HomeMy WebLinkAbout20062977.tiff RESOLUTION
RE: APPROVE ADDENDUM TO FIVE 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 five Agreements to Purchase
Child Placement Agency Services between the County of Weld, State of Colorado,by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Social
Services, and the following providers, commencing July 1, 2006, and ending June 30, 2007, with
further terms and conditions being as stated in said addendums, and
1. Adoption Options
2. Creative Beginnings
3. REM Colorado, Inc.
4. Smith Agency, Inc.
5. Top of the Trail
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 five 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.
2006-2977
SS0033
00 ss / /-D9 O�
ADDENDUM TO FIVE 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 25th day of October, A.D., 2006, nunc pro tunc July 1, 2006.
f� E a WELD COUNTY, COLOR DO STONERS
G1 � _�� •
ATTEST: !� � • €v��EXCUSED
�M. J. Geile, Chair
Weld County Clerk to th 1
EXCUSED�►�� „.,�I�� David E Long, Pro-Tem
BY: itt
Depu,, Clerk the Board
Willi m . Jerke, Acting Chair Pro-Tem
VEDAS TO •
Va Vt_
Robe D. Masden
County Attorney 4-ef
il
Glenn Vaad
Date of signature: II'AIUP
2006-2977
SS0033
a4kt
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
11 lip O Fax(970)346-7663
•
COLORADO MEMORANDUM
TO: M.J. Geile, Chair Date: October 23, 2006
Board of County Commissioners y
FR: Judy A. Griego, Director, Social Services CL 01
RE: Addendums to Agreements to Purchase ChiYd Placement
Agency Services with 5 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 23, 2006. The
Addendums are with providers for reimbursement during SFY2006-2007 (July 1, 2006 through
June 30, 2007).
A. Rates are based on Needs Based Care Assessment.
B. The vendors include:
Provider ID
Number
1. Adoption Options #45078
2. Creative Beginnings #39342
3, REM Colorado, Inc. #37832
4. Smith Agency, Inc. #44882
5. Top of the Trail #28112
If you have any questions, please contact me.
2006-2977
•
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Adoption Options and Weld County Department
of Social Services for the period from �� XI -9 AM 11 04
October 1, 2006 through June 30, 2007.
The following provisions, made this I9' day of 5,.; , 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#45078. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold 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.
1 wPu r,.�,.,n,CC-11A e &rho e- / 7/
• 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.
rJ
13. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to 3
constitute a waiver of any immunity the parties or their officers or employees may o
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 intendedt2
circumvent or replace such immunities.
o '
14. Add Paragraph 9 to Section VI. The Director of Social Services or designee may a
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 Wrl.l Cnnnh,CC-11A Addendum
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those 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:
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C )
3/40
O '
3 Weld rnnnn,cc_11A 4ddpndnm
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 1HH# 1DATE OF ASSESSMEI
AGENCY NAME PROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES I DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for the following: Therapy; Medical
treatment; Family visitation; Extraordinary educational needs; Etc.,as outlined in the treatment plan?
❑0)one round trip a week or less ❑I)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?
❑0)Once a month DI)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''/3 hour per day DI)1/4 hour a day
02)more than ''A hour per day,up to 2 hours per day ❑3)more than 2 hours per
0
P 4. How often does the child require special and extensive involvement by the provider in scheduling and 2
monitorin of time and/or activities and/or crisis management?
D0) 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 appropride
needs with feeding,bathing,grooming,physical,and/or occupational therapy?
❑0)less than 5 hours per week DI)5 to 10 hours per week
02) 11 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 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?
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 0
P 2 Therapy/Counseling 0 ❑ 0 0
P3 Educational Intervention 0 ❑ 0 0
P 4 Behavior Management ❑ ❑ ❑ 0
P 5 Personal Care 0 ❑ 0 ❑
A I Case Management ❑ ❑ ❑ 0
T I Therapeutic Services 0 0 0 ❑
4 Wald Cn„nh,ccJYA Add.ndnm
•
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
t r'',^7
....:::......
.......... .
:-.•::'•••:!1!:;:", :i.!:1::.: .. .:��.i. (Check... ..
t
� :�;
; . .., rttE
'ASSESSMENT AREAS Nt aMild : Moderate Severe Commenb•
Aggression/Cruelty to Animals 0 El ❑ ❑
Verbal or Physical Threatening El ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ El ❑ El
Stealing 0 El ❑ ❑
Self-injurious Behavior 0 0 Cl ❑
Substance Abuse 0 ❑ ❑ El
Presence of Psychiatric Symptoms/Conditions 0 ❑ El 0
Enuresis/Encopresis ❑ ❑ ❑ 0
Runaway ❑ ❑ ❑ 0
Inappropriate Sexual Behavior ❑ ❑ El ❑
Disruptive Behavior ❑ ❑ El ❑
p
c--)
Delinquent Behavior ❑ ❑ ❑ CI +
t
Depressive-like Behavior ❑ ❑ El ❑ No
Medical Needs ❑ ❑ ❑ ❑
Emancipation El ❑ 0 0 o
VI
Education 0 ❑ ❑ ❑
Involvement with Child's Family 0 El ❑ ❑
` CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) El 0 ❑ 1 ❑ 2 ❑ 3
5 WPM rettt.,h,SC-11A eri,iP,,,+tt..,
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)
0
-c
O '
VI
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 s` TI ;•• ADDENDUM
P1-P6 a t ti
Level Rate Admin.Overhead Case Management
Therapy � . ..
9
.:- (Admin.Services) `._
(Admin.Maint.) (Admin.Maint.)
0 Age 0-10...$11.47 Level 0...$6.25 Level 0 $0 Level 0 $0
. Level 0 $4.93
0 Age 11-14..$1289. , (Therapy not needed or provided (None)
Age 15 21...$13.91 (Minimal CPA involvement by another source, i.e mental
0 and/or no crisis intervention i.e. health.)
mutual care placements.)
+$.66 Respite Care
1 Level 1 $8.22 Level 1 $4.93
$19.07 Level 1......$2.99
+$.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)
Level 2 $11.51 Level 2 $9.86
2 $25.64 • (Face to face contact two times (Weekly scheduled therapy, Level 2 $4 47
+$66 Respite Care Level 2...$6.25 per month and/or occasional 4-8 hours a month with 4 hours of
($26.30) crisis intervention) Group therapy.)
14:-
Level 3 $14. '!
Level 3 $14.79
• $32 22 (Regularly scheduled weekly —a
3 • •
+$.66 Respite Care Level 3...$6 25 (Face to face contact 1-2 times multiple sessions, can include I Level 3 S6.02
($32.88) per week and/or ongoing crisis more than 1 person, i.e.family ....0
• therapy, for 8-12 hours/monthly.)
intervention.) ›i-
Level4 $18.08 Level4
$14.79/1
4 $38 79 (Face to face contact 2-3 times (Regularly scheduled weekly Level 4 Neg.
RTC + per week minimum, High level multiple sessions, can include
$.66 Respite Care Level 4..$6.25
Drop ($39.45) of case management and CPA more than 1 person, i.e.family
Down involvement with child and therapy. for 8-12 hours/monthly)
provider, including on-going
crisis intervention.)
•
Assess. Assessment Assessment Assessment
Period Period.... .$26.30 Period $6.25 Period $11.51 Assessment Period $0
(Includes Respite)
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
1 44O A
ATTEST:
Weld County Clerk to the Board
,�r ;cc 1/1 WELD COUNTY BOARD OF
1-4-- a, ,e ,i,.'- ;mot SOCIAL SERVICES, ON BEHALF
€FNt 7;z°�A, ' OF THE WELD COUNTY
,1?-61 �U c ?),Val. 1 DEPARTMENT OF SOCIAL
``"^ SERVICES
e'r0,
By: !' tic — By: --c1-1-77/w.-./
D uty Cle to th Board William H. Jerke OCTActing Chair Pro-Tem V4 2 '5 ?�Ot?
CONTRACTOR
Adoption Options
13900 E Harvard Ave, Suite 200
Aurora,
,CCO 80014 1
By: vl 1���i
�
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
i
By:
irector
t�-
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cm
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8 Weld County SS-23A Addendum
dace, - a97J
• WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Creative Beginnings,and Weld County
Department of Social Services for the peadd'from
July 1, 2006 through June 30, 2007. - t
The following provisions, made this ( day of S , 2006, are added to at 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#39342. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will he made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
1 Weld rnunw cc_ne 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 W h1 r,.,,nw cc_vae ead,n,d,,.,,
• A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Social Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Social Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
in a case, which involves services provided under the agreement. The Contractor, within
five (5) calendar days after being served with a summons, complaint, or other pleading
which has been filed in any federal or state court or administrative agency, shall deliver
copies of such document(s) to the Social Services' Director. The term "litigation"
includes an assignment for the benefit of creditors, and filings in bankruptcy,
reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 wau rem cc_fan nndpn,d,,..,
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 ASSESSMEN
AGENCY NAME ROVIDER NAME ROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR
CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for the following: Therapy; Medical
treatment; Family visitation;Extraordinary educational needs; Etc.,as outlined in the treatment plan?
O0)one round trip a week or less ❑l)2-3 round trips a week
❑2)4-5 round trips a week ❑3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
O0)Once a month ❑i)Two times a month but less than weekly
❑2)Once a week ❑3)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with
a regular or special education plan?
DO)less than a'/:hour per day ❑1)'h hour a day
O2)more than ''A hour per day,up to 2 hours per day ❑3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorin of time and/or activities and/or crisis management?
D0)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?
O 0)less than 5 hours per week ❑1)5 to 10 hours per week
O2) 11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
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?
O 0)not needed or provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 ❑ ❑ ❑
P 2 Therapy/Counseling 0 ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ 0 ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management El ❑ ❑ ❑
T 1 Therapeutic Services 0 ❑ ❑ El
4 Weld Chun,.,CC-11A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
t 6E�mlrr
ill it t P ' rrl'1! I ! I i a ! r s 0i Nq1�0•II; fir)�i
ttF� .p jai �1 r eit+�itdd�1�,iliiii m,'-
f•)fiiCf9 + c rili 1rr'� .'ix fie`r i,',!;,:.4,,,!;'.1,:i i 1n. )I �i. 1l'j,^, ; 4 '
rrd.G;I I�wI , r r as ` �iS i#u ill .m C i rrd)t�n.
# m r*sj r I '*^1 PW k 11 ��;��,l r r r P r.. r ;rikfi 'i" ^' 1 r riVI
iia,, i-i?'-.1,,.,—;• ^�Y ' {1 r ii iiJru"x� ', irr!:, r
i T li 1 n : I„; ve'{ii ��,4J r z t£e
.�...b; ..... , 1 d 'dtvr'u titi,i'a'.,u; .l
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing 0 ❑ ❑ ❑
Self-injurious Behavior El ❑ 0 ❑
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 ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 El 3
5
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: (Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
mr,y'JI �'„ i(,r 4") i - ' '�pI 'i R i'N'r 1p I !"i," !(I I ,I i), rJd , i .: I'9 li 1 "? f l a ! `�° y,i{Y' ' 1.
1311::`
d r �i q ;, i� 'I ! �I t f' ,r , ! ,(i', Weld t,ivh I�I') �'$, {+ 'It 1 ! _ �If i!;l I J i ,1, m I Io 1 r it ,h i.1.14:41!;1:.1.-;;.;;'.9r.
Ito I ' �,.. {r ,rerttt - .A Ili 11 t 'll, hr n li u a r�
x 'a i r + , ;''''--;;;4;911;!;)9!‘!;1 I I ,,I �+ 114 ar 1+.. i I) !1,r�1, 'i a d ky,t . 9)ap 4 '+ •
1744'.,i'":riiJ I j, t 1 , i llll i # Ui I � y) Tx
«� i l t 'a , I, I I, I 'h } + s ! , , I ! !poor",pI hlq, tae"$9 fr n.(y.4' .
I� I .iw 1 - , ' 994,49 , IIII;h1'r ! ! v�d� „ Ir JI + iii t' v 1 1, w+.
! : iii 9 4 ( i 1!,'!;;9911 �� Q r. N r i19.4i Ii 9I 1 t i wt ! u
r r , 1 ! . Ira) I Ij'' NIio§ :.;WHIP-Oilb 'rl h ! �iI �..a
x�fiul' ,�' • ..a -•i! it!( t I,r I I, 1 1 iii µ°9f�I'6 'kis -girlIII, Ia �` ,I n, , i ifa
' (,r., x ltut.dln + a 9 r :I 99,9 F.u.....--
'"r , If,,1T , ; - 't III i�tl �� 1 , ' ,,, , v, I rq�,, �- -j1 'III
" �gg �„�,��vR �r5��1(IjNLL
'+ , ' �.+ , i 'I,11 r•fl a
1'' .I''i ,i Y) I- r , c' 1>f'} !alt ; + I 0rt,t' al1� ( . Ii II rE a D !�, m x I ,t L�raj till
('la,-r1 I
Till y04.,;;„t - ,! Ja Fi . ,,I,.I,I I (,I !, (;,il , r Nsrl,' Ili I ,( , e x a,.7�4 'HI. ,1 A 'A'M r lit C : W , :U.1t �I I r� 0 ,,'t�I.bd�ilJ t:ll riulk ,,...I.I�, .:e.:,l:hlu,t �,.,,:� �,II !�u�....11llR1 :;2r:�tt rt�tHliall�mltllullIn �r 8m ,'urL
r W+ �u�( T!�g
0 Age 0-10...$1147 Level 0...$6.25 A.1 'I'§Level 0 $0 y! Level 0 $0
I
ilk Level $4.93 i�_
0 I. Age 11-14...$12 89 Ilin irl I. (Therapy not needed or provided 'ill (None)
(Minimal CPA involvement M I by another source,i.e.mental ti)I
0 Age 15-21...$13 91 r; '�'i and/or no crisis intervention i.e. IA health.) i,
„' mutual care placements.) 'hi !e
3 +$.66 Respite Care ilk ia )
++. Level 1 $8.22 f Level 1 $4.93
1 i + u d Level 1 $2.99
.1. $19.07 IV l': i li„'
+$.66 Respite Care ''( Level 1...$6.25 {7( (Face to face contact one time +,M (Regularly scheduled therapy, t,
ill ($19.73) !( per month and minimal crisis 4 hours/month.) li
Er I pii intervention) II ;11
I'
:r rlt lr I'1) xir wl
h Al�
AA, ,�f A 1 Level 2 $11.5111 Level 2 $9.86
_I ,1 (Face to face contact two times ` (Weekly scheduled therapy,
2 911 +$.66 Respite Care Ir1 Level 2...$6.25 a., per month and/or occasional ,l,;1, 4-8 hours a month with 4 hours of Level 2 $4.47
($26.30) II„ -, crisis intervention) ,, Group therapy.) ,)
I; lei
t)!ill il
I,
fii
"� ifI Ai 1
1=t I i
i '' Level 3 $14.79 1
1'I I {Level 3 $14.791 I
I il 1 ; It (Regularly scheduled weekly :j
3 $3222 , { �- multiple sessions,can include 'i Level 3 $6.02
1.1 +$.66 Respite Care 1!( Level 3...$6.25 , (Face to face contact 1-2 times .! more than 1 person,i.e.family ?N
($32.88) III per week and/or ongoing crisis
9 ,. 'i therapy,for 8-12 hours/monthly.) ,!
�* intervention.) 1; 94
If I
il1 ,.
l :, 0;;Level 4 $18.08 ,I Level4 $14.79 l L.4 ' $38 79 y i (Face to face contact 2-3 times I ) (Regularly scheduled weekly ! Level 4 Neg.
11
RTC '� ! per week minimum,High level ; multiple sessions,can include
! +$.66 Respite Care . Level 4...$6.25 :
Drop 1 ($3g 45) 1 of case management and CPA ! more than 1 person,i.e.family t
Down 1, ill involvement with child and ,jr therapy,for 8-12 hours/monthly.) i;,
b provider,•including on-going i,
('gip l;-;! crisis intervention.
fa
.L 4: Ii. 111, Y
is ) ( k,
Assess. Assessment Assessment r., Assessment ! �
Perod Period $26 30 period $6 25 I Period $11.51 } Assessment Period $0
(Includes Respite) ;�
F.:i NM :9t
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.
/11
ATTEST:
Weld County Clerk to the Board
{ , ir ',"a WELD COUNTY BOARD OF
11 °,r,s, r" c� '`t
:„� SOCIAL SERVICES, ON BEHALF
o „ f - OF THE WELD COUNTY
Y'.1- „ , „ ° DEPARTMENT OF SOCIAL
SERVICES
p
By: �l By: '2-7 / 1' u(
puty C k to the Board William H. Jerke
Acting Chair Pro-Tem OCT 2 5 2006
CONTRACTOR
Creative Beginnings
7100 N. Broadway Unit 6-0
Denver,
BY: �.t Jk-d --
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ctor
8 Weld County SS-23A Addendum
02666 7/
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between REM Colorado, Inc. and Weld C>unty
Department of Social Services for the period from .;
July 1, 2006 through June 30, 2007.
O
The following provisions, made this I day of J74 (j , 2006, are added to the referenced
Agreement. Except as modified hereby, all terms of the/Agreement remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#37832. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County,prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II, Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
1 Weld rnunn/cc.9lA 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 Wald rnunw CC-11A Adrian/him
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Social Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Social Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
in a case, which involves services provided under the agreement. The Contractor, within
five (5) calendar days after being served with a summons, complaint, or other pleading
which has been filed in any federal or state court or administrative agency, shall deliver
copies of such document(s) to the Social Services' Director. The term "litigation"
includes an assignment for the benefit of creditors, and filings in bankruptcy,
reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
cc_'lA AitiA,d,A,
• • WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
•
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX trails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT HH# }DATE OF ASSESSMEN
AGENCY NAME ROVIDER NAME 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 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 ❑l)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 ❑1)Two times a month but less than weekly
02)Once a week 03)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with
a regular or special education plan?
00)less than a'A hour per day ❑l) Yz hour a day
02)more than'/2 hour per day,up to 2 hours per day 03)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and
monitorin of time and/or activities and/or crisis management?
H0)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 ❑3)21 or more hours per week
A 1. How often is CPA case management required?
00) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
03) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
00)not needed or provided by another source(i.e.Medicaid) 01)less than 4 hours per month
02)4-8 hours per month 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling ❑ ❑ 0 ❑
P 3 Educational Intervention 0 0 ❑ ❑
P 4 Behavior Management 0 0 0 ❑
P 5 Personal Care 0 ❑ 0 ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services 0 0 ❑ ❑
4 Weld rn„nn,cc-71A Addand„n,
• WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
•
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ['Initial Assessment ORe-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
d1 : I, "'0....:I' i 1 :::11';'',.•!..' iN) r•a1,1 '.rA ,:, Ki,I.,:
" .:e e.. nue ,..',..,,.,..,/t.,g , j ... , n 1 u;F, xuJw..
, .' , . i ii Ei,� iI1iUKd i' ^#s $ 3 i. I.�Ii1 i; Y4..
).;: 1 f3§i ' tfl .z y a �1, yi l I'(1 `n ,AIII { i:, ��YSa, n ,
li itlua ,,,, ..1 jlnxu!, lit ad , :daidru, �
if ,i e
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ 0
Stealing ❑ 0 ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ 0 ❑
Runaway ❑ 0 ❑ ❑
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 ❑ 1 ❑ 2 ❑ 3
5
•
• WELD COUNTY DSS
•
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of PI through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
' WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
•
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
•
(Attachment C)
1 1 r i ;i: i n , 4,: tl r• r ,, !I _I +, P rr Pp, .1) I + -
:ii 1 '+a ) � z." f; 7- r I! k , 1 7 ,.,:;,:{4.,Ir i i , Pi.W+ r Ia l- tigti.u6r1., 1( 1 I ( y _1
{ , d j: I I 't li, t tiq x 1, l l 1 l Ti"f v { �{ i 4
i la ul ,JI +' ii ', l i , ' 1 ( ri,t: .l �nl it i f : ,Ir ,lb!!! 1 t: '.M 1 tki.uI kk I:r i�+i.,:t t i f�l�e. ti r.� a r.
r i�111l r �i, I lli, iiiJ +, 7 ' _ t '
.; ti r q r r: 1 aI p ., 7M1i Ii i ' '' tlii t hA ;I 11
i pu, �, i ; 1 i P (III ,' i ti 1 ii i t I � I 1 4 ' t� r .
'4.41
5 1 ■ i i 1 i1 i t li s i t 1
» a i I§t'� � n a In 7 a.' I ' , 4'O1r4`,4
tl I I t',l li"i r� , il,!) ,444,40$ ,1�1�� yl'tu'tY l Id prg9i _� 1� , it
1 i9 , II`�1 (i r rd,;::.I..,-1;)'• I I ( i I l : 611 i i I !Nili ( ,.P i jir l l ' ipi i IPPN'i ih; {{ 'I " it I
la 6c" an;. j l�ii - i lI, ..;Vic,!-..,1}};!1!,}11,.,,,..l,...,,..,', 1 . f 1 III r t 5 ,1 I„ -,iill iI, 9I , i6r1! I . i raft
ro dG r (,l 7' P+II ,d i all 1_1,1'' ✓' ', ( u 1,I!i1 r! i 1 i I I' i'X i3O":„.,:,,,,-,,,Q, ( , I 1, Y1 'i '
tfi11 0 1 ; i li:olioi it ti IIf. 4 Ir'i r f 1 , I. :tt' 11 I f 'ill11' ,i 1 ,ii} w- ,1+���1 , I b i,', 11 I
44( i , ' tl'I,) it '4.114 1411 ( I t.t.lo�it r i l 'll ril ill ilia, rdi P M tj, Iqs - rlii - U+JU/I ,H ;. t II Y,.it ,, i.
!. '�sili Fr':'1.4I'iJ, u i 1 , I iii. '� I i• r ' Irl'I, ' la ti i a 1 't,..';;;.,/,:!,, l - r t4,�tt,�.� - (. imild C! ; 1 1 F + 1 l<t 1 16 a ti's.1.. ,. , Lif;itt- )y: , .� Il l: As •7
III eN�� ndluli,Wlli a,lltanar.7 �tC �.,,.,.....( . �IIL l lhudbl.I. 6..n . . ,,,,•,...• d ,dv dmu urw . wsldW x �x1.a
I.., Age 0-10...$11 47 ',j Level 0...$6.25 i i• i 1_Level 0 $0 :i Level 0 $0
,t Level0 $4.931;, +'
,• Age 11-14.,.$12.89 i II p b' (Therapy not needed or provided r (None)
y 1 a (Minimal CPA involvement f by another source,i.e.mental ji
0 3p Age 15-21...$13.91 I 111. and/or no crisis intervention i.e ilil health.) I
' , i: mutual care placements.) i �".;±
+$.66 Respite Care ) IV. Get 111 ( GGIIIIl
T Pt PIP inf :t
'"� i 'I"Level 1 $8.22( t Level 1 $4.93
1 yi $19.07 1'11 s' 1 j,,1 Level t $2.99
n +$,66 Respite Care III: Level 1...$6.25 1 (Face to face contact one time (Regularly scheduled therapy, li
'Ili ($19.73) i �j1 per month and minimal crisis g 4 hours/month.) I
:I , intervention) .l
I Illi n°
,.r
is
•
iI T.:Level 2 $11.511.r Level 2 $9.861,1
Ili ''
I $25.64 (Face to face contact two times '. (Weekly scheduled therapy,
2 j� y9 �'j er month and/or occasional :, 4-8 hours a month with 4 hours of j g Level 2 $4.47
+$.66 Respite Care ., Level 2...$6.25 p i,'
1` ,cj •-' crisis intervention) Group therapy.) _.i;_
1111 ($26.30) ,1. r.I!
e
h: i
i
i
t l Ii i 9
} ' i' Level $14.79 I
:Level3 $14.79r
$32 22 , , (Regularly scheduled weekly •.,
3 y I ' multiple sessions,can include Level 3.......$6.02
1 +$.66 Respite Care i Level 3...$6.25 tt (Face to face contact 1-2 times :•
ii ii ! more than 1 person,i.e.family
. ($32.88) !_ :' per week and/or ongoing crisis („ therapy,for 8-12 hours/monthly.) t
li.
il intervention.) i1. I.
,
•
RN_d.
."Level 4 $18.08 '1 Level 4 $14.79
4 1'i $38 79 (Face to face contact 2-3 times (Regularly scheduled weekly j Level 4 Neg.
RTC hi.. +$,66 Respite Care Level 4...$6.25 '' per week minimum,High level , multiple sessions,can include ;
Drop of case management and CPA r i, more than 1 person,i.e.family 1l
Down i ($39'45) ' i.. involvement with child and F,. therapy,for 8-12 hours/monthly.)
'1 1'111 . provider,including on-going I/ ('}
- 114' I�1 crisis intervention.)
;Li 11; 7'a
I N.
Assess Assessment ':
Assessment Assessment
; Assessment Period $0 M
Period I Period $26.30 Period $6.25 i Period $11.51
(Includes Respite) I I
,., it I'1
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day,
month, and year first above written.
ATTEST:
k,£Tru '1 �U' v"""1 �,
Weld County Clerk to the Board
/:' ,r`; w`"'.., WELD COUNTY BOARD OF
\S-
' °e.) SOCIAL SERVICES, ON BEHALF
Pi`.,„` OF THE WELD COUNTY
Isar --, 4 DEPARTMENT OF SOCIAL
SERVICES
!(ki N
By: a' 4 By:• — //i.(
'
putt' rktot Board , William H. Jerke Acting Chair Pro—Tem OCT 2 5 2005
CONTRACTOR
REM Colorado, Inc.
4815 List Dr, Suite 111
Colorado, Springs CO 80919-3340
By:Jann € so $.29-0‘
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
D ector
N
8 Weld County SS-23A Addendum
acre- 0199 27
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Aw�cy Services
(the"Agreement") between Smith Agency Inc. and WelW(rty
Department of Social Services for the period from
July 1, 2006 through June 30, 2007. q
/0.•
The following provisions, made this / day of 2006, are added to the refe of ced
Agreement. Except as modified hereby, all terms of the remain unchanged.
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Attachment B, shall be used to determine levels of care for each child
placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#44882. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number (970) 304-2749.
7. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
1 Weld r,.,,,,r„CC/II e aAdend,,..,
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 4 ement, the
Contractor will complete or obtain a completed IEP. A copy will then beiwvarded to
the County. /*1
4
10. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: sp
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 Cr.,nt,CC-11A AAAnnA„rn
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 oRi erables which
have not been performed and which due to circumstances caused 4,e
Contractor cannot be performed or if performed would be of no value tW�e
Social Services. Denial of the amount of payment shall be reasonably relied to
the amount of work or deliverables lost to Social Services; .Sp
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
in a case, which involves services provided under the agreement. The Contractor, within
five (5) calendar days after being served with a summons, complaint, or other pleading
which has been filed in any federal or state court or administrative agency, shall deliver
copies of such document(s)to the Social Services' Director. The term "litigation"
includes an assignment for the benefit of creditors, and filings in bankruptcy,
reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3 WPl,l rni.nn,CC_11A Addendum
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
COT
IDENTIFYING INFORMATION 4
CHILD'S NAME STATE ID# SEX Trails Case W }DOB
Sex I 4�
WORKER COMPLETING ASSESSMENT 1f1H# !ATE Oh j6SSESSMEN
AGENCY NAME ROVIDER NAME I ROVIDER CWEST ID S�
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 I. 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 Di)2-3 round trips a week
❑2)4-5 round trips a week ❑3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0)Once a month ❑l)Two times a month but less than weekly
❑2)Once a week ❑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'/1 hour per day ❑1)'/,hour a day
❑2)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
monitoriny_of time and/or activities and/or crisis management?
D0)less than 5 hours per week ❑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 DI)5 to 10 hours per week
❑2) 11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) Minimal CPA involvement per month and/or no crisis intervention i.e.mutual care placements.
❑1) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
❑0)not needed or provided by another source(i.e.Medicaid) ❑i)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A I Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 wniA rni,nh,CC-)1A AAd cued„rn
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued) lGG
'9 RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPi,A�-
3rp
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. A
9
Assessment Period: ❑Initial Assessment ORe-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
R7'j�d t F rI "xi ti, cv, # ,i tE t i i I i41 G n. n
j V'; h+� 117tj(* '�' " a.K ' } °` '}'�F='x' } .+ 'lnp i i i �,,I��i� 4 ")` s i�M�ai� r ���`'i;qfiglphi,1„„„,,,,,,,,,,..,k,..,,,i . e.m.,. ., a du3 r °d...;:: usit cw8�i a�
d:4, r . X'5"€' 5 *z i iIt9:I `i 9 �"Ti
It 4 t .l6' ��u $ �T, c i ':!;'',I'll'...-.Pi � , ti� i � T= _ v ,l,n�
rt }' , . . c„-,, ��Et — ,..-'l 2,...- - iii t Ilotr'`z „ i i P'I� wi7w "�
� � 4 I f u � � 5 h. I 1 1
qi , ±as ui J j , '. tv� 1 el_ i II.a I
ilikkrittkii � 1 ....", ,,iii,,i1;,....,0.:n w'.- .w.. : ha.hd'`�,tha �a `dur'4�WlasuH�Iwl �.,IL».�'�.ia �'A" �Ic� iil'ti!$I '� �, �...�; +.
Aggression/Cruelty to Animals ❑ 0 0 ❑
Verbal or Physical Threatening 0 0 ❑ 0
Destructive of Property/Fire Setting 0 0 ❑ 0
Stealing 0 ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse 0 0 ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ 0
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ 0
Inappropriate Sexual Behavior ❑ ❑ ❑ 0
Disruptive Behavior ❑ ❑ 0 ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior 0 0 ❑ ❑
Medical Needs 0 ❑ ❑ ❑
Emancipation 0 ❑ ❑ ❑
Education ❑ ❑ ❑ 0
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL:
(check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3
5
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
ter
SUMMARY-Please identify all specific requirements and expectations which support Level of Care. GCS
LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
PERIOD 1: LEVEL# 4,,
Comments: s9
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 �Jm
Calculated as Daily Rates
(Attachment C) .UGC
'9
+r iHh l.t si+92-tp.Y"f5Taii I. I { d ><, $, -f 61 II �,d1Piip(��i !i'To n,1,il 'i.`P I'q iI 11 1 Inh[i fi'�::Iy�Iv't I, F Y 7 'i:!
of ,I s 4f �!e 1 r i 1•' iitsilh{Vd - li II �i ti)(-m- l } l{Iirfl,y W09 :till; t1 uwIii r 7ii'm+d ,i@+ ,It
x a �'� zl !1 I,�, )N,;�, } .I � �.� rl tt�lC� � (00lii,� 61.�III l�� {!� p� � A'� � i � � iti� i�;~,
!ti'. '� tat , 1 I iI ll• f !- 't 1 f i 11 I i l '!I I fi hA 4 !.K v I ( �I ir• ry li�a I'I 'NN r IM' I) �, ,.iyJ U,ItiI i i t ftli
I i1 I trI 1 111 '! + I)' , {ly 4i w n M
(±,✓,.):.y I 1.'-. b''f i III, i ,011,10111,11.111 i II110111I I i ) ! {1 f it jf ,_� 4 11 i ') dtLlll,�q ��fi;10+1111010010t1� i-!11 L II G i 4 IL t 1 i,I
V!I 1 ,7 1 ; ,;111,10,1';',100'"1 i ( ' � ,tl i it I l! ,•14! 1,0',:•01;;;;4111,0 0 E 3 IllLL tx Ikl l lfl All 1 ', I) i li�{'.11
410.;;;.0•,•01;„;•...,i;I K - ,40:0;,..,Q0,00,. i i 1111 i ! ! 'd :,,t i�h d-p f.kikjl Itf , �! ! I ' rll q , '1'
( ` - I 1 I 14- III 1'I i U k! i I i t I I I i It .
,,. 1} lr ., d la ..{ 1 I •: '. !I•I I I kill',)IIII i'__ I w'I I i'k J 1 w o{ 1. 1 v 9I I AIG I
IIN yI I F t t 1 I I If 1 .i'Jt1 Ill I t,l r l' fD DAN'Mu+u xa ' a. I l i
ri Nil LI1 f i I ( ili - , IfPill.)1 1111 I.I ! (tlrk' t 1 it ! t+.
i., xf I { t 1 I I 1Ir ( { ,Ii � a I i I t il ' .t i I
I � 11 l II i r (!I I l .!I li i I I11' ' Ii1 A ,Iii I 4 iip :.�i..�� 1, I t ll l llt � I It i
' ( I 'I .:... I.I w:411 if:..a.:...ii Iv 1.. lia:id Ural:: 111,! y!I�fak ( I !!ry;It a, k ,1. ' :ii , 1 I('
7�iG;I ��We�i�;sl,u,Y .I.......n 1 _i. .i i 'ua_.L.)a,uv�i'f11�I I I a61I!II.Ju a.�..15111 ���u3i9i�h' 'i- �:I!�",��� J..Y I �°. .. .!7',I i;
$1≤ II �I, I ,f,
0 Age 0-10...$11.47 'f. Level 0...$6.25 ,;� 'Level 0 $0 i�ry. Level 0 $0
I' ; Level 0 $4.93 Eli;
C Age 11-14...$12 89rj' I I i; 4'4
g ! , ii i! (Therapy not needed or provided I I. (None)
4;',
iJ,�J,I (Minimal CPA involvement l by another source,i.e.mental t"
o Age 15-21...$13.91 h. P�' and/or no crisis intervention i.e ; health.)
V „, mutual care placements.) `,' u
I +$.66 Respite Care Ij !'I,, W e
i..:i .n (I..4_ M
:.Level 1 $8.22 :Level 1 $4.93
1 rzi ° (G Level 1 $2.99
n, $19.07
fill +$.66 Respite Care 1 Level 1...$6.25 I,II (Face to face contact one time f i (Regularly scheduled therapy, ,
ii ($19.73) i t Iii per month and minimal crisis I! 4 hours/month.) iM
,wS ' intervention) i IN
Ti4
',IS 'l.l i+ i .p
L1 ,,,,,•, ' .'. a:IIIII;' {Level 2 $11.51 Li Level 2 $9.86
I';
$25.64 (Face to face contact two times I ., (Weekly scheduled therapy,
2 Level 2 $4.47
i5, +$.66 Respite Care Level 2...$6.25 I,. per month and/or occasional 4-8 hours a month with 4 hours of
k'y' ($26.30) crisis intervention) + Group therapy.) i;
9 I ra
I' L'ii
r.. 4
is! .4..
ill i,, I1'Level3 $14.79Ct
( - . :Level 3 $14.79 (Regularly scheduled weekly
3 $3222 multiple sessions,can include , Level 3 $6.02
t . +$.66 Respite Care Level 3...$6.25 ._ (Face to face contact 1-2 times t•- more than 1 person,i.e.family .;'
Y ($32.88) per week and/or ongoing crisis i thera hours/monthly.)
., 4 intervention.) jl py:for 8-12
',41Ii
i,.ii u:1
9 it, k';
, ; 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 Respite Care Level 4...$6.25 per week minimum,High level multiple sessions,can include I;,
Drop I „ ($39 45) ' of case management and CPA I more than 1 person,i.e.family ;;l
Down it I involvement with child and ,i therapy,for 8-12 hours/monthly.) -:
1 1 provider,including on-going
'I crisis intervention.) "' I.;.
€a :.:;1 .>.:! 'ill! t,•
d.
i
Assess I Assessment ! ' ,� I
Period Period $26.30 Assessment ,,., Assessment 'Assessment Period $0
Period $625 n.- Period $11.51 a„
(Includes Respite) , , +
Effective 07/01/06
7 Weld County SS-23A Addendum
IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as o jf.the day,
month, and year first above written. �a-
4
ATTEST: nt / 'l/�Ll _ -0,.
•
Weld County Clerk to the Board OO
'-- WELD COUNTY BOARD OF
s = SOCIAL SERVICES, ON BEHALF
w OF THE WELD COUNTY
issi . i er' '*, ' DEPARTMENT OF SOCIAL
1 , SERVICES
a , iH
By: CJJAkill -4i(L '1; ; By: l., ( ir/v,_,/
puty Cl to 1 e Board William H. Jerke 0CT 2 5 2006
Acting Chair Pro—Tem
CONTRACTOR
Smith Agency Inc.
7169 S Liverpool St
Centennial, CO 80016
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
ector
8 Weld County SS-23A Addendum
aoc6-aj-7J
WELD COUNTY ADDENDUM
To that certain Agreement to Purchase Child Placement Agency Services
(the "Agreement") between Top of the Trail and Weld County Department
of Social Services for the period from
July 1, 2006 through June 30, 2007.
The following provisions, made this / day of 0, 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#28112. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. Section I, Paragraph 2. All bed hold payments for a child's temporary absence from a
facility, including hospitalization, need to have prior written authorization from both the
caseworker and their supervisor before payment will be released.
4. Add Paragraph 6 to Section I. A minimum of one polygraph test per Colorado fiscal
year, if needed by the child, will be furnished under this contract for facilities that
provide sex offender treatment.
5. Add Paragraph 7 to Section I. Any additional costs for specialized services, which
include, but are not limited to; polygraph tests,plethysmographs, and urinalysis screens,
which are not provided within the negotiated provider rate, will need to be authorized, in
writing by the County, prior to the service being performed. Any payment for specialized
services not authorized in writing will be denied.
6. Add Paragraph 5 to Section II. Contact by the Contractor with the County regarding
emergency medical, surgical or dental care will be made in person-to-person
communication, not through phone mail messages. During regular work hours, the
Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake
Screener of any emergency medical, surgical or dental issues prior to granting
authorization. During non-regular work hours, weekends and holidays, the Contractor
will contact the Emergency Duty Worker at the pager number(970) 304-2749.
7. Add Paragraph 13 to Section W. Agree to cooperate with any vendors hired by Weld
County Department of Social Services to shorten the duration of placement.
8. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14
days after placement, dental examinations within 60 days after placement and forward all
appropriate information to the County.
1 WAld/Mum,CC-11A
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,,nn,cc_11A Addendum
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
Social Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Social Services;
C. Recover from the Contractor any incorrect payment to the Contractor due to
omission, error, fraud, and/or defalcation by deducting from subsequent payments
under this Agreement or other agreements between Social Services and the
Contractor, or by Social Services as a debt to Social Services or otherwise as
provided by law.
15. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in
the event that the Contractor learns of any actual litigation in which it is a party defendant
in a case, which involves services provided under the agreement. The Contractor, within
five (5) calendar days after being served with a summons, complaint, or other pleading
which has been filed in any federal or state court or administrative agency, shall deliver
copies of such document(s) to the Social Services' Director. The term "litigation"
includes an assignment for the benefit of creditors, and filings in bankruptcy,
reorganizations and/or foreclosure.
16. Add Section VII-ATTACHMENTS:
3
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE BO SEX Trails Case ID f OB
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?
❑0)one round trip a week or less ❑1)2-3 round trips a week
❑2)4-5 round trips a week ❑3)6 or more round trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0)Once a month ❑1)Two times a month but less than weekly
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'/n hour per day ❑l) '/x 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
monitorin of time and/or activities and/or crisis management?
D0)less than 5 hours per week ❑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 ❑I)5 to 10 hours per week
❑2) 11 to 20 hours per week D3)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.
DI) Face to face contact one time per month and minimal crisis intervention.
❑2) Face to face contact two times per month and/or occasional crisis intervention.
❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention.
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group or more than one Weld County foster child is placed with the same provider.
T 1. How often is therapy services needed to address child's individual needs per NBC assessment?
DO)not needed or provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ❑ ❑
P 5 Personal Care ❑ ❑ ❑ ❑
A 1 Case Management ❑ ❑ ❑ ❑
T 1 Therapeutic Services ❑ ❑ ❑ ❑
4 Weld(`nunry CC-11A Addendum
•
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO
THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ORe-Determination-Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT
PLANNING.
,t r 4 I �0 i i �,ryh dd
t `A� lx , `# a tai. t i111,I -1r7i r a t i "1�N1, Ii,1+tt�.t
t a �J.wrak f e k�i�� kt �fa"1 'u'�`,I �id�ii �ll �1I ti:ta x
II - T v Ii f 4,l:ili c
° :+.f•'''•:::;),").•::•!;:i:
P i/I k }I !D,, ti i.. +kl'"•••••'::::,:1:1,' li'.,,.:.1,!••;':•1;1:::::111::
Ii 1114 ro+ a ; '''';,::1::,11•• i : i ps „� i�li. 1VIi'
iy I,. t =TM$,k. .ai iti�,�h • :i 3 lj i° tF�l�i}jl �11�11�� Iti��..
la
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ 0 ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ 0 ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ 0 ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ 0 ❑
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, Cn,l.,n,ca»A A,lnpi,iu..,
••
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(Attachment B Continued)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
PERIOD 1: LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Tl)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
6 Weld County SS-23A Addendum
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
i'i#aia ih ,�%d,I q,(�i 111 i,,li ai ,t4 aA r FM: I i ,, ppw,„„,,„ii ���I r t 0,i el t fir+ I m,.
y `�� 'Vc d Lk I VI I I; r I' C I 1 a x dliii,il(,Iiii r4ttl Iu I i y a.,llri�. a� ' " d), "." � a i
a y I- 1 , �,I Iw I (i• a� i Fit, G t °'ipr r�„l h
IrI A iM A p , t i f . -F. tl Ili)% hl i it �IIII �{ t II �� i i14 �
�'," ti 4 k A, iR I i I Fi) - � I i i ,I � ,I.I I t,�(ir, , �i�"t .a l"�'I �.'Hi `. ( !. ��1 V'gn
i 7:"L ( i'i. N vi 1111 , ,I is ,I it i it III. (i i �M ii, it iA' id*
i i x I ,y7
jai-s- e I d i I r ,,,, n ( ��#I!% iih ,'6 ui ,y leIpp�I ll;le I Jere
a e,I4{����"yj'w i ripe I i S"`ppl (xefi` e ::
A ry � l I' , I, { +AIM i�I„ I0II I N !127 R'...,",,...,,. th ,III I liti4
k i II „ ' f i „ , Illli@ I i9Y`t1 ,i i.�g II l 4 rl 7 '� it {,�y3�,6�11w�`�! is -
kkiili tidlikiidhl ' tl{,, I ... x III'.h. 1 1 , ';(d I ilir) (r II I% 0iln is J }rllr II N,.r , 1 q Na i G III � §r.'1 KAP r.ili:V.l' .RII
p ;p. i NINA a i I aIhhh , t I , i A t, Ii,i , q ,i IIIIP x i i 11, y • i -0 I nil I i•i,k,, jd
F. rJ'I Ix , i,, %,i r I I , I ,,, ,ij µ �r' i iii i7i'l,li� bit ,t,I Li I� I,i) IT% *I'll1 ' I. pit't
# i i r I i i i 'i i r
1 i , , e4 n i t• ,I i ,., ar!t p z
.., L' PIN I , i i i i, I I 1 hi Ihi l i x.i ' n. 1' '11
q{.'� 1 r
akrilrLli 'I gl5n WUWin:ht.',;v; gi' IL, 6 ,,.an .II �ua.�.v. i,l',I.I I,i�6I�rhd§4a.•N hi..I �i�I��idl "i t�I�ii ` i L� F i SIk9Yi
„ III!,IN
Age 0-10...$11.47 I I Level 0...$6.25 (i Ali Level 0 $0 Level 0 $0
0 HI, Level 0 $4.93 i
I Ii
0 a; Age 11-14...$12.89 ill , . (Therapy not needed or provided i (None)
III 1;i ,hi (Minimal CPA involvement II by another source,i.e.mental
0 Age 15-21...$13.91 U9l i.
i and/or no crisis intervention i.e i health.)
le i mutual care placements.) ,)
+$.66 Respite Care iAl1.II r i..
II. iIm I,
I I I iIi r i Id'i VI
, '.{.1i Level 1 $8.22 1:(Level 1 $4.93 II;i
1 III', $19.07 Llk ' i ; +w Level $2.99
IN
;c- +$.66 Respite Care 14.; Level 1...$6.25 it i (Face to face contact one time lip.gr (Regularly scheduled therapy, is
I4 7 per month and minimal crisis ;3 4 hours/month.)
! ($19.73) i, 1;
intervention) j
li5 I II i.'
.I' r�' ,t: .nl
u i ,I t,. .;It
g5't a: C
P pi
[„i �� hit :hi
$11.51 Id,Level $9.86
iy: :i II J.i au
','•: $25 64 I : (Face to face contact two times n; (Weekly scheduled therapy, X,. Level 2 $4.47
2 i per month and/or occasional Hlra 4-8 hours a month with 4 hours of ll
V; +$.66 Respite Care i ' Level 2...$6.25 III,"r
i''. ($26.30) I is crisis intervention) ' Group therapy.)
I
gi
I re
pp
IJ: I i I,I
f' ( I'. i y I
ri 11' !• Level 3 $14.79,,1
1 :
a Pi pp
I. �Level3 $14.79 i, pg
(Regularly scheduled weekly r(
"` $3222 i ! multiple sessions,can include {t," Level 3 $6.02
3 �[I +$.66 Respite Care (; Level 3...$6.25 1' (Face to face contact 1-2 times pI4 more than 1 person,i.e.family 4{
per week and/or ongoing crisis
�.� ($32.88) }?, li therapy,for 8-12 hours/monthly.)
ir, I il I intervention.) .
i ' L.NI; II I,
',III: I,�� ;I Level 4 $18.08 I:�i'Level 4 $14.79 i;i,
4 1r v I (Face to face contact 2-3 times II (Regularly scheduled weekly Nu Level 4 Neg.
RTC ItI +$.66 Res p e Care.79 i Level 4...$6.25 IJ per week minimum,High level i:, multiple sessions,can include ',i
Drop i'� ($39 45) I ,I,i of case management and CPA I i more than 1 person,i.e.family I
Down rl i involvement with child and r,.S therapy,for 8-12 hours/monthly.) ,
provider,including on-going
i i crisis intervention.) II', .
4ti',
d t 1
Assess. Assessment Ii Iil
Period I I Period $26.30 Assessment 'I Assessment• r i.Assessment Period $0 Pi:
(Includes Respite) I,;i Period $6.25 Period $11.51
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.
jytu r St�aG(i'r t
ATTEST:
Weld County Clerk to the Board
WELD COUNTY BOARD OF
SOCIAL SERVICES, ON BEHALF
-f OF THE WELD COUNTY
A,;t ≥C r. \i 'k DEPARTMENT OF SOCIAL
no' ( �
r� ., SERVICES;
By A 11.iL .-t l LC 1 �C °S .,, By. /jam �l /1-ii-, /1I uty Cl tot e Board �' William H. Jerke OCT n �. UU 2QQS Acting Chair Pro-Tem
CONTRACTOR
Top of the Trail
146 W M • Stmt, Suite 130
Montros 0,8`1401-3456
B .
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Dire for
8 Weld County SS-23A Addendum
acc6 - 972
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