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Home My WebLink About20060139.tiff RESOLUTION RE: APPROVE ADDENDUM TO NINE 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 nine Addendums to Agreements to Purchase Child PlacementAgency 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 October 1,2005,and ending June 30,2006,with further terms and conditions being as stated in said addendums, and 1. Alpine Children's Environmental Services, Inc. 2. Eagle Homes 3. Foster Care Connection 4. Hope and Homes 5. Kids Crossing 6. Loving Homes, Inc. 7. Lutheran Social Services of Colorado 8. Opportunity in Living 9. WhimSpire CPA 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 nine Addendums to 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. 2006-0139 SS0033 ADDENDUM TO NINE 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 9th day of January, A.D., 2006, nunc pro tunc October 1, 2005. '"^_..N. BOARD OF COUNTY COMMISSIONERS 'i '1-1?-'t '`�:'`a WELD COUNTY, COLORADO ATTEST: LA/ .9 �t$'f EXCUSED ` •' ' M. J`. le, Chair Weld County Clerk to th �) v` U C BY: Uu , 1 /ail David E. Long, Pro-Tem D uty CI k to the Boa EXCUSED William H. Jerke AP V AS TO &i %I — Robert D. Masde in ty A ey _22 1'.AAkt Glenn Vaad Date of signature: 111ID(.0 2006-0139 SS0033 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 "ligC. COLORADO MEMORANDUM TO: William H. Jerke, Chair Date: December 28, 2005 Board of County Commissioners /�1 1/ r FR: Judy A. Griego, Director, Social Services "AL4U (k �+,/t(,2Y�� RE: Addendums to Agreements to Purchase Chid Placement Agency(CPA) Services with Various Vendors Enclosed for Board approval are Addendums to Agreements to Purchase CPA Services between the Weld County Department of Social Services (Department) and various vendors. The Addendums were reviewed at the Board's Work Session held on December 12, 2005. All of the Agreements are amended to include the provision that rates will continue to remain the same until June 30, 2006. The Department requests the extension to deal with the Statewide issue regarding Medicaid reimbursement negotiations with the Federal Agency. The vendors include: 1. Alpine Children's Environmental Services 2. Eagle Homes 3. Foster Care Connection 4. Hope and Homes 5. Kids Crossing 6. Loving Homes 7. Lutheran Social Services of Colorado 8. Opportunity in Living 9. WhimSpire If you have any questions, please telephone me at extension 6510. 2006-0139 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 October 1, 2005, through June 30, 2006. The following provisions, made this C7 day of Z + ' ✓u , 2004 are added to the referenced Agreement. Except as modified hereby, all term 'of the A 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#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. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 02 66)4 -0/39 1 Wpld r..,,nn,cc_ne Addendum 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 Weld rnnnni CC-11A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: // �� i� ,i/✓_' /pt'- / ,;, t( /it i`c:e/i4, 3 Wald r.,,,.,n.QQ_)1A 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 IFIH# (DATE OF ASSESSMEI AGENCY NAME PROVIDER NAME I PROVIDER ICWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑I)2-3 trips a week ❑2)4-5 trips a week D3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? DO)one a month DI)twice a month D2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a''/,hour per day DI)S hour a day ❑2)more than '/3 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 LI 2)at least daily D3)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 I. How often is CPA case management required? DO) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month D3)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 ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 Weld enmity cc_11 A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. Rating of Conditions (Check one box for each category) • ASSESSMENT AREAS ,iii:,:None .'. Mild Moderate Severe Comments: 0 1 2 3 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 ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior LI ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ Education ❑ O 0 0 Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 S W,.I,I rn„nty CC-71A AAAandum • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD l: 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 RAIL 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 RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDERRATE :: `" Al ", Ti •'.:.ADDENPUM • Pt.-PS " ' Therapy LeJel Rate •,:,•••,::. Admin.Overhead Case Management (Admin.Services) •• ' (Admin.Maim.) (Admin. Maint.) , 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) • (Minimal CPA involvement, no by another source,i.e.mental • Age 15-21...$13.91 crisis intervention. Only doing health.) 0 what is necessary to maintain +$.66 Respite Care monthly responsibility.) • Level 1 $8.22 •`'`Level l $4.93 1 Level1 $2.99 $19.07 (Low level of case management, ! (Regularly scheduled therapy, +$.66 Respite Care Level 1...$4.56 minimal crisis intervention,2-3 4 hours/month.) • ($19.73) contacts/month,minimal crisis intervention, 2-3 contacts/month.) • Level 2 $11 51 Level 2 $9.86 2 $2564 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...54.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) • Occasional crisis intervention, • Face to face contact 1 time • Per month.) • • Level3 $14.79 Level3 $14.79::;1 $32.22 (High level of case management (Regularly scheduled weekly 3 4.56 and CPA involvement with child ,-• multiple sessions,can include Level 3 $6.02 +$.66 Respite Care Level 3...$ ($32.88) and provider including ongoing `` more than 1 person,i.e.family crisis intervention and face to " therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level 4 $18.08; :Level 4 $14.79 4 • (High level of case management'' (Regularly scheduled weekly Level 4 Neg. RTC $38.79 and CPA involvement with child multiple sessions,can include Drop +5.66 Respite Care • Level 4...54.56 and provider,including on-going • more than 1 person,i.e.family Down ($39.45) • crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period S4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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 Bo. • � `�4.\\, WELD COUNTY BOARD OF #44*,*�%SOCIAL SERVICES, ON BEHALF 1861 F THE WELD COUNTY isI1.71,t IEPARTMENT OF SOCIAL t`r. 4SERVICES i By: {Ltd � 4,,11 FOLi 1fl, By: C .. Deput Jerk to the and David E, Long, CHai ?ro-Tem 01/ 9/2006 CONTRACTOR Alpine Children's Environmental Services, Inc 301 N Cascade Ave, Suite C Montrose, CO 81401 I By: �i/' /% ,,; WELD COUNTY DEPARTMENT OF SOCIAL SERVICES /1141)1Al\Direct4kit 8 Weld County SS-23A Addendum sIce -U/3e WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Eagle Homes and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this,Z 't day of L. eix 1 , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#31058. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. x ooh -O/S9 1 Weld I'nnnh,CC-11A Addend., 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 WPIA Cnnnfu CC-11A AddAndnm C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld cc_11A 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 HH# 1DATE OF ASSESSME] AGENCY NAME PROVIDER NAME PROVIDER ICWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month D2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? DO)less than a%,hour per day ❑1) 14 hour a day D2)more than '/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 monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑I)5 to I O hours per week D 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 ❑l)5 to 10 hours per week ❑2) I I to 20 hours per week ❑3)21 or more hours per week A I. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑D 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e. Medicaid) DI)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 ❑ ❑ ❑ ❑ P3 Educational Intervention ❑ ❑ ❑ _❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A I Case Management ❑ ❑ ❑ ❑ T I Therapeutic Services ❑ ❑ ❑ ❑ 4 U/aIA Pn,,.,t,,CC-21A Addand„m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. ting of Conditions, (Check one box for each category), . :' ASSESSMENT AREAS None Mild Moderate Severe commentsl,: 0 1 2 3 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 ❑ ❑ El El 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 ❑ I ❑ 2 ❑ 3 5 WPM Cnnnh;CC-)74 Ad ioniinm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE •Al ••> Ti ..' .•.. ADDENDUM P1 -P5 Level Rate Admin.Overhead Case Management Therapy (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement,no by another source,i.e.mental 0 Age 15-21...$13.91 crisis intervention. Only doing health.) what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Levell $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact1-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 (High level of case management (Regularly scheduled weekly Level 4 Neg. $38.79 RTC +$,66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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: 124441114-G ( Weld County Clerk to the Board ETI...l ' WELD COUNTY BOARD OF �" ` � SOCIAL SERVICES, ON BEHALF c �A t 1361 OF THE WELD COUNTY :, DEPARTMENT OF SOCIAL SERVICES (.,..— , I .(1 ".. p By: I^� (^t 1 �UI Ft^ 7/ By. �/ ct C, / Deput Clerk to the Board David E. Long, Chai ro-Tem 01/ /2006 CONTRACTOR Eagle Homes 1225 Redwood St Fort Collins, CO 80524-2052 By: ,,tt it-L- gi'6�., WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Direct 8 Weld County SS-23A Addendum �?co6 - CiSy WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agettt y,Services (the"Agreement")between Foster Care Connection and Weld Conty Department of Social Services for the period from /'•- October 1, 2005, through June 30, 2006. 2 /, The following provisions, made this ` day of ' r u U , 2006, are added to the referenced Agreement. Except as modified hereby, all term f the A 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#45079. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section W. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section DI. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. :a?DOb -(3/39 1 OJ,.id/`n„nn,cc-11e Adn.nd,,m 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a goverment entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 \X/eld rn,,nh,CC-11 A A AAandnm C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 1A/FIA rnn t.,cc_93A Adrlmndnn, • 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 IIII# DATE OF ASSESSMEI AGENCY NAME PROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? O0)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'/hour per day 01) 12 hour a day O2)more than '/hour per day, up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 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) 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 ❑1) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 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 ❑ O O O P 2 Therapy/Counseling O ❑ ❑ O P 3 Educational Intervention O O O O P 4 Behavior Management O O O O P 5 Personal Care O O O O A 1 Case Management ❑ ❑ O O T 1 Therapeutic Services O O O O 4 mein r„,„•r.,Ccn1A A.rdp.,d,„„ WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. :. 1111 ,• ::� ,:.,' . . 1.1:1: 1111.. ... .. 111.1,.,. ..._ : ... �... 1111 ..1111.s—�.: 111 1111 . 111. ... ...z:. �'_.�:.::..i:::;;;;"''�O,:,O . 1111 1111 1111 .. . ..: ...... . . ..t. 1111. .r:;,. � s:,.. 111 . :.. �.. <:,... •... ... .......t�:..:.:' :::'. 1111.. 1111. . . r_ . ...... t.i — . 1111 .. .� Cs .;...�. �. . .. .:. 111. .. .. . 1111 . . .. .: ..i. 1111: _ s.. .. ..... .. .. .. . : 111. ..: 111. 111 z...... ... ,.,':•+ — ... .. 111... ... .. . .....:.......�:. .�.. . ! — — � , 11 —. 1111... .. 1111 1111.. 1111..' ..•.. ... .. 111... ... 1111.... .�.::,�.:Y.:^ t.:� .. ... ... ...1111 �:��_ _._.:.. —•: 1111. .. :..:....�...z. �_.:.:.'�'.. '..... .��.•. . � 1111.. ...1111..}:� ' ..'. . .. ....:. 1111 �.: •ez•t.r • 1111 ASSESSMENT AREAS ' ;':!1,19,0:t.,..'::::.:;:...,' Mild 'Moderate Severe C0 i Q ! 2. 3 m'ii�ent�.. r Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ O ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ El Substance Abuse ❑ El ❑ El Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis El ❑ ❑ ❑ Runaway El El El ❑ Inappropriate Sexual Behavior El El ❑ El Disruptive Behavior ❑ ❑ El ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ El El ❑ Medical Needs ❑ El El ❑ Emancipation ❑ ❑ El El Education ❑ ❑ El El Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) El 0 ❑ I ❑ 2 ❑ 3 Sw,i4 rr,,,,,h,cc_11 A A.i.iA„,lit.n WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY- Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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 # Coimnents: NEXT SCHEDULED RAIL REVIEW: InitialDate: (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 RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS. SERVICE PROVIDER RATE Al Ti ADDENDUM Level Rate Admin. Overhead Case Management Therapy (Admin.Maint) (Admin, Maint.) (Admin Services) Ag e ge 0-10...511 47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0......$0 0 Age 11-14..$1289 (Minimal CPA involvement,no .` (Therapy not needed or provided (None) 0 Age 15-21...513.91 crisis intervention. Only doing by another source,i.e.mental what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) 1 Level 1 $8 22 Level 1 $19.07 $4.93 +$.66 Respite Care Level 1...$4.56 (• Low level of case management ' Level 1 $2.99 ($19.73) minimal crisis intervention,2-3 (Regularly scheduled therapy, contacts/month, minimal crisis 4 hours/month.) intervention, 2-3 contacts/month.) Level 2 $11.51 Level 2 $9.86 2 $25.64 (Moderate level of case +$.66 Respite Care Level 2...$4 56 Management including (Weekly msconth with it therapy, Level 2 $4,q7 ($26.30 4-8 hours a 4 hours of ) Weekly support services, Group therapy.) Occasional crisis intervention Face to face contact 1 time Per month.) ii Level 3 $14.79 Level 3 $14.79 g $32.22 (High level of case management (Regularly scheduled weekly +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 ($32.88) and provider including ongoing more than 1 person,i.e.family $6.02 crisis intervention and face to therapy,for&12 hours/monthly.) face contact1-2 time per week minimum.) Level 4 $18.08 Level 4 $14.79 4 RTC $38.79 (High level of case management ': (Regularly scheduled weekly Level 4 Neg. Drop +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Down ($39.45) and provider,including on-going more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 (Includes Respite) Period $4.56 Period $11.51 Assessment Period $p Effective 10/01/01 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: ^ ""e /��!/YGLI Weld County Cler o the Board 1 , ss al E� a WELD COUNTY BOARD OF I d SOCIAL SERVICES, ON BEHALF 136ts2 f OF THE WELD COUNTY DEPARTMENT OF SOCIAL WA/ SERVICES N. By: V t,� k . , 1, r _ .{ By: . F / l�j ! 4( J R - Deputy(S jerk to the Board David E. Long, Chai Pro-Tem 01 09/2006 CONTRACTOR Foster Care Connection 4860 Robb St., Suite 203 Wheatridge, CO 80033 By: ,_. -�___2_1_,/,),Q) WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: )'rector 8 Weld County SS-23A Addendum LQCod.- oi.39 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 October 1, 2005, through June 30, 2006. The following provisions, made this (- - day of�i,( ,,;41( , 2006, are added to the referenced Agreement. Except as modified hereby, all terms f the Agieement 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. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 Weld Cn„nh,cc_nA AAArndn.n C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld Cnnni.,QC_T1A Addandun, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX IT Case ID !DOB Sex WORKER COMPLETING ASSESSMENT HH# [DATE OF ASSESSME] AGENCY NAME PROVIDER NAME ROVIDER 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑I)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? DO)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a 9 hour per day DI) S4 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 monitoring of time and/or activities and/or crisis management? DO)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? DO)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? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑I) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month D2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 ❑ ❑ ❑__ P 2 Therapy/Counseling 0 ❑ 0 ❑ P 3 Educational Intervention 0 ❑ ❑ 0 P 4 Behavior Management 0 ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ 0 A 1 Case Management ❑ ❑ ❑ 0 T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 Wald r,a,..n,cc_11 A AdAendnn. WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. :...,. •°:: :Check one:bo*.Fo.:e ch°c, .teg.•ry ?;,::!;.! :':: ::::..` : .:. ... !: ASSESSMENT AREAS >::: None. Mild Moderate Severe :.. .. . :.... .. . ,.. . . Comments: :. . .. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ El ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ 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) ❑ o ❑ 1 ❑ 2 ❑ 3 5 W I,i C ,,nt.,CC-71A e,4ivnAnm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE • Al TI<< ADDENDUM P1 •PS Level Rate Admin.Overhead Case Management Therapy (Admin.Services) (Admin.Maint,) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing 0 what is necessary to maintain health.) +$,66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level 1 $2.99 $19.07 Low level of case management, (Regularly scheduled therapy, +$.66 Respite Care Level 1...$4.56 • (mi ( gnimal crisis intervention,2-3 4 hours/month.) ($19.73) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 (High level of case management (Regularly scheduled weekly Level 4 Neg. $38.79 RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Dropand provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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: ' '1S% Weld County Clerk to the Board E Ak,, WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF 1 OF THE WELD COUNTY 1861 DEPARTMENT OF SOCIAL SERVICES FBI By: ` fl.ilti n4 �, I, CG By: cl-__,_ el ( Deput Clerk to the Bp rd ', David E. Long, Ch r Pro-Tem 01 09/2006 CONTRACTOR Hope and Homes 620 Southpointe Ct. Colorado Springs, CO 80906 ,/ By: �'1 LO WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: N/", C I.4 ctor 1 8 Weld County SS-23A Addendum /34 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Kids Crossing and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. - The following provisions, made this V— day of .0 , 2006, are added to the referenced Agreement. Except as modified hereby, all terms f the Agreement remain unchanged. CT-- County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement,based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#79752. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. o7oO66-.0/2 1 Weld en.mt„cc_ne e(Mann,,,., 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 weld!'Wont.cc_1fA Addrndn.n C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wald! n.nt,CC/11A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID nOB Sex WORKER COMPLETING ASSESSMENT [DATE OF ASSESSME] AGENCY NAME ROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? O0)one a month 01)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'''A hour per day O1)15 hour a day O2)more than ''A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week 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 El 2) 1 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 01) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)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 ❑ ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care 0 ❑ 0 ❑ A I Case Management ❑ 0 ❑ ❑ T I Therapeutic Services 0 ❑ ❑ 0 4 Wpld rm.'' ,cc-11A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ['Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. Rating of Condifto olS (Check one box for each cate a ASSESSMENT AREAS None Mild Moderate Severe Comments: 0 1 2 3 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ O Self-injurious Behavior ❑ ❑ O O Substance Abuse ❑ O ❑ O Presence of Psychiatric Symptoms/Conditions ❑ O ❑ ❑ Enuresis/Encopresis O ❑ O ❑ Runaway Cl ❑ O ❑ Inappropriate Sexual Behavior Cl ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior Cl ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation Cl ❑ ❑ ❑ Education Cl ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) El o O 1 ❑ 2 ❑ 3 5 Wo1A Cn..„t.,CC-11A Aririrnriiirn WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY -Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of PI 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) • LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al Ti ADDENDUM P1 -P5 Level Rate Admin.Overhead Case Management. ..:; • Therapy • (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing ) 0 what is necessary to maintain health. +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level 1 $2.99 $19.07 (Low level of case management, (Regularly scheduled therapy, +$.66 Respite Care Level 1...$4.56 ( gminimal crisis intervention,2-3 4 hours/month.) ($19.73) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, '< Face to face contact 1 time Per month.) Level 3 $14.79 Level 3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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. , Liiiikla ATTEST: Weld County Clerk to the Board E La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF Its 0,2 OF THE WELD COUNTY DEPARTMENT OF SOCIAL n W „4 SERVI ES By: �� "iUL x.�t 1�Lti( /`lifly( By: 4 �. Deputy Clerk to the Ooard David E. Long, Ch 'r Pro-Tem 01 09/2006 CONTRACTOR Kids Crossing 1440 E Fountain Blvd Colorado Springs, CO 80910--33502 By: ✓ .il (c,,,, y / WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: e 0 f Di ector 8 Weld County SS-23A Addendum ,≥2oe a -00/39 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 October 1, 2005, through June 30, 2006. The following provisions, made this 7— day ofCft , 200b, are added to the referenced Agreement. Except as modified hereby, all terms of the A cement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#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. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. d1©n 6 -0439 Weld l`nunn,cc_91A d ddendum 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 wain r,.,,rr.,cc_lin nnnann„n, C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 W,1,1(',.,,,,p,cc_nae edAP.,d,,.., WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE.ID# SEX irrails Case ID rOB Sex WORKER COMPLETING ASSESSMENT HH# IDATE OF ASSESSME] AGENCY NAME PROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑I)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'/x hour per day El) Vs 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 monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week El I)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? DO) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e.Medicaid) ❑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 0 ❑ ❑ 0 P 2 Therapy/Counseling 0 0 D ❑ P 3 Educational Intervention ❑ 0 ❑ ❑ P 4 Behavior Management 0 ❑ ❑ ❑ P 5 Personal Care D ❑ ❑ 0 A 1 Case Management ❑ ❑ ❑ 0 T I Therapeutic Services ❑ 0 0 ❑ 4 weir r.,..nt.,cc.ne Addendum . • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. Rating of Conditions (Check one box for each category) ASSESSMENT AREAS None Mild Moderate Severe Comments: 0 1 2 3 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 ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ 0 ❑ ❑ Emancipation ❑ ❑ 0 ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ o ❑ I ❑ 2 ❑ 3 5 WPIt1 Cniintu CCJ'i A Aritivnrium WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY -Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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) • LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al .• •••• Ti ADDENDUM P1-PS Therapy Level Rate Admin.Overhead Case Management (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 . $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement,no Age 15-21...$13.91 crisis intervention. Only doing by another sourch �.e.mental 0 what is necessary to maintain ) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Levell $2.99 $19'07 (Low level of case management, ? (Regularly scheduled therapy, +$.66 Respite Care Level 1...$4.56 minimal crisis intervention,2-3 4 hours/month.) ($19.73) contacts/month,minimal crisis intervention, 2-3 contacts/month.) • Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 ? Level4 $14.79 4 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC $38'79 and CPA involvement with child multiple sessions,can include Drop +$•66$39 4 Respite Care Level 4...$4.56 and provider,induding on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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. akar ATTEST: Weld County Clerk to the Board ' ,4) WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY 4 DEPARTMENT OF SOCIAL Q g SERVICES By: 41,1t 1/a1 (cykr By: n F ' Deput Clerk to the B and David E. Long, Cha' -Pro-Tem 0 09/2006 CONTRACTOR Loving Homes Inc. 212 W 13th St Pueblo, co 81003 By: f, ///�`e WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: f{) ctor 8 Weld County SS-23A Addendum &606, -(5/3y WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Lutheran Social Services of Colo. and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this,pf day oO4vbeer- , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#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. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section 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. &cc -C/SY 1 Wald rnuinl.,cc_Y A AdAPnn,,,., 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 Weld!'nnnty CC-11A Addendmn C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 WMA r,.,,nn,cc_11A Armand,,.., 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 IBM (DATE OF ASSESSMEI AGENCY NAME ROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a''/ hour per day ❑1) 1/2 hour a day ❑2)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 monitorinP,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? ❑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 ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) Ell)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 rnnnry cc.11A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO ' THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. Rating of Conditions: (Check one box for each category) ASSESSMENT AREAS '.:::None::•.:. MildModerate Severe Comments:' . ••>. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ El ❑ ❑ Stealing ❑ El ❑ ❑ Self-injurious Behavior ❑ ❑ El ❑ Substance Abuse ❑ ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ 0 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 W l,A rro int r CC-124 ArIAPnrinm • WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE • INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al :.. .. ..;..:: : :. Tt- ADDENDUM. P1 -P5 • Level Rate Admin.Overhead Case Management • Therapy. (Admin Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement,no by another source,i.e.mental 0 Age 15-21...$13.91 crisis intervention. Only doing health,) what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level / $2.99 $19'07 (Low level of case management, (Regularly scheduled therapy, +$.66 Respite Care Level 1...$4.56 minimal crisis intervention,2-3 4 hours/month.) ($19.73) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact/-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$,66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11,51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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: Mia:44 Weld County Clerk to the Board E WELD COUNTY BOARD OF , . � .J SOCIAL SERVICES, ON BEHALF tut t. OF THE WELD COUNTY tett. , DEPARTMENT OF SOCIAL ° I AV°�lc ti tzr SERVICES 1 It AVM By: ' /tit 1 1 h f i c�i By: c, ; Deput GClerk to the oard David E. Long, Chai Pro-Tem 01/09/ 6 CONTRACTOR Lutheran Social Services of Colo. 3800 Automation Way, Suite 2007 Fort of �CO 85 Byte 's�9�`, 1911/1740 WELD COUNTY DEPARTMENT OF SOCIAL SERVICES '/ (it ( t ) 7By. LI jtrector lJ 8 Weld County SS-23A Addendum 51Oll -C'/39 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services 3 (the "Agreement") between Opportunity In Living and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. - The following provisions, made this 9 day ofjpituM QC , 2006, are added to the referenged Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. r.? 1. County and Contractor agree that a child specific Needs Based Care Assessment, o 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. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours,weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section 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. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. .a2 006 -t9Z 1 Wald nom'',cg-914 Addandu.n 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local)terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 Weld rnu,nh,cc_rnn Addpn,d,'m C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wnl,i rn„nh,cc.1'iA Addrndnrn WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID [DOB Sex Sex WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMEI AGENCY NAME PROVIDER NAME I PROVIDER ICWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less 01)2-3 hips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month 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 ❑1)'/z hour a day O2)more than ''A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin 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 ❑l)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 Dl) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e.Medicaid) 01)less than 4 hours per month ❑2)4-8 hours per month ❑3) 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 P 5 Personal Care 0 0 ❑ 0 A I Case Management 0 ❑ 0 0 T 1 Therapeutic Services ❑ 0 0 0 4 wpm rn,,nn,CC-11A Addann,,m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ERe-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. Rating of Conditions (Check one box for each category) ASSESSMENT AREAS None Mild Moderate Severe Comments: 0 1 2 3 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ O O ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing O O ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ O O ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ O O ❑ Medical Needs ❑ O O O Emancipation O ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 O 2 O 3 5 w,i,+rn,,nr.,CC-11A Ards..,,,.,, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P 1 through P5) PERIOD 1: LEVEL# Comments: 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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al TI ADDENDUM P1-P5 Therapy Level Rate Admin.Overhead Case Management (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental 0 Age 15-21...$13.91 crisis intervention. Only doing health.} what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level1 $2.99 $19.07 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ' ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level 3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 +$.66 (Respit) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$,66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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 - ' e d WELD COUNTY BOARD OF #� ', SOCIAL SERVICES, ON BEHALF l"l '"t ' II OF THE WELD COUNTY `I DEPARTMENT OF SOCIAL • ' 1 SERVICES aft 10" T By: ,ti el �Zl'iitY By: e, r eputy lerk to the Bland David E. Long, Chai Pro-Tem 01/ 9/2006 • CONTRACTOR Opportunity In Living 7061 S University Blvd # 301 Centennial, CO 80122 By: WELD COUNTY DEPARTMENT E—kr e� -.Aa�c r OF SOCIAL SERVICES garfx � I+ SZIN C \ \ By: ector 8 Weld County SS-23A Addendum 3269e -ci39 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between WhimSpire CPA and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this Cj day ofr, tlutlicr , 2004 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#19562. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 Weld County ec_ne ,0c -C/-�9 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the 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; 2 Weld(`nnnh,cC91A Addendnn. C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wald Cn„nn,CC-11A AAAan.ln.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# IDATE OF ASSESSMEI 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less [11)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'/ hour per day 01)1/2 hour a day ❑2)more than '/3 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 monitoring 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 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) I 1 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 ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑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 ❑ 0 ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services 0 ❑ ❑ ❑ 4 u/44 rnunty CC-11A Addrnd„m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. . Rating of Conditions (Check one box for each category) ASSESSMENT AREAS None Mild Moderate Severe Comments: 0 1 2 3 Aggression/Cruelty to Animals ❑ El ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ O ❑ O Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ Cl Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ O ❑ ❑ 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 Ell ❑ 2 ❑ 3 5 W.1,+r.,...,f.,cc_1ze Arhionelo.,, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of 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) LEVEL OF RECOMMENDED • • RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al TI ADDENDUM P1 -P5 Therapy Level Rate Admin.Overhead Case Management (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement,no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact1-2 time per week minimum.) Level4 $18.08 > Level4 $14.79 4 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC $38'79 and CPA involvement with child multiple sessions,can include Drop +$.66 Respite Care Level 4...$4.56 and provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 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: iaK �G'4 Weld County Clerk to the Board a WELD COUNTY BOARD OF X. OP SOCIAL SERVICES, ON BEHALF ' Off i; t3NA22 OF THE WELD COUNTY A r i '; , 4 Y rf DEPARTMENT OF SOCIAL F .o.i ,q� SERVICES CBy: i` itil ^AZ 1 �7I i (() i ( 4 By: Deput Clerk to the oard David E. Long, CH r Pro-Tem 01 09/2006 CONTRACTOR WhimSpire CPA 70 Morning Sun, Suite 300 Woodland Park, 80863 By. '�/l2Ne J tn)tt_ WELD COUNTY DEPARTMENT l OF SOCIAL SERVICES i By: titit ' Director 8 Weld County SS-23A Addendum ?GOd- -G''/3�f Hello