HomeMy WebLinkAbout20063054.tiff RESOLUTION
RE: APPROVE ADDENDUM TO TWO AGREEMENTS TO PURCHASE CHILD
PLACEMENT AGENCY SERVICES AND AUTHORIZE CHAIR TO SIGN
WHEREAS,the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS,the Board has been presented with Addendums to two Agreements to Purchase
Child Placement Agency Services between the County of Weld, State of Colorado,by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Social
Services, and the following providers, commencing July 1, 2006, and ending June 30, 2007,with
further terms and conditions being as stated in said addendums, and
1. Imagine
2. Kids Crossing
WHEREAS,after review,the Board deems it advisable to approve said addendums,copies
of which are attached hereto and incorporated herein by reference.
NOW,THEREFORE,BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services,that the Addendums to two Agreements to
Purchase Child Placement Agency Services between the County of Weld,State of Colorado,by and
through the Board of County Commissioners of Weld County,on behalf of the Department of Social
Services, and the above listed providers be, and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said addendums.
2006-3054
SS0033
(0 . SS //-/`{- U
ADDENDUM TO TWO AGREEMENTS TO PURCHASE CHILD PLACEMENT AGENCY
SERVICES AND AUTHORIZE CHAIR TO SIGN -VARIOUS PROVIDERS
PAGE 2
The above and foregoing Resolution was,on motion duly made and seconded,adopted by
the following vote on the 1st day of November, A.D., 2006, nunc pro tunc July 1, 2006.
BOARD OF OUNTY COMMISSIONERS
r1� �� . / 4�% WELD CO TY, COLORADO
J
,� �f. '- �aY g' `22 fLG-
ATTEST: r guar . '
:,i . J. 'le, Chair
Weld County Clerk to th= ' •- •` a `� 11
\ � David E. Long, Pro-TernBY: C \L1ttt-1Ct
C 4415( r-.7
Dep Clerk a the Board "k�
�7 William H. Jerke
APPROVED AS TO POW: EXCUSED
Robert D. Masden
�A ornjy %'�7 �� ,f.Lu.t ataiS
Glenn Vaad
Date of signature: I 1114)C(
2006-3054
SS0033
cf(
3/441t1;a
S DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY,CO. 80632
Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
C
Fax(970)346-7663
MEMORANDUM
COLORADO TO: M.J. Geile,Chair Date: October 30, 2006
Board of County Commissioners
a 61
FR: Judy A. Griego, Director, Social Services 2(_, ti L(,(,
'i
RE: Addendums to Agreements to Purchase Child Placement
Agency Services with 2 Vendors
Enclosed for Board approval are Addendums to Purchase Child Placement Agency (CPA)
Services between the Weld County Department of Social Services(Department)with 5 vendors.
The Addendums were reviewed at the Board's Work Session held on October 30, 2006. The
Addendums are with providers for reimbursement during SFY2006-2007 (July 1,2006 through
June 30,2007).
A. Rates are based on Needs Based Care Assessment.
B. The vendors include:
Provider ID
Number
1. Imagine #21369
2. Kids Crossing #79752
If you have any questions,please contact me.
2006-3054
• • WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Imagine and Weld County Department of Social
Services for the period from
October 1, 2006 through June 30,2007.
The following provisions, made this /5"day of Uc4ob ec , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#21369. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and his or her supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
I Weld fnnnn,CC-11A Addendum
9. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local)terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
2 Weld rn„nh,CC-11A A ddendn.n
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Social Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Social Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event in which it is a party defendant or respondent in a case, which involves services
provided under the agreement. The Contractor, within five (5) calendar days after being
served with a summons, complaint, or other pleading which has been filed in any federal
or state court or administrative agency, shall deliver copies of such document(s) to the
Social Services' Director. The term "litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII -ATTACHMENTS:
3 Weld('nnnh,cc_ l8 Addandnrn
• 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 IIIH# 1ATE OF ASSESSMET
AGENCY NAME (PROVIDER NAME ROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for the following: Therapy; Medical
treatment; Family visitation; Extraordinary educational needs; Etc.,as outlined in the treatment plan?
❑0)one round trip a week or less ❑I)2-3 round trips a week
O2)4-5 round trips a week O3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0)Once a month 01)Two times a month but less than weekly
O2)Once a week O3)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with
a regular or special education plan?
O0)less than a'A hour per day ❑I)'A hour a day
O2)more than '/2 hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorin of time and/or activities and/or crisis management?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate
needs with feeding,bathing,grooming,physical,and/or occupational therapy?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week
O2) II to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
DO) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑I) Face to face contact one time per month and minimal crisis intervention.
O2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
DO)not needed or provided by another source(i.e.Medicaid) 01)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation O O O O
P 2 Therapy/Counseling O O ❑ O
P 3 Educational Intervention O O O O
P 4 Behavior Management O ❑ O O
P 5 Personal Care O O O ❑
A 1 Case Management ❑ ❑ O O
T I Therapeutic Services ❑ O O O
4 wpm n.,,nh,cc-ne eddp„d,,m
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
•
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Aggression/Cruelty to Animals O O ❑ ❑
Verbal or Physical Threatening ❑ ❑ El O
Destructive of Property/Fire Setting LI ❑ O El
Stealing ❑ O O El
Self-injurious Behavior ❑ ❑ El El
Substance Abuse ❑ O ❑ O
Presence of Psychiatric Symptoms/Conditions ❑ El ❑ El
Enuresis/Encopresis El O ❑ El
Runaway ❑ El ❑ ❑
Inappropriate Sexual Behavior O ❑ El ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior O ❑ O ❑
Depressive-like Behavior ❑ O El ❑
Medical Needs El O ❑ ❑
Emancipation ❑ El ❑ El
Education ❑ ❑ O ❑
Involvement with Child's Family El El ❑ O
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) O 0 El 1 O 2 El 3
5 W Irl rn:,nt.,CC-71A AAAvnA,,m
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY - Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD I: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(TI)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
" :+4E.:E':::r.^:r.,�:;,j-„...r..is�;arpi�:..rjr..:.t:: lt`.rf•:'::�i:�i ) :i"r ',=`i'::7'.
h
Y�. 1 t tl•t:x.:y?..=:q"•'••Ci.:i�e i i�'.4 •:il•E•,:°;E.
LEVEL OF 'RECOMMENDED E t ; [# ► "� INTERVENTION RATE MEDICAL NEEDS
..!'".'i,i iFi::EiE7�:'.^Sie EE:�iT.'=t. . ::::3••:.< i,
Y
SERVICE PROVIDER RATE `: .:.:'-.`. :'A , ,iVi ADDEND T] - UM
EE
�r`r E
,,,;i:4 Therapy
Level Rate Admin.Overhead Case Management #
l (Admin.Services) . .:...
(Admin.Maint),. .(Admin.Maint) '
0 • Age 0-10..$11.47 Level 0...$6.25 Level 0 $q 93 Level 0 $0 Level 0 $0
0 Age 11-14...$12.89 (Therapy not needed or provided (None)
(Minimal CPA involvement by another source, i.e. mental
0 Age 15-21...$13.91 and/or no crisis intervention i.e. health.)
mutual care placements.)
+$.66 Respite Care
Level 1 $8.22 Level 1 $4.93
1 Level 1 $2.99
$19.07
+$.66 Respite Care Level 1...$6.25 (Face to face contact one time (Regularly scheduled therapy,
($19.73) per month and minimal crisis 4 hours/month.)
intervention)
Level2 $11.51 Level2 $9.86
2 $25.64 (Face to face contact two times (Weekly scheduled therapy, Level 2 $4.47
+$.66 Respite Care Level 2...$6.25 per month and/or occasional 4-8 hours a month with 4 hours of
($26 30) crisis intervention) Group therapy.)
it
a
Level 3 $14.79
Level 3 $14.79 ' (Regularly scheduled weekly
$32.22
multiple sessions,can include Level 3.......$6.02
8 • m
+$.66 Respite Care Level 3...$6.25 (Face to face contact 1-2 times
($32.88) per week and/or ongoing crisis . family
more than 1 person,i.e.fami•!i therapy,for 8-12 hours/monthly.)
intervention.)
Level 4 $18.08 Level 4 $14.79
4 $38.79 (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC +$66 Res Ete Care Level 4...$6.25 per week minimum,High level < multiple sessions, can include
Drop . p of case management and CPA more than 1 person,i.e.family
Down ($39.45) involvement with child and therapy,for 8-12 hours/monthly.)
provider, including on-going
crisis intervention.)
Assess. Assessment Assessment Assessment
Period E Period $26.30 period $6.25 Period $11.51 ;ii Assessment Period $0
(Includes Respite)
Ni t
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
.
ATTEST: , 1/4// }
Weld County Clerk to the t oard
d.
a ' WELD COUNTY BOARD OF
♦ SOCIAL SERVICES, ON BEHALF
I i8,: ta9 OF THE WELD COUNTY
' DEPARTMENT OF SOCIAL
r j / SERVICES
aft ir
By: Ln By: 114,
e uty Cle the oard . J. Geile, Chair Nov 01 2016
CONTRACTOR
Imagine
1'00 I' Ave
fay tte, C• 80026
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By
Director
8 Weld County SS-23A Addendum
X696 ���y
WELD COUNTY ADDENDUM 1j
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
July 1, 2006 through June30, 2007.
The following provisions, made this /S`day of CS/ the,- , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#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. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and his or her supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or intake
screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement. y'
'v
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
' 7
ac.c6 .3C5 y
wPu r„u,.,w QQ_11 A Add...d,,..,
9. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan
(IEP) for youth designated as a Special Education Student will be conducted every 3
years and reviewed every year. If the IEP is due while the child is in placement, the
Contractor will complete or obtain a completed IEP. A copy will then be forwarded to
the County.
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local) transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery,bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
C. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
D. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
11. Section V, Paragraph 5. Children in Psychiatric Residential Treatment Facilities,
Therapeutic Residential Child Care Facilities, Residential Child Care Facilities and Child
Placement Agencies are not eligible to receive clothing allowances as outlined in the
Weld County Department of Social Services Policy and Procedure Manual.
12. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the
enforcement of the terms and conditions of this Agreement, and all rights of action
relating to such enforcement, shall be strictly reserved to the undersigned parties or their
assignees, and nothing contained in this Agreement shall give or allow any claim or right
of action whatsoever by any other person not included in this Agreement. It is the
express intention of the undersigned parties that any entity other than the undersigned
parties or their assignees receiving services or benefits under this Agreement shall be an
incidental beneficiary only.
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to
constitute a waiver of any immunity the parties or their officers or employees may
posses, nor shall any portion of this Agreement be deemed to have created a duty of care
that did not previously exist with respect to any person not a party to this Agreement.
The parties hereto acknowledge and agree that no part of this Agreement is intended to
circumvent or replace such immunities.
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may
exercise the following remedial actions should s/he find the Contractor substantially
failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy
the scope of work shall be defined to mean incorrect or improper activities or inaction by
the Contractor. These remedial actions are as follows:
2 w.0 Cn,'nn,CC-71A AdA,,,A,,..,
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Social Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Social Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event in which it is a party defendant or respondent in a case, which involves services
provided under the agreement. The Contractor,within five (5) calendar days after being
served with a summons, complaint, or other pleading which has been filed in any federal
or state court or administrative agency, shall deliver copies of such document(s) to the
Social Services' Director. The term"litigation" includes an assignment for the benefit of
creditors, and filings in bankruptcy, reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 Wpin rnnnn,cc_ne AAdnndnn,
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for the following: Therapy;Medical
treatment; Family visitation; Extraordinary educational needs; Etc.,as outlined in the treatment plan?
00)one round trip a week or less ❑1)2-3 round trips a week
02)4-5 round trips a week 03)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
00)Once a month El)Two times a month but less than weekly
02)Once a week 03)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with
a regular or special education plan?
00)less than a'/x hour per day D1)1/4 hour a day
02)more than '/1 hour per day,up to 2 hours per day 03)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitoring of time and/or activities and/or crisis management?
00)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)at least daily 03)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate
needs with feeding,bathing,grooming,physical,and/or occupational therapy?
00)less than 5 hours per week ❑1)5 to 10 hours per week
02) 11 to 20 hours per week 03)21 or more hours per week
A I. How often is CPA case management required?
00) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
02) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T I. How often is therapy services needed to address child's individual needs per NBC assessment?
00)not needed or provided by another source(i.e. Medicaid) ❑l)less than 4 hours per month
02)4-8 hours per month 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ 0 ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ 0
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care 0 ❑ ❑ 0
A 1 Case Management ❑ ❑ ❑ 0
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 weld('nnnh,ccfiA Adda..dn...
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: DInitial Assessment ORe-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
(ri i ' 1 . {t+��Ii t) I{I�R�� 1 Pi tt i E1unl'''I u � G + t,
M III IIIIIIIIIIII! p 1�;�UIISIiii�M r
t i1 , n b 'e ki t, fl1t• 0 �'1 A Ip 1` ' 11i !, PliMplillii
.il'; I� l+f,,
[:' ''.''..':111111-r!11 I 11
•
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•�. n ; :It
?i' :F� ) ,{".!fi °1 ".y 1 h� I i s" r '� f • °i I
��t �} n i..4 01, , it I �i
� $ 1 ��� d N 1tk, Severe.at i (iu i"'i ,pin 01 {} �}i } i�,f,; ppppqq� �jj��� _If i IHAR1t �l,I.ir i� A l ,1 ii i f �. f
�� {{�1��I�t �HI 1 I�: _ 7i11M�I"tl�„ �'. � i .�.�. . I I � i. I+ {-L-1,iii
Aggression/Cruelty to Animals ❑ O ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting O ❑ O O
Stealing O ❑ ❑ O
Self-injurious Behavior O O ❑ ❑
Substance Abuse O O ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis O ❑ ❑ ❑
Runaway O O O ❑
Inappropriate Sexual Behavior ❑ ❑ O ❑
Disruptive Behavior O O ❑ ❑
Delinquent Behavior ❑ O El ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ O O O
Education O ❑ O ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
` '
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 El 1 ❑ 2 ❑ 3
5 wv1.i r,,,,.,..,cc-11A e`Llon,in n„
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
i ; Ili .IIII I'4!i Illitill'i I if I rII gird 1 II ii I i ,. ,_•LEVEL m I I I I'•I I a . MEDICAL NEEDS
• RECOM a yi„.i I ,, r, a }I It., 1113 . ,lI IIIIl4't` !l .. " Ill I ! I I j
, 0i `I l I l
� (I I G Irl�1�, { ADDENDUM
•
SERVICE ; ,�pROVI• •1, f r II r[ f I IIIf '`I i 1f l' l•' 1 I Li 1 r1}1Iiiip,� i I, I !1 i 1 I { I ,i f t.i I I iI` t'illi�'I .I.;:i!r}1I 1 if; I1 S li li I.Ili i11i i i 'I lY {I I it Ehl ( I A €.!rlllri I i's'" "' 1•
ii i, �Ijp ii. iiliillifli;ill
Level �d�;fl>tzll''' �:h;l ';�r�lf"pip ;glq:'l r I�lll�ll it,�II•it
,1'' 'tillr �������'�'����li ,' I11I'I�i I[ �•ilm i,ii'',r''`F��rill l .�l`'�Y .• ..ii '•i.
•
I I I Itip �. .r l' ',
a,di.l ri R 1 r .Mti:
+i�1 I ..�• TV...it .....f i 1� I �1. . �'��NIIIII Arm:t13t
0 Age 0-10...$11.47 II Level 0...$6.25 I Level 0li
$0 I Level 0 $0
Age 11-14...$12.89 (Therapy not needed or provided (None)
0i iII i - I by another source,i.e.mental
0 Age 15-21...$13.91 III' �� and/or II health.)
I . _ 'I I
+$.66 Respite Care I
I,:
,I l iI 1
I',
Lill
(l - Level 1 $4.93
1
$19.07 J jl Level 1 $2.99
+$.66 Respite Care I.I Level 1...$6.25 t' •face contact (Regularly scheduled therapy, i,
($19.73) .Ill I per month_ 4 hours/month.) }i
lit
I. Ili.
i 11
I rll ,
ill
fI�I i I Level 2 $11.51 III Level 2 4.
$9.86;;
Ilil }I i'f' ll i I
}r�? ,! r (Face to face contact two times f (Weekly scheduled therapy, •l
2 ;� $25.64 1 i EI Level 2 $4.47
+$.66 Respite Care 'If Level 2...$6.25 per month and/or occasional i 4-8 hours a month with 4 hours of II'
'>'; ($26.30) crisis intervention) II Group therapy.) ,,
,- III 1i ;.
,i r li III }J'
A, Iii II 11 Vii;'
i I•
i Ili; r Iii ,
I$ { III
Irl } I? ill
IIII i!,1 i Level 3 $14.79 II
a 1'Level 3 $14.79 �'i
i' !I I I (Regularly scheduled weekly '.1
$32.22 multiple sessions,can include Level 3 $6.02
3 ,!r +$.66 Respite Care • Level 3...$6.25 I.
(Face to face contact 1-2 times more than 1 person,i.e.family I
;' ($32.88) 1 r per week and/or ongoing crisis I'� therapy,for 8-12 hours/monthly.) i
11 !��� IIII intervention.) i I
,lib)!
,I•;`
t"ill I'
jr'i 'It
I1r!i
1, I la iii Ilih
f,, 11••1 ,1 i ,
Level $18.081 Level4 $14.79 to. 11
4 :II- lily 'f (Face to face contact 2-3 times I'i. (Regularly scheduled weekly Level 4 Neg.
RTC l5 $38.79 Ili. I <
iIfj "II per week minimum,High level iai multiple sessions,can include
Drop I ; +$•66 Respite Care Level 4...$6.25 II of case management and CPA lil. more than 1 person,i.e.family i
) It i
Down ($39.45 • i' involvement with child and '`i therapy,for 8-12 hours/monthly.)
r provider,including on-going ,f •
ii crisis intervention.)
" ' I' I iii'
iI I :ii
it; X1;1
Assess. Ili Assessment Iiil ;r, ii
yll Assessment Assessment
Period �. Period $26.30 i!t Assessment Period $0
(Includes Respite} III Period $6.25 'I Period $11.51 II I
li iii ( !EI ,i!
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
f 1
ATTEST:
Weld County Clerk to the Board
ti ' iii/7 WELD COUNTY BOARD OF
1861 t ` SOCIAL SERVICES, ON BEHALF
OF THE WELD COUNTY
1861 till
p'
DEPARTMENT OF SOCIAL
O tqs SERVICES
By: .it - .4 7-t!?lt_ By:
uty Cl c to the Board M. J. Geile, Chair NOV 0 1 2006
CONTRACTOR
Kids Crossing
1440 E Fountain Blvd
Colorado Springs, CO 80910-3502,,
By: // r l
f�:,�
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: -Th�
irector
8 Weld County SS-23A Addendum
ia26 -_3 es-y
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