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Home My WebLink About20053304.tiff RESOLUTION RE: APPROVE ADDENDUM TO NINETEEN 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 nineteen Addendums to Agreements to Purchase Child Placement Agency Services between the County of Weld,State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf of the Department of Social Services,and the following providers,commencing October 1,2005, and ending January 1, 2006, with further terms and conditions being as stated in said addendums, and 1. Adoption Alliance 11. Commonworks D.B.A Synthesis 2. Children's Network 12. Creative Beginnings 3. Colorado Family Services, Inc. 13. Hope Family Services 4. Griffith Center for Children 14. Kidz Ark, Inc. 5. Jacob Family Services 15. Laradon Hall 6. Youth Ventures of Colorado 16. REM Colorado, Inc. 7. Bethany Christian Services 17. PATH 8. Carmel Community Living Corp. 18. Smith Agency, Inc. 9. Dungarvin Colorado, Inc. 19. Bridges, Inc. 10. Frontier Family Services WHEREAS,after EREAS,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 nineteen Addendums to Agreements to Purchase Child Placement Agency Services between the County of Weld,State of Colorado, by and through the Board of County Commissioners of Weld County,on behalf of the Department of Social Services, and the above listed providers be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said addendums. 2005-3304 110 55 SS0032 //_,aZ-3..CC- ADDENDUM TO NINETEEN AGREEMENTS TO PURCHASE CHILD PLACEMENT AGENCY SERVICES AND AUTHORIZE CHAIR TO SIGN -VARIOUS PROVIDERS PAGE 2 The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 9th day of November, A.D., 2005, nunc pro tunc October 1, 2005. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Lik,Weld County Clrk to thi�illam H. J rke, Chair M. eile, Pro- m BY: 1-) I O41putt' rk to the rd j 10.), D vid E. Long • APP D AS T . F M: Robert . Masden, u ty t net' Robert Glenn Vaad <. -- Date of signature: 1117:165 2005-3304 SS0032 a ra F.� DEPARTMENT OF SOCIAL SERVICES ss P.O. BOX A GREELEY, CO. 80632 Website:www.co.weld.co.us I'D Administration and Public Assistance(970)352-1551 Child Support(970)352-6933 C. COLORADO MEMORANDUM TO: William H. Jerke, Chair Date: November 3, 2005 Board of County Commissioners FR: Judy A. Griego, Director, Social Services ( ln RE: Addendums to Agreements to Purchase Ch' d Pla IJementJAgency (CPA) Services with Various Vendors Enclosed for Board approval are Addendums to Agreements to Purchase CPA Services between the Weld County Department of Social Services (Department) and various vendors. The Addendums were reviewed at the Board's Work Session held on November 2, 2005. The Colorado Department of Human Services and the Colorado Department of Health Care Policy&Financing began negotiations in late June 2005 regarding funding formulas to include reduced Medicaid funding for 24-hour care facilities including Residential Treatment Centers (RTCs), Residential Child Care Facilities (RCCFs) and to finalize rate negotiations with Child Placement Agencies (CPAs). The Addendums provide for a continued 90 day period beginning October 1, 2005 through January 1, 2006, to maintain current reimbursement rates with vendors under the current contractual terms for CPA services. Rates are established by using the Needs Based Care Assessment. The vendors include: 1. Adoption Alliance 11. Commonworks D.B.A. Sunthesis 2. Children's Network 12. Creative Beginnings 3. Colorado Family Services Inc. 13. Hope Family Services 4. Griffith Centers for Children 14. Kidz Ark,Inc. 5. Jacob Family Services 15. Larden Hall 6. Youth Ventures of Colorado 16. REM Colorado 7. Bethany Christian Services 17. Path 8. Carmel Community Living Corporation 18. Smith Agency Inc. 9. Dungarvin Colorado 19. Bridges, Inc. 10. Frontier Family Services If you have any questions,please telephone me at extension 6510. 2005-3304 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Adoption Alliance and Weld County Department of Social Services for the period from October 1, 2005,through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#71259. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person V communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 77. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. &CDs— 3_G'/ 1 Weld Cn,unty cc_91A Addrndurn 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Wald!'aunty CC-1146 Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wpu en,,nn,ccnla Addpnn,,,,, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT 1IH# IRATE OF ASSESSME] AGENCY NAME ROVIDERNAME ROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? DO)one a month ❑1)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'''A hour per day ❑1) ''A hour a day O2)more than '/:hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? D0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑I)5 to 10 hours per week O2) II to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e.Medicaid) DI)less than 4 hours per month ❑2)4-8 hours per month O3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 ❑ 0 ❑ P 2 Therapy/Counseling 0 ❑ 0 ❑ P 3 Educational Intervention 0 0 ❑ 0 P 4 Behavior Management 0 ❑ 0 ❑ P 5 Personal Care 0 ❑ ❑ 0 A 1 Case Management 0 ❑ 0 0 T 1 Therapeutic Services ❑ ❑ 0 0 4 Weld Crumb,cc_1lA Addnndn,n WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT • (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. 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I:' 'yy i -=:ziz......i::i.........!i:�::::.:1:4,,,..110.,!:,::L•'• E£:4i.::. ..�� .....i::::::::':::::::::£:•`3 i!i:ii:ii:i :::..i:�:'i'i i t t.,tt:i.5.....5_............ .........."... : ::::::-::- :: ::....... .. ...i..i.;F₹•::::::•:£,.,.,...,_......... 5s ..'I,. a.........:.......tE _L.,.•.i, ....,.,..,,i ........... ;:-. ::. : : ...,,.. ........t...z.s...:...:."u:.:e:•::::::a:�•.z:i?.... ::4s:z:.�r7 i...£s,:1:. :r.�::x::j;::'•;!-.-.- ..:_:....... ..... .................... g, {{ rr�� ..... ..... �: ...........E.i::.::: ....:......_.......z.₹ Aggression/Cruelty to Animals ❑ El El ❑ Verbal or Physical Threatening El ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ El ❑ Stealing El O O ❑ Self-injurious Behavior ❑ El O O Substance Abuse O El O ❑ Presence of Psychiatric Symptoms/Conditions O El O El Enuresis/Encopresis El ❑ ❑ ❑ Runaway El ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ O ❑ ❑ Disruptive Behavior ❑ ❑ O O Delinquent Behavior El El O El Depressive-like Behavior El O ❑ O Medical Needs O O El LI Emancipation O O El O Education El ❑ ❑ ❑ Involvement with Child's Family ❑ O ❑ O CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) O 0 ❑ I O 2 ❑ 3 • 5 W,E,r Cr,,,nr.,CC-11A 4rlrirnrinm WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) • LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS ..........=.... s SERVICE PROVIDER RATE ;.;:•-:::�::_:•�: Al , ,, , • TI ADDENDUM .• . P1 -P5 Therapy , .,.... Level Rate Admin.Overhead Case Management __. ; •(Admin. Services) .. (Admin.Maint.) , (Admin.Maint.) 0 Age 0-10511.47 Level 0...$4.56 Level 0 54.93 Level 0 S0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source, Age 15-21...$13.91 crisis intervention. Only doing health) i.e.mental 0 what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level 1 $2.99 $19.07 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +5.66 Respite Care Level 2...$4.56 Management including '' 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level 3 $14.79 Level 3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 and CPA involvement with child multiple sessions,can include Level 3 $6.02 +S.66 Respite Care Level 3...$4.56 (532.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38 79 (High level of case management :. (Regularly scheduled weekly Level 4 Neg. RTC and CPA involvement with child h multiple sessions,can include Drop +5.66 Respite Care Level 4...$4.56 andprovider,including on- oin more than 1person,i.e.family ($39.45) 9 9 9i` Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per ft week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Ifs Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: atWeld C _lehe Board ,tN 4\ WELD COUNTY BOARD OF tbttt`' � p= rX SOCIAL SERVICES, ON BEHALF j'� OF THE WELD COUNTY DEPARTMENT OF SOCIAL `i SERVICES ByB y Deput Jerk to the Bollard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Adoption Alliance 2121 S. Oneda St, Suite 420 Denver, CO 8022442,116 By:� idyl // 4 , WELD COUNTY DEPARTMENT I Li OF SOCIAL SERVICES Ot By: (i(AleDirectr 8 Weld County SS-23A Addendum 070 a-36 V WELD COUNTY ADDENDUM • To that certain Agreement to Purchase Child Placement Agency Services (the"Agreement") between Children's Network and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#77512. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 WPu r,.,,nn,CC-11A A(MP„nh]m C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld rni,nt',cc_nA A ddenenm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX 'Trails Case ID !DOB Sex I WORKER COMPLETING ASSESSMENT rH# DATE OF ASSESSMEI 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less DI)2-3 trips a week ❑2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑l)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'/a hour per day ❑1)'/3 hour a day O2)more than''A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week O2) 11 to 20 hours per week O3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑l) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ 0 P 4 Behavior Management ❑ 0 ❑ 0 P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ 0 0 ❑ T 1 Therapeutic Services ❑ ❑ ❑ 0 4 wnld Cnnnty CC-11A Mend.inn WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. t r ...............777... ............ .... ......................:....�.,...,.,... ,...:::4.s.....:i£₹F..::'.£�:£^: l•�� m �.s..__..,................, ...₹z.:z₹zt₹...s ...t...� .. . .........₹.............. �1. ... ..._.. «L c,,::,E,₹:+ :,:'.::....:::::c:� ::::z:, t.. .E;,s Aggression/Cruelty to Animals ❑ El ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting El ❑ ❑ ❑ Stealing ❑ ❑ O ❑ Self-injurious Behavior O O ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O O ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway O ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ O Disruptive Behavior O O ❑ ❑ Delinquent Behavior O O ❑ ❑ Depressive-like Behavior O ❑ ❑ ❑ Medical Needs ❑ ❑ El Cl Emancipation ❑ O ❑ ❑ Education ❑ ❑ ❑ O Involvement with Child's Family El ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 El 3 5 wPi,i Cn,,nty cc-11e e,iai.ntil,,,, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(Ti) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE - Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED ?;RECOMMENDED AGENCY RATE :! INTERVENTION RATE MEDICAL NEEDS , SERVICE PROVIDER RATE r Al Tl ADDENDUM 11(, P1 -P5il r_ Level Rate Admin.Overhead Case Management Therapy Admin.Maint. (Admin.Services) { } , . . tAdmin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 ? Level 0 $4.93 Level 0 $0 ?. Level 0 $0 0 Age 11-14"'$12.89 (Therapy not needed or provided (None) • (Minimal CPA involvement, no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing ) 0 health. what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level I $2.99 +S.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level 2 $11.51 i:'Level 2 $9.86 ;! 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +S.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, • Face to face contact 1 time Per month.) • Level 3 $14.79 Level 3 $14.79 ,: $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to :, therapy,for 8-12 hours/monthly.) face contactl-2 time per week er; minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly ' Level 4 Neg. RTC s_ +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going '' more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: 44441"4 Weld Coun Clerk to the Board ' ! 4a WELD COUNTY BOARD OF .w� SOCIAL SERVICES, ON BEHALF 1161 -Q i, OF THE WELD COUNTY DEPARTMENT OF SOCIAL • ® SERVICES is v\il By: U "1 cG By: eputy lerk to the B rd William H. Jerke, Chair NOV 0 9 zoo, CONTRACTOR Children's Network 7651-W 41st Ave, Suite 96 Wheaykdge, CO 80033By: . / WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Di ector 8 Weld County SS-23A Addendum &G = ≥. D7 • WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Colorado Family Services Inc. and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#26885. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. aces- 1 Weld rnunw cc_JQ A Addendum, • 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope.of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 weld("minty CC-11A Addend,,,, C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 wn1A rn,,nh,CC-11A AAAnnd,.n. WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT 1IH# (DATE OF ASSESSME] 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 I. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less 01)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'h hour per day ❑1)'h hour a day O2)more than 'A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? D0)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? DO)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) 11 to 20 hours per week O3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention O2) I face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e. Medicaid) ❑I)less than 4 hours per month O2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling 0 ❑ 0 ❑ P 3 Educational Intervention 0 ❑ ❑ ❑ P 4 Behavior Management ❑ 0 0 ❑ P 5 Personal Care 0 0 ❑ 0 A 1 Case Management 0 0 ❑ ❑ T 1 Therapeutic Services ❑ ❑ 0 ❑ 4 Weld("Aunt,CC-11A Addendum • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. iiiii.. ' �. !€£EEC€i � ! .._. i'r°did. s.. :• . .. .. . .. .. ..... ................................_. ...e. ..s.. ..: . .E z_ ...s.r.:s.t??....z3:_......z3.... o:�.:,:::,..?i:::f£i::�t�:::£E::":'�d;:d?.;........ :.: :: :...:: :::.:::.::��.:-: ::•:::,::,::::: .::..: . . . . ..I"_:...:.......3 ,..... a .. s .t.s,.z................ .........:.......s.1 . ........... ::.:;.;::::.::.::..........:.:.:::,ij.. .. ... ..................... ................::•:�£........zs::�::� �...........s...,s .., s s. e......_..........., ez..:.a..s.s. �'..:.:s::s::::................::z:::£:�::a:ii:idi:::.:;::.:.:.:.:: :�:�::�:::::::•:�: i:� ;:::d';�:::;..;£:.; .... .. ..:::..��:�:�...:. .s...r.................,:.,,.: ,.....I.5zs.s.msls.:. ^M p.......le....sr..:ss:...::•:..:. t•,...z:::s::�:::..,;.....�. ... .. .. s . ...ez£.zE.sez.sss:::.. . ..........E;:Ed::::.:::::e:i :£-i::'•`::::3 t: :':r,f; :dd,::d£..ii: .;.;. . s., .....;.•� ...... ::! :;:s:s::......ie.;:°:':°dd:'.... ••::.. ...z::;i':;:;::.....,...........,• s••: 1t� Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ O ❑ Destructive of Property/Fire Setting ❑ ❑ 171 ❑ Stealing ❑ ❑ ❑ El Self-injurious Behavior O O O O Substance Abuse ❑ O O O Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ O Runaway ❑ O ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ O ❑ Disruptive Behavior ❑ O ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ O Medical Needs ❑ ❑ O ❑ Emancipation ❑ ❑ El ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family O O ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 5 w.lr1 rnonts,CC-'TiA Arlrinnrinm • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum • WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVELOF :• "!RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS • S RVICE PROVIDER RATE Al l E Tl. ADDENDUM P1 -PS , . E Therapy Level Rate Admin.Overhead Case Management (Admin,Maint.) (Admin.Maint.) (Admin. Services) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0......$0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing 0 what is necessary to maintain health.) ` +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level t $4.93 1 $19.07 Levell $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +S.66 Respite Care Level 2...$4.56 Management including > 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3.......$6.02 ($32 88) and provider including ongoing ;; more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 (High level of case management (Regularly scheduled weekly Level 4 Neg. $38.79 RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider, including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy, for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Assessment Period $0 (Includes Respite) Period $4.56 Period 511.51 Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Weid:Cotitity Clerk to the Board IIll` ` / �� WELD COUNTY BOARD OF I ` SOCIAL SERVICES, ON BEHALF 0 , "� OF THE WELD COUNTY ttbt DEPARTMENT OF SOCIAL X °" Y + ' SERVICES Deput Clerk to the t lard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Colorado Family Services Inc. 1200 S Wadsworth #300 Lakewood, ,C,O 80232-5434 By: /2 G� WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: erector A�.lit�'., 1111 0 8 Weld County SS-23A Addendum 0,1a5_ .LSD' WELD COUNTY ADDENDUM RECEIVEr: To that certain Agreement to Purchase Child Placement Agency Services OCT 6 2005 (the "Agreement") between Griffith Center for Children and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#1531601. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld!'nunr.r CC-11A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld rnunnr gcniA Addendum • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT FIH# 1ATE OF ASSESSME] 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a''A hour per day ❑I)''A hour a day ❑2)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 monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week 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 ❑1) 2-3 contacts per month and/or minimal crisis intervention O2) I face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e.Medicaid) ❑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 O O ❑ ❑ P 2 Therapy/Counseling ❑ O ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ ❑ P 4 Behavior Management ❑ O O ❑ P 5 Personal Care ❑ O O ❑ A 1 Case Management ❑ O ❑ ❑ T 1 Therapeutic Services ❑ ❑ O ❑ 4 wpm n.,,,,,,,CC-71A Addend',,., WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. St ..: .. ....• :•:'.'.'..'... .t .:.:, t:: : : :₹tktF:.::... :•,sE.' . T :_ '„1 .Y .E :: :.₹ .�{y�yy . k ... . ......... . .............................................E,t s'E�:h,t•te.::^.�d'r»::.�::_.•� :.:::r......t.. .... .. .. ... .. .. ...tt......................... .. .r.�..,t?..................r i..r...Es3J. ...s r...,r E:::kr.�.....................t.;r:::_.;:..... .s....�₹:::: ::c.:::c:;.,,......., ::::�.:.:..,. ... ................ E. .....................e. 4 E s....r..t s...,,,'�a,'�.t�.tt r.s.s........ .. . .... .. ...._............. ....... .•................. ..:u s...........:..................rs t..t....t.,-.f.!.tEr E:err..,. ..,..,E ................... .... .. ......,... ' ;.::.;:xE•t ........... t .::;:.:::::::-;re�E ... t. .. r... ..... ........:::�. ::.Et'•.044 ...₹;. ��y,.t4it 'si•. s 0 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ 0 ❑ Self-injurious Behavior 0 ❑ ❑ ❑ Substance Abuse ❑ ❑ 0 ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ El Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ El Depressive-like Behavior ❑ LI El ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ o ❑ I ❑ 2 ❑ 3 5 wpm('n,,nt,,CS-11A AridvnAnm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE tNTERVENTiON RATE MEDICAL NEEDS t SERVICE PROVIDER RATE Al E Tt ADDENDUM P1 -P5 . ... Level Rate Admin.Overhead Case Management Therapy (Admin.Maint.) ,_(Admin.Maint.} (Admin.Services) 0 Age 0-10...x11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 py(Thera not needed or provided (None) (Minimal CPA involvement, no Age 15-21...$13.91 crisis intervention. Only doing by another source, i.e. mental 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis . intervention, 2-3 contacts/month.) '.`:::Level 2 $11.51:; Level 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 514.79 Level 3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32 88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider,including on-going ,; more than 1 person,i.e.family Down ($39.45) crisis intervention and face to .I. therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) . Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: goillia Weld Count Clerk to the Board jie • % WELD COUNTY BOARD OF � SOCIAL SERVICES, ON BEHALF I f•w3 _ �. OF THE WELD COUNTY o,;4.o DEPARTMENT OF SOCIAL V - SERVICES By: (-) KY rl (Si / By: ` 1 ., � �G ---., Deputy lerk to the Board William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Griffith Center for Children 14142 Denver West Pkwy, Suite 225 Lake od, CO 8 401 By✓� . WELD COUNTY DEPARTMENT OF SOCIAL�SERVICES By: ul a hector 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Jacob Family Services and Weld County Department of Social Services for the period from • October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#71260. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 Weld rn„mn,cc_1ze na "Si)/ 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Wem r„,.nr.,cane n ddp„deem C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 WPId rn,,nw cc-11A AdddpnAnm 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 HIH# PATE OF ASSESSME] AGENCY NAME ROVIDER 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑I)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month El)twice a month O2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'/z hour per day ❑l) '/z hour a day O2)more than'A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? 00)less than 5 hours per week ❑l)5 to 10 hours per week ❑2)at least daily ❑3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) 11 to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention 01) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T I. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) ❑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 ❑ ❑ 0 ❑ P 2 Therapy/Counseling 0 ❑ ❑ ❑ P 3 Educational Intervention 0 ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T I Therapeutic Services ❑ ❑ ❑ ❑ 4 Weld l,.,,nt'CC-l1A Addendn.n WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. I E f rss r....,r r ........,r.IEn_._......._........ .. ........u..z..:::: e::::.:::+Srii ' .� ..:.:.:::.............rr..........._..!.., r. ..i................:rr.. .v x..: .Lr.f..... .......................:,,:';;;•"{ : .`:-aii;d..liait'2".==:;ts .. zr....................z.rs...:?..................e ,.zE',:.....................:.,r.r............_..i�'.:.•.•.ss........?..�.....::::E;:.::::::: ::::::::.r:: ... .. Srrr....., . :ikitg ..... .....r:::r::::.:..:.: Ez ..,r.. s i r. M7zl7f Aggression/Cruelty to Animals ❑ ❑ 0 ❑ Verbal or Physical Threatening ❑ ❑ Cl ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ 0 Stealing ❑ ❑ O ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ 0 ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ El ❑ Emancipation ❑ ❑ ❑ 0 Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ t ❑ 2 ❑ 3 5 Weld Count,'cc_11 A A Aiivnc111m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of Pl through P5) PEkIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED ;RECOMMENDED AGENCY RATE :INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al Tl ADDENDUM P1 -Pb Level Rate Admin.Overhead Case Management Therapy (Admin.Maine.) (Admin.Maine.) -> (Admin.Services) i . 0 Age 0-10...$11.47 Level 0...S4.56 ':',' Level 0 $4.93 Level 0 $0 Level 0 $0 ±its' 0 Age 11-14...$12.89 ;: (Therapy not needed or provided (None) (Minimal CPA involvement, no Age 15-21...$13.91 ;. crisis intervention. Only doing by another source, i.e.mental 0 what is necessary to maintain health.) +S 66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +5.66 Respite Care Level 1..54.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +5.66 Respite Care Level 2...54.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level 3 $14 79 Level 3 $14 79 $32.22 (High level of case management (Regularly scheduled weekly 3 + and CPA involvement with child multiple sessions,can include Level 3 $6.02 S.66 Respite Care Level 3...54.56 and provider including ongoing more than 1 person,i.e.family ($32.88) crisis intervention and face to therapy, for 8-12 hours/monthly.) face contact/-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38 79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child Al, multiple sessions,can include Drop and provider,including on-going more than 1 person,i.e.family Down ($3945) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: gala Weld County Clerk to the Board r y 4% WELD COUNTY BOARD OF t /`In SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY DEPARTMENT OF SOCIAL Nr `�' `I SERVICES T['��Yy�l ✓ C ,..By: 0,41,t 1 I r , eyq By: �� ) IL, Deputy lerk to the Btrd William H. Jerke, Chair NOV 0 9 Z0("5 CONTRACTOR Jacob Family Services 729 Remington Fort Co 'ns CO 80524 By: , all WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: ector 8 Weld County SS-23A Addendum 0700.E- 33oy WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Youth Ventures of Colorado and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#1529601. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. c 5t3_or I Wolr rnnnw C C_91A AAAnnA,,m 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld Cnnnh CC_11 A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld ennnn,cc_91A d ddend..m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT jIIH# PATE OF ASSESSME] AGENCY NAME PROVIDER NAME ROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less Ell)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month 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? ❑0)less than a'/2 hour per day 01)1/2 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 monitorin of time and/or activities and/or crisis management? 00)less than 5 hours per week ❑1)5 to 10 hours per week ❑2)at least daily 03)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week 02) 11 to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention 02) 1 face to face contact per month and/or occasional crisis intervention 03) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ 0 P 3 Educational Intervention 0 ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ 0 ❑ ❑ A 1 Case Management ❑ 0 ❑ ❑ T I Therapeutic services ❑ 0 0 ❑ 4 weld(`nnnhi CC-114 AAArndu.n WELD COUNTY DSS - NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. t. . ......... itailit .:.:....... Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting El ❑ ❑ ❑ Stealing ❑ ❑ ❑ El Self-injurious Behavior O ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ O O O Inappropriate Sexual Behavior O ❑ ❑ O Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ El ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ O ❑ Emancipation ❑ ❑ ❑ O Education ❑ ❑ ❑ O Involvement with Child's Family O ❑ ❑ O CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 El 2 ❑ 3 5 w.0 rnnnh,CC-71A Aririenrinm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED %RECOMMENDED AGENCY RATE 1,. INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al €': ` T1 ADDENDUM P1 -P5 . Level Rate Admin.Overhead Case Management Therapy (Admin.Services) (Admin.Maint.) (Admin.Maint.) Age 0-10...$11.47 Level 0..$4.56 Level 0 $4 93 Level 0 $0 + Level 0 $0 0 Age 11-14...S12.89 (Minimal CPA involvement, no (Therapy not needed or provided (None) crisis intervention. Only doingby another source,i.e.mental Age 15-21...$13.91 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 ' 1 S19.07 Level 1......$2.99 +$.66 Respite Care Level 1...54.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, • 2-3 contacts/month.) Level 2 $11.51 iip Lever 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, • Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, • Face to face contact 1 time • Per month.) ..r- Level3 $14.79:' Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family • crisis intervention and face to therapy, for 8-12 hours/monthly.) face contact1-2 time per week minimum.) Level4 $18.08 Level4 $14.79 l,. 4 $38.79 (High level of case management! (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child ' multiple sessions,can include - Drop and provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) ail Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: L1/041.4 Weld Co i t Clerk to the Board rWELD COUNTY BOARD OF S SOCIAL SERVICES, ON BEHALF v i" ' L. OF THE WELD COUNTY I %Poi �� DEPARTMENT OF SOCIAL F I SERVICES UNA�� r By: ., 4 _ � ,Ii a By: Deput lerk to the :;,ard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Youth Ventures of Colorado 4785 Granby Cir Colorado Sprin s, CO 80919 By: WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: , 2)1 Min O I 7 rector v 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Bethany Christian Services and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#45514. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 69O65 -SSL7y 1 Weld rnnntu cc_'T1 A Addendum 9. Add Paragraph 16 to Section W. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not,within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld rn„nh,CC-11d AAAPnAu,n, C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 WpIA(`nnnh,CS-11A AAAondnrn 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 HH# IDATE OF ASSESSMEI 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month 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 01)''/ hour a day O2)more than'A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? 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) I 1 to 20 hours per week O3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) 01)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 0 0 0 P 2 Therapy/Counseling 0 0 0 0 P 3 Educational Intervention 0 0 0 0 P 4 Behavior Management 0 0 0 0 P 5 Personal Care 0 0 0 0 A 1 Case Management 0 0 0 0 T 1 Therapeutic Services 0 0 0 0 4 wain rn,,nn,cc-TzA A&.tann,,,., WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment DRe-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. . ..... :',.1::'!:'i;:!:: ..& ._: thE :':,6:' t:f. ��q .:...:.... .. t� ilf, ..rE�� .... ..........: :.......... :._.................................r .i................. ==nrifls .,.�...,EEci._.......!`4't�i°�.......::___!x?i₹E}:-4₹==........:._...„I,...fn:p;;.:c_".'' ..; :..iii',.•E�'iT{}[c^;�;�s, ..., ........d;:. .•..:;:s:Ef4:itr tEE!:!€i:.::»:.:..: ,t i'i�"^�r...."•� i₹is E€..I..........-.,iii" u,..ni . .....,..,.., ........E......... € {10!13118Hr Aggression/Cruelty to Animals ❑ CI ❑ ❑ Verbal or Physical Threatening El ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ El ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ El ❑ Presence of Psychiatric Symptoms/Conditions CI ❑ ❑ ❑ Enuresis/Encopresis ❑ O El El Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior O ❑ El ❑ Disruptive Behavior ❑ ❑ ❑ El Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior El ❑ ❑ ❑ Medical Needs ❑ O O O Emancipation O O ❑ El Education ❑ O ❑ ❑ Involvement with Child's Family ❑ Cl ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: ' (check level of need) ❑ o CI I ❑ 2 :13 5 whirl(",,,m,•.,CC-114 Ar ri•n,1„m • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE ` E, Al ,,,, Ti ADDENDUM P1 -P5 _.. E Level Rate Admin.Overhead Case Management Therapy (Admin. Services) (Admin. Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...S4.56 Level 0 $4.93 Level 0 $0 Level 0......$0 0 Age 11-14...$12.89 (Therapy not needed or provided ` (None) (Minimal CPA involvement. no by another source, i.e.mental Age 15-21...$13.91 crisis intervention. Only doing ) 0 health. what is necessary to maintain +$.66 Respite Care monthly responsibility.) Ti Level 1 $8.22 Level 1 $4.93 1 $19.07 H Level I $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) iiiii Level 2 $11.51?, Level 2 $9.86 " 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, 's Face to face contact 1 time Per month.) Level 3 $14.79 .. Level 3 $14.79 iiii $32 22 (High level of case management " (Regularly scheduled weekly 3 +S.66 Respite Care Level 3...$4.56 and CPA involvement with child s;§' multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing ! more than 1 person,i.e.family crisis intervention and face to '.,iii therapy,for 8-12 hours/monthly.) face contact/-2 time per week . minimum.) Level4 $18.08 Level4 S14.79 iiii 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$_66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider, including on-going '' more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period 826.30 Period $4.56 Period $11.51 !Assessment Period SO (Includes Respite) iiiii r:r-: Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: /""""'F��6!!!6', 9 Weld County Clerk to the Board WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF ,a OF THE WELD COUNTY 161 ' ` - 1,, DEPARTMENT OF SOCIAL `; k,ap SERVICES By: C By: `'&�- riL Deput Clerk to th oard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Bethany Christian Services 4820 Rusina Rd, Suite C Colorado Springs, CO 80907-8127 B}. WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: 1/ 0,, , 2• At a Director U ,,_ ,1 r v 8 Weld County SS-23A Addendum . WELD COUNTY ADDENDUM 13j. 0 To that certain Agreement to Purchase Child Placement Agency Se cgs (the "Agreement") between Carmel Community Living Corp. and Weli County Department of Social Services for the period from October 1, 2005, through June 30, 2006. cP The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#44383. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 Weld rnimw CC-11A Addendum 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receivingstolen property; C. Are not presently indictedst for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 WPIA rn..nn,cc_ 1A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wr1A Cnnnt',CC-11A AAAandnnt 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 1IH# [DATE OF ASSESSME] AGENCY NAME PROVIDER NAME ROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? DO)less than a'h hour per day ❑I) 'h,hour a day ❑2)more than'/,hour per day,up to 2 hours per day 113)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 2)at least daily ❑3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) 11 to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 Weld rnnnt,,CC-71A Addendum • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. r₹ E si E�g of Con tiop+* 1 E ..... ....... z .. .................s..............::-:.:�.:z..�.....,deSe..s.r if;;-..."."1— .�:.n;.4:c;.,::: ............ : .is•�:: ............................................�.....r.,,.x..,.. ..= a :.. s.....ss...o,o...o.us8.�r:i:::::::�•:::::::ssE ... j•��...... ..::.,...E:zsz :.: �....y.....�..r....r..:.:...,:::::sJ.:ASS ;';::.:ail.: :i!;_:i::•;i�:::::::�:;::.:::.i:..'::;: [.::;: .. : ...:::".: :+� .. �:.....:..s. . .: :.s.. "'�S"�'..:.. t,.......z :i ::i ::Si, . .. ... ...............r :...........�:::rs a ...... .,:fit:........ LL . 2 7.3,, ,,,•, Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ O O Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ O O Substance Abuse O ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway O ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ O O [Ti Disruptive Behavior O ❑ ❑ ❑ Delinquent Behavior ❑ O ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ Education ❑ El ❑ O Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 O 3 5 w.l,i("north,CC-11A A,IAPn,lnm • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED (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) • . LEVEL OF RECOMMENDED :•;; RECOMMENDED AGENCY RATE,,,_,.•..•E' INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al €' Ti ADDENDUM - P4 •PS . Therapy Level Rate Admin.Overhead Case Management (Admin.Maint.) (Admin.Maint.) (Admin.Services) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 54.93 Level 0.. $0 ''.; Level 0 SO 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing ) 0 health. what is necessary to maintain +S.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +5.66 Respite Care Level 1...$4.56 '`(Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level 2 $9,86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, ''• Level 2 54.47 +S.66 Respite Care Level 2...54.56 Management including . 4-8 hours a month with 4 hours of .. ($26.30) Weekly support services, E Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 + and CPA involvement with child multiple sessions,can include Level 3 $6.02 5.66 Respite Care Level 3...54.56 and provider including ongoing more than 1 person,i.e.family ($32.88) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per t week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 period $4.56 Period $11.51 ' i Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum • • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: i / Weld Co I e k to t o Board I 4 % WELD COUNTY BOARD OF fit, SOCIAL SERVICES, ON BEHALF r� gke l OF THE WELD COUNTY %,ito DEPARTMENT OF SOCIAL 8' WSERVICES By: ,1� f 61 c By: el`-t,_c)frutiu eputy Jerk to the B a d William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Cannel Community Living Corp. 3030 terling Circle Bou O/b301 ..(Ws WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: ,dial/00- A OC) trector , 8 Weld County SS-23A Addendum ODD .j0 • WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Dungarvin Colorado, Inc. and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#98960. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 Weld/'nnnnr C0.91al�m 3xO7 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement,been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld rnnnw cc-11A AAAondnrn C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld rnnnh,QC-11A AAAnn Anm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex I WORKER COMPLETING ASSESSMENT IEIH# (DATE OF ASSESSME1 AGENCY NAME PROVIDER NAME IPROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑I)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'/z hour per day 01)%hour a day ❑2)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 monitoring of time and/or activities and/or crisis management? O0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? O0)less than 5 hours per week 01)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? ❑0) Minimal CPA involvement per month and/or no crisis intervention 01) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. Haw often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) 01)less than 4 hours per month O2)4-8 hours per month O3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ 0 0 P 2 Therapy/Counseling 0 ❑ 0 0 P 3 Educational Intervention ❑ 0 ❑ ❑ P 4 Behavior Management 0 0 0 0 P 5 Personal Care ❑ ❑ 0 0 A 1 Case Management ❑ 0 ❑ ❑ T I Therapeutic Services 0 ❑ 0 0 4 Weld room,,cc-)1A Addrndu,n • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. :.i .. ... .........................Rahn of Conditions ... , (Check one box for each category) " ' ";?,i,,;,•:::, ., ASSESSMENT AREAS None Mild Moderate Severe ...::. ... 0 1 2 3 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ 0 Substance Abuse 0 ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ 0 ❑ Disruptive Behavior ❑ ❑ 0 ❑ Delinquent Behavior El ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation El ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ CI CI , CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 LI 1 ❑ 2 ❑ 3 5 W.i,1 Cm,nw cc-Ile ean..,,i,,.,, • • WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY -Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through 135) 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) LEVEL OF RECOMMENDED ,RECOMMENDED AGENCY RATS INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al ;=s'si isi's: ADDENDUM P1 -P5 EE f . .•• Therapy ,,;•z:.;;. : — Level Rate Admin,Overhead Case Management , Admin.Maint. (Admin.Services) ( } (Admin.Maint.} 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 ? (Minimal CPA involvement, no (Therapy not needed or provided (None) Age 15-21...$13.91 crisis intervention. Only doing by another source,i.e.mental 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level/ $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management. (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis • intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 • 2 $25.64 (Moderate level of case (Weekly scheduled therapy, • Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management: (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact/-2 time per week iiii minimum.) Level4 $18.08 Level4 $14.79 4 (High level of case management ' (Regularly scheduled weekly Level 4 Neg. RTC $38.79 and CPA involvement with child multiple sessions,can include Drop +5.66 Respite Care Level 4...54.56 and provider,including on-going more 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per ,•,. week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum . • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: /h/1 WA nt. erk to the Board E L` WELD COUNTY BOARD OF " SOCIAL SERVICES, ON BEHALF 1861t -A? - OF THE WELD COUNTY � DEPARTMENT OF SOCIAL ® I j� SERVICES ' �� By: 414 21srt t / 117 By: f Deput lerk to the Bard William H. Jerke, Chair • NOV 0 9 2005 CONTRACTOR Dungarvin Colorado, Inc. 4704 Harlan St., Suite 200 Denver CO 80212- 417 By: l C WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: a Director 8 Weld County SS-23A Addendum L')Q5- Sae)f WELD COUNTY ADDENDUM OCT 0 7 2005 To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Frontier Family Services and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#38041. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 \Veld/Thumb,cc_9IG Addendum 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Wald fnnnh,CC-fl A AAAondnm C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld r,mnt.,cc_'1A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT �IH# IDATE OF ASSESSME] AGENCY NAME ROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week 03)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? 00)one a month ❑1)twice a month 02)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? 00)less than a'/2 hour per day DI)1/2 hour a day 02)more than '/z hour per day,up to 2 hours per day 03)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? 00)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 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? 00)less than 5 hours per week ❑1)5 to 10 hours per week 02) II to 20 hours per week 03)21 or more hours per week A 1. How often is CPA case management required? 00) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention 02) 1 face to face contact per month and/or occasional crisis intervention 03) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)not needed or Provided by another source(i.e. Medicaid) 01)less than 4 hours per month 02)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 0 ❑ ❑ P 2 Therapy/Counseling 0 0 ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ ❑ P 4 Behavior Management 0 0 ❑ 0 P 5 Personal Care 0 ❑ 0 ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 wpm r,.,,.,w cc-v1 A Aanenn,,m WELD COUNTY DSS - . NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ['Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. as...... � Q .......:.:�:.:: �:::::'::�' :':t:.:i..:...................tEi:•^... E,.,.. 'k :t:t ..t.:iftE: ..............�:::��.,� .. '•.....••:..:..:::.:'.: i ............. ....... ........................, t =rtizri. .� ...�.•.�5........'::. ., .:i J .ri it ..: ASSESp1'l� .::':::J�Io r...„ i .., ..��..{l:: :i.E:,..i s ti , . '0,0O ::..:.:::::...:...: Aggression/Cruelty to Animals ❑ O O ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ El ❑ ❑ Stealing El ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ O ❑ Substance Abuse ❑ O ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ O Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ El ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ El ❑ Emancipation El ❑ ❑ ❑ Education El ❑ El El Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 El 2 ❑ 3 5 W.l,l Cn,,nh,CS-11A AII,IPnAtttn WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(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) LEVEL OF' RECOMMENDED RECOMMENDED AGENCY RATE �l INTERVENTION RATE , MEDICAL NEEDS SERVICE PROVIDER RATE Al Ti ADDENDUM E ;; E P1 -PS 7,;:- Therapy Level Rate Admin.Overhead Case Management (Admin.Services) i` (Admin.Main*) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 Age 11-14...$12.89 (Therapy not needed or provided (None) 0 (Minimal CPA involvement, no Age 15-21...$13.91 crisis intervention. Only doing by another sour i.e.mental 0 what is necessary to maintainhealth ) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) t— • - Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, ' Level 2 $4.47 +$.66 Respite Care Level 2...S4.56 Management including 4-8 hours a month with 4 hours of • ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level 3 $14.79 Level 3 $14.79 $32 22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management' (Regularly scheduled weekly ii Level 4 Neg. RTC +$66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down I' crisis intervention and face to therapy,for 8-12 hours/monthly.) ;` face contact 2-3 times per week minimum.) ... Assess. Assessment Assessment Assessment Period Period $26.30 Assessment Period $0 Period $4.56 Period $11.51 (Includes Respite) Effective 10/01/01 7 Weld County Sti-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, • month, and year first above written. ATTEST: _ We d Co lerk to the oard mitaa$ ti Il J ,� WELD COUNTY BOARD OF %Y ''t f� SOCIAL SERVICES, ON BEHALF lut �; OF THE WELD COUNTY � - DEPARTMENT OF SOCIAL ,. A SERVICES oC�� `'• By: 41,( i add itmi By: -V i.✓ Deputy erk to the Bo William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Frontier Family Services 1290 Boston Ave Longmont, CO 80501-5810 B • - L WELD COUNTY DEPARTMENT OF SOCIAL SERVICE S By: / Director D rectoor I/4A,O,A J 8 Weld County SS-23A Addendum WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Commonworks D.B.A. Synthesis and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#104085. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section W. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. c.t 1 Weld Cnnnt.,CC-11A Addendum m ��• C�'� 9. Add Paragraph 16 to Section W. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees,and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 WpIA Cnnnn,CC-11A AAAcndnrn C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 wau rn„nn,CC-71A Addendum) WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX trails Case ID 1)OB Sex WORKER COMPLETING ASSESSMENT 1HH# 1ATE OF ASSESSMEI AGENCY NAME ROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑l)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'''A hour per day El) 1/2 hour a day ❑2)more than %hour per day,up to 2 hours per day ❑3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? O0)less than 5 hours per week El)5 to 10 hours per week ❑2)at least daily E3)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) I I to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention E3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 wnld rnimro CC-11A Addpndnm • WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. ..,;:;.„•:,,,,,,....,..,....,„...,Eq�� ..:.. :.'. .. :�. ..::.:...:....... ...•....... ...................[/........._.. *iii.:: '�'�'•7'�'��'�"�:c:��:ii_'• ..• ... yr ':7.,. '.i i;;::. ........ .... . .............................................................. ......:3 . .................................a.'.... ..............":"""'"W::::- .....:::v:. ..r .... !::c,........�.}..... ......"!.'.,".'.i.'"....,::::::::::::. :::::::::::: .::....... ..... ...... Aggression/Cruelty to Animals ❑ ❑ 0 0 Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting El ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ Education ❑ ❑ 0 ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 El 3 S wnLl rnnnnr cc_11A AM..niinm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of PI through 135) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED (TI) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: 'Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) r LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE, MEDICAL NEEDS SERVICE PROVIDER RATE �'''iE;. Al .:;::. •.'•.:: T] ? ADDENDUM P1 -P5 Therapy Level Rate Admin.Overhead .:•Case Management • .• (Admin. Services) (Admin.Maiint,) (Admin.Maint) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0.. $0 Level 0 SO til Age 11-14...$12.89 i` 0 g (Minimal CPA involvement, no (Therapy not needed or provided (None) by another source,i.e.mental Age 15-21...$13.91 crisis intervention. Only doing : health ) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level / $4.93 1 Level 1 S2.99 $19.07 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level 2 $11.51 Level 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +5.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management (Regularly scheduled weekly 3 and CPA involvement with child multiple sessions,can include Level 3 $6.02 +$.66 Respite Care Level 3...S4.56 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) ;, face contact/-2 time per week minimum.) Level4 S18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) • face contact 2-3 times per week minimum.) ii Assess. Assessment Assessment Assessment Period Period $26.30 period $4.56 Period S11.51 Assessment Period $0.::` (Includes Respite) iiii Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: JGte#M- ?% Weld County Clerk to the Board ' IE ® WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF IItoI vv`#E ^' +� OF THE WELD COUNTY 2= w DEPARTMENT OF SOCIAL Trir rj SERVICES By: ,lug, ,1 By: � L ✓ Deput V lerk to the and William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Commonworks D.B.A. Synthesis PO Box 12528 Denver, CO 88O0212-052- _8 BY: l O -C4 52 TJC �- WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: hector 8 Weld County SS-23A Addendum o7CC5- 33CS/ 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 period from • October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#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. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. dDAA- dizt 1 Weld rnlinw CC-94A Addrndnm 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended,proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery,bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 w.in rn„nn,cc_nn nnnbnn,n., C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 wain r..,,.,n,CC-71A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT II-IH# 1ATE OF ASSESSME] AGENCY NAME ROVIDER NAME IPROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month DI)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? DO)less than a'/,hour per day ❑1)'/,hour a day ❑2)more than'h 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? ❑0)less than 5 hours per week ❑l)5 to 10 hours per week ❑2) 1 I to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? DO) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention D3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month D2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation D ❑ ❑ ❑ 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 rn,,nw CC-11A Addendun. WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. . } {y4+s di FE E sEs i .�,iiiiii: s ..... :Ec ₹ri�i�o^'•y4iil:1. € •₹!₹ ..... _..a'k .t. Y �S� .... .................... s -F'm•:::.:::av:........,.t. i t......«. x::..,.:�.. . . . . .... ........�..t. . ...............»............•... =Est. v..t.... ......::::.............. ..J.. .. .:......... .. .........{,. �....^y.............,s::E::is:;.:::::i:i:f�:•i'i₹:'F �'.: E'E ::i:ii₹:₹₹}':i₹L::s₹E' . ......�.. ': i Aggression/Cruelty to Animals O ❑ ❑ O Verbal or Physical Threatening ❑ ❑ O O Destructive of Property/Fire Setting O ❑ O O Stealing O O O O Self-injurious Behavior ❑ O O ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ O O ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ O O O Emancipation ❑ ❑ O ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 5 W.},i C „nw CC-11A e,ia.,,,1tt,,, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(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) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al :.................................. TI ADDENDUM '. P1 -PS i E : Level Rate Admin.Overhead Case Management Therapy r (Admin.Services) ::: _.••g , (Admire„Maine.) (Admin.Maine.) .... 0 Age 0-10...$11.47 Lever 0...$4.56 ,i, Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source,i.e.mental 0 Age 15-21...$13.91 crisis intervention. Only doing what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Lever 1 $8.22 Level 1 $4.93 1 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis • • intervention, 2-3 contacts/month.) Level2 $11.51 I Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...S4.56 Management including . 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) • Level 3 $14.79 Level 3 $14.79 $32 22 (High level of case management s° (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child' multiple sessions,can include Level 3 $6.02 (S32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level 4 $18.08!, Level 4 $14.79 4 $38.79 (High level of case management,' (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...54.56 and CPA involvement with child multiple sessions,can include • Drop and provider,including on-going more than 1 person,i.e.family ' Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) ri Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: giadet4 • Weld County Clerk to the Board WELD COUNTY BOARD OF fj• C \ •`° SOCIAL SERVICES, ON BEHALF OF THE WELD COUNTY y DEPARTMENT OF SOCIAL SERVICES A4 ✓ �� , By: {14 By: -t, i !' Deput Clerk to th f oard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Creative Beginnings 7100 N. Broadway Unit 6-9 2/3- Denver, CO/ 80221 By: la- WELD WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: DirecHoorr s Weld County SS-23A Addendum &GCS- WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Hope Family Services and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#42942. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. n9 VS- 1 Weld!Thum.,CC-11A Addendum 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld('nfl,ntw CC/11A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 weld Comm,Qc_Y18 Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX fI'rails Case ID BOB Sex WORKER COMPLETING ASSESSMENT IFIH# DATE OF ASSESSME] 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? O0)one a month 01)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'/n hour per day ❑1)'/2 hour a day O2)more than 'A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? 00)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? O0)less than 5 hours per week ❑1)5 to 10 hours per week O2) 11 to 20 hours per week O3)21 or more hours per week A 1. How often is CPA case management required? O0) Minimal CPA involvement per month and/or no crisis intervention 01) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T I. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month O2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 0 0 0 P 2 Therapy/Counseling 0 0 0 0 P 3 Educational Intervention 0 0 0 0 P 4 Behavior Management 0 0 0 0 P 5 Personal Care 0 0 0 0 A I Case Management 0 0 0 0 T 1 Therapeutic Services 0 0 0 0 4 wa'A rnnnh,cc_11 A Anaa„n,,.„ WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ['Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. ....... . :::,-:-::,:::::;,,..t._,........_rr� ..• t� lam. .. I. .. ............ ............. ......................r:�:v:::�.....,is.................:::......�..,<..s:s................K?:':::::: £:_: ::'i::"i:t:?::'::::::r.:::;:::;�:::£ii ::: :��':�:i .................:... m t .......... ............:..... ... .. ............s.:........... ....r_., _.. .... ._ E! ,. t...s.... ..,.::,,.:., ..es..... ...... .:E:::i:i:i;::.r.a. 'l ccccr '. Aggression/CrueIty to Animals 0 ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ 0 0 Self-injurious Behavior O ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ 0 0 ❑ Runaway El ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ [] O ❑ Delinquent Behavior O ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ 0 0 ❑ Education El ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ I ❑ 2 ❑ 3 5 WPLd rn.,n..,CC-11 ItAd,h.n1Ellm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum • WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED ;RECOMMENDED AGENCY RATE .;• INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al �`'.,�;;€s TY ADDENDUM ;.....E si ₹ P1 -P6 Level Rate Admin.Overhead Case Management Therapy (Admin. Maint.) (Admin.Maint.) (Admin.Services) 0 Age 0-10.,.$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 no t ot needed or provided ;'. (None) CPA involvement, no Age 15-21...513.91 crisis intervention. Only doing by another source,i.e.mental 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 S19.07 Levell $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, • Level 2 $4.47 +$.66 Respite Care Level 2...S4.56 Management including 4-8 hours a month with 4 hours of • ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level 3 $14.79 Level 3 $14.79 :. $32.22 (High level of case management (Regularly scheduled weekly 3 + and CPA involvement with child multiple sessions,can include Level 3 $6.02 $.66 Respite Care Level 3...S4.56 and provider including ongoing more than 1 person,i.e.family ($32.88) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 period $11,51 Assessment Period SO (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Mild/SA/ Weld County Clerk to the Board t WELD COUNTY BOARD OF f , j6 °ey SOCIAL SERVICES, ON BEHALF r OF THE WELD COUNTY issir VittO DEPARTMENT OF SOCIAL SERVICES C4 By: I .G. By: ��,✓ Deput lerk to the B and William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Hope Famil Services 1115 . 1 St Gre: ey, CO 81 � r By. WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: �'l / - ' uector J 8 Weld County SS-23A Addendum ace s- 3361g WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Kidz Ark, Inc and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#40900. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. �✓ 3Sey 1 Wald r,ui.,n,CC-11A en ienchim 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Wpld('nnni,CC-11A AAdpnAnn, C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld rnnntu cc_)1A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX trails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT HH# IDATE OF ASSESSMEI 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? O0)one a month ❑I)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'A hour per day 01)1/4 hour a day O2)more than 'A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorinPP of time and/or activities and/or crisis management? O0)less than 5 hours per week ❑l)5 to 10 hours per week ❑2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? O0)less than 5 hours per week 01)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? O0) Minimal CPA involvement per month and/or no crisis intervention 01) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e.Medicaid) 01)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 r 1 2 3 P 1 Transportation ❑ ❑ 0 ❑ P 2 Therapy/Counseling ❑ 0 ❑ ❑ P 3 Educational Intervention ❑ 0 ❑ 0 P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ 0 A 1 Case Management 0 ❑ ❑ ❑ T 1 Therapeutic Services 0 ❑ ❑ ❑ 4 wnlA(`n,,nh,CC-11A AAAnnr„n, WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. : • rsu : . ..5E :.c::r:..,_.r. p .,.. s s Ea E . . .,' . RA�tII Of�Q �E E .e{ E r£ y�y1 �,E,. ..... ..... ..:.... ....:...r:r..r.::.:n .....a..a ..,,.,.. ..t,.t ..,r:axr, .u:r::,r. te:,... ...... .... .:,xr...,.,'₹ s r:�o:: r.:a?.....;Lr::::c:r,r E:PFiha ::.: ........... ....... ...... .................... ....: .ere::nr.........................................., ..r::....::ri::::::::��............. . .. .. . . ....r........,,r. t oysu,..,.....r:rn r.t.r.....:n..... . r ........�:,.,;�£':i"::s:�:�•_:�: ':i.' E: ..'. � � - �f Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ O Destructive of Property/Fire Setting ❑ ❑ ❑ O Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ O Substance Abuse ❑ ❑ ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ O O ❑ Enuresis/Encopresis ❑ ❑ O ❑ Runaway ❑ O O ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ [I] ❑ Delinquent Behavior Cl ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ O El Emancipation ❑ ❑ O O Education ❑ ❑ ❑ O Involvement with Child's Family ❑ ❑ ❑ O CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) O o El I ❑ 2 ❑ 3 5 wain r,,,,.,n,CC-11A A Arinnri,.m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED (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) • LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS: SERVICE PROVIDER RATE Al Tt ADDENDUM P1 -P5 ,.._. ,,,: Level Rate Admin.Overhead Case Management Therapy (Admin.Services) (Admin.Maine.) (Admin.Mai(*) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another source, i.e.mental Age 15-21...$13.91 crisis intervention. Only doing 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 ' Level 1 $4.93 1 Level 1 $2.99 $19.07 (Low level of case management, (Regularly py, +$.66 Respite Care Level 1...$4.56 9 (Re ularl scheduled theta ($19 73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) llT ':Level 2 $11.51 Level 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...54.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, - Face to face contact 1 time Per month.) Level 3 $14.79;i Level 3 $14.79 ' ' S32.22 (High level of case management ' (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3.......$6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to ii‘iir, therapy,for 8-12 hours/monthly.) face contactl-2 time per week :: minimum.) Xrli Level 4 $18.08 i'.' Level 4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider,including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: f ida% Weld County Clerk to the Board IF.La WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF �� '� OF THE WELD COUNTY t3st " DEPARTMENT OF SOCIAL ? ', A SERVICES By: Al I l [ . LI By: `7'1-'2 �G�✓ Deput Jerk to the and William H. Jerke, Chair NOV U y LOOS. CONTRACTOR Kidz Ark, Inc PO Box 1725 Sterling, CO 80751 1 /7 By: WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: ector 8 Weld County SS-23A Addendum &a95-33O7 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Laradon Hall and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#45200. Rates outlined maybe negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. c9UG'5-saev 1 Wpld r,pinh,cc_ 1A Adrpnd'im 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended,proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Weld rn„nh,cQ)1A d ddendnm C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 weld rn„nn,CC-11A Adnand,,.., WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX trails Case ID DOB Sex WORKER COMPLETING ASSESSMENT IDATE OF ASSESSME] AGENCY NAME ROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? O0)one trip a week or less ❑l)2-3 trips a week O2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑1)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? O0)less than a'''A hour per day ❑1) '/ hour a day O2)more than ''A hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? O0)less than 5 hours per week ❑l)5 to 10 hours per week ❑ 2)at least daily O3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? • O0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) II to 20 hours per week O3)21 or more hours per week A 1. How often is CPA case management required? O0) Minimal CPA involvement per month and/or no crisis intervention ❑l) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention O3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e.Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month O3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ 0 ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention ❑ 0 0 ❑ P 4 Behavior Management ❑ ❑ ❑ 0 P 5 Personal Care 0 ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services 0 ❑ ❑ ❑ 4 wain county CC-11A Andp„n.,m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) • RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. € > ' ' EE . .:.::. ._,..._.................. � : � ,,apz `A a stet .. • `: ..:::.... ...,•••.;,,.....:,,:,,:;,.:,:,.„..,-;:,:x:.............:...r.....:.......:::x:::.is s................ "-!,.....� s :£,?miiimiiK.. ; ��?�: ............... .....•...... ... .......... :?—.• ... s ::s:•441_..:. :•....••e:ji;^LIKe.e...:r,.;':i�`':`.i�:i: ::.?3';�Eii '::'`..!•.:. .............. ............ ... Aggression/Cruelty to Animals O ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ O ❑ Destructive of Property/Fire Setting O ❑ ❑ El Stealing O ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ O Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ O O O • Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ El Depressive-like Behavior [] O O ❑ Medical Needs El ❑ ❑ ❑ Emancipation O ❑ ❑ ❑ Education ❑ O ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 ❑ 3 5 wpm rm.,.cc_124 Aritiontium WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) • 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED sRECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al; TI ≥; ADDENDUM , . P1 -P5 Level Rate Admin.Overhead Case Management Therapy (Admin.Services) ; (Admin. Maint.) (Admin.Maiat}.., 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 SO Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no crisis intervention. Only doingby another source, i.e.mental Age 15-21...$13.91 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8 22 Level 1 $4.93 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level 2 $11.51 Level 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy Level 2 $4.47 +S.66 Respite Care Level 2...$4.56 E: Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management' (Regularly scheduled weekly il 3 +8.66 Respite Care Level 3...S4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38 79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC and CPA involvement with child multiple sessions,can include +$ .66 Respite Care Level 4.-.$4.56 Drop and provider, including on-going;,1 more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) iiii Assess. Assessment Assessment Assessment Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum • ' IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: We . o er to e board �� ....fi)1"4,„ ,- w\ WELD COUNTY BOARD OF t 'tip SOCIAL SERVICES, ON BEHALF I imi 1 OF THE WELD COUNTY its DEPARTMENT OF SOCIAL a SERVICES turi . By: %' _i}t4 i; `,ad1 '1 ' By: '�_ -Jf/i.-/ Deput Clerk to the oard William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Laradon Hall 5100 Lincoln St. Denver CO 80216 B}4;_r. _iUcL; L WELD COUNTY DEPARTMENT ) OLick i )‘ 1t(iCe OF SOCIAL SERVICES By: (j' '9ector 8 Weld County SS-23A Addendum moos-33G / WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between REM Colorado, Inc. and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#37832. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 \Veld rn,,nh,CC-11A A A elfJ✓T-`.] �% 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. • 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 wnlii Pnnnty CC-11A AAiinnrnm C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Wain cc_1zn Annrnnh".n • 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 1IH# 1DATE OF ASSESSME] AGENCY NAME PROVIDER NAME PROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week O3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? DO)one a month ❑1)twice a month O2)once a week O3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a Yx hour per day ❑I)'A hour a day O2)more than '/3 hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitorin of time and/or activities and/or crisis management? 00)less than 5 hours per week ❑1)5 to 10 hours per week ❑2)at least daily ❑3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) II to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention O 3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? ❑0)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month O2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS, Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation O O O O P 2 Therapy/Counseling O O O O P 3 Educational Intervention O ❑ ❑ O P 4 Behavior Management O O ❑ O P 5 Personal Care O O O ❑ A 1 Case Management O O O O T 1 Therapeutic Services ❑ O O O 4 Weld r`nnnt,,CC-11A Addendum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. :....:,�.. ... . .._ii.:::� :•..: _:h ;� i..... ��r. Imo' ... ..E.r ......_.,..... .�......... .......................................................... .............. !, ■�.. ::s£sis:.:x�::i i- •: '.iii!........................... i i:::„ : :. ....... ..c.,.,..6.....t�:�_...�F�..,...;�.......u�l...i�si.. .i.:i::':::'�:!.-�:E•i.:�!:?2ii:iii°.:ii:iEid�.: ,:�:=i:::£::r':;�::, ,.Es.r ..... .. ''::'1!.'I:'!: . ........................... .... ......: ................................................... ...c!£ri£i E�stias:;�.:::..............;:.._:;i...............=:uE.iE..s.... ............................;...,...,....,.,. ,..,:....:�.: ........... ............................. s..{=:=si iii Es f..i 'i:,c:.�,,..,...........is .. _d.S; i�.......:.........::;;i-,.3..` BZ'{.f.f.r: .t f); ...E ...;. :E!E: .................. '::::.:';';5;±/''''' .. ................c.�T :::£:�::a�;�+'�=+sr•;; . . ,'�..,.,......,.,. . •:::., :=:G4'lkMltt ;:: .•�. Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior • ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ ❑ 0 Presence of Psychiatric Symptoms/Conditions 0 ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ 0 0 Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior ❑ ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ ❑ ❑ ❑ Education 0 ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) O 0 ❑ 1 ❑ 2 ❑ 3 5 W..Id rn„Mv CC-11A 4 ddondum WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED (T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED a RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS. SERVICE:: PROVIDER RATE Al:.') Al I Ti ' ADDENDUM:••.:.. P1 P6 ... E • Therapy Level T., Rate Admin.Overhead Case Management (Admin.Services) (Admin,Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0.,.$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 iii 0 Age 11-14...$12.89 (Therapy not needed or provided (None) iii (Minimal CPA involvement, no Age 15-21...$13.91 crisis intervention. Only doing by another source,i.e.mental 0 what is necessary to maintain health.) +$.66 Respite Care ;I monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level 1 $2.99 S19.07 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, (S19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis iifi +! intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 Tf (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time yi Per month.) Level 3 $14.79 Level 3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) ti face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38 79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +S.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider, including on-going more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment "" Period Period $26.30 Period $4.56 Period $11.51 Assessment Period $0 (Includes Respite) il Effective 10/01/01 7 Weld County SS-23A Addendum • IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: iLle/A4a4 Weld Clerk to the Board i`'X t:,,, .30 fA WELD COUNTY BOARD OF • � �` \ SOCIAL SERVICES, ON BEHALF 1161 '`LT)n OF THE WELD COUNTY ` - ,l DEPARTMENT OF SOCIAL ®UN oc. 4 SERVICES By: 4'l i ail 2 el tl fV 1 By: "& Z 7 a Deput Clerk to the and William H. Jerke, Chair N0V 0 9 2005 CONTRACTOR REM Colorado, Inc. 4815 List Dr, Suite 111 Colorado, Springs CO 80919-3340 By: CAT. )1 Re-1-r-, ,, 6vu.6. WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: 1.h� /O i ) Director 8 Weld County SS-23A Addendum &Cps— 3 3cy WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between PATH and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement,based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#1502692. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. O7O45-- 23:321 Wpld rnv,nh,CC-11A Addendum 9. Add Paragraph 16 to Section W. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 Wild('nnnw CC-11A Addendum C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld(Minify cc_ne Addnndnm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION 'CHILD'S NAME STATE ID# SEX j1'rails Case ID IDOB Sex WORKER COMPLETING ASSESSMENT 1IH# PATE OF ASSESSME] AGENCY NAME PROVIDER NAME ROVIDER CWEST ID ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY THROUGH 18 YEARS OLD. • For each question below,please select the response which most closely applies to this child. • Please check the number for that response in the corresponding box below. THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE: P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? 00)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? 00)one a month ❑1)twice a month 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 01)1/2 hour a day ❑2)more than ''A 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 monitorini of time and/or activities and/or crisis management? 00)less than 5 hours per week 01)5 to 10 hours per week ❑2)at least daily 03)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week 02) I 1 to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) Minimal CPA involvement per month and/or no crisis intervention 01) 2-3 contacts per month and/or minimal crisis intervention ❑2) I face to face contact per month and/or occasional crisis intervention 03) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? 00)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 ❑ 0 ❑ P 2 Therapy/Counseling 0 ❑ 0 ❑ P 3 Educational Intervention ❑ ❑ ❑ 0 P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ 0 ❑ ❑ A 1 Case Management ❑ 0 0 0 T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 u/pid n.,,nn,cc.-rt Addpnd,,m WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. : .................. . . �£EE ...................... .. ... ..••:•.••.;„,;:.,-.-:,..,;,,:::„;:„::„:„,,,,,,,,,. . . ................:: +:::::. ................. . .:=.`f ...E». t iiiii;:.: ....... ,.,...t.... .....:..... t.,.r r .. ... .. .... ... • ..............s..=....s.s....t...r...... ...:..................... .... ..,.,.....:. :..............-. ...t..£Ei? :�'is4;ts.;4..:::::,::iii:i(?:: £:'.i:iD,fl=, Aggression/Cruelty to Animals ❑ LI ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting LI ❑ ❑ ❑ Stealing ❑ ❑ ❑ ❑ Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ LI ❑ ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ LI LI Disruptive Behavior ❑ ❑ O ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ ❑ Emancipation ❑ LI ❑ ❑ Education ❑ ❑ ❑ LI Involvement with Child's Family ❑ LI ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ o El I El 2 ❑ 3 5 WPM Crtuntv CC-lid, Arlderwttn. WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through PS) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE; .;.:;' INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al - Tl ADDENDUM P1 -P5_ Therapy Level Rate Admin.Overhead Case Management (Admin.Services) (Admin. Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 S4.93 Level 0 $0 . Level 0 SO Age 11-14...S12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no by another Age 15-21...$13.91 crisis intervention. Only doing health 'i.e.mental 0 what is necessary to maintain health.) +$.66 Respite Care monthly responsibility.) Level 1 $8.22 Level 1 $4.93 1 Level 1......$2.99 $19.07 +$.66 Respite Care Level 1...$4.56 (Low level of case management. (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) • Level 2 $11.51 'Level 2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 54.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) —.. ti . . Level 3 $14,79 Level 3 $14.79:;s S32.22 (High level of case management (Regularly scheduled weekly +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy, for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level 4 $18.08 s, Level 4 $14.79 4 (High level of case management~; (Regularly scheduled weekly Level 4 Neg. RTC $38.79 and CPA involvement with child ".!I multiple sessions,can include Drop +$.66 Respite Care Level 4...$4.56 and provider, including on-going <'` more than 1 person,i.e.family Down ($39.45) crisis intervention and face to therapy, for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period 526.30 Period $4.56 Period $11.51 Assessment Period $0 ' (Includes Respite) • Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: Pa '{ W .‘1:21.4/‘ : . . Clerk to the Board P 1:,- <di WELD COUNTY BOARD OF P Efr.;; ' SOCIAL SERVICES, ON BEHALF 186tr s OF THE WELD COUNTY t� M1 DEPARTMENT OF SOCIAL O 4� SERVICES By: U I „I tali 6U By: q ---- 77/._.-/ Deput' Clerk to thjCoard William H. Jerke, Chair NOV 009 2005 CONTRACTOR PATH 6355 Ward, Suite 305 Arvada, CO 0004 l By: 1 AA-V. A. 1 fr.-beet. ns2.- WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: i D ector 8 Weld County SS-23A Addendum o7CC5- ,3S6/!� WELD COUNTY ADDENDUM T7'a •fir•f. To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Smith Agency Inc. and Weld County i Department of Social Services for the period from October 1, 2005, through June 30, 2006. i The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#44882. Rates outlined may be negotiated based on the child's CHRP application and the COPAR assessment. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number(970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. d _ . a f 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 weld(Minify ccnlA Addpndmn • C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: • 3 Wrld r,nmt.,CC-11A Addnndom WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) IDENTIFYING INFORMATION CHILD'S NAME STATE ID# SEX Trails Case ID IDOB Sex J WORKER COMPLETING ASSESSMENT fHII# DATE OF ASSESSME] 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? DO)one trip a week or less ❑1)2-3 trips a week O2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? DO)one a month DI)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'/3 hour per day ❑l) 'h hour a day O2)more than '/z hour per day,up to 2 hours per day O3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑l)5 to 10 hours per week ❑2)at least daily ❑3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑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 01) 2-3 contacts per month and/or minimal crisis intervention O2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T 1. How often are therapy services needed to address child's individual needs per NBC assessment? O0)not needed or Provided by another source(i.e. Medicaid) ❑l)less than 4 hours per month O2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation 0 0 ❑ 0 P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention 0 ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ 0 ❑ ❑ 4 Weld rn,,nty CC-11A Addendum - WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. .. . .. .... . ... .....:...... .. :,... ... .......:.:.:.:.:::.::r..::::�is•:.::.:::.::::::::::::?::.:.: •,:i::�,.................... r=:;: :�..... .. .. ............................... ..........ss.......................,_.........:._. s.. .....,.:.......:c:.c-7iiiF7e? i:.: ? .,:..r': ::' . :::}Vu :::::: :' III': 4:-,ilf+todcr fe:::: :; ;.5ee:;: Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing ❑ ❑ ❑ O Self-injurious Behavior ❑ ❑ ❑ ❑ Substance Abuse ❑ ❑ El ❑ Presence of Psychiatric Symptoms/Conditions ❑ ❑ O ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway O Cl ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ Cl O Disruptive Behavior ❑ O ❑ O Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior O ❑ O ❑ Medical Needs O ❑ ❑ ❑ Emancipation O ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ O ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ o El 1 El 2 El 3 5 WPM Cn„nta,CC-11 A A,L1Pn,inm WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED (Average of P1 through P5) PERIOD 1: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(T1) LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE • Calculated as Daily Rates (Attachment C) LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE Al Ti ' ' ADDENDUM: P1 -P6 . Therapy Level Rate Admin.Overhead Case Management , (Admin.Services) (Admin.Maint.) (Admin.Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 0 Age 11-14...$12.89 (Therapy not needed or provided =.- (None) (Minimal CPA involvement, no by another source,i.e.mental 0 Age 15-21...$13.91 crisis intervention. Only doing health.) what is necessary to maintain +$.66 Respite Care monthly responsibility.) Level I $8.22 .:iii Level 1 $4.93 1 $19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management.. (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 „I 2 • $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including "•• 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) • • Level 3 $14.79 Level 3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include • Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy, •-i:. afor 8-12 hours/monthly.) face contact1-2 time per week minimum.) • iii Level4 $18.08 Level4 $14.79:`ii` 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop ($39.45) and provider,including on-going more than 1 person,i.e.family Down crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Assessment Period Period $26.30 period $4.56 Period $11.51 Assessment Period $0 l; (Includes Respite) Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: 4141/1/044; Web y. d; Clerk to the Board , at\ / � `` JWELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF 1811 Q OF THE WELD COUNTY I ti. ��p ' DEPARTMENT OF SOCIAL % V'� ... 1 SERVICES `=/ . �" By: 1 ,L�/1��/rCWI By: 1 �G�c,/ Deputy ' lerk to the Board William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Smith Agency Inc. 7169 S Liverpool St Centennial, CO,80016 BY. .2y ,X r • WELD COUNTY DEPARTMENT ci- 2c . 5 avert dna OF SOCIAL SERVICES ` «era;ed-re-sit -21-ere‘ By: ( hector 8 Weld County SS-23A Addendum o?c:cs - 3 01 WELD COUNTY ADDENDUM To that certain Agreement to Purchase Child Placement Agency Services (the "Agreement") between Bridges Inc. and Weld County Department of Social Services for the period from October 1, 2005, through June 30, 2006. The following provisions, made this day of , 2005, are added to the referenced Agreement. Except as modified hereby, all terms of the Agreement remain unchanged. 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated as Attachment B, shall be used to determine levels of care for each child placed with Contractor. 2. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement, based on the Needs Based Care Assessment levels determined. The specific rate of payment will be paid for each level of service, as indicated by the Needs Based Care Rate Table, designated as Attachment C, for children placed within the CPA identified as Provider ID#1980. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. Add Paragraph 14 to Section I. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 4. Add Paragraph 6 to Section II. Contact by the Contractor with the County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, the Contractor will make every effort to notify the assigned caseworker, supervisor, or Intake Screener of any emergency medical, surgical or dental issues prior to granting authorization. During non-regular work hours, weekends and holidays, the Contractor will contact the Emergency Duty Worker at the pager number (970) 350-8389. 5. Section V, Paragraph 5. Children in Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Social Services Policy and Procedure Manual. 6. Add Paragraph 13 to Section IV. Agree to cooperate with any vendors hired by Weld County Department of Social Services to shorten the duration of placement. 7. Add Paragraph 14 to Section IV. Agree to schedule physical examinations within 14 days after placement, dental examinations within 60 days after placement and forward all appropriate information to the County. 8. Add Paragraph 15 to Section IV. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student will be conducted every 3 years and reviewed every year. If the IEP is due while the child is in placement, the Contractor will complete or obtain a completed IEP. A copy will then be forwarded to the County. 1 FJ]A AdAP„n'.m 9. Add Paragraph 16 to Section IV. Assure and certify that it and its principals: A. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by a federal department or agency. B. Have not, within a three-year period of preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; C. Are not presently indicted for or otherwise criminally or civilly charged by a government entity(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) above. D. Have not within a three-year period preceding this Agreement, had one or more public transactions (federal, state, and local) terminated for cause or default. 10. Add Paragraph 7 to Section VI. It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties or their assignees, and nothing contained in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties or their assignees receiving services or benefits under this Agreement shall be an incidental beneficiary only. 11. Add Paragraph 8 to Section VI. No portion of this Agreement shall be deemed to constitute a waiver of any immunities the parties or their officers or employees may possess, nor shall any portion of this Agreement be deemed to have created a duty of care that did not previously exist with respect to any person not a party to this Agreement. The parties hereto acknowledge and agree that no part of this Agreement is intended to circumvent or replace such immunities. 12. Add Paragraph 9 to Section VI. The Director of Social Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: A. Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed; B. Deny payment or recover reimbursement for those services or deliverables which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Social Services. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to Social Services; 2 wain rn„nt,cc_oan Addenn,,,., C. Recover from the Contractor any incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation by deducting from subsequent payments under this Agreement or other agreements between Social Services and the Contractor, or by Social Services as a debt to Social Services or otherwise as provided by law. 13. Add Paragraph 10 to Section VI. The contractor shall promptly notify Social Services in the event that the Contractor learns of any actual litigation in which it is a party defendant in a case, which involves services provided under the agreement. The Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any federal or state court or administrative agency, shall deliver copies of such document(s) to the Social Services' Director. The term "litigation" includes an assignment for the benefit of creditors, and filings in bankruptcy, reorganizations and/or foreclosure. 14. Add Section VII-ATTACHMENTS: 3 Weld('Winn,cc A Addend,,.., 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 1fIH# 1DATE OF ASSESSMEI 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 one of the following: therapeutic or medical treatment,emotional or social counseling,etc.,as outlined in the treatment plan or approved by the caseworker? ❑0)one trip a week or less DI)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week P 2. How often is the provider required to participate in child's therapy or counseling sessions? ❑0)one a month ❑l)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a'/:hour per day ❑1) ''/ hour a day D2)more than''/ hour per day,up to 2 hours per day ❑3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑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? DO)less than 5 hours per week ❑l)5 to 10 hours per week ❑2) 11 to 20 hours per week ❑3)21 or more hours per week A I. How often is CPA case management required? DO) Minimal CPA involvement per month and/or no crisis intervention ❑1) 2-3 contacts per month and/or minimal crisis intervention ❑2) 1 face to face contact per month and/or occasional crisis intervention ❑3) Face to face contact 1-2 times per week and/or ongoing crisis intervention T I. How often are therapy services needed to address child's individual needs per NBC assessment? DO)not needed or Provided by another source(i.e. Medicaid) ❑1)less than 4 hours per month D2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention D ❑ ❑ ❑ P 4 Behavior Management D ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A I Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 4 U/Pld m..uint',cc-l1A Addand„r., WELD COUNTY DSS • NEEDS BASED CARE ASSESSMENT (CONT.) RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE SIGNIFICANT IN TERMS OF DURATION AND INTENSITY. Assessment Period: ['Initial Assessment ❑Re-Determination -Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. . ........ . . . ti ... .� •' � : • ' s? i; ::;;.".:•::, a,E₹ '7�w................................`, � s... r.....cEEiE i s :.:1bi:2�EF:₹re, :r.::::c:o...................::::: ..:..... . :•5.::..:._.._. . _,. .•• •:•'::!:t::'-:!.'',!"::''.':'•:-'-';''''''",.''':. �:.............. ...........f...i._S.1... t ..,..............1........ .... .1lY2WM:Ai............. .. �, ..., ,....:.:::::::�::::::�::::•:::�._.,..:•::• ::1::::::.�........iiHi..... 3 Aggression/Cruelty to Animals ❑ O ❑ ❑ Verbal or Physical Threatening ❑ O O ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ El Stealing El ❑ ❑ O Self-injurious Behavior El ❑ O O Substance Abuse ❑ O O ❑ Presence of Psychiatric Symptoms/Conditions ❑ O ❑ ❑ Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway O O ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior O ❑ ❑ O Delinquent Behavior ❑ ❑ O ❑ Depressive-like Behavior ❑ O O ❑ Medical Needs ❑ ❑ E Cl Emancipation ❑ ❑ El ❑ Education O O [] El Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF NEED: AVERAGE LEVEL: (check level of need) ❑ 0 ❑ 1 ❑ 2 El 3 5 wviri rn,,,n*.,CC-114 4ririrnrium WELD COUNTY DSS NEEDS BASED CARE ASSESSMENT (ATTACHMENT B) SUMMARY-Please identify all specific requirements and expectations which support Level of Care. LEVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5) PERIOD I: LEVEL# Comments: LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al) LEVEL # Comments: LEVEL OF THERAPY SERVICES NEEDED(TO LEVEL # Comments: SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only) LEVEL # Comments: NEXT SCHEDULED RATE REVIEW: Initial Date: (maximum of 6 month intervals) 6 Weld County SS-23A Addendum WELD COUNTY DEPARTMENT OF SOCIAL SERVICES NEEDS BASED CARE RATE TABLE Calculated as Daily Rates ' (Attachment C) LEVEL OF RECOMMENDED -;;:.::RECOMMENDED AGENCY RATE?i:_;;;;;;;+ INTERVENTION RATE MEDICAL NEEDS' ....:......::. E , ADDENDUM, .:: SERVICE PROVIDER RATE •' E ;:��:.:...-.,,:' Al ... ........ Tl, P1 -P6 '' '₹ $L: ..., €, .. Level Rate i Admin.Overhead Case Management Therapy s (Admin.Maint.) (Admin.Maint.) (Admin. Services) 0 Age 0-10...$11.47 Level 0...$4.56 ;:!. Level 0 $4.93 Level 0 $0 Level 0 $0 iiiii 0 Age 11-14...$12.89 (Therapy not needed or provided (None) (Minimal CPA involvement, no • Age 15-21...S13.91 crisis intervention. Only doing by another source,i.e.mental 0 what is necessary to maintain ;H: health.) +$.66 Respite Care monthly responsibility.) iiii iii Level 1 $8.22 fi:::i Level 1 $4.93 1 S19.07 Level 1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ii ($19.73) minimal crisis intervention,2-3 4 hours/month.) iiii contacts/month,minimal crisis . intervention, 2-3 contacts/month.) ii Level 2 $11.51 Level 2 $9.86 El 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, Face to face contact 1 time Per month.) Level3 $14.79 Level3 $14.79 $32 22 (High level of case management (Regularly scheduled weekly 3 +$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $38.79 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop and provider,including on-going more than 1 person,i.e.family Down ($39'45) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) 14 Assess. Assessment rtil Assessment Assessment `'i Period Period $26.30 period S4.56 Period $11.51 tli Assessment Period $0 (Includes Respite) tiIi Effective 10/01/01 7 Weld County SS-23A Addendum IN WITNESS WHEREOF, the parties hereto have duly executed the Addendum as of the day, month, and year first above written. ATTEST: LS1- 41 Weld T Clerk to the Board \ WELD COUNTY BOARD OF SOCIAL SERVICES, ON BEHALF 1861 r O- i OF THE WELD COUNTY ® SERVICES DEPARTMENT OF SOCIAL By: V I .1 ang den By: Deput Clerk to the 13 and William H. Jerke, Chair NOV 0 9 2005 CONTRACTOR Bridges Inc. 1225 N Main Street, Suite 102 Pueblo, C 181003 By WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: Director 8 Weld County SS-23A Addendum aces- 336 Hello