,'I.IJ ..L.�39I�.NWA 1""r:�tfl(M16IIII��GI19itirs61llliili' fi�iGAii:N@i3 t�W�V�rU48IiG�' 1,� r
lio 46.
Age 0-10...$11.47 rI i Level 0...$6 25 (�� t 4
0 Irr^ 1 I,g Level 0 $4.93 'd;Level 0 $01,11 Level 0.....$0
Age 11-14...$12 89 Irri Ill!
0 j.. _ 11' .iC (Therapy not needed or provided li (None)
iI ' ; (Minimal CPA involvement ,1 by another source,i.e.mental
i Age 15-21...$13.91 I-1 I': and/or no crisis intervention i.e. health.) ?H 0 i_ I
(`'� +$.66 Respite Care -'I till
mutual care placements.) ( L Ir
ir
at ,Ii;
1i' I �'
1'.'I'.1' . Level 1 $8.22 i.4 Level 1 $4.93 to
1 $19.07 i _r Level 1......$2.99
il
r
a +$.66 Respite Care r ` Level 1...$6.25 (Face to face contact one time 1' (Regularly scheduled therapy,
r ($19.73) ,'i per month and minimal crisis :rot 4 hours/month.) ril
c intervention) !, 11
I ' in
II,' ii
'�Level 2 $11.51 rd
Level 2 $9.86 M4
Fr y li i
(Face to face contact two times ' �l'
2 NI, $25.64 �p I . it,. (Weekly scheduled therapy, r r Level 2 $447
4) +$.66 Respite Care 11 Level 2...$6.25 I ) per month and/or occasional i1ii 4-8 hours a month with 4 hours of Oil
j ($26.30) ,I.' , ,j crisis intervention) (4 Group therapy.) FA
r:Iii
dill 1 :1 II Ift4
is :Piii
Pt "_ Level 3 $14.79 -I1
I'.r
li " Level3 $14.79 Re ul
L.N $32 22 ( g ariy scheduled weekly
3 11 +$.66 Respite Care a I1 Level 3...$6.25 ! (Face to face contact 1-2 times lit, multiple sessions,can include n Level 3 $6.02
1 i' -I a per week and/or ongoing crisis I 'I more than 1 person,i.e.family r r,� ($32.88) I!, : therapy,for 8-12 hours/monthly.) i
I ':,, �,, intervention.) q'.
I'i i
`I I iir`r IIII'
J Li
jl' I r'
I I Level 4 $18.08 fLI',r Level 4 $14.79 il
Ii
RTC ' + ( e ( I
4 '-I $38.79 i d (Face to face contact 2-3 times ! (Regularly scheduled weekly .r d Level 4......Neg.
lii $.66 Respite Care :rift Level 4...$6.25 Per week minimum,High level multiple sessions,can include IN
Drop ,I:) ($39 45) - r ' of case management and CPA I r more than 1 person,i.e.family hi
Down r „ involvement with child and 4': therapy,for 8-12 hours/monthly.) ll
Ifril 11 rl provider,including on-going +i ,d
• i•., ill
I crisis intervention.) it I
Assess ' Assessment i Ir('
Period L. Period $26.30 Assessment Assessment
Period $6 25 !< Period $11.51 "
Assessment Period $0 ilpfi
}, I (Includes Respite) i : 11
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
E� i OF THE WELD COUNTY
[ ^r d DEPARTMENT OF SOCIAL
SERVICES
By: Att1 -LI2Ff \ . By: 22,c4/�
uty Cle to e the Board ✓` M. J. Geile, Chair Elu 3 0 2006
CONTRACTOR
Commonworks D.B.A. Synthesis
3000 Youngfield Street, Suite 155
Lakewood
-
CO 80215
_ ,
BY: lipX -L- DOO.1.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ector
8 Weld County SS-23A Addendum
Deb
.• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Dungarvin Colorado, Inc. and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this ] day of S , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th 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#98960. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. 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.
8. 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.
caQ9e46- 397
1 U/P14 rnnnhi CC-11A AAAan Anm
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wpm Cnnnhcc-11A errand,,..,
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.
16. Add Section VII-ATTACHMENTS:
3 Weld rnnnh,Cc_11A Addend„n,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID jOB
Sex
WORKER COMPLETING ASSESSMENT IITH# 1ATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment; Family visitation; Extraordinary educational needs;Etc.,as outlined in the treatment plan?
O0)one round trip a week or less El)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?
O0)Once a month ❑1)Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a''A hour per day ❑1) 'ii hour a day
O2)more than'/1 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?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑ 2)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?
O0)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) Minimal CPA involvement per month and/or no crisis intervention i.e. mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e.Medicaid) El 1)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 ❑ ❑
P 2 Therapy/Counseling 0 ❑ 0 ❑
P 3 Educational Intervention ❑ 0 ❑ ❑
P 4 Behavior Management 0 0 ❑ 0
P 5 Personal Care 0 0 ❑ ❑
A 1 Case Management ❑ ❑ 0 ❑
T 1 Therapeutic services ❑ ❑ ❑ ❑
4 ward r,.,,.,h,CC-11A AddP.,di,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
1 I �r i f 1 o f ;: tl,"rTT i
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I. s r 9'° 1 1 it .flii� ,,,.
ks
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c,i.11.1 B t tjm z .,...!,'''.;;;::::.1, ul.1 l':1 IW.1 i. �::'.,1 ...,1')„dv d
. ` 1 wlaf >�;.— - ac '` € ,, a...1.1,....:;..,,,sS ,. -VF, }rv;II i77.I I' Ii .tisa.
5� c; cS ,� 4., i4 } �i "I it , 4. , n ! "II' J .
k
` dn�l `x�'iIjuh,..INu m�.wil�lifuiY 4.,.I{:J,.a i., ..u,a . . i r.L,.:u� pIA i.IIi IIiI�IIJ�t„IICn�W '� ��.
Aggression/Cruelty to Animals ❑ ❑ 0 ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting 0 0 0 0
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior 0 ❑ ❑ ❑
Substance Abuse 0 0 0 ❑
Presence of Psychiatric Symptoms/Conditions ❑ 0 0 ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway 0 ❑ ❑ ❑
Inappropriate Sexual Behavior 0 ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ 0
Depressive-like Behavior 0 0 ❑ ❑
Medical Needs ❑ ❑ ❑ 0
Emancipation ❑ ❑ 0 ❑
Education ❑ 0 ❑ 0
Involvement with Child's Family ❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
5 wPI4rn.mt,cc-71A eathwi••,,,
•• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily;tie:Ili,
(Attachment C
15'1,411.'011WI MIT 9IlIlf:ETEKEPP4ISFJ ,,,1 Pll {Illiii'Iiill;�MPEEM if'ir'}4� 1' I'pI4� '�I lif illi Ii' l 'l i rsh A.r y�f. . �.! 7.
It!: i� i '� i�IfF I,'° ,. I) id 1 i,!i �-i' f f q 1 L .( i a• :tins ( 4 fi 10:bv nIiii,g M1 iii li liiN (f, ip, eN'+
d 1 I t i � _ y I Is l-x ir' ( a ( I' ��t (i') 4a �' f� ai u,� � ��k Ijj I i.,,'"I WI � e
rhht'1'kk.i,IrTf 11-I, ,, ii ,,, f ' iJ 1,r,,..;41,i,,,,,.(f ,i , apf' if !f rf r,yfy i ! I dl '. i'f .iiif i v.t;i 11 �u i
Irjii ++.8 i ? ' f iy ;t jry ll II 1 }ii'. if ii ii f4'S'.' !till f ,:l Ifni I h�'t) 11I7� it;i l,g1'i it
ii , .,it �. , f N t II�i!'f �. l ' 1 f i14 ,iIfj I i F� l„ a f ,,,1 r, f4"
��fI i f I,,.it a� l�i I ( p) f i if '� iI I .4., I � Y'i�6'1 �I��il llll�i�lii fji�Ij�Q/ ifi!!i �'� �'I'ir4m� flii'lI �' ff� �. , toil,��'i�4�, ' u� �di
f I I i 1 f I II a I !!f f ff ( f 11� 1 f It
I� 'i f rf 11i• Ifl / 1 ipuI; ( i i ffli ?iH °Id
i 'a'IA.f i '.r l l fi I f l,.; f I f , , i{ r I, I l l i t r. , f f l I I h k �'y ' '
f. Ii. I'ii ��( xf , � ) d 1 i I I IGAlIj i�I(fii IILI/I i r � i)cA) ��A( III iu '''If ii�'r.. p...'hU ,',atil� I� ��L'il]'�i4
, iii. I) 'PPE of �I P. 1 f Il I'fi I i ix t � - iy^if d -'i I i�l`r 4i I i ° fl + f 1E,r , ':TEh iiif ;',,�fFi Er . ypi ' iI E 'l ''if " ., i ,5 1",s)y', i,p�, tg1 1 1 iI� i I�1Pr l Ill (Ill , " ', ffiiml.k� 1 , I f i ,i. I i fr : f f(' � J(NPh.' II i 'Ill..�!_ .ti f, f r ' li i i., -,!I f , �. If I I I' 7..'i...i.�tx"u.�7�.,b'ini6,ihM14`�.s E.ul�ll a ili.ld§tl�>I aun,� ,al'I� P u ti f ' .�.ii),��I,,.�I,x�..fl iJlf�d,
. I•'f)1111 J"r":.fu.ruxls helliii 1.G.,..Et .::..:.:�i ii l Ifia.lai�'iili�lu ii ' f �,) I I1. .'L, I( ,IIV I a ' 'I I
Age 0-10...$11 47 ill, lit) M «I
0 i IIie ILevel 0...$6.25 it - r ,r Ii'Level 0 $0 i)) Level 0 $0
Age 11-14...$12 89 'u:
o ! g II„_ ,, ` (Therapy not needed or provided l (None)
i!' ' i by another source,i.e.mental lif
0 : Age 15-21...$13.91 ii ,'il , , , , - . l? health.) 'i
�'I f.
� r„iill „I
;Ed +$,66 Respite Care II I III 1:.,t ly (i
r, iI 'in
(F
1 f l - i Level 1 $4.93 t.; Level 1 $2.99
'Ip"r $19.07 i , ii4 I4
+$.66 Respite Care a Level m1 face - - );i (Regularly scheduled therapy, p
($19.73) (1. Cri, lr in
4 hours/month.)
ifIri
k � I
,i i e 1 icy
i s I l3 :
H' i
Eli - "' Level 2 $9.86.,1:
, e ill
2 i $2564 face contact two i (Weekly scheduled therapy, 4'_)
;♦� +$,66 Respite Care - ; 4-8 hours a month with 4 hours of IA Level 2 $4.47
Iiii Group therapy.) •t
li ($26.30) .I, l!
r' .i f i' r„
rr ) L i.
IL:ii, i ,E
,� F. ,ii -1
j :I Level 3 $14.79 '.
l Level 3 $14.79 !I! (Regularly scheduled weekly �'
3 $32'22 ' 1 multiple sessions,can include 'i Level 3 $6.02
I' +$.66 Respite Care Level 3...$6.25 I (Face to face contact 1-2 times .I more than 1 person,i.e.family i
($32.88) :' per week and/or ongoing crisis ;i therapy, c'
' intervention.) ,1 py for 8-12 hours/monthly.) is
I ,i
,1i 3!
iiIii _ i'r ''I Ai..
.•
„i ;I..',..Level 4 $18.08 ;.y Level 4 $14.79;:.
4 $38 79 I (Face to face contact 2-3 times (Regularly scheduled weekly ., Level 4 Neg.
RTC t +$.66 Respite Care Level 4...$6.25 I , per week minimum,High level multiple sessions,can include .1111.
Drop „i ($39.45) i_ . of case management and CPA :i more than 1 person,i.e.family iv,
Down ti I . involvement with child and pi therapy,for 8-12 hours/monthly.) 4
1 �t provider,including on-going jt, C t
I i crisis intervention.) jj }Ix
is
.iii V
Iii i1F 1
Assess ri Assessment I.' '1'
i
Period j Period $26.30 I . Assessment i Assessment -i Assessment Period $0 II II
Period $625 1 Period $11.51 II
dl (Includes Respite) i
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
14021116/24
ATTEST:
Weld County Clerk to the Board
WELD COUNTY BOARD OF
ELa SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
1161 It "Th Q� t EPARTMENT OF SOCIAL
'} ERVICES
By: l t,4 " q LGi2, t4 r By:
puty Cl k tot e Board M. J. Geile, Chair .j i2 3 O - ,
CONTRACTOR
Dungarvin Colorado, Inc.
4704 Harlan St., Suite 200
Denver CO 80212-7417
By: .0G.L (7\
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
rector
8 Weld County SS-23A Addendum
o*V6- a?59/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Frontier Family Services and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this day of J u , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th 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#38041. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. 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.
8. 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.
07496' -45'fr
1 wpm r,,,,.,n,cc_ne eenane,,rn
9. Add Paragraph 15 to Section W. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wain/`nu...n,cc-11 n nnnp,n",i
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.
16. Add Section VII-ATTACHMENTS:
3 WnIA cc_flA Addpnn',..,
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# rATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment;Family visitation;Extraordinary educational needs; Etc.,as outlined in the treatment plan?
O0)one round trip a week or less ❑1)2-3 round trips a week
❑2)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?
O0)Once a month on Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a'A hour per day ❑1) 1/2 hour a day
O2)more than Y: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?
O0)less than 5 hours per week 01)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 ❑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?
DO) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 ❑ ❑ _
P 2 Therapy/Counseling ❑ 0 0 ❑
P 3 Educational Intervention 0 0 0 ❑
P 4 Behavior Management 0 0 ❑ ❑
P 5 Personal Care ❑ ❑ ❑ 0
A 1 Case Management 0 ❑ ❑ 0
T 1 Therapeutic Services 0 ❑ 0 O
4 wau ra, t,,cc-lzn Addend,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
li 411k,iHi ��PI'hJ ii lFI�l '`imn a a pC 1 �I 7 �i i W , At
4 §' �. I uni d1lii iiiki InII I4 (tl slim l it 1 u
?. W.a y I 'IIId ii , � � A. 3'1. P1 I�§M ti I I � 10,11Aiiii i '� i :4
't Y � xI. P t A ! i �i�� ,ufy� �i�s 1
allittigiBlAin .r:.$ .I. I _ i l .„!,e .. ili,u , . ii.,,i,...i,.._i0i
�. � i i � � I it i � i:;;;');;:i1:10
i pt�
li
t 'liui I: idi i i 'i ii 'GI lii ::1/1,1 i i^ . i it
u .i ��1 �il _Il d it .�� � ti i� � ; 1 I ( P ; il' i io-i 4I
i' 'Ili/ Y } ti
1 I I,ir+ iil tl � � I '�,ul d ial-Y 7 u ;i
.. k1s Ip Iv, ' iigata a,, Lklu₹ltd1 i'l`.
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ O ❑
Presence of Psychiatric Symptoms/Conditions ❑ O O ❑
Enuresis/Encopresis O ❑ ❑ ❑
Runaway O ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ O ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ O ❑ ❑
Emancipation ❑ O ❑ ❑
Education ❑ ❑ O ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
S
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
A
NEXT SCHEDULED RATE REVIEW: itial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
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i 1 , {t' I 1 i){q ,�'dF r I{k k N[!II ! I)Ik ll���prlrN r,l kik:tl i{Nl ilt I imi �t {k { , -r j•k j i'���I �I I6 {`i
1'i ). II , i Lri1iIl�It M', i.Iik 111 A4y4R� 1,11 !11411I"ry.1 1I't1 tk I1It IIN h�(tibI `ti+WI k POI i i { PI 1( i,i,„•.1I: 1 ;1 h]If1 tF
!� 1 ' �li�!IhikhV tY !tIIli (it1 loo iii �!!7 ,I.Hk:Y iki pi it I,i I l I, 1 ,v" ' aLAu1W�,,'l
{.t i I,isliai.lIA.d�1:'w.,l..mt...i.l.d..;Ji.til.k iii, i.1,1 (I r:ail . II 1 } -
I Age 0-10...$11.47 �t IIIII ot
Level 0...$6.25 1:Level 0 $0 Level 0 $0
0 I- ci•
; ;! Level $4.93 q
u Age 11-14...$12.89 I (Therapy not needed or provided (None)
{ (Minimal CPA involvement ki, by another source,i.e.mental
0 Age 15-21...$13.91 i and/or no crisis intervention i.e. Ilk; health.)
t,I mutual care placements.) IN I
+$.66 Respite Care �
II
II1
1 Level 1 $8.22 (F'Level 1 $4.93
1 it Level Level 1 $2.99
$19.07 4I'
+$.66 Respite Care Level 1...$6.25 ;; (Face to face contact one time (Regularly scheduled therapy,
($19.73) i del' per month and minimal crisis Ili;. 4 hours/month.)
;ii : intervention) i4
rr
Ii1
,;, I,: Level 2 $11.51 t,Level 2 $9.86
t
It;I It I
$25.64 w I: (Face to face contact two times . (Weekly scheduled therapy,
21 -1 Level 2 $4.47
+$.66 Respite Care II Level 2...$6 25 1!I per month and/or occasional 4-8 hours a month with 4 hours of
($26.30) I,!ii crisis intervention) III Group therapy.) jill .
i
t ;i Level 3 $14.79
Level 3 $14.79 „ (Regularly scheduled weekly
3 $32'22 t multiple sessions,can include Level 3 $6.02
+$.66 Respite Care J. Level 3...$6.25 I (Face to face contact 1-2 times l more than 1 person,i.e.family
($32.88) i' ( per week and/or ongoing crisis INi therapy,for 8-12 hours/monthly.)
t„i i. intervention.)
Iii
I., II
j' ,T ill
Ii; .'Level 4 $18.08 . Level 4 $14.79
4 i (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC ' $38'79 per week minimum, High level multiple sessions,can include
Drop *$.66 Respite Care k1P Level 4...$6 25 )' of case management and CPA ' more than 1person,i.e.family
($39.45) !I'' 1,[!. 9
Down I1; .k- involvement with child and e therapy,for 8-12 hours/monthly.)
' ^ ,t provider,including on-going ti
crisis intervention.)
C'
;1 :: 'y
Assess. j; Assessment i;'- I : '!
Assessment Assessment 'k;
Period ..! Period $26.30 Assessment Period $0
(Includes Respite) 1 Period $6 25 TT, Period $11.51
1
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
Elsa WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
i` OF THE WELD COUNTY
ci -t?Z
61 n.,111/4?
DEPARTMENT OF SOCIAL
•° g SERVICES
r
By: /tit' ClCC.L `' ' By:
uty Cl rk to the Board . J. Geile, Chair AM 3 0 2006
CONTRACTOR
Frontier Family Services
1290 Boston Ave
Longmont, CO 80501-5810
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
hector
:2146-239/
8 Weld County SS-23A Addendum
• •
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Griffith Centers for Children and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this day of 3 , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#1531601. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
C rn1 wPra r,.ii.,r.,CC-71A en a..,..,
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld fnnnh,QQ_flA Addnndn.n
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.
16. Add Section VII-ATTACHMENTS:
3 \uau rn„nh,cc_nn n nrpnd,,m
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 1HH# DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment;Family visitation;Extraordinary educational needs;Etc.,as outlined in the treatment plan?
00)one round trip a week or less ❑1)2-3 round trips a week
❑2)4-5 round trips a week 03)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
O 0)Once a month 01)Two times a month but less than weekly
02)Once a week 03)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?
00)less than a''/2 hour per day ❑1)54 hour a day
02)more than'/,hour per day,up to 2 hours per day 03)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?
DO)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)at least daily 03)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
02) II 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 i.e. mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
02) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e. Medicaid) 01)less than 4 hours per month
❑2)4-8 hours per month 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ ❑ ❑
P 2 Therapy/Counseling 0 ❑ ❑ ❑
P 3 Educational Intervention 0 0 ❑ ❑
P 4 Behavior Management 0 0 0 ❑
P 5 Personal Care 0 ❑ 0 ❑
A 1 Case Management ❑ 0 ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ 0
4 wPu('n,,.,h,cc_ne nddpnd,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
rn� ^ t t ni �
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il g � �tah� i J � it t4^r �i �'i�l �jinn �`_
4 4 i,•,} '.,,$ rn t uti 'II:N.L tt ii r xk u i ws L..: zt'" S. 3` 'L " > a ',,d' N i V 1 , n [
t iu $p � - ,...x � €�S [ /,',..,.;..;..:;k4:,�.;',,,;]',L4'�' i 1�ruti
!al!iii 'v R' d,'. °' }a a° ;"''„?;.-,L;;'" !..:.:c.;;!../.49,1.t.', y;t 7 r t i.Il �t ni qi MA
Ektl3 i t t � } { '" Ii t; v.i` i.1 tii1,� IJ Jtlist �i rnn
sli i , 'Pi r � . tltji.il+
f 11,t tl it iii , dh ' i'9 i ai 1 iiiiiii1!,tfi
Aggression/Cruelty to Animals 0 0 0 ❑
Verbal or Physical Threatening ❑ 0 0 ❑
Destructive of Property/Fire Setting 0 0 0 ❑
Stealing 0 ❑ ❑ 0
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis ❑ ❑ 0 ❑
Runaway ❑ ❑ 0 0
Inappropriate Sexual Behavior 0 ❑ 0 ❑
Disruptive Behavior ❑ ❑ 0 ❑
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) ❑ 0 ❑ I ❑ 2 ❑ 3
5 weld('n,mn,CQ9l A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: 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
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
i u iiiR i (i-. 4Il �y i ni ,u".GI 11i� I I ,.iiiiro It t It l" iii , i i al!ri��/ �Il Ii' i.. n W,illiri q T t r,14 Miri I I -i4M �t I i ! ili, IE!IP:"'VI i i it ! 5
�'.ry a II (i__k I:o'i ii (I i :i..:.:4 ,1 1 '£iI i 1 !I i nl!IGppe G l'(1!,��)n i t4 (iy,,in !I'Ii�i,i�� I(1 "x11 .i* ,,4!iiG a @ ! tt i e i 7k .4�
�' ! �. I a II I , y- I h ! J '.I„�f 1 111 f I! 141 k� I� 1. ni �f'. 'I i *� � �'V �� `�.
�,ii!'- ' i I t! i (Vi ( 1) i,l.'ry! 1, 1711,j!:I'll In ',h' Il,li�ylllii'! % ai Li i4'.a16 bi r l i ' k
' !Ilk i11i , iis II!I , ! !!I . II'i 111 i .!: ill tl111:1:011"."141
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!L ,k iI(lIk Ii 1 ii i i rI 6 i 1 , 111 11 !1 1:1i ! IIII!IH! II au) Ia ! ! II!a1 I lil I11,M,__i•I4 x r ,, 9 .i
III I:i l ,i !i;i I!11 I4i 1 i1,i+! ii i. i 1 ( i i I i� -ulu6 ! iit.11 1 i� ! tIiil. m.I6,�_x?....�'k'11F� --�N:�. ,6@��,�aLeICIM,.t.0.x dt�aw'.a
rail Itl i i Iii , , I i i i i i -'!11 .11111ii i rerrittynnoniiii
r ,• ! 'i .0 �di - ! Int it(I� I„ I, ! ik� ,nrn irno1 Iili[lliinp l iI '4 t ii -"-_iu �) !sir i innYjigil1.ii:J3
i': Ih i xii'ir, f i i l( t II mii xI I IiItII iiI iii' rt llI l t II 1 ill!Iill iit(t Iill iN!,',, t li;4 litr 'blgio,111u({i '' i
I iI i1 I' 'i- 4i i II i 1, 41Ii, 1l i i'; II ir;iir'h h 1 h iito,:i i ! i ,=i:riW _ 1 , r- !j 1 I 1 11, I it ifa I i t ii !� �I� t��Ii)_,')
''' Il.�u�i.y:�''H1I. °I3iIIIIi.i iI��;EI� (�11�I:ili, I(J;!n1I t�9iI�'��im �i .. I I . I � INuJ' �:8�'IIi�4�G lJVI�)
i nj ai' �4!^a
0 f Age 0-10...$1147 Level 0...$625 iill'll Level 0 $4.93 ` Level 0 $0 ttlt it Level 0 $0 tit 0 iiii
Age 11-14...$12 89 Ii INii (Therapy not needed or provided ": (None)
! , tol :e (Minimal CPA involvement r e by another source,i.e.mental .
0 ii
) . Age 15-21...$13 91 :li and/or no crisis intervention i.e. ,it health.) N.
titl
IN �I,, mutual care placements.) 1 ga
yip +$.66 Respite Care 4 1i !iii
hi NI . IA 4.11
I hit Di ¢9
Vet
e i Level 1 $8.22 Level 1 $4.93
1 r!1 t d 4 Level 1......$2.99
�r $19.07 ji+' : ill
+$.66 Respite Care Level 1...$6.25 ,1! (Face to face contact one time iG) (Regularly scheduled therapy, (i;
ligi 1,0
iiii ($19.73) I)el, (l:Ii per month and minimal crisis Iii 4 hours/month.)
p03,
I ( intervention) NI '
iiii Ili Ir
Level 2 $11.51 1',Level 2 $9.86,t
$25.64 (Face to face contact two times I scheduled therapy, '�$
2 Respite ill
I (Weekly +i Level 2 $4.47
+$.66 Care , Level 2...$6 25 ,0 per month and/or occasional 0, 4-8 hours a month with 4 hours of ;lit,
($26.30) iiip !', crisis intervention) ill. Group therapy.)
;1 I'. ill I ,
1 I' I Ali
Ir:
IA
it �;1 i.
t rill .iii Level 3 $14.79?'-
. I
i1! H.Level 3 $14.79 i l-
(Regularly scheduled weekly I0.
3 it' +$.66 Respite Care , Level 3...$6.25 I (Face to face contact 1-2 timeslir ' ? multiple sessions,can include i i Level 3 $6.02
more than 1 person,i.e.family ril
t ($32.88) I 1 i; per week^dervvention.)nd/or ongoing crisis i., therapy,for 8-12 hours/monthly.) tit
rl ,t) ii :IN .
i'
..I
liP'
_� ,; Level 4 $18.08 l Level 4 $14.79)
4 "1 $38 79 III (Face to face contact 2-3 times (Regularly scheduled weekly ii Level 4 Neg.
RTC +$.66 Respite Care (f' Level 4...$6 25 i; per week minimum,High level ;i multiple sessions,can include
Drop I p I'." a, of case management and CPA till more than 1 person,i.e.family t
Down i ($39'45) I:4 I 1 involvement with child and i therapy,for 8-12 hours/monthly.) 1i
}4 i�f . provider,including on-going 1`a 5
F r:1 j€, crisis intervention.) I I'P,
VN
Assess. 'l i li
Assessment i t k!l
Assessment Assessment lir Li;;
Period ,a Period $26.30 Eiji, Assessment Period
1,;l Period $625 Period $11.51 �i1 $0 Il
(Includes Respite) V! hl
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
.`-, ,' WELD COUNTY BOARD OF
`' SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
at, Ittetz, DEPARTMENT OF SOCIAL
tr. SERVICES
By: jot t-(LCG7t: By:
eputy lerk to the Board . J. Geile, Chair AUG 3 0 2006
CONTRACTOR
Griffith Centers for Children
14142 Denver West Pkwy, Suite 225
Lakewood, CO 80401
WELD COUNTY DEPARTMENT a� r) a O 0
OF SOCIAL SERVICES
By:
rector
8 Weld County SS-23A Addendum
&OO6-83%1
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Hope and Homes and Weld County Department
of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this ( day of J j J , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#29867. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
1 wau r ���n,cc_�zo Addendum-.o(126—,.
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wain r.,,,..n,ccnn ennpnn,,n,
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.
16. Add Section VII-ATTACHMENTS:
3 Weld!'minty Qc_'1 A Addendn.n
•
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 �IH# IDATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy;Medical
treatment; Family visitation;Extraordinary educational needs;Etc.,as outlined in the treatment plan?
DO)one round trip a week or less 01)2-3 round trips a week
❑2)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?
DO)Once a month ❑l)Two times a month but less than weekly
O2)Once a week O3)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''/x hour per day ❑1) S4 hour a day
O2)more than'/z 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
monitaringof time and/or activities and/or crisis management?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑ 2)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 DI)5 to 10 hours per week
❑2) II to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
O2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ 0 ❑ 0
P 2 Therapy/Counseling 0 ❑ ❑ 0
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ 0 ❑ ❑
P 5 Personal Care 0 ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 wan rn,,nn,cc-niA Adna.,A,,...
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
J ym , trlii: t
I"�.0 � ri 1� t 7, is i i ,an '�......i �'+P�( ... �
�� � ! '� i nap.. �. �� ski
3 t'i[t t mug t s s .. 2 x i h Plitt
Ai ry { I9 ye kt '.; .' p h i��y '
i�lklh� r .R 4� � `�'-14 �7" § r F i 11 �� �� 3�� �'�� 1 i
1iii i s� iii s9,.��:,�.2.ud , p 4Lw( a. e,h4. wp«e I
(�. ):::if,,::. ,� T� Fret 2L Ifip 1 ii;ggg��i
��F� y°. �&_'TM `h �� `�%, Y ` 1 ,�lil j.,,„,i ii. hg _ `. i�dq rn ffi� n e ,.p _
,clil 01
'1 i�ltie . .�® = a .s t j s� . .d..d7.......�o „
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ O ❑ ❑
Destructive of Property/Fire Setting ❑ O ❑ ❑
Stealing ❑ ❑ O O
Self-injurious Behavior ❑ ❑ O ❑
Substance Abuse O ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ O ❑ ❑
Disruptive Behavior ❑ O ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation O ❑ ❑ ❑
Education El ❑ ❑ ❑
Involvement with Child's Family El ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
S
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (TO
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
•
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
, .t • MJ'r�i�i=.f °'�- '�"''tlr ul fl. Ip�t' I�{ Irj!,.. ' +''', l ' I,!(,i` H>. - 'li( ',I'�1 '+ �f t..
: ,1.. ,i f' 7, q a-'.5.. n. Iw I i I , tL a b,,. , %.. ! :
� ..��I '� ,s !;f + `"-it' coil
fit , ii `� I I NT[QM RAE 11,�t il{ , AL NEEDS�h ri', +�`t��,!f{ , ;��,, ' 11 8". : 1 [� ' r, , :'I li { .I ` ,. x I. , �. F _,.�..;'. Y t.�r} t"'t;.E ''+ ! `W 1 �I�fl , ,I :.{ 1 �'+�',{` �I nrY x� s{a,.{�� , I i'rr �'... _...
r �'II,I•'f!' d '.:` , ! �t F�,!� h' Ilal l' n •': wy { ' r� °! M, '
1 I � 'l �j!� t,.. ts!�;I'• ri 1 h'y, ,
II j�l iriiat"T ry. ' , � HlI y , ij �(t�If li „ helm � h '
;:a:. 11iuL' to .'k... t.t t i ;~i , 'i n;;, ,,,
: r It; i' ,i !I' -� : , 5 i r-: i
1�11ri1 ,h 1 Ali ll�f j' �p t ,I�,I l i n;Cava "' o. >!I n 4 N 11' I C herapY ,t r i k t .t t�
g �! P ,.It t, r '{7�+`n 1.r (R` " 1{1 kl 4A' I `+ _F , 1 I I _, ,+,•-
t!I � 1' I ! ( I'f�,vk }I i f' a t! s x,,,6 l,t'I'!t 1 i yt
l 41 ' I`, ►d .P 1 t ,•�I ti 1 Ilj •icr,r '' ,r�r_, w d�'_ Ii II',t 1 .,Iihi r i I C 1{,. 1•:.
♦, (' .�I ;I: I�, : rl I ,I" ...; l ikOnt - , i{ ''•4. F, !0 I .(I i i lt#I tl y � {
H1 Y'�'1 , !`. fl 0, @IC i 41 ,'-1!' j li Ilia lint), l iki l; N1 � er {I O;iS ii6i4k!I4-114 ,
ty
Age 0-10...$11.47 ( (?j IiF
p ,i Level 0...$6.25 �II;1 Level 0 $4.93 !V Level 0 $0 i i Level 0 $0
Age 11-14...$12.89 j.' (Therapy not needed orprovided ii 0 ��i a r! (None)
illf: Age 15-21...$13.91 (Minimal CPA involvement ' by another source,i.e.mental
p li 9 (ij;l �;, and/or no crisis intervention i.e. health.) �kF
is mutual care placements.)
+$.66 Respite Care
p 1 li i i
11 c; jli E
II•i, ;.I Level 1 $8.22 Level 1 $4.93
1 I
uai
$19.07 li Level 1 $2.99
f�,
4.66 Respite Care ,j;i Level 1...$6.25 (Face to face contact one time i,l (Regularly scheduled therapy, ;s
ly ($19.73) " � per month and minimal crisis +;; 4 hours/month.) I'
intervention) I( j111
Izl
'•ti � ! ILr ,,,
Level 2 $11.51 Level 2 $9 86 I'i!
2 1, $25.64 , (Face to face contact two times (Weekly scheduled therapy,
+$.66 Respite Care ''+ Level 2...$6.25 l per month and/or occasional 4-8 hours a month with 4 hours of .l Level 2 $4.47
($26.30) crisis intervention ' roup therapy.)
'G I I�i Iii
lj
11 Level 3 $14.79 'S
Level 3 $14.79
(Regularly scheduled weekly yr
.'f $32.22 :!
3 fe t multiple sessions,can include tl; Level 3 $6.02
$.66 Respite Care Ii Level 3...$6.25 (Face to face contact 1-2 times more than 1 person,i.e.family
($32.88) per week and/or ongoing crisis therapy,for 8-12 hours/monthly.)
intervention.) I:
?; (: Level 4 $18.08 ; Level 4 $14.79„y
4 i $38.79 , (Face to face contact 2-3 times ! (Regularly scheduled weekly Level 4 Neg.
RTC r +$,66 Respite Care '{ Level 4...$6.25 I f' per week minimum,High level j multiple sessions,can include
Drop li ($39.45) I; of case management and CPA i more than 1 person,i.e.family
Down ,i involvement with child and therapy,for 8-12 hours/monthly.) d i
provider,including on-going
crisis intervention.)
Assess. Assessment Ei
Assessment Assessment
Period Period $26.30 I1 Assessment Period $0
Period $6.25 I Penod $11.51 t
!s!
(Includes Respite)
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
Weld County Clerk to the Board
WELD COUNTY BOARD OF
,c;:'"1, SOCIAL SERVICES, ON BEHALF
�' OF THE WELD COUNTY
lssl0. , DEPARTMENT OF SOCIAL
,`usVi SERVICES
trqb
By: It e� � � By: d
�1
eputy Cl rk to the Board . J. Geile, Chair AUG 3 0 2006
CONTRACTOR
Hope and Homes
620 Southpointe Ct.
Colorado Springs, CO 80906
By:
WELD COUNTY DEPARTMENT ale C EW C6g1 tC9
OF SOCIAL SERVICES
By:
Di ector
8 Weld County SS-23A Addendum „�
J jLCc
�
-?9(26_.4;l/57/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Hope Family Services and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this / day of , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#42942. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
ne- ,95/
1 wPin rnmity cc_nn earb.ndi..,
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld rnunty CC-11A Addand,,...
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.
16. Add Section VII-ATTACHMENTS:
3 wall Cnnnn.CCYl A Addandnn.
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX trails Case ID OB
Sex
WORKER COMPLETING ASSESSMENT IHH# (DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 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 ❑l)2-3 round trips a week
❑2)4-5 round trips a week ❑3)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 El)Two times a month but less than weekly
❑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 El) 'h hour a day
D2)more than 'A hour per day,up to 2 hours per day ❑3)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?
DO)less than 5 hours per week El)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 El)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) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T I. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e.Medicaid) ❑l)less than 4 hours per month
❑2)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 ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 Weld Pont',. cc-lie edda.,d,,..,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
rifii.E'illide.::!c!.;ij!!Ii: Yi s » l ilr WI �n �1 i: i't i. i14 �� i
. � i � �oiy i��� t(s�'e4i�r£{��,4ii ,n� � �ii i r��� t ��
i � V '' y . 1E x ' ' di1i''.a!i:' dlIFJ '�7'l�NIM' �Ii i�l III Tipp s
' ₹ ' i ' r J I� ii���i it � � �I1��'
ilillWiltibiliFiltiitieltlki
�. .3'"�e=mar wtw ., - '4'. .. : .i . . y
p"s. .rz':I'i^ ..-R�s* t ,f halt i I xt�' i"A l �iil�i) �1 U lei i t1.1Sl�I
� 7
[( 11i i1;%!::!!!!,;!V !, i ' a Ei i i 1 id n n�1i�Vi # i� fl
t I iiibilibilitiliPl i...i1bili{ 8 ' W ' 4, x.111, t�� p lt
Aggression/Cruelty to Animals 0 0 0 0
Verbal or Physical Threatening 0 0 0 0
Destructive of Property/Fire Setting 0 0 0 0
Stealing 0 0 0 0
Self-injurious Behavior 0 0 0 0
Substance Abuse 0 0 0 0
Presence of Psychiatric Symptoms/Conditions 0 0 0 0
Enuresis/Encopresis 0 0 0 0
Runaway 0 ❑ 0 0
Inappropriate Sexual Behavior 0 0 0 0
Disruptive Behavior 0 0 0 0
Delinquent Behavior ❑ 0 0 0
Depressive-like Behavior 0 0 0 0
Medical Needs 0 0 0 0
Emancipation ❑ 0 0 0
Education 0 0 0 0
Involvement with Child's Family 0 0 0 0
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) 0 0 0 1 ❑ 2 ❑ 3
5 world r..�,.,n,cc_nn Addendiun
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
l EVEL OF THERAPY SERVICES NEEDED (Tl)
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
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
Ilia
i10011040:0000p00001' I a 't, 1>j II I ,I:(, rr , 'h , ( , b i,:. i:l 1 �a' t t i '..y ii p , -ii
0, ' 9 I I:I i MIIIII;;M i t I I i li�i i Ii q n �rl. ,1 ,a Lill iI i u^. ;;;w ,
� + ��'Y ��,� I' i�i ,� 1 ,I-1^ 1iI c{ �_ .tv N 4i.�} � i) iA it ��"�y-'1_';;;;;R
I. !lifter}, I , ,t iii,, „ t i ,i, r ei
Ii � 1�IP x it ii t, I, a I ::wlii lfi� err!- I, I pp � 1, 7tt a' .:iii ql li,, , U I
_ ' li'I �,+..ql,, t ' iI In 1pi. III, i4) , I. 4� I r+f i ' „'Iii !il
iii 1 E r h 1 1 � i , i y�(,, ' I i ;- i I I , q1i ,ip illli F
1�r ' '6 i II 'IA ii iili {:, 1 ii ii.; (Ii i�I!I I i N.li iµ !-.: i :,I,i I i nip..
i I'' 2}�byG) t',, ,"mil
lii
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�I J I�I �1 ("t1 I'M' Ii'I A l%I"i 1iw41 ial I1400, ' , iiii liM i ' i .$ !ip I 4.h'� iH1 iil .19024401 Y W
s 9�i Jr 701.9 .tq. Ii. s d'f liY I yi^a� l+"Y.I�ilhl,i ' pp{10i 0,0,0 ' u .40.EsI1 - I'i Hill ',I ioi'I� " 0: P i,l, .ii0
i 4000 IINI�ii ..I,, k i i I II( .; y 0.0I0.00°0, ! II !, F, 100 it:,
I�Y 'i i' + Ii ;44.00 -.i I
I�: 11 ii, 'I,1! II,I i s fPq , l( ,' ( 4 I i^ i h 4C 4!) i
nOl 1 f {jiii. ' "in i ii !i 1loi,,: u 1 ,Iiilll iii N1 Nil Ai
_I i'I i� ) (IIII �II Ir Ii{i j '',1$ ''iA Iw i,fi��
11149 iE tL!Ii::3:s,J....ib u.a.' ,iiI.n.:'/AL , I I .,i..,..0...dal....i'liddd ..fllllililn; .3,. i .t+�:n y l_ imi Li i'is xm
I7 Ph; I I $
Age 0-10...$1147 I,i�t Level 0...$6.25 III: I lit
; Age
o ';) Iii Level $4.93 i�Leve10 $0 iq Level $0
a Age 11-14...$12 89 1:'u '`f I,. 3:I
0 I� I !., (Therapy not needed or provided 1,I11 (None)
I(f, -i (Minimal CPA involvement '41 by another source,i.e.mental
0 Age 15-21...$13.91 'pill'
I ( i and/or no crisis intervention i.e. ,t health.) di_
+$.66 Respite Care II, i•i mutual care placements. ili
)
a IlY
•Yf ,.q 1IIi4 I„ +I
*i Ii€ i Level 1 $8.22 j Level 1 $4.93 ,
1 $19.07 Ilt 'i- , Level 1 $2.99
I (Face to face contact one time 'Ii+$,66 Respite Care i.�i, Level 1...$6.25 ,� (Regularly scheduled therapy,
($19.73) 111
yi per month and minimal crisis II;, 4 hours/month.) iii
intervention)
C;. 'a Hit
;_ ai
iGi iii s_
i
$11.51 a
ttl
1;11 !',1 Level 2 l �i
Til
i
y.,i Level 2 $9.86
2 - $25.64 " !it+ 'I (Face to face contact two times ,; (Weekly scheduled therapy, ';I1 Level 2 $4.47
+$.66 Respite Care (l; Level 2...$6.25 „_, per month and/or occasional ,I,. 4-8 hours a month with 4 hours of
y ($26.30) ;l crisis intervention) ,iii Group therapy.) :i;$
ht 1
.I I n 'i
' lit:.
:II
i •
il:q ICI= ;; Level 3 $14.791'1
Ii t Level 3 $14.79 hid
it
$32 22 I (Regularly scheduled weekly t::.
3 ` 'II 1 multiple sessions,can include 'III Level 3 $6.02
+$,66 Respite Care , Level 3...$6.25 I (Face to face contact 1-2 timespipmore than 1 person,i.e.family
($32.88) per week and/or ongoing crisis i &
L�I, intervention.) (!I therapy,for 8-12 hours/monthly.) iil6'
If Iq i!I 'Ii di
NI i (
{i El ,i441
ll 11 4+
ill (, ; Level 4 $18.08 i Level 4 $14.79 ift
q, �I.
di I l
4 + $38 79 ' a I (Face to face contact 2-3 times (Regularly scheduled weekly 1, Level 4 Neg.
RTC lwill +$.66 Respite Care 11'j Level 4...$6.25 I per week minimum, High level i, multiple sessions,can include 4I
Drop ii Alof case management and CPA more than 1 person,i.e.family
Down ($39.45) :! I: i.
I,i involvement with child and ;i therapy,for 8-12 hours/monthly.) l,;i
(ii i Id 'i provider,including on-going
qqi
,7 ,,, I' crisis intervention.) - 11
Ii:
`�I .Iy u6ry
Assess Assessment diII
PR
Assessment I Assessment '
Period I I' Period $26.30 I ' I Assessment Period $0
3 Period $6.25 '1 Period $11.51 ii l r
1: (Includes Respite) 1 '', :i Hi)
,q a .. : Ni l,fl
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: atai et
Weld County Clerk to the Board
eas tr, , ,* WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
te.:31,,,„' OF THE WELD COUNTY
Ismr j: ''" " DEPARTMENT OF SOCIAL
(, ? t SERVICES
By: t1. .g r lc CL By:
D uty C1er to the oard . J. Geile, Chair AUG 3 0 2006
CONTRACTOR
Hope Family Services
1115 llth St _
Greeley O806
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
8 Weld County SS-23A Addendum
„,oCCE a!5%/
• •
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Jacob Family Services and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this Wiay of AV,. , 2006, 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#71260. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. 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.
8. 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.
- /
1 w, n.,,.,n,cc_n e Ad,1P�d,,n,id
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld/`nnnw CC_11A Addc,d»m
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.
16. Add Section VII-ATTACHMENTS:
.� wau r,.,,..n,cc_lc e eadenn,,...
• •
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 �IH# 1DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 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
❑2)4-5 round trips a week 03)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
DO)Once a month ❑1)Two times a month but less than weekly
02)Once a week 03)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''/ hour per day ❑1)'/a hour a day
02)more than 1/2 hour per day,up to 2 hours per day 03)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?
00)less than 5 hours per week ❑l)5 to 10 hours per week
0 2)at least daily 03)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
02) II to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
01) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
00)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ 0 ❑
P 2 Therapy/Counseling 0 0 ❑ 0
P 3 Educational Intervention 0 ❑ ❑ ❑
P 4 Behavior Management 0 0 0 ❑
P 5 Personal Care 0 0 ❑ ❑
A 1 Case Management 0 0 ❑ ❑
T 1 Therapeutic Services 0 ❑ ❑ ❑
4 wPu cn,."n,ccnlA An,i,..,,-li...
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
' "r`; 2 5#I t i, i iii Th s
1 M t3 z , i i err w ! 11n
I�fii 4i71 f h` 'iif i:i � illtil �
I^a ml i ,I iww nPY+ j N « . � ,1
p
II.I�iD tNL x s Y PPP���p . t ii , w i u 4 . j
lilitialil'iii Liiiiititgliifilli6;riiiiiibrdigillitiUlthilliiii Et VI' irkiiiiliiiiigiggiiiiiiil hit .,
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ D ❑
Destructive of Property/Fire Setting ❑ ❑ 0 0
Stealing 0 ❑ ❑ 0
Self-injurious Behavior 0 ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ 0 ❑ ❑
Runaway ❑ 0 ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ 0 ❑
Disruptive Behavior 0 ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ 0 ❑ ❑
Involvement with Child's Family ❑ ❑ 0 ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 0 2 ❑ 3
S waia r,. �n,ccoae AdA�dnm
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
4
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
i 1' I.1 ' -:14747I i "A iir n r I I" ^,i'.e fpc. I i 'P gjSg 1. It, j) r1i 'M"cla a(G ii.
=bn i� ,I,, � ,➢ t iI�l ;IT lil. ,I ka , 'l4fri ryf q ji;r,�i i t' ! ( g I n, � t �'4 �'' °j.U. i't:IP
,' ii0 F� ,'t�.�,111 ' �1'0
i+� �, ��I II ' r '{ ' k51.' >, RIi t�r�r'I ,� I " c- lc it II I'� t13. ;' 01001,101' I Mil i 'I I j r ' 11 's, :fillr rf 9 t.: 'w 4d
r ' ' } T id'd I �n ti ) I 0 s I ii .i. 'i ,, u dr I f Rit tri.hi' hliI ti)
(i I I N,:—OR -4 i 'A girt. a I i ! 1i {pal�,'q�r�}t',,�t aIx'�':'" t::jiI.4, i'�ili I,i" !
IFIBMI .la'') I iIW i ({ i n. I:id �'Pia dr i,II - - IX ' [till
tailitii '1*I i� ItY b ,1 i, ~ { v!L] Jl
�1,V P � ' f.' i^, :k l ,-,du1r ...I�. ti t �V [mitt�! , •
it : lit I! Age O-10...$1147 Ili
o � Level 0...$6.25 �t " r',
hr. Level 0 $q gg IifE Level 0 $0 r� Level 0 $0
0 "± Age 11-14...$12 89 ';�I. ' a.
it (Therapy not needed or provided .1 (None)
i I„' 'I, (Minimal CPA involvement 'i, by another source,i.e.mental ji
Age 15-21...$13.91 11 xi
0 iijl f Iji and/or no crisis intervention i.e. j. health.) .,
l! iP mutual care placements.) H II,
+$.66 Respite Care ry I . 41 III,
n'� I li fq
:iid III fill Iv tl :1 Level 1 $8.22 :Level 1 $4.93 "
1 Irr, ;k i' Ill Level 1 $2.99
$19.07 0
+$.66 Respite Care t Level 1...$6 25 4 (Face to face contact one time !, (Regularly scheduled therapy, ij
($19.73) '= if' per month and minimal crisis Iii 4 hours/month.)
intervention F`
fit
ni! ,
n,
!t f Level 2 $11511 Level 2 $9.861+
1.i!f I ' , I;I
$25.64 'j :I (Face to face contact two times f (Weekly scheduled therapy,
2 .., Level 2 $4.47
+$.66 Respite Care Level 2...$6 25 'i per month and/or occasional ,.I' 4-8 hours a month with 4 hours of .
($26.30) i ,, crisis intervention) Group therapy.) 313 d
,{ #;p
I , iit
f'a
1. .I ' Level3 $14.791,1
i Level3 $14.79
Id II
.1,ri!f (Regularly scheduled weekly it
$32.223 Respite ') Iq multiple sessions,can include e.,1 Level 3 $6.02
+$.66 Care ;I Level 3...$6.25 1_I (Face to face contact 1-2 times more than 1 person,i.e.family ,�
($32.88) ;` yl per week and/or ongoing crisis - therapy,for 8-12 hours/monthly.) I'�
II,. l�
Ill
FA
a I Di
,l# : WI
,, Level $18.08 Level4 $14.79 „i
4 $38.79 ,;H (Face to face contact 2-3 times (Regularly scheduled weekly I Level 4 Neg.
RTC +$.66 Respite Care iii Level 4...$6 25 ! per week minimum, High level ; multiple sessions,can include iiffl
Drop ) ii, ,m; of case management and CPA more than 1 person,i.e.family I
Down ($39.45 involvement with child and " therapy,for 8-12 hours/monthly.) attit
F'.. provider,including on-going fli rhl
crisis intervention.) t', it
:It til
' i i. 'Ill
Assess. Assessment , ,
.i
4 Assessment Assessment ,.
Period Period $26.30 I;k Period $6.25 + Period $11.51 I Assessment Period $0
(Includes Respite) j,rI ::Iiii 1 di
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: Mil r
Weld County Clerk to the B d
4,:„1,A,,,,/,,,, ,,
:c-: _i - A WELD COUNTY BOARD OF
41, 'te .. >, SOCIAL SERVICES, ON BEHALF
1 m t r ca t-1�`. 1 - 1 OF THE WELD COUNTY
V..;..>"I�► 1- DEPARTMENT OF SOCIAL
^, 7/ SERVICES
By: "tit I ie?q C_ _ __• By:
uty Cl to the Board M. J. Geile, Chair AUG 3 0 2006
CONTRACTOR
Jacob Family Services
729 Remington
Fort Coll' s CO 80524
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Direc or
8 Weld County SS-23A Addendum
a9m6-&39/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Laradon Hall and Weld, unty Department of
Social Services for the period from!!;
July 1, 2006 through June 30, 2007.
The following provisions, made this 3( day of , 2006, are added tare referenced
Agreement. Except as modified hereby, all terms of the greement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45200. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. 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.
8. 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.
aMMDE'-a'3%/
1 wptn r,.,,..n,cc_11 Afirb.,n,,n,
' 9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wain cc-nn nndpnn.m..,
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.
16. Add Section VII-ATTACHMENTS:
3 Weld l'nuh,CC-11A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE BD SEX Trails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT 1ATE 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 the following: Therapy;Medical
treatment; Family visitation; Extraordinary educational needs; Etc.,as outlined in the treatment plan?
DO)one round trip a week or less ❑1)2-3 round trips a week
D2)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?
DO)Once a month ❑1)Two times a month but less than weekly
O2)Once a week O3)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''A hour per day ❑1)''A hour a day
❑2)more than'V2 hour per day,up to 2 hours per day ❑3)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?
00)less than 5 hours per week ❑1)5 to 10 hours per week
0 2)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?DO)less than 5 hours per week ❑I)5 to 10 hours per week
O2) 11 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑I) Face to face contact one time per month and minimal crisis intervention.
D2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T I. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e.Medicaid) 01)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ 0 0 ❑
P 2 Therapy/Counseling ❑ 0 ❑ ❑
P 3 Educational Intervention ❑ 0 0 ❑
P 4 Behavior Management ❑ 0 0 ❑
P5 Personal Care 0 ❑ 0 ❑
A 1 Case Management 0 ❑ ❑ ❑
T 1 Therapeutic Services ❑ 0 ❑ ❑
4 weld r„,,nt.,QC?) A Adde.a,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
3 mky ? G v h �n 1
+t -...!"..°: i i"Ju� �a ttrP f t tit r r t � �r S.,, fC�. y n� ��4
� a m f5 i 3,.0 , i � � x »e Ydt £ '� ' a I I U Yg- 0
I ( + " uI IF •'I a r$ s 4y1 „I,
i..w': (1 is 1.,.........:,...i:Lit.' w,, i! u c.L :ittta°
A�> , gel f s sl Ay v.." h` s ;O') N �,l it it i . �6' y 1,l s8,i a rs'
�t rk ` 3 ' : .l l $t., : s ,iy f" i .
t f
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ O O O
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ O ❑
Runaway ❑ ❑ O O
Inappropriate Sexual Behavior ❑ O O ❑
Disruptive Behavior ❑ ❑ O ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family O ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
5 warn C0.ior.,cc-ne enna�n,..,
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
li it e1 7 Iiir I,I P l ' ' ,I' lit 1 i ! 'I ii I i I `E i t PI' , 11 , liii li V ti f Ci i* ip' h i ,:.1
yew 1 l- i iii I I 1,1 1 I I i -�, 4 N 1 Il„tl 4 'I P a , yEW l,ilyy ,I(t Ill'� Vi i , t,;' -t i
WJI i i 'f 01 <.I I,'Ll bk " , 1 ., 'III,f10 !41 Ct LLI{ilp� l Si}.1tl • Il bt i� i ri1 pl ciIA I 1:111.-?;t1'11111,1,11,.)
ciil i ' KUIB I itll , II 1 i i 1111 ii h I + ! W d 4 � I
Iip1 t f ItI� li i iI ithi {Ifltt111 iN_i, A r i yI ,TI k,tl46.11' 'i ( f'1 µµr�li -:'1
R :)I bti N- I it!IIlIt {" i li '-I 1 rrS i r !tf 1I 1,1 ri I Ir I HI!! 1:9 A i._ I Mt Pit'' [�'N 'tit,' rti)i( i,
f.(.., ie i v 11 l I i ti .�Iily with, i' (I i 3I(Ii dlivi.. IY1 f it
i 1�r�iTT. i '.! r„( 1 'ail tt I,;I
I itl I Ir I i t i PP Jigili ,t d t' - 1 I _ r1ll,,w�!l h`I td t tti lI I i; I IIIIi i i rt I, '� 9i k,c ,Ili 1
:ell il�il1 I I!Lk.? i l dlllil u ai kll dirl:3 lGiilil I,I.�1 I k t 114 t iiF'1'lL�i I III Iii l i fi Ili! illaILI iii i I III Midi + - i.' M, �M
y iiiirni ji lli p i Ilil,) ,.p,, 1 y t i , li4un I I II li i nI , i i P i w
ac it I) A p Ifn i I It;ltiti llll 11'.?1 l��Pl11 v-l) I� !Ij j�IntIIIl pPill f ztl. IIf ill1 '{i,'i. (Atoll C I,P 5 d9. ( 'l Ya Z .I-It
`46i �I'... fit.it)ioliki I tichll ky iiillll Piliy911' .,�, I il�i 'IP pits) n till i.i i Pi,kiii ll i Il , iin'v'.}+ro iii k '�IililllI'''ihlliilltfn„ :.3
Elti
it ''kr r I�u�Ii!Ilg, w.Lull.�, tl�'ilf�N�!� f.1,i�II.ii�!i,1J Iihall,I h l+,'Iu.: � ! ifii i, I,Ii Idi'�iki Il,i'. 2 it aIfllil�IICIIIkIIIIIII116II" '
i.
0 pi Age 0-10...$11 47 �(' Level 0...$6.25 i Level 0 $4.93 Level 0 $0 '�;t Level 0 $0
,t.
I . !, ,I It
11
0 Age 11-14...$12.89 '. ,,.' '. (Therapy not needed or provided lift (None)
diI iEft
(Minimal CPA involvement l_, by another source,i.e.mental 'it
0 R,II Age 15-21...$13.91 l; !' and/or no crisis intervention i.e. !' health.) l;
11 '`( mutual care placements.) !I i!I
.1, +$.66 Respite Care h( ) ri
; ,
l•.
it mi i I ^I Id
illIk Level 1 $8.22 �.�Level 1 $4.93 ja
1 14, iii(; $19.07 I': Ili Level l $2.99
it,, +$.66 Respite Care t Level 1...$6.25 .I. (Face to face contact one time :' (Regularly scheduled therapy, !g1
pit ($19.73) 1 1!, per month and minimal crisis It 4 hours/month.) 'if'
'Pit
... 'C intervention) ! ,i�
r Level 2 $11.51 Level 2 $9.86#t
2 l' $2564 ;till (Face to face contact two times (Weekly scheduled therapy, I t Level 2 $4.47
ri +$,66 Respite Care , Level 2...$6.25 v per month and/or occasional 4-8 hours a month with 4 hours of i 1,
Fr
($26.30) 111 crisis intervention) Group therapy.) I I.
1y ! H+
t
I
i,r d..1
H=
I I '' ( Level $14.79 i,
.1 Level 3 $14.79
f 4 (Regularly scheduled weekly i t
3 l„ $32.22 ; tt
multiple sessions,can include I!I Level 3 $6.02
.t +$.66 Respite Care Level 3...$6.25 1. (Face to face contact 1-2 times „
al AI 1'� more than 1 person,i.e.family ,°
per week and/or ongoing crisis ,, �;j
rt, ($32.88) , therapy,for 8-12 hours/monthly.)
1 t intervention.) f1
p6'. tr.
ill
I
'a A1. 11
Level4 $18.08 4 Level4 $14.791,.
4 (Face to face contact 2-3 times (Regularly scheduled weekly (_ Level 4 Neg.
RTC k +$.66 Respite Care II I� Level 4...$6.25 I i $38.79 per week minimum,High level multiple sessions,can include till
51.1
Drop ,II. ($39 45) I I( of case management and CPA more than 1 person,i.e.family lu'
Down P{' 1. :li involvement with child and therapy,for 8-12 hours/monthly.) F
Ph' I .;I provider,including on-going ' ''°
I'' crisis intervention.)
I,. i't II .11
iill
ii t ' it pt
Assess. Assessment Assessment Assessment t gi-
Period ; . Period $26.30 I period $6.25 Period $11.51 Assessment Period $01
If
L i (Includes Respite) 'tit �� V.
131 Lit .,, a...
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
gegibitalaaa
ATTEST:
Weld County Clerk to the Board
'- ; t WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
fig. r'a OF THE WELD COUNTY
;' Y ? . ° DEPARTMENT OF SOCIAL
,, c �19 SERVICES
(Rt.
By: lit ill tilt- Li^ .L By: ,>
uty Cl k to t e Board . . Geile, Chair AUG 3 o 2006
CONTRACTOR
Laradon Hall
incoln St.
Denver O 80216
Y: .- c . a ...,
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dir ctor
8 Weld County SS-23A Addendum
y
'--et-- q9/
• •
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the"Agreement") between Loving Homes Inc. and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this 3) day of 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the eement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#72767. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. 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.
8. 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.
1 Weld r,. .,r.,cc_»e re-&39/
��
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended,proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wan rmint',cone AdApnn,,...
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.
16. Add Section VII-ATTACHMENTS:
3 WPl,d r,.,,.,n,cc_l1A A(Man(i,,.,,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX trails Case ID IOB
Sex
WORKER COMPLETING ASSESSMENT IFIH# IDATE OF ASSESSMEN
AGENCY NAME PROVIDER NAME ROVIDER 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 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?
O0)Once a month ❑1)Two times a month but less than weekly
❑2)Once a week O3)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''/x hour per day 01) 16 hour a day
O2)more than 1/2 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
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 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?
O0)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) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
01) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is 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)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 ❑ ❑
P 2 Therapy/Counseling ❑ 0 0 ❑
P 3 Educational Intervention 0 ❑ ❑ ❑
P 4 Behavior Management 0 ❑ ❑ ❑
P 5 Personal Care 0 0 0 ❑
A 1 Case Management ❑ ❑ ❑ 0
T 1 Therapeutic Services 0 ❑ 0 ❑
4 w•1,1 nn,,..n,cc_l1n Addend,,..,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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 Elite-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
' .! laji d l£ ry�
£ , a , s s r a l ! allill .. b .,i1,1#1,114:1.1111
„ry.,'ti,-Yi7,1 ' �',:il,�r4'I wi.4t '' 1. .., 9;,.• A ` 71,1a�*r& 11'.lt
t 1 I lrry, ��£1b��}}},,, .. x ..'• ' z>tk b s �.p'f•' d a'k' £ i£ulrl -.£l t ,e
+� • .,... .a r t .,. ., *s'. , s ia. '.I. 1l� s : .u a,w uJwu x.irtry,1210/4,-,i.:.,.......,.. Syy't`,€ 3ffi t$et a�aa: `Fv • , k! e„ • I, G.,r: h Ilyi I 7� ..
£it 11 to,�'I =u r . : i lk ` '° a , , ,�� i
Aggression/Cruelty to Animals El ❑ El ❑
Verbal or Physical Threatening El ❑ El ❑
Destructive of Property/Fire Setting El ❑ ❑ ❑
Stealing ❑ ❑ 0 ❑
Self-injurious Behavior ❑ ❑ 0 0
Substance Abuse ❑ ❑ El El
Presence of Psychiatric Symptoms/Conditions ❑ El ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ El ❑ ❑
Inappropriate Sexual Behavior El ❑ ❑ El
Disruptive Behavior ❑ El ❑ El
Delinquent Behavior ❑ 0 El El
Depressive-like Behavior El ❑ 0 El
Medical Needs ❑ ❑ ❑ ❑
Emancipation El ❑ ❑ ❑
Education 0 ❑ ❑ ❑
Involvement with Child's Family 0 ❑ ❑ El
,
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) El 0 ❑ 1 ❑ 2 El 3
5 wpm('n,,nn,CC-91A Adidendn.n
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
„'i+-•, it ' 7 ,�I {Yrl1[�?:iw.:ssu^r.{ V. , ;•�, ��.' i t ! lr, J f. �S s y_ « H -c-;r'w#! x- kt[y t i t ,�1 pt.
I1 ia{ j ,�I '9." �` :.21 r :T r`, Vj 1 p�+iiP.I! f i!i,t �, . 71 l+j 114it f °'iaiufIttSF
Dili u ■ C • t k_ n , _
s, , �„� �;l l t r REC : , DE j r I` INTERVENTION RA1 , , t�JEFDS'.
� i Itl .1? �- y tt' �', k"� r a�'#!h�- r--� �_ �'`�. �'WF Air
, t � iP¢¢rti i I 1, �+ ��i ,� 1 t ,'�� �';1�1�.' u I' .,�..proa�:
I, y I+,�:� t d.".h i � ht t$c• t: t • I t , { � ,� N,{lt. � ,- ?� i4 :,t 4 t .4, �Jt IN (�hM! l�l r{�
i ✓11 _i t , r krl I t _l 1 + t'y ya {� 'I ..' l� k P. i , ADDENDUM
,` r.�7 if I , , , ".'?it i 11 t�'I[I i i ,t lt}i l •i ( r Ij•�}.I 116� f
k !.I I li !` �� A�H 1'I ' )$ � � 01441�', '1 '��II I'� 1�, t) I �y `� 1 s fir..,«...r..tr ,+ � atln u, �r
d .In e�i)_t �d l t{ ��' 1.4,E U t�l fiGw+(�3,. " 3 �', t�' �! 1
11 1I1 ry f{I h - t, {i 1 7 it 1"M u 5, 1 ut ( J •{•0.'��( ;i i
` •
, �{ 1 t ' t l{1 ,II I( h{ ,...' •Kµ1d_4,;_ J (y i rlr 1 • ,•
4l .� �4 i11)fiil�'i I t c a r a1"
1 itl sa �caBeManagerrl6ttfx it it! ;
�!f !1+ki1�till i! i t'It1' �f � C �t��i, _.�� , w,z, ! 1 -,� q ,.,.1a1'ti:. I A'O t iEfii i;� ,ls(iit` ) ! ( �' x� �tit�r ��. �� tl miry: ,i•.::(At1111111f[Att.� 1.�.. 1 PrFi• r' t PP
H
0 ; Age 0-10...$11.47 Level 0...$6.25 Level 0 $0 Level 0 SO
Level $4.93
Age 11-14...$12.89 �+;
o ,(, (Therapy not needed or provided (None)
(Minimal CPA involvement by another source,i.e.mental i
0 . Age 15-21...$13.91 , and/or no crisis intervention i.e. `((" health.)
;.1.
mutual care placements.) I , I
+5.66 Respite Care
5 t
,IIII
Level 1 $8-22 Level 1 $4.93
1 ' $19.07 , Level 1 $2.99
i+1'1 + .66 Respite Care Level 1... .2 (Face to face contact one time (Regularly scheduled therapy, +--
t. $ p 56 5 ( 9 Y
($19.73) i,`t per month and minimal crisis 4 hours/month.)
intervention) 4.4
�H`
Level 2 $11.51 Level 2 $9.86 ji!
I, ,.
2 ; $25.64 (Face to face contact two times • (Weekly scheduled therapy, Level 2 $4.47
+$.66 Respite Care Level 2...$6.25 , per month and/or occasional 4-8 hours a month with 4 hours of il
($26.30) crisis intervention) ;It
Group therapy.)
pp Elli-
y6 t
h
k
' 1 Level 3 $14.79
Level 3 $14.79, ;
' $32.22 ,ll :j; (Regularly scheduled weekly
3 !' multiple sessions,can include Level 3 $6.02
li. +$.66 Respite Care Level 3...$6.25 (Face to face contact 1-2 times '
'( more than 1 person,i.e.family
(532.88) , per week and/or ongoing crisis therapy, for 8-12 hours/monthly.)
+' intervention.)
c
Level 4 $18.08,i.Level 4 $14.79
4 $38 79 '; (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC • +$.66 Respite Care Level 4...$6.25 },' per week minimum,High level I. multiple sessions,can include 19.
Drop ?.`' ($39.45) 'ti', of case management and CPA more than 1 person,i.e.family .1;
Down �! !I '''.1 involvement with child and therapy,for 8-12 hours/monthly.) '✓
? provider, including on going 4t- ,,
crisis intervention.)
tI
Assess. Assessment
Assessment Assessment
Period }, Period $26.30 Assessment Period $0
(Includes Respite) Period $6.25 �1; Period $11.51 .,
_
__ c C
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: �°' '""",r �� G"""�
Weld County Clerk to the Board
� WELD COUNTY BOARD OF
s , SOCIAL SERVICES, ON BEHALF
' „ `e' OF THE WELD COUNTY
test ti
`' _'' ` DEPARTMENT OF SOCIAL
�l` c t 4f SERVICES
O
w.El By: h. 1 r 1flLc By:
eputy C rk to e Board M. . Geile, Chair AUG 3 0 200&
CONTRACTOR
Loving Homes Inc.
954 W Montebello Dr
Pueblgst, CO 81007-3 9 /
By: 17127,V___ �/ �( /A
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
'rector
8 Weld County SS-23A Addendum
dart-ta??%/
•
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Lutheran Family Services and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this /tday of 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45080. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Add Paragraph 13 to Section W. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. 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.
07421?-X5%7
1 Weld Count,CC-11A AdArnd,,.n
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 WPI1 Pont,,„ cc_l 1 A Addnnd,,n,
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.
16. Add Section VII-ATTACHMENTS:
3 Weld rnnnh,CC/11A AAAe..An.,,
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 "DATE OF ASSESSMEN
AGENCY NAME IROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES I 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?
00)one round trip a week or less ❑1)2-3 round trips a week
02)4-5 round trips a week 03)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
00)Once a month 01)Two times a month but less than weekly
02)Once a week 03)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?
00)less than a''A hour per day ❑1) 'G hour a day
02)more than'/3 hour per day,up to 2 hours per day 03)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?
00)less than 5 hours per week ❑1)5 to 10 hours per week
0 2)at least daily 03)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?
00)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week 03)21 or more hours per week
A 1. How often is CPA case management required?
00) Minimal CPA involvement per month and/or no crisis intervention i.e. mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
02) Face to face contact two times per month and/or occasional crisis intervention.
03) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month
02)4-8 hours per month 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ ❑ 0
P 2 Therapy/Counseling 0 ❑ ❑ 0
P 3 ,Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management 0 ❑ ❑ ❑
P 5 Personal Care ❑ 0 0 ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services 0 ❑ ❑ ❑
4 wad co,,nh,canA Addend,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
,," ,t n �r
itYi,,;,n iV rI ,!klLI 3 • .3r4 3F .r e , , r , a c
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!� i i�tl i� ir) ii,1il 7 ;, 4"i I I I ; iiit i�i I,�i ;k+�t r� ,1 A {', i.
t F,, I k.w kkl;,2:i ;:.L.dae,„u..,x...: 4di i.! , t t; gt c, g �i, , �I i I, +i; r ' it ii ` 'q,"
tI
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ El
Self-injurious Behavior • ❑ ❑ ❑ ❑
Substance Abuse ❑ 0 ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ 0 0 ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ El
Depressive-like Behavior ❑ 0 ❑ ❑
Medical Needs ❑ El 0 ❑
Emancipation 0 El 0 ❑
Education 0 ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ 0
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 El 2 ❑ 3
5
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: 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
•
' WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
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(f'{1N 1RIIII 4NU 1 ni i�,) �, .t,lif'll:u, ifl u f l',1 �i R�.fl,li{i41 i1Vl,',Ij i�n�Iiiljal +1', ilf jE l I1fflii 1� i t "iri, r'tlfIlili ,1I 1' T r A ai'1, ial
i Ixi 1 r i -,, I f I, 43I'Ih t `�f ,I f1 ri(GIIItI i' 1 1{i'I ,1111(41RN,'I I 11 )t'I� itiv i
II �pO�ff�7,,�Milt!! 1 ( I t 1�1) f l i" �k - t ixM1 ��ff Ili nt ll�44444{,I� I Ill 1i b 'tffatittl'7.:.I �� r i v4i„t ;!tillii fill Ell IIi 314!II 1 1 1''A�fi1 Yt' i p�i �!J�Nx'11 ,1ta l `f I I 11 h.., i
�f G NINd&I'ItAl. III IIII '.,x111.13 A4.uld.4.:)I:6I1�i@a$. kddd.4 1 ILIWwIil': �u Id f Ili.F i
FPI 1N � ff
0 Age 0-10...$11.47 �' Level 0...$6.25 rl $4.93 I'i Level 0 $0( Level 0 $0
��� ii,d Level 0I'�s
d l Age 11-14...$12.89 G 'I° (Therapy not needed orprovided it None
o I!! I! III (None)
(Minimal CPA involvement !I: by another source,i.e.mental Isr
0 11 Age 15-21...$13.91 and/or no crisis intervention i.e. I health.)
J .i mutual care placements.) l
iii +$.66 Respite Care iI ,j Al
:" i 1 114
fill I ' f1
r Level 1 $8.22 hi! Level 1 $4.93 bli
1 1fili $19.07 .III4 f14
II 4:i µLevel 1 $2.99
I +$.66 Respite Care )III Level 1...$6 25 II'1 (Face to face contact one time . (Regularly scheduled therapy, ttI, ($19.73) is{ per month and minimal crisis {li 4 hours/month.) li!
,Ii F`, U intervention) I n
I.rI, I; I, r
Id.. I (it I'll
II i.:
hh�hh"914: ' II 111
l' I 'Level 2 $11.51 i' Level 2 $9.86I
il
'i.+ I (Face to face contact two times (Weekly scheduled therapy,
2 1 ' i ' Level2 $4.47
+$.66 Respite Care Level 2...$6 25 Ii' per month and/or occasional III 4-8 hours a month with 4 hours of($26.30) ;� I,;' crisis intervention) diGroup therapy.)
II.
'
.1 I I 111 1. x
IIt
..
J
3.4SI :I
11i Level $14.79!?
Y. E.
Level 3 $14.79 p
,I , (Regularly scheduled weekly (
3lit, +$.66 Respite Care ` Level 3...$6 25 ,j1 (Face to face contact 1-2 times II lit multiple sessions,can include { Level 3 $6.02
ti, i HI' more than 1 person,i.e.family
($32.88) I t I per week and/or ongoing crisis IfI I therapy,for 8-12 hours/monthly.)
n, �' intervention.) I (i
N.,III I it Iii i ' ,
IIIII1 1141 I i�f
-I, fI. f y 4
:I 1 Level 4 $18.08 i I Level 4 $14.791 lt
4 L $38.79 , (Face to face contact 2-3 times (l;l (Regularly scheduled weekly 1 V Level 4 Neg.
RTC " +$.66 Respite Care II Level 4...$6 25 per week minimum,High level ; multiple sessions,can include Vii
Drop ($39.45) . i of case management and CPA I lilt more than 1 person,i.e.family i i
Down in!I t„! al involvement with child and I,IU therapy,for 8-12 hours/monthly.) M':
'1!, provider,including on-going ';
G'' crisis intervention.) i t rz
Nr
ellII
�I,a iw
I Iwi
Assess. I Assessment 1 I 11141 I
.I Assessment Assessment
Period , Period $26.30 I1t,Assessment Period $0 i.
P t Period $6.25 Period $11.51
I i (Includes Respite) a lli
sl
kit
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: LlY�G r//(
Weld County Clerk to the Board
WELD COUNTY BOARD OF
J A , SOCIAL SERVICES, ON BEHALF
�acF fvit r y# ,`'# OF THE WELD COUNTY
{ DEPARTMENT OF SOCIAL
et, Filb
ifee SERVICES
By: It_ By:
uty Cler to the card M. . Geile, Chair AUG 3 0 2006
CONTRACTOR
Lutheran Family Services OF0[Dr900
3800 Automatic ay, Suite 200
Fort Col ' 525
•
WELD COUNTY DEPARTMENT v„ /ifraEi net. )-/
OF SOCIAL SERVICES
By:
Ihr for
8 Weld County SS-23A Addendum"02, /��jj/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Maple Star Colorado and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this / day of Or , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th�ement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#90967. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. Add Paragraph 14 to Section W. 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.
-269/
cc_ne AMa„a,,m
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph(B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Wald count,CQ11 A Aldan darn
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.
16. Add Section VII-ATTACHMENTS:
Weld rn,,nn,CC/II A Add.nd,,m
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 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 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 ❑I)2-3 round trips a week
❑2)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 a month but less than weekly
O2)Once a week O3)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'''/ hour per day E11)1/2 hour a day
O2)more than'/3 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
monitorin of time and/or activities and/or crisis management?
IIU0)less than 5 hours per week ❑1)5 to 10 hours per week
❑ 2)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?
DO)less than 5 hours per week ❑1)5 to 10 hours per week
O2) 11 to 20 hours per week D3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
DI) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ 0 ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management 0 ❑ ❑ 0
P 5 Personal Care ❑ 0 0 ❑
A 1 Case Management 0 ❑ ❑ 0
T 1 Therapeutic Services ❑ ❑ 0 ❑
4 wau cc-l1 A A,t,dpnd,,..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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. p'�HgI�{IgI
iiia r a )<'If'tppa i." {I if 7 r ,.::::11:1'!1!., t.i'.III 1�( I r . ^f r:{.t1 s�� r.'* �s x`1.9. 1� i ' f it I1IlC"!�11I '
11��j�`e 4�� , f�,pl- I • ( V t I, r F
1L' { ot J 1 J I 4� v d.i.t .+.. S v,v. f ! R� i
1 r�. +' y i�A�t a! I I II 1• �t 1 a1� �r. �ir'i�,, .20:,..„;!-...:
......,,..,,.....,,?...,,,,,41,..1.:414,. .*... 1 1 ,� sllit `
�y { I' I, i1i sl .� 1 ' i"•I7 �4y,...1,1,,,-
N i $r 1 a�(�� '1;.t '.�+,T.�r�yt fI4rJ�u�eN< f 1
: k 1 .V1, i rt°n ' d I' - t ,: Jrt "w•''r'. . YIi.Y•. 4. ilIIGI tgi J�f, .l,b y r FIa14! II ar 11 x;11I,.i
'v r 4401 �y 3'.. 4:1 ,a Ifr Il w �� � +vt J11 aii..1 4 ,` r .
bJi f�l/tl.Ml J JaS i fyli rFL)e 'y�{ �
:t 1 f ¢? '';';'''''•r;;
e 3,��"1' I� '�U3 tl�!I y II T I l !I,I,n II'; Tfll 4 F t,��l�j 11'M w
{f{ 1 I t ! r I I P�r i I 1 f I" iJ fIf i J N y I}II I% 71 1 �I I IlifirIC •I. . PiiI '�I 1,7J
kF 1 1 1 ,:I ' 1I !! J .� w u rll � { r F.�1.{ f� 1fJI .f.' 1 01 t.I` ry I I 1 , .i Jill I�` 1 1 I V:114 0t 4: J lift pl"f��1j�� �1;,Jgt{{„} Iik ..�jr f aYJLJrJ1• MI fN ; y�. f 1 '`Illl�i f i t}14;.fist l tiIIIIII II it1JL^I! I� lliI `I '' ' '1'.-r • 'I, rv,,I i, Nfu'.,:ii ii,A.:P..r Iiii tlff'
f, whlfbt„i{.rl.�l,nll(.,Ill:li�iln<.J„,I{i.l '.I'„I,{, I,',, ,I,1 Jl.f{,, lirlrlll'fflWifJli Irt${J LW I
Aggression/Cruelty to Animals ❑ El ❑ ❑
Verbal or Physical Threatening ❑ O ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ O ❑
Self-injurious Behavior O O O ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ O
Enuresis/Encopresis O ❑ ❑ ❑
Runaway O ❑ El ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ O ❑ ❑
Medical Needs ❑ O ❑ ❑
Emancipation O O ❑ ❑
Education ❑ O O O
Involvement with Child's Family ❑ El ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
•
5 W..1A("Aunt.,cc_,1 A Ari.lvnrillm
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: itial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
s A ill
u� d, Y • .a '. h,;-q:^..
1 `r .................................' '.r ,r1,11'-.04,1 1 t,.1nN � �� r
''HH^^ �9�L:OF� R� T'E ,' t I TION RAT EEC
�tl M I ,,,,,,,,,...„,,,,.,c„.:,,,,,,,,,,,,,.:„.,lt, „ rF '''I n t, rp hell''G tl' .i i{,ff E!:,
LI. r 1L rE c , ,Fkrc A nY t n r J �qu 'r' ':i rP . 'i �t r N';� W!t;� ;,r I7q 1, u. ���tit, d.
i ",r q 4iK II p-1r I i11 �Ii11 I It l:,I�i. a. J :..wn. 7t *: ADDENDUM
-I-, I t !fT '4$'41''''‘''''''''''''''
'k. *ItYrt c .≥:• r. tl �, 9 •i. 1 ! ll ''''10'1151 I, I t °Y A 1, .ef: - '.1,,
'N11 t 'f�� f' r '=��a �. � L'! .,�. e i -;fi , � !.r I1;`:!;,il �'f! � �.lfrll..� ih� R' �"S•l
' ri '4 =` ,' ''' wy la Ir'. I��I jt., r I 1 ! 1 �{. !rl PI : n m: nq I' ,' .1,iii.,; - {,� ' 1 Pi P� 'F ':. Y. ¢ ;14.-.1u ;I1ii I 1 tf • ,tt, r F 7
ti,I, .s Fr, . ' � � k 'IA 1I AV ,.I„,,,.1 ..II,I a ; �}! ,�I �i"P i h{• i'� �I .I �
`' f f _ r "'. ,..T ' t i-N,f pi h4 li� 1 I1 �, I'!1 1��.,!!4
i , '7 r. , c ,
1 u ( f' r F it f t il'�"`I' • nt c' ::r, .;, (,
it!t Y+ '.114'1271"
t,I" il'!' I I Pt ' j < ,. , In
� ill 11'
Ill, aI r P{ 7'� r�t 11 i ,I a.,,. fi`I In�'r (Admint:Maint-1 la't"", t ,,,r, , R Se vi a ) �, 11.' 1� I114, a . t Aq aI
r
0 h` Age 0-10...$11.47 Level 0...$6.25 Level 0 !I Level 0 $0 Level 0 $0
$4.93 �,
0 Age 11-14...$12.89 I r i''i (Therapy not needed or provided (None)
I;
(Minimal CPA involvement Il: by another source,i.e.mental
o Age 15-21...$13.91 and/or no crisis intervention i.e ii, health.)
mutual care placements.) '''
+$.66 Respite Care 4(
•.!FI
1 Level 1 $8.22.:,!Level 1 $4.93
$19.07 1'i Level 1 $2.99
+$.66 Respite Care Level 1...$6.25 ;; (Face to face contact one time 1j{) (Regularly scheduled therapy,
($19.73) per month and minimal crisis I 4 hours/month.)
intervention) I
,,1t
I,'
Level 2 $11.51;i. Level 2 $9.86
,
2 $25.64 (Face to face contact two times (Weekly scheduled therapy, Level 2 $4.47
+$.66 Respite Care Level 2...$6.25 per month and/or occasional PIE 4-8 hours a month with 4 hours of
($26.30) ' i crisis intervention) i'E: Group therapy.)
fi, Level $14.79
Level 3 $14.79 (Regularly scheduled weekly
$32.22
3,: multiple sessions,can include Level 3 $6.02
+$.66 Respite Care Level 3...$6.25 a (Face to face contact 1-2 times ill;, more than 1 person,i.e.family
($32.88) .. per week and/or ongoing crisis therapy,for 8-12 hours/monthly.)
intervention.) ;•i
I
ail
Level 4 $18.08 i ' Level 4 $14.79
4 $38.79 (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC +$.66 Respite Care Level 4...$6.25 per week minimum,High level multiple sessions,can include
Drop of case management and CPA more than 1 person,i.e.family
Down ($39.45) involvement with child and !: therapy,for 8-12 hours/monthly.)
provider,including on-going ;`•
crisis intervention.) o:
Assess. Assessment
Assessment Assessment 0
Period Period $26.30 Period $6.25 Period $11,51 Ill Assessment Period $0
(Includes Respite)
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: /MG
Weld County Clerk to the Board
WELD COUNTY BOARD OF
t ,of j SOCIAL SERVICES, ON BEHALF
' OF THE WELD COUNTY
.1865 !Ter,;.- - DEPARTMENT OF SOCIAL
SERVICES
rritc>
By: _4-11- 4 1 _ By:
uty Cl to the Board J. eile, Chair AUG 3 0 2006
CONTRACTOR
Maple Star Colorado
2785 Speer Blvd, Suite 340
Denver, CO 80211
BY:ClItirdi `f' Ph . 0',
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ector
8 Weld County SS-23A Addendum
&a -a'39/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Opportunity In Living and WWld.county
Department of Social Services for the period from
July 1, 2006 through June 30, 2007. `„
The following provisions, made this day of 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of th 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#1511157. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
elllcls..im..y 111c11i.,al, ou15ical or do,.1al ..u.., .Tlll to
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
1 WPM(`n,nh,CC-11 A A ���
• 9. 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 cop7wi11 then be forwarded to
the County.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals?. ,s
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld(`nnnh,CC-11A Addendum
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 servia.pr deliverables which
have not been performed and which due to circumstances cafd by the
Contractor cannot be performed or if performed would be of no :6;115 to the
Social Services. Denial of the amount of payment shall be reasonably rated 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.
16. Add Section VII-ATTACHMENTS:
3 WpIA(',,,..h,CC-71 A Addand,,n,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION <"h
CHILD'S NAME STATE ID# SEX!" grails Case ID !DOB
Sex
WORKER COMPLETING ASSESSMENT r rrATE OF ASSESSMEN
2
AGENCY NAME ROVIDER NAME ROVIDER t WEST 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?
00)one round trip a week or less ❑1)2-3 round trips a week
❑2)4-5 round trips a week 03)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 a month but less than weekly
02)Once a week 03)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?
00)less than a'A hour per day ❑1)'A hour a day
02)more than '/x hour per day,up to 2 hours per day 03)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 01)5 to 10 hours per week
❑2)at least daily 03)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?
00)less than 5 hours per week 01)5 to 10 hours per week
❑2) II to 20 hours per week 03)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
On Face to face contact one time per month and minimal crisis intervention.
02) Face to face contact two times per month and/or occasional crisis intervention.
03) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
DO)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
02)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ 0 ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention 0 0 0 ❑
P 4 Behavior Management 0 ❑ 0 ❑
P 5 Personal Care ❑ ❑ ❑ 0
A 1 Case Management ❑ ❑ ❑ 0
T 1 Therapeutic Services 0 ❑ ❑ ❑
4 Wpid rn,,nn,CC-91A Add.„d,,n,
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
j
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES3'HAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND IN(TEIcSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination-Months in Care CS
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
1 §` Y e S#6 9 1 1
�yw -1 ��I� �r 1 nsi�' r �1 ti i i'a nii j I� ( i;�
i s esz�, ,x,� , u c.�� Lv�i 2 1 � i � I n eF �a� i4 k �e
1 i 1 Irn�'1 Iti !I �� �
. t d t ry :id:::
t i q rr li lI Flllh(41 .. .
i..kb UT.+3,..vJ.W..LLmas ..:. . =_i '..SS's � . I .n
n... a.. x nl,t Ir p L P,,,,I: it w11 r •:
+.tXkT(,y 1! I) 1 iff 4 'a trro ` ,Fti G. 1 fled I..1'll it .. n 0 1k.
!.46s t q.) �₹as 1 a' 2 . '}:'',. ' t l 4 x� �-3 ,. •d"d W�t:Ih t �im.l�l �1 x.11;11
II WI x�3 41d,I Ih..t waNl Nin 4u...auxE{:.diYak�irtd.vc..i A
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ 0 0 ❑
Self-injurious Behavior ❑ ❑ 0 ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ 0 0 0
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ 0
Medical Needs ❑ 0 0 0
Emancipation ❑ ❑ 0 0
Education ❑ ❑ ❑ 0
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ I ❑ 2 ❑ 3
5 Wa1A rn,,nh'cc_nA Addan.t,,..i
WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
i.
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: 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
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates ?,�
(Attachment C)
/r,
n
r ',
i I!!
rP d i .{ y 1 r!'U 'N Ij tl rj{Ij rl:.g' i'�z I w 77 I,r..+ ml Rrr f t 1 r:pr !a-
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y -.{ i 1 I r'1 i�i r) I er 1UP
LvTJ!irir
; N,: i ( i r I% I I °I rii Ir Ir i r. hI ii ! �. O, i i t}{ Ilb)Ir y l i i it r�� II 1IIrJ r - . l i f{ .,, ,15 r Idl� I i0II r iIt ikl' n 111i r �ytr. 1 il ili Sii(.Itl nlil r ( i rd9 _ rq ( rl.Ii 4IIj1 I 1 h r h hH I .ip 1 u}t::ii (I L i i i / r i ; :. i rni i i II1( lrd �; { r Ili', i .11 isI it (Ii 1 I'I ,� I , -.nr_ra _ IM i '-ir d .n i �:, i iin it i i iut. I �li ,., �'i d;) � I i wn --Ip; r' I !L
'r - I 1 il{ rnr ' iiii,f i , iii uo 1 v �i
rd≥•606'61116: .::!!!!!:6:66.6616,, li r Alll a V I r(� 7 Y vrr -i r
',!•4:66,6,1,,,i,�� �aIi �r � r ( i f r I !!!.!..!',6,, r�' } Ii( ( r :191 it '�' � ai-Y'I�Iq� li ii j i �I ( 3 I' dh ''I �i�iii {'R 'f rri�II.
, : itIIii Ii r !. r ii 1'W 1 i P' IIil5 11 Ili gillI Ir
PopII' i ° ai it 46.6'f rl.:, NI LI ri rld lkilii {�Jijhl�r}IIIV t, 1`til i1 . kitkl!II :Hid) (� _ 'fhb v�Ithl ! rr i
Gd' -- ::I`wkN. uI�vWIlJ 1.w.o I I ..I.I...d:,.e,.r..1lldniW .,I6�i�i��il�i�I 3..I...al.r�: %n.1.7n,.cIllIII.I.e;:n 7� rulSil.I) - Im61�,�ri>. ti.i.m3:iiii.> 'i
illii ii r" N
Age 0-10...$11 47 ; Level 0...$6 25 ),i Level 0 $0 Level 0 $0
o
(r( ,' Level 0 $4.93 SI 1d114
td.0 I Age 11-14...$12.89 tI. i'' rj11 (Therapy not needed or provided ill (None)
,1' (Minimal CPA involvement •:: by another source,i.e.mental
o �'iI: Age 15-21...$13 91 o' i �'�
u 9 i. di and/or no crisis intervention i.e. i, health.)
' i,. mutual care placements.) (�i 4
'
4 +$,66 Respite Care ids' ;gip f Sill
r
. A, Level 1 $8.22 Level 1 $4.93 r'
1 ; $19.07 rI Level 1 $2.99
+$.66 Respite Care II' Level 1...$6.25 r€ (Face to face contact one time Ii; (Regularly scheduled therapy, hih
($19.73) lyi; (j per month and minimal crisis 1','I's4 hours/month.) C
li
NI
intervention) I`
G" cI
7:1Iii
t`: r Level 2 $11.51 -Level 2 $9.86 Ili
i,
2 1: $25 64 (Face to face contact two times (Weekly scheduled therapy, Level 2 $4.47
Jr +$.66 Respite Care ;; Level 2...$6.25 - per month and/or occasional ;. 4-8 hours a month with 4 hours of I
sd
iT ($26.30) I. crisis intervention) 1,i. Group therapy.) idl
i i! s
rid s
r.
Ih. i
I:.
I,, Level3 $14.79 ssd
I' Level 3 $14.79
I; (Regularly scheduled weekly .s
3 I $32.22 multiple sessions,can include Level 3 $6.02
+$.66 Respite Care Level 3...$6.25 t (Face to face contact 1-2 times , more than 1 person,i.e.family
($32.88) -) per week and/or ongoing crisis therapy,for 8-12 hours/monthly.) `_'j
1, Ili intervention.) „ -�
3I
Pi d's it 7;?
po pp
','�,Level4 $16.08 ' Level4 $14.79
4 Li :.. (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC $3 s it per week minimum,High level multiple sessions,can include r
Id' +$,66 Respite Care Level 4...$6.25 :
Drop !di of case management and CPA ); more than 1 person,i.e.family :li
($39.45) involvement with child and - therapy,for 8-12 hours/monthl
y.)n .hl' '
; . provider,including on-going 1'1
crisis intervention.) �F
•
s II
IdsAssess ! Assessment •,
Period j_ Period $26 30 i;: Assessment Assessment Assessment Period $0 .1
, , (Includes Respite) Period $6.251.Period $11.51 d .:1
S L 1,
•
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
Y
12141/4/114 ,
ATTEST: S
Weld County Clerk to the Board
et > WELD COUNTY BOARD OF
`'c: > • SOCIAL SERVICES, ON BEHALF
.t" _ OF THE WELD COUNTY
361 to
ng y - i DEPARTMENT OF SOCIAL
f� SERVICES
By: i By:
D uty Cler to the oard M. . Geile, Chair AUG 3 0 2006
CONTRACTOR
Opportunity In Living
7061 S University Blvd# 301
Centennial, CO 80122
By:
WELD COUNTY DEPARTMENT �`«-� "-
OF SOCIAL SERVICES
By:
D ector
8 Weld County SS-23A Addendum
, 1216-.239/
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between PATH and Weld County Department of Social
Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this I day of T,i,1 , 2006, are added to the.referenced
Agreement. Except as modified hereby, all terms of th 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#1502692. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
er6-5/39/
1 wain r,....,r„CC-11A e
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 wain re,,.,n,cc_,1 e nnna.a,,...
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.
16. Add Section VII-ATTACHMENTS:
3 Wald CAI,..n,a¢_91 G Addand,,n.
•
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 1HH# 1DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy; Medical
treatment; Family visitation;Extraordinary educational needs;Etc.,as outlined in the treatment plan?
O0)one round trip a week or less ❑1)2-3 round trips a week
❑2)4-5 round trips a week ❑3)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 a month but less than weekly
❑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'4 hour per day DI)1/4 hour a day
O2)more than ''A hour per day,up to 2 hours per day ❑3)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?
00)less than 5 hours per week ❑I)5 to 10 hours per week
❑2)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) II to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑l) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ 0 0
P 2 Therapy/Counseling 0 ❑ ❑ ❑
P 3 Educational Intervention ❑ 0 ❑ ❑
P 4 Behavior Management ❑ 0 ❑ ❑
P 5 Personal Care 0 ❑ ❑ ❑
A 1 Case Management 0 ❑ ❑ 0
T 1 Therapeutic Services ❑ ❑ 0 ❑
4 Weld rnnnn,cC_lil Addendum,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
u..1A 1 ni ;1s'tA#.x� r ' + e Iwn I '* iii r 4
s f ° '- rn �{ a i :
i -.-'+t rn. ...
avr..+. R 4 to
.f - ' t4Y '7 'CIE •tr'; :11t t4 icy
x i
tliipn ."1 1e �� ujY ''''..C171 f tt 4a r., 'r� { y��l� i ri I.I`i1�� ,�l+a ll ajJtcN'..6�tiggli 13h;llig2 . ,(at lg �
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ 0 0
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior 0 ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ 0 ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ 0 0 0
Inappropriate Sexual Behavior 0 El ❑ ❑
Disruptive Behavior 0 ❑ ❑ ❑
Delinquent Behavior 0 ❑ ❑ ❑
Depressive-like Behavior 0 ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation 0 ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ 0 ❑ El
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ o ❑ 1 ❑ 2 ❑ 3
5
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
31 l pGl ii ' .Iii t mi ,(Lill II ( 4 i i 1 ,j ll5 t lI, '�:It11,ii,I.`°,�'i e�I�l i , s .?It`"II ri tlil iii ; p i _I
a i h' itt it p,':'P':!,',.. I i i i i _ I ' N!, "1 I t o d , ,�j'�I � IRI iiir II:ii , „I iiN'- , !!':',0,,-!-::!,,H,'''''
1 i , , , ti i,li-•1I�l ,Ilq , ' 4f 1' � tl, " �,I to --i i� i M r " n ,
,t,':,:,,,,14, i i l I 11 t Ii ,. 1p
ii , ' 4::,!:',,:',,,:',,',,.!,,..:17,!!!!,:11,!:k4
i '1 i'I �I -i^ 4 I dI Ii. hi ')(tI� )1 1 i 11 '1
I1,.tIry)a .li t , hl. 'a x'il it�I I,it i,t4,l i N , 'II "14Pa 'I 8 •
�� i i ,I I i hi
�,J i oG q 31t t
y �I 1 " .„,,,,,,,,r,,..,,,, 15,,,,,!,,,,,,,, I34,O,,:,,,,,,,,,,,,,,iM;
Nti r li -, III „1 !..1.1.0.!!..!!!!!!:4:, Ii �l', till Iii ,,, , -., i ,I t, I
is , 'i' ,I t I,{l , , - ,i,1 xk" i I i 3.Kf Iii i�tn.: t `
''II i. iii M 1 I hll N ,,m N I,( Ir i , + r t lik II) V, -a (ill) i, a !GI I I �I p. i .+iC f
, , Ili,iii i - i II I�51 � II i Nail!!! '� .�: �L�IY:, ( •"�
' rnlil�ti T iii i ,i i l I 10" - I8, 0 i •1 m t( i i l Vann In .)Ii, � I, i _fil .c I � i'Idiit� I iiI,i iji ell it ii AIa j I ' iiiiiiilt"t - ',ti p j,lij a'+ . � 9�4 � •, tt rfilr !1w9
,4x:FJbivislltEt �IrImm l� i.mP.il:�IiEluEal���W1i,.:111jJ. 1�1itP�.l..t����it 141I' i7 g.I4 i11
Age 0-10...$11.47 'f lei It IS p
p 't Level 0...$6 25 th Level 0 $4.93 $1 Level 0"la $0 Level 0 $0
o ' Age 11-14...$12.89 a (i' (Therapy not needed or provided ill (None)
I E�lI (Minimal CPA involvement II by another source,i.e.mental
0 Ill Age 15-21...$13.91 'I it 9 and/or no crisis intervention i.e. ' health.) !$
'u .p mutual care placements.) $ I •
+$.66 Respite Care 1, Olt
/�I' 1 '
WI' h.,:I .Li
I Level 1 $8.22 ;1 Level 1 $4.93 j 1�.
,a $19.07 i ,; t Level 1 $2.99
I.•
I'( +$.66 Respite Care Level 1...$6.25 .l (Face to face contact one time till (Regularly scheduled therapy,
($19.73) :I per month and minimal crisis ,I 4 hours/month.)
intervention) 4;1I
l i 't
lI I M
M,
III
N • 11 IM
III Jo Level 2 $11.51 11 Level 2 $9.86 Ili
it
iI lli
$25.64 I! (Face to face contact two times ;it{ (Weekly scheduled therapy,
2 d la • t' el Level 2 $4.47
k +$.66 Respite Care Level 2...$6 25 ill per month and/or occasional 4-8 hours a month with 4 hours of
$ crisis
I ($26.30) 'lt intervention) I:? Group therapy.) .+
I 9
ilI i Level 3 $14.79{$,I,
kI :Level 3 lt
$14.79 I!t
i, (Regularly scheduled weekly to
$32.22
3 L + �,: t multiple sessions,can include lit' Level 3 $6.02
l! $.66 Respite Care Level 3...$6 25 , (Face to face contact 1-2 times 1 I
,.It _ more than 1 person,i.e.family
Ii ($32.88) t`r. per week and/or ongoing crisis lt. therapy,for 8-12 hours/monthly.) N I Ir,
ell L,�t intervention.) 1,
E'ln
il, .r
ti I'll
•
Pi
0Level 4 $18.08 Ill Level 4 $14.79 III
4 r ,l r (Face to face contact 2-3 times t I (Regularly scheduled weekly ha
Level 4......Neg.
RTC t: $38'79 I- - per week minimum,Hi h level " multi le sessions,ran include �,
llil +$.66 Respite Care 'd Level 4...$6 25 1 e 9 19j p ,I
Drop of case management and CPA I tt.I! more than 1 person,i.e.family
Down ($39.45) ,.� -,j involvement with child and , I therapy,for 8-12 hours/monthly.) �l
h yl provider,including on-going ll• 'u
i crisis intervention.) 'I Ii,
till .iia iha iuk I'I'
at I
Assess. .' Assessment ') 'i j Itl
Assessment I Assessment 1,
Period ( Period $26.30 - i:I Assessment Period $0 :i
It (Includes Respite) Period $625 ''I Period $11.51 ,i a'h
, ,�
iI ,..Y .i! •µ tjI
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: J4 "'.a c1 /i�!/�u'
Weld County Clerk to the Board
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
ct,_
"
1851Vii;- DEPARTMENT OF SOCIAL
"`' SERVICES
: F
1 By: it it Zl2 By:
eputy C k to fhe Board . J. Geile, Chair AUG 3 0 2006
CONTRACTOR
PATH
6355 Ward, Suite 305
Arvad CO 00104
By: w� A
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
8 Weld County SS-23A Addendum
&ere' &59/
� p t� CFlp
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Savio House and Weld County Department of
Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this ( day of , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of tthAgreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#37330. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include,but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
1 Wald('nii..n,cc_91oPa 6-a9/
9. Add Paragraph 15 to Section W. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 WP,d!`n,,nh,Qc.1t A Addnn,i.in,
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.
16. Add Section VII-ATTACHMENTS:
3 Weld Count,CC-71A Addnn,V,,...
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 ItHH# 1ATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 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 ❑t)2-3 round trips a week
❑2)4-5 round trips a week ❑3)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 a month but less than weekly
❑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?
DO)less than a'/3 hour per day ❑1)'/z hour a day
❑2)more than'A hour per day,up to 2 hours per day ❑3)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?
�0)less than 5 hours per week ❑1)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 ❑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?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e.Medicaid) ❑I)less than 4 hours per month
❑2)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 ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 Wald rl.nntl,CC-11A AddnnA,,.n
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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. `}
+G� ' . , . , j... d tN Sr. ! 'Cc, {�itI�B : {, K :4, ,1 1.} ':? 1 �!i fat iTa fI�
'. pmt St"-. ', ` ''" j!l'} .11.:1
}�:'' > t " " "lit,, �C�eA. tritr;J uul.!: i ..l l�I.�(I 4 II ! i!
dl C ₹yk ltn4- "R } 'F^'!fi 5I I y! +I 4 MI '�+` 11
al:,..:, :c 3waWa ;r.. ;, ,. ... hrrn&,,[e'•i,t,,,;;A�,,so-� .:Ali4l2ili iii$l,�i,J inlf!3 l c F A. I$
fdw :(g:,',i ,'� i cry rt `{ I x ! �I ! a 1 ) i� IFtI l !1 t
t �� `l1aF��� $ X w .: -4 P'- %�+,rai§ fie i Y 5 ! �!' ,{.9��.1.; � �u� i f u ! !;-
Aggression/Cruelty to Animals ❑ ❑ ❑ 0
Verbal or Physical Threatening 0 ❑ 0 0
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ El ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ 0 0 ❑
Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior Cl ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ 0 ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
5 weld rm inh,cc 11 A A dAendorn
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
" iii +:'a , lI' , I (ii II (i ,."zk Ii Ili I~roi"i i , III `.II yri l "rtr' r:rill 51 1 �''� iln la , ,ii i,".i A �IIII.IIIIii I i') mY it1 q$liII� ijg* 1'Pill « Rj
lk 'A"'IAIII .,, ni li i.Tl 1 it I 1 u ,I'�,I`'t 7', I,,IF ix ,tAi dt '(�lei ' ._. (II l . i itI ( - it 47 "xGa 'L'l . ten} tx. r I 1 I) i i,ll Ilj Ii i" I i') l I)b tlh 1Ppr F 111"$9,3 1 , I i h ii ai s 11 g hi � , 1 f I I , i P e l I" hni�fl �, - ( 1 i, ii. 111, III i iii««{( 3Ii cite,'1 �)BM1r: t J�}r ..!
�.�f 4 f i) J." 1111 'f 1 i i ii..r. 'C �I "41 i( �y "„ilr'I i I I.. N i 11 p� , ,r�q �14 1 I"Cl,�" a i r o- E i,
' 'I _ I(I ib'li," it ; i II', il'li, , l I(i. hotli, II "D,I IIl7 iii 1 a,«�if)I'FF' ' qG ,,. 't5' I h11,,.'i i� I!) ," "III
'-1I ' ril (Ili ibiiilll iij'I,IIIIiI' iii, Ili,illl Nfi t.illilii Ili+,ptlll qi Ill, II�,�„ 'i liint ' 'I2 il l'!h ( e`I it ( III 'I;I (ill III III
'( .,i..,j ;I.n. �iII II I ":"iu I '" x III., . it i ,�1! 3„IIt �,��,.f u'.u" ',il i,I �Inu,� �i d i d�) ji k o-I (I� _ i�II���III;�� r�L'. �.:.I Iullli i.hwii�w '.irfl
.Mn gi 1ir r d ir41 " ,' !i'II
','l it aillllluji'jilktilll`t{'1,i9 I a,::::: U'�`''I,N,{IF axg�di4 02:40"JIII',3 n 9i iI Rix I '..;: li 1 tiir ix{+. ,lip i 1.r
rifij III i' Ip P ,! ':�I itt I „r iii 0 ii II itioili,) ",.: .i-,A ey l i +I t Vii''ub,t ,ii II (� 0 �,Il ,�I'' ;t I'1N 4j�'P�''�
I 'i ,,,, ' t 1 III ,I a i14 1 1 1 i r irli 11 i iiN iM i , , n iii.. ril plai It!mil 1,i II, ,Pi 1 i11 'l r lii,bird II IIw r ¢' I l P ii I i i II NIa r1 I I,Il igi i'�;ilili+,,...li.filii.. !fell a I ,cku ��Ii � �Iail.IAC u (I'.d 1I3��W aI,I A� 'j
ligithl Naha lid
iill4. Age 0-10...$1147 dill9) "
o (lr n Level 0...$625 i; Level $4.93 HILevel ill;
Level $0
0 �p
,. Age 11-14...$12.89 ' 1.4 j4 (Therapy not needed or provided I' (None)
�l ill (Minimal CPA involvement idi by another source,i.e.mental r!I
o (It Age 15-21...$13.91 .1 Ili and/or no crisis intervention i.e. I:,i health.) di 1 Pi mutual care placements.) b,
j' +$,66 Respite Care 4 �I1 II:: '«d
i i' 1,1 t.
'4 , III
5� rl Levell $8.22 I: Level 1 $4.93 it
1 u $19.07 iI I� id Level 1 $2.99
^, +$.66 Respite Care „j Level 1...$6 25 I S (Face to face contact one time q7III (Regularly scheduled therapy, t',
�_ ($19.73) Y I q per month and minimal crisis 1i' 4 hours/month.)
iii _. { intervention) 49 �'
1I Ij
ih P tiILill!
id « I Iti
ititix ( p
Pt
I 'f I I Level 2 $11 51 ,i Level 2 $9.86 ,.
I II ih i '' n,«
2 f7 $45,64 ,1 (Face to face contact two times 1 (Weekly scheduled therapy, L. Level 2.......$4.47
1:" +$.66($2e6s Respite Care ,d Level 2...$6.25 per crisis onth and/or tion occasional II 4-8 hoursGroup therapy.)a month hours of i'.30) j id R
4 I l i:.
I;11r; l I, Illi
�� ,,, 11: Level 3 $14.790;
vd;idi -; j Level 3 $14.79I' (Regularly scheduled weekly
3 fir; $3222 I ii, multiple sessions,can include j Level 3 $6.02
d;_ +$,66 Respite Care ,1 Level 3...$6 25 !1 (Face to face contact 1-2 times
($32.88) .y 1 I. more •than 1 person,i.e.family 'I"
,I u f I, per week and/or ongoing crises ", therapy,for 8-12 hours/monthly.) i.'
intervention.) I'
u, ,
lirI
it ' F
lit i
i. F,
I...Level 4 $18.08 :I Level 4 $14.79 Li
qn li ( u r.
$38.79Face to face contact 2-3 times Ai (Regularly scheduled weekly ill Level 4 Neg.
RTC Li
jjj Respite 1; r (per week minimum,High level r' multiple sessions,can include 'j
IL +$.66 Care 4, Level 4...$6 25 i,I g P
Drop «id� ) „i I I of case management and CPA more than 1 person,i.e.family I
Down i' ($39.45 0 involvement with child and •1, therapy,for 8-12 hours/monthly.) )i:
j provider, including on-going j'.
.1 crisis intervention.) i
Assess. Assessment '
Period Period $26.30 1 Assessment "l, Assessment id Assessment Period $0 a
' Period $625 ;I Period $11.51
(Includes Respite) r;1 d. �r
w' .. .d) ! rii
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
atAi
ATTEST: gell
Weld County Clerk to the Board
' ' q WELD COUNTY BOARD OF
tr
" 4 , SOCIAL SERVICES, ON BEHALF
w OF THE WELD COUNTY
^ h n 4
twt 2 " DEPARTMENT OF SOCIAL
4"%-i SERVICES
Chi it a'c\ /
By: Pat 1 r �K By: 1
uty Cle to the Board . . Geile, Chair AUG 3 0 2006
CONTRACTOR
Savio House
325 King Street
Denver, CO
880221/9, /�,!/
80219
By: �;v/s/�G
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
6, 91.,
uector
V
8 Weld County SS-23A Addendum
, mb-. 39/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Youth Ventures of Colorado and Weld County
Department of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this / day of O, /v , 2006, 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#1529601. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. 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.
8. 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.
1 world rnunt',cc_9 1 A Addendnn,
9. 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.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity(federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
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:
2 Weld renn,..cc_Il Addend",,,
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.
16. Add Section VII—ATTACHMENTS:
Weld rn,,nn,cC_11A AA,iend,,m
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX iTrails Case ID !DOB
Sex
WORKER COMPLETING ASSESSMENT [ATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER 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 the following: Therapy;Medical
treatment; Family visitation;Extraordinary educational needs; Etc.,as outlined in the treatment plan?
O0)one round trip a week or less El)2-3 round trips a week
❑2)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?
O0)Once a month ❑1)Two times a month but less than weekly
O2)Once a week O3)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?
O0)less than a''/z hour per day 01) '/,hour a day
O2)more than'/z hour per day,up to 2 hours per day ❑3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorinf of time and/or activities and/or crisis management?
O0)less than 5 hours per week ❑1)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?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) I I to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
O0)not needed or provided by another source(i.e. Medicaid) 01)less than 4 hours per month
❑2)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 ❑ ❑ 0 ❑
P 2 Therapy/Counseling ❑ 0 0 ❑
P 3 Educational Intervention 0 ❑ ❑ 0
P 4 Behavior Management ❑ 0 0 ❑
P 5 Personal Care ❑ 0 ❑ 0
A 1 Case Management ❑ 0 0 0
T 1 Therapeutic Services ❑ 0 ❑ 0
4 w>id rn„nn,cc-o1A Adde„dii..,
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
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.
II ' t r r S 11 "n{ Ia, I.1:
- a .. ,ri �L! ,5if z {, 1 * R ..,; 21,
pi
{ fi
t � AL i MI6,xxxxxx{ 1 �' I i T �u T : � s. 2 i Ld �� �i 1 u�� ��IiW dmi � '
i, I IIJ .. I ...........
� µ T `g -4. � .i 1 �1{_I (Iy,o o!.{{i
}'i ia9.hid.i x,+ Ti. i`tr bst TYit 1 iii id L� n �f
.. 1, . I I 7 ;. 4 N .i .fi fh 1' V 11�1" gllitik
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ 0 0 ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ 0 0 ❑
Self-injurious Behavior 0 ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ 0 ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ 0 ❑ ❑
Delinquent Behavior ❑ ❑ ❑ 0
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation 0 ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ 0 0
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 0 3
5 Wald rn,,..h,cQ-J1A A nnann',nn,
• •
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
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
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
riiiidi , 'I ,( Ai � l PItf,((p ':. ia iNi'! W i yii n4 1, ,x i -
N i I I i ,Itii riI .Gilµ r .-.iii, 0 617 , P i rs,tp'GH„{t 1 ii' + l,,•p'.. „Ili qi I' 1 (i,111.'•) adl�rll I li' :11 i 3 II.`tF i q !q�'�'!! i .ry,;`i I'P r i t'1 A! I ',l .f i � 4 ' ICI i` r ) i a� � I � ��,,�{[ i it Ii( )Ii lll� i� iIi�i� 1 '��ii�r� �i� N' Ar��(N'� �. ;r3
t E>! CIl�f yii I.' ' d''il �,i r Gl iir ,a ' a t i I' Ili, '1 Imiif' lip. i i It [ roor i f 'liiitiN �i. iccripi 6
I� 1 C ia 'I II( i,t. irrF 'iii l' Ii k pril'o1pIIiiii 'Q„!' Ii, r , Il,l lil{�r'1i 'i'llm t i i �I
�..i r �� 'I �-. ..,N!..:ii,
:.t) I' �r� ,ii ! it!� IP'i i�!I!'1111 i ,'�r IIII"i '�' ! lillll'1�i�� , '.,-ii� i a r
it 'iii ,iii' L 'il li �� � 1 1 ,I P111I' `IMIIII i I '� ,i 114 ( 1 i r 1 iii' ( id
tl i ( n i� i, j {' , ill:. �1'..ri 1i i t, ri, It (!.2 I Ili 'I I a�iii i. dII ' .14 iW1 )
i arh,� iu ) 1 -, I'I „t Gl i r'- I.Illl,r ei V U lilt iIS3' I '�ild 4r.Jl ! - Biil i
:Eta i: iii it I i i 1 , i I! y, lig ptc, i "nit
r 1p, im ��' +ii 'ii R Ili i' � Rn ileP.pi "," 1111, 'IiI,I4 rc4IIAt11.1 pow Fool At.ifDi �i ( hg'Plitt
,' ,!iii ' �,.'I +,i,t ,',i 1) it '.
,(!Ii ti r a ,i i i I '.: W _i 1 V IIiI li.1! i i. ' i1 I'<�1i I r4� o,, I Apo tv.
•1141''•
41''1 , ii t 1 ! i r i9 i i i i .:k ,� , k r kA II !I'i �'4 3 t„Ii AI( � '�l'b i l III I i�i,' li last i'_"Atli ( • yl'laialg,.
�I as Ill .1.:,. ,,.Ga r!i .�ill is'I fr I„I 6.....,C, .,w I,II.,.IG.,,Ix.,t,i,,u,._sBB `31lµ t
0 hl Age 0-10...$11.47 ' Level 0...$6.25 I? Level 0 $4 93 ImI
r'Level 0 $0 I I Level 0 $0
Age 11-14...$12 89
It
• 1
0 i;, I�I (Therapy not needed or provided , (None)
4, (Minimal CPA involvement ,IIII by another source,i.e.mental dH
0 { Age 15-21...$13 91 44,, .
; y ( t,. and/or no crisis intervention i.e. Ili' health.)
�I , mutual careplacements.) I
F +$,66 Respite Care �s �I
utt
I i, i,i !
'i I. ':Level 1 F 1. Level 1 1I $8.22 i, $4.93 III
IcrI $19.07 ':' ( «` J, Level 1......$2.99
it +$.66 Respite Care 4_ Level 1...$6.25 , (Face to face contact one time i) (Regularly scheduled therapy, '
($19.73) ' '- per month and minimal crisis CI 4 hours/month.)
III; II
1 intervention) :II
#' 6i' r i II,
GhI Level 2 $11511 Li Level 2 $9.86 ,
2 $25.64 (Face to face contact two times -1 (Weekly scheduled therapy,
4 +$.66 Respite Care '' Level 2...$6.25 ! per month and/or occasional A4-8 hours a month with 4 hours of Level 2 $4.47
! ($26.30) I'I' crisis intervention) ail Group therapy.) ,IIII I4
rI.0 .I 11,
I,,; 'l',55 i,r fit
er
A .he,
1;1f " ,; Level 3 $14.79 rv�
I
, Level 3 $14.79 ', -a
$32 22 i ] (Regularly scheduled weekly !:
3 + I multiple sessions,can include ,' Level 3 $6.02
$.66 Respite Care Level 3...$ 25 : (Face to face contact 1-2 times t
($32.88) 1 ._ per week and/or ongoing crisis more than 1 person,i.e.family
I�
i f r,i' intervention.) i therapy,for 8-12 hours/monthly.)
is irIi al
i',!a
i'i L IW
q i
, 'yj
lA i )i. lijill
6i{
,i; ! Level $18.08; ":Level4 $14.79 ill
RTC $38.79 ! (Face to face contact 2-3 times (Regularly scheduled weekly I'll Level 4......Neg.
.�' +$.66 Respite Care .r. Level 4...$6.25 N- per week minimum,High level multiple sessions,can include G
Drop !PI of case management and CPA more than 1person,i.e.family rd'
Down ($39.45) G 9 l
involvement with child and therapy,for 8-12 hours/monthly.) 4,
provider,including on-going G
crisis intervention.) C
u�' w. Iii( i
fl! v
Assess '. Assessment Assessment • Assessment ' int
Period , . Period $26.30 �;: period $6.25 Period $11,51 Assessment Period $0 i
,''; (Includes Respite) i:I' ! .,,4 PP
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST: "4-94144/44
Weld County Clerk to th Board
mow"
41 ', i n . WELD COUNTY BOARD OF
F SOCIAL SERVICES, ON BEHALF
1St i (1‘-:::::-.7:`,r �, '-' OF THE WELD COUNTY
i , ,V ;ft, ;"/ DEPARTMENT OF SOCIAL
4t 7/ SERVICES
Ko ,� '..
By: ii.it , i _ LIZtC By: 7 &
puty Cl to the Board M. J. Geile, Chair AUG 3 0 2006
CONTRACTOR
Youth Ventures of Colorado
4785 Granby Cir
Colorado Springs, O 80919
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES By: c lei
Drbtor 9111°
`J
8 Weld County SS-23A Addendum
7e 4;1'JJ/
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