HomeMy WebLinkAbout20041737.tiff RESOLUTION
RE: APPROVE TWENTY 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 twenty Agreement to Purchase Child
Placement Agency Services between the County of Weld, State of Colorado, by and through the
Board of County Commissioners of Weld County, on behalf of the Department of Social Services,
and the following providers,commencing July 1,2004,and ending June 30,2005,with further terms
and conditions being as stated in said agreements, and
1. ABBA Family Services 11. Jacob Family Services
2. Adoption Alliance 12. Kids Resources Network, Inc.
3. Children's Network 13. Kidz Ark, Inc.
4. Colorado Family Services, Inc. 14. Lost and Found, Inc.
5. Commonworks D.B.A. Synthesis 15. Loving Homes, Inc.
6. Creative Beginnings 16. Lutheran Social Services of Colorado
7. Eagle Homes 17. PATH
8. Emily Griffith Center- Chins Up 18. Trinity Foster Care
9. Foster Care Connection 19. Youth Ventures, LLC
10. Hope and Homes 20. Hope Family Services
WHEREAS,after review,the Board deems it advisable to approve said agreements,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 twenty 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 agreements.
/ \ 2004-1737
ee : SS 0.°0'z`� J SS0031
7-/5-ax'9
AGREEMENT TO PURCHASE CHILD PLACEMENT AGENCY SERVICES - VARIOUS
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded,adopted by
the following vote on the 28th day of June, A.D., 2004.
BOARD OF COUNTY COMMISSIONERS
E�f``� WELD COUNTY, COLORADO
not MME
Robert D. Masden, Chair
d !, Clerk to the Board ,{
William rke, Pro-Tem
Deputy Cler t• the Board
M. eile
O D AS TO C�
David E. Long
ttorn y
Glenn Vaad
Date of signature: %i9/y
2004-1737
SS0031
a
re
DEPARTMENT OF SOCIAL SERVICES
P.O. BOX A
GREELEY,CO. 80632
Website:www.co.weld.co.us
Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
11111,1 O
•
COLORADO MEMORANDUM
TO: Robert D. Masden, Chair Date: June 16, 2004
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services J 0
Purchase Child Placement F: enc (CPA)
RE: Agreements to g y( )
Services Between Weld County Department of Social
Services and Various Vendors
Enclosed for Board approval are Agreements to purchase Child Placement Agency
(CPA) Services between the Weld County Department of Social Services and various
vendors. These yearly Agreements are in accordance with Board approved policies of
Sections 2.320 and 2.902.22 of the Weld County Department of Social Services
Operations Manual. The Agreements were reviewed at the Board's Work Session of
June 14, 2004.
The major provisions of the Agreement are as follows:
1. The term begins July 1, 2004, and ends June 30, 2005.
2. The Department agrees to reimburse the vendors at a rate based on the Needs
Based Care Assessment levels that include room, board, and treatment services.
The vendors are as follows:
A.ABBA Family Services K.Jacob Family Services
B.Adoption Alliance L Kids Resources Network,Inc.
C. Children's Network M.Kidz Ark,Inc.
D. Colorado Family Services,Inc. N.Lost and Found,Inc.
E. Commonworks D.B.A. Synthesis 0.Loving Homes,Inc.
F.Creative Beginnings P.Lutheran Social Services of Colorado
G.Eagle Homes Q.PATH
H. Emily Griffith Center—Chins Up R.Trinity Foster Care
I.Foster Care Connection S.Youth Ventures LLC
J.Hope and Homes T.Hope Family Services
If you have any questions, please telephone me at extension 6510.
•
2004-1737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
a
THIS AGREEMENT made this day of 2004 between the Board of Weld
County Commissioners,sifting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and ABBA Family Services, 10995
Independence Circle East,Parker, CO 80134,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called"State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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#6567. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing,to terminate this Agreement,whichever event
occurs first.
4. This Agreement maybe renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail,return
receipt requested. If notice is so given,this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase 1 A7,004—1737
Contract No: PY 04/O5-SS-23A-CPA
earlier,and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance),Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy,Polygraph,
Plethysmograph,Parent Training for Teens,Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care,Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1.(F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility,the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 6567
ABBA Family Services
10995 Independence Circle East
Parker, CO 80134
Agreement to Purchase 2
CPA Foster Care Services
Contract No: PY 04/OS-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131),the contractor may obtain: 1)Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s)and the County,the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7)days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death,to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute,ordinance,or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan @EP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which maybe
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04!05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
CPA Foster Care Services 8
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
O Placed through a Vohmlary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed though a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the fact ity/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
• Therapeutic(Behavior Modification) O Secure ❑Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender O Aggressive/Violent O Substance Abuse O Truancy O Victim Behavior O 0.y„ssion
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring ❑ Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes arc not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansk,Administrator Signature of Person Authorized to Sign Agiccnm,t
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME 'STATE ID# SEX ITrails Case ID DOB
ex
WORKER COMPLETING ASSESSMENT Hll# DATE OF ASSESSMENT
AGENCY NAME FPROVIDER 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?
O0)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special
education plan?
❑0)less than a'/hour per day ❑1)'h hour a day
O2)more than%hour per day,up to 2 hours per day ❑3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑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 ❑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) 1 face to face contact per month and/or no crisis intervention
01) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact per week and/or ongoing crisis intervention
r 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑o)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 E 0
P 2 Therapy/Counseling ❑
P 3 Educational Intervention O
P 4 Behavior Management ❑ 0
P 5 Personal Care 0
L
A I Case Management 0 0
T 1 Therapeutic Services ❑ 0
lgreement to Purchase 10
WA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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 Eke-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING.
._. i _. I
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ' ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ O
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
EVEL OF PROVIDER SERVICES NEEDED(Average of P1 through P5)
ERIOD 1:LEVEL#
omments:
EVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
EVEL #
omments:
EVEL OF THERAPY SERVICES NEEDED 01)
EVEL #
omments:
PECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
•
EVEL #
omments:
SCHEDULED RATE REVIEW: 'Initial Date:
maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
•
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 ;s. (Therapy not needed or provided (None)
crisis intervention. Only doing t by another source,i.e.mental
0 Age 15-21...$13.91 what is necessary to maintain -s health.)
monthly responsibility.)
+3.66 Respite Care
Level 1 $8.22 :: Level 1 $4.93
1 a Levell $2.99
$19.07
+j.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 =,qi
intervention,
2-3 contacts/month.)
s
Level2 $11.51 �
r
Level2 $9.86
y
2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47
+3,66 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 $1479
3 $32.22e
32 22 (High level of case management (Regularly scheduled weekly
+j,66 Respite Care ' Level 3...$4.56 - and CPA involvement with child multiple sessions,can include Level 3 $6.02
($32.88) mre 1 person,i.e.fam
crandisisprovider interventionincluding and faceongoing to theraapy,than for 8-12 hourslnanthlyily.)
face contactt-2 time per week
minimum.)
,' Level4 $18.08 Level4 $14.79
$39.45
RTC (High level of case management (Regularly scheduled weekly '.. Level 4 Neg.
+$66 Respite Care ; Level 4...j4.56 and CPA involvement with child , multiple sessions,can include
.
Drop ($40 11) 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 j '. 1 r
Period Period $2630 ' period Tetra -Assessment Period $11.51 Assessment Period................ $0
(Includes Respite) Period $4.56
.
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
aoCV--/737
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: f �' /4
u ses, Weld County Clerk to the Board
. ,
'r4z ` WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
''' _ , WELD COUNTY DEPARTMENT OF
r AR SOCIAL SERVICES
B}` Zet rm r z. /�ai By.
1,uty Clerk to the Board Robert> . asden,Chair
JUN 2 8 2004
APPROVED AS TO FORM:
CONTRACTOR
County tto ey
ABBA Family Services
10995 Independence Circle East
Parker, CO 80134
BY01 ,i4C, _
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: a i
Direr or
•
•
Agreement to Purchase
14
CPA Foster Care Services
aoay—JYS7
Contract No: 1W 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
n Cie
THIS AGREEMENT made thisa8 day of 2004 between the Board of Weld
County Commissioners, sifting as the Board of Soci Services, on behalf of the Weld County
Department of Social Services, hereinafter called"County" and Adoption Alliance, 2121 S.
Oneda St, Suite 420,Denver, CO 80224,hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called"State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing,to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
0700 y-/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility,the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 71259
Adoption Alliance
2121 S. Oneda St, Suite 420
Denver, CO 80224
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County,the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death,to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance,or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two(2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation maybe by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placcuand Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
- O Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ in home services O Placement with Relative O Cty CC Foster Care O Shelter Care
tment
❑ CORE Services O Receiving Home O CPA OORTC regular egul Abuse Care
❑ Day Treatment O Kinship Care 0 Group Home 0 Ind.Living 0 Cty r(Specify)
') Care
O Other(Speeify)
S. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
0 Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
O Individual O Family O Group
Appropriate Treatment:
0 Sex Offender ❑ Aggressive/Violent O Substance Abuse O Truancy O Victim Behavior 0 Depression
❑ Self-destructive O Delinquency cY 0 Special Medical Needs 0 Behavior Modification 0 Anger Management
❑ Other (Explain)
Appropriate Educational Services:
0 Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Inde
pendent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child Is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
•
if the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
;Worker Name) Date
31oria Romansk,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
PA Foster Care Services 9
Contract No: PY 04/05-SS-23A-CPA
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 HI{# (DATE OF ASSESSMENT
AGENCY NAME (PROVIDER NAME (PROVIDER CWEST II)
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 ❑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 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 Ian?
DO)less than a/2 hour per day 01)'/2 hour a day
O2)more than'/:hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
O0)less than 5 hours per week ❑1)5 to 10 hours per week 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, hysical,and/or occupational therapy?
U0)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?
❑0) I face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least I face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0
P 2 Therapy/Counseling 0 0
—
❑
P 3 Educational Intervention ❑ ❑
P 4 Behavior Management 0 c 0
P 5 Personal Care ❑ 0
A 1 Case Management an 0
T 1 Therapeutic Services 0 0 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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 i. ) Ij' f eater
ti .., .,_.w'',_.,e...,._. *zat
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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 it
Comments:
NEXT SCHEDULED RATE REVIEW: itial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES '
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
, �ni�Y , 4 +. ['
O Age 0-10...$11.47 i Level 0...$4.56 .; Level 0 $4.93 Level $0 Level 0 $0
H.
ri
O Age 11-14...$12.89 ' ' (Minimal CPA involvement,no (Therapy not needed or provided (None)
`:. crisis intervention. Only doing . by another source,i.e.mental
Ls
0 Age 15-21...$13.91 what is necessary to maintain health.) till
monthly responsibility.) .
+$.66 Respite Care ;
Di
Level 1 $8.22 Level 1 $4.93
1 Level 1 $2.99
$19.07
+5.66 Respite Care Level 1...54.56 r (Low level of case management, (Regularly scheduled therapy, fiA
($19.73) minimal crisis intervention,2-3 ii,z, 4 hours/month.)
contacts/month,minimal crisis
intervention,
2-3 contacts/month.)
. p Level2 $11.51 Level2 $9.86
2 $25.64 (Moderate level of case (Weekly scheduled therapy,
` 4.66 Respite Care Level 2...$4.56 r Management including 4-8 hours a month with 4 hours of Level 2 $4.47
($26.30) ia. Weekly support services, Group therapy.)
i • Occasional crisis intervention, ;„'
§a Face to face contact 1 time
° . Per month.)
1
ifrii
r. Level 3 $14.79 Level 3 $14.79
w "{
$3222 (High level of case management we(Regularly scheduledweekly
3 and CPA involvement with child multiple sessions,can include
. Level 3 $6.02
+5.66 Respite Care Level 3...54.56
($32• .88) �.d and provider including ongoing s ± more than 1 person,i.e.family prii
'• crisis Intervention and face to therapy,for 8-12 hours/monthly.) P.
face contactl-2 time per week
minimum.) p
rrs
-3 " °{.Level4 $18.08 Level 4 $14.79
t;
y w4;(High level of case management (Regularly scheduled weekly pin!` Level 4 Neg.
$39.45
RTC ". and CPA Involvement with child multiple sessions,can include ..
+$.66 Respite Care ! Level 4..44.56
Drop ($40 11 and provider,including on-going more than 1 person,i.e.family
Down ) a`#E crisis intervention and face to -! therapy,for 8-12 hours/monthly.) le,,
r face contact 2-3 times per
week minimum.) 7
Assess. Assessment
Period "'' Period $26.30 . period $4t50 ..Assessment Period........$11.51 r"Assessment Period $0 g
(Includes Respite) a;'.
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
, --"c%Id County Clerk to the Board if ,.: �` WELD COUNTY BOARD OF SOCIAL
( ��, SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
`r it? � SOCIAL SERVICES
• 2� u� C By: \\) S\' ,", -
eputy Clerk to the Board Robert D.I�fasden,Chair
APPROVED AS TO FORM: JUN 2 8 2004
CONTRACTOR
Co ty homey
Adoption Alliance
2121 S. Oneda St, Suite 420
Denver, CO 80224
By:` . lc&a,y of.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES By: au ,(
Directo J
Agreement to Purchase 14
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made thisoco
p lay of 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Children's Network, 7651 W 41st
Ave, Suite 96, Wheat Ridge, CO 80033,hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing,to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30)days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
cipo0di—/73]
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance),Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 77512
Children's Network
7651 W 41st Ave, Suite 96
Wheat Ridge, CO 80033
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71,2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor,including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7)days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services,the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
'. information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at rime of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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, which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
CPA Foster Care Services 8
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative ❑ Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O lad.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
O Sex Offender ❑ Aggressive/Violent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
O Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goab are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
•
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX rails Case ID DOB
Sex
,WORKER COMPLETING ASSESSMENT IIFI# 'DATE OF ASSESSMENT
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?
DO)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 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?
DO)less than a%:hour per day ❑1)'//hour a day
❑2)more than 1/2 hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily ❑3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming,physical,and/or occupational therapy?
DO)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
DO) 1 face to face contact per month and/or no crisis intervention
DI) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O 2) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0
P 2 Therapy/Counseling 0 0 ❑
P 3 Educational Intervention [ ❑ 0
P 4 Behavior Management 0 0 0
P 5 Personal Care ❑ 0 0
A 1 Case Management [ ❑ 0 0
T 1 Therapeutic Services 0 ❑ ❑ 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
! s i v d Yirvl : vii,
._......... ... ..... ..z......a......;......:..ei'.n�}a ,fia. I... a .,.,,..,..,......_.. _ _
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ El
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ El
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 1113
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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)
PERIOD 1:LEVEL#
•Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(11)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Ilnitial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
._. .. ... l
0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4,93 Level 0 $0 w Level 0 $0
0 Age 11-14...$12.89 (Minimal CPA involvement,no j (Therapy not needed or provided (None)
crisis intervention. Only doing by another source,i.e.mental
0 Age 15-21...$13.91 what Is necessary to maintain health.)
( monthly responsibility.)
+$.66 Respite Care , t .
1 �u.. ? . Level 1 $8.22 Level 1 $4.93=-=.
€ Level 1......$2.99
$19.07 level of case management, (Regularly scheduled
a +$.66 Respite Care ' Level 1...$4.56 (Low o 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 EGz $25.64 r (Moderate level of case ` ' (Weekly scheduled therapy,
, 4.66 Respite Care ,.: Level 2.......$4.47
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.)
fi=
Level3 $14.79 Level 3 $14.79 i
,
$32.22 (High level of case management (Regularly scheduled weekly
3 +$.66 Respite Care Level 3...$4 56 and CPA involvement with child ' multiple sessions,can include .: Level 3 $6.02
r ($32.88) er and provider including ongoing more than 1 person,i.e.family
'3 crisis Intervention and face to : therapy,for 8-12 hours/monthly.)
;:. face contactt-2 time per week i
3 minimum.)
#- t ' Level 4 $18.08 ';Level 4 $14.79,
4 t 3 „(High level of case management (Regularly scheduled weekly Level 4 Neg.
$39.45
RTC +$.66 Respite Care Level 4...54 56 ` and CPA involvement with child multiple sessions,can include
Drop 'r-,t and provider,including on-going more than 1 person,i.e.family •
Down ($40.11) ;. r a. crisis intervention and face to therapy,for 8-12 hours/monthly.)
face contactcontactI 2-3 times per ,) ,
week minimum.) `
i
Assess. g. Assessment Assessment ° A :`
Period Period $26.30 Period $4 56 'Assessment Period $11.51 Assessment Period $0
(Includes Respite) E wu a
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: P'(04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
T: 12,144144/1“4
Weld County Clerk to the Board
-o:
mil . % WELD COUNTY BOARD OF SOCIAL
Jul ,se=, = ' SERVICES,ON BEHALF OF THE
''%ii�` WELD COUNTY DEPARTMENT OF
� � SOCIAL SERVICES
•• 11
By\ Zr L / By:
I eputy Clerk to the Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FO •
CONTRACTOR
C ty omey
Children's Network
7651 W 41st Ave, Suite 96
Whe 'dge, CO 80033
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: a
rector
���JJJ
•
Agreement to Purchase
14
CPA Foster Care Services
aooy—/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
pa
THIS AGREEMENT made this,X0 day ofC �/itt 2004 between the Board of Weld
• County Commissioners, sitting as the Board of Soc. 1 Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Colorado Family Services Inc.,
1200 S Wadsworth#300, Lakewood, CO 80232-5434, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
cuet1-/7S7
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management,Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 26885
Colorado Family Services Inc.
1200 S Wadsworth#300
Lakewood, CO 80232-5434
Agreement to Purchase
CPA Foster Care Services 2
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening,Diagnosis and Treatment Program.
Agreement to Purchase
CPA Foster Care Services 3
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure, where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral)or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services,the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
CPA Foster Care Services 5
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04!05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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, which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
S
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care
❑ CORE Services O Receiving Home O CPA O RTC O Substance Abuse TreatmentCare
❑ Day Treatment O Kinship Care O Group Home ❑ Cty regular Foster Care
O Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment: •
O Sex Offender O Aggressive/Violent O Substance Abuse O Truancy
ID Self-destructiveO Delinquency O Victim Behavior O Depression
q h' O Special Medical Needs O Behavior Modification O Anger Management
O Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature
(Worker Name) Date City,State,Zip
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agrcu,,,ent
Date Date
Agreement to Purchase
CPA Foster Care Services 9
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE BO SEX [Trails Case ID IDOB
•
Sex
WORKER COMPLETING ASSESSMENT IHH# DATE OF ASSESSMENT
AGENCY NAME (PROVIDER NAME (PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES I DAY
THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for 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 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 DI)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 Ian?
O0)less than a'/ hour per day 01)%,hour a day
O2)more than'/,hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
O0)less than 5 hours per week O1)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 Ell)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) 1 face to face contact per month and/or no crisis intervention
01) 2-3 contacts per month(must include I face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 0 0 0
P 3 Educational Intervention C 0 0 0
P 4 Behavior Management C 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
Agreement to Purchase
CPA Foster Care Services 10
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
-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.
n
f iii ' 1. 1 az F;
• • gj
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ I ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/O5-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD 1:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(A1)
LEVEL it
Comments:
LEVEL OF THERAPY SERVICES NEEDED(Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: ihal Date:
(maximum of 6 month intervals)
Agreement to Purchase
CPA Foster Care Services 12
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
g Age 0-10_41147 Level 0...$456 Level 0 $4.93 Level 0 $0 Level 0 $0
0 Age 11-14...512.89 " (Minimal CPA involvement,no (Therapy not needed or provided (None)
crisis intervention. Only doing by another source,i.e.mental
0 s Age 15-21...$13 91 , ,` what is necessary to maintain health.)
r! monthly responsibility.)
v.t +5.66 Respite Care se€
§a;
f
1 ,. Level 1 $8.22 �,Level 1 $4.93
$19.07 " Level 1 52.99
+$.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
3 intervention,
t a) 2-3 contacts/month.)
t r s Level 2 $11.51 j Level 2 $9.86
2 $25.64 a, (Moderate level of case (Weekly scheduled therapy,
4.66 Respite Care Level 2...5456 ih Management including 4-8 hours a month with 4 hours of Level 2 $4.47
($26.30) . Weekly support services, ! Group therapy.)
Occasional crisis intervention r.a
1 Face to face contact 1 time
); €'y : Per month.) r
'.
Level 3 $14.79 Level 3 $14.79
t e(High level of case management } (Regularly scheduled
t $32.22 '.. 9 weekly
3 +5.66 Respite Care •�? Leve13...S4.56 . and CPA involvement with child a multiple sessions,can include Level 3 $6.02
(332.88) ? and provider including ongoing more than 1 person,i.e.family
e-4 crisis intervention and face to (:t therapy,for 8-12 hours/monthly.)
-' : face contactt-2 time per week
minimum.)
i� Level 4 $18.08 Level 4
x ( t . $14.79
4 $39.45 (High level of case management (Regularly scheduled weekly Level 4 Neg.
RTC I +5.66 Respite Care s Level 4...54.56 and CPA involvement with child 's multiple sessions,can include
Drop ` ($40 11) and provider,including on-going more than 1 person,i.e.family
Down - ' crisis intervention and face to k therapy,for 8-12 hours/monthly.)
....„. ci,: face contact 2-3 times per ;.
3 week minimum.) e
`,
Assess. Assessment . A;
Period _ Period $26.30 fr Assessment
: Assessment Period $11.51 Assessment Period $0
(Includes Respite) Period $4 56 a
_tip 4. , L.+
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
Weld County Clerk to the Board
1861 WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
Cu P a�. - v SOCIAL SERVICES
By " Zit 2� , By: 0 t La__
Deputy Clerk to the Board Robert D.Masden,Chair
APPROVED AS TO FO • JUN 2 8 2004
CONTRACTOR
oun A omey
Colorado Family Services Inc.
1200 S Wadsworth#300
• Lakewood, O 80232-5434
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: \ j" 3Direct " 1°
or
Agreement to Purchase
CPA Foster Care Services 14
aooy-/7$7
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
•
THIS AGREEMENT made this day of 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Commonworks D.B.A.
Synthesis,PO Box 12528, Denver, CO 80212-0528, hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. A child specific Needs Based Care Assessment, designated as Attachment B, shall be
used to determine levels of care for each child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services,which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#104085. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
QV°9—/732
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter,clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider 1D#: 104085
Commonworks D.B.A. Synthesis
PO Box 12528
Denver, CO 80212-0528
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71,2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure, where possible, permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological(mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan (IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which maybe
amended from time to time.
5. Monitor child's progress in accordance with the treatmenticase plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
. 5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contact signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Conmients:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O hid.living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment: .
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
O Other (Explain)
Appropriate Educational Services:
O Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
•
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agr=meld
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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 IHH# DATE OF ASSESSMENT
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 ❑l)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 DI)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'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 monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming,physical,and/or occupational therapy?
DO)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) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 0 O 0
P 3 Educational Intervention 0 0 0 0
P 4 Behavior Management [ 0 0 0
P 5 Personal Care C 0 0 0
A 1 Case Management 0 0 0 O
T 1 Therapeutic Services 0 0 0 0
Agreement to Purchase
CPA Foster Care Services 10
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE
SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING.
G i
IE
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
• Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-S5-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD 1:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (T1)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
•
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
I 1 .."-'".2r.t.' u F 4
t::' vet;&' "F#A-,d+I ,"'
•
g Age 0-10...511.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0
o Age 11-14...$12.89 (Minimal CPA involvement,no (Therapy not needed or provided (None)
` crisis intervention. Only doing by another source,i.e.mental
0 : Age 15-21...$13.91 what is necessary to maintain health.)
monthly responsibility.) .,,
`
34
+5.66 Respite Care ll Level 1 $8.22 Level 1 $4.93
1
$19.07 Levell $2.99
+$.66 Respite Care =,. Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy,
($19.73) minimal crisis intervention,2-3 .y 4 hours/month.)
zu ll ;74
contacts/month,minimal crisis ni';
intervention,
Pi ii.4
2-3 contacts/month.)
Level 2 $11.51 '`_. Level 2 $9.86
2 bi lin
$25.64 r.ii (Moderate level of case (Weekly scheduled therapy,
Level 2 $4.47
+5.66 Respite Care ° Level 2...$4.56 1 Management Including >, 4-8 hours a month with 4 hours of
($26.30) Weekly support services, Group therapy.)
l; Occasional crisis intervention,
Face to face contact 1 time I
Per month. -�
1 r3'
ry Level 3 $14.79 Level 3 $14.79
LA
$32.22 (High level of case management 4 (Regularly scheduled weekly
3 +5.66 Respite Care Level 3...54.56 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.) I :
$'
Level 4 $18.08 Level 4 $14.79
(High level of case management (Regularly scheduled weekly Level 4 Neg.
RTC $39.45 . and CPA involvement with child multiple sessions,can include
+$.66 Respite Care Level 4...54.56
Drop and provider,including on-going more than 1 person,i.e.family
Down V. (E40.t 1) ¢ crisis intervention and face to therapy,for 8-12 hours/monthly.)
face contact 2-3 times per
, week minimum.)
Assess. Assessment
Period Period $26.30 _ Assessment • x Assessment Period $11.51 Assessment Period $0
(Includes Respite) st Period $4.56
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: 1W 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
AllEST: lite/a/1a
• , 1a . , Weld County Clerk to the Board
`�• �` WELD COUNTY BOARD OF SOCIAL
M I (( c: 1♦1 SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
`/ ►� SOCIAL SERVICES ^� (�
®� ice•, "VV
y: — l By:
Deputy Clerk to the Board Robert D.Masden,Chair
APPROVED AS TO FORM: JUN 2 8 2004
�(� —� CONTRACTOR
CounljtAttc�iney ezVeCommonworks D.B.A. Synthesis
PO Box 12528
•
Denver, CO 80212-0528
By@b-n......) isbj5atra.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: `/
irector
Agreement to Purchase
14
CPA Foster Care Services
moo s1—'737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
g
THIS AGREEMENT made this,c A day of Q,�004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Creative Beginnings, 7100 N.
Broadway Unit 6-0,Denver, CO 80221,hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees,in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30)days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
owe V---47.37
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance),Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. My transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan,and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 39342
Creative Beginnings
7100 N. Broadway Unit 6-0
Denver, CO 80221
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION IL MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72,2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131),the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County,the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7)days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports, which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15)days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services,the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
CPA Foster Care Services tl
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected fee visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ hi home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA O RTC O Cty regular Foster Care
O Day Treatment O Kinship Care O Group Home O bid.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
O Thu.peutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
0 Individual O Family O Group
Appropriate Treatment:
O Sex Offender O Aggressive/Violent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency ❑ Special Medical Needs O Behavior Modification O Anger Management
O Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan Is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B) '
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID DOB
WORKER COMPLETING ASSESSMENT IIH# eX l 1ATE OF ASSESSMENT
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 ❑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 01)twice a month O2)once a week ❑3)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special
education Ilan?
O0)less than a Y2 hour per day ❑1)Y2 hour a day
O2)more than%hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to I0 hours per week O 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming, hysical,and/or occupational therapy?
IVI)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) I face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least I face to face contact 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
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 O O O O
P 2 Therapy/Counseling O O O
P 3 Educational Intervention O D O O
P 4 Behavior Management O O O O
P 5 Personal Care O O O O
A 1 Case Management O O O O
T 1 Therapeutic Services O O O O
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
RATE THE BEHAVIOR CONDITTONS 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.
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of PI through P5)
PERIOD I:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (TI)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
•
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
- .. —...
y
gg ,3 �7
7.1
0 Age 0.10...$11.47 Level O...$4 56 Level $4.93 Level 0 $0 Level0 30
o . Age 11-14...$12.89 (Minimal CPA involvement,no
(Therapy not needed or provided (None)
.ry 3 crisis intervention. Only doing by another source,i.e.mental
0 a) Age 15-21...313.91 aj, what is necessary to maintain health.)
(,' monthly responsibility.)
3 +$.66 Respite Care
5,
Level 1 $8.22 ?Level 1 $4.93
1 519.07 c Levell $2.99
+5.66 Respite Care Level 1...54 56 's (Low level of case management (Regularly scheduled therapy,
11'S ($19.73) y minimal crisis intervention,2-3 4 hours/month.)
Ni contacts/month,minimal crisis
n Intervention,
� ``1 2-3 contacts/month.) `.
l,.
Level 2 $11.51 Level 2 $9.86
2 ej
$25.64 (Moderate level of case ?i (Weekly scheduled therapy,
+$.66 Respite Care Level 2...54 56 r Management including I.# 4-8 hours a month with 4 hours of Level 2 $4.47
5 ($26.30) Weekly support services, Group therapy.)
c Occasional crisis intervention, -j
Face to face contact 1 time t
Per month.)
r
a ; Level3 314.79 Level $14.79
(High level of case management I
V • (Regularly scheduled weekly
3 F.1 $32.22 ' and CPA involvement with child multiple sessions,can include Level 3 $6.02
!,1,
cl +S
.66 Respite Care Level 3...$4.56 ; ,
(332.88) ,.i and provider including ongoing - more than 1 person,i.e.family
crisis intervention and face to therapy,for 8-12 hours/monthly.)
l face contactl-2 time per week.
. 0 minimum.)?
+It d
t
Level 4 $18.08 :Level 4 $14.79 I
A111 x
4i $39.45 (High level of case management - (Regularly scheduled weekly Level 4 Neg.
RTC .c and CPA involvement with child = multiple sessions,can include+$.66 Respite Care r+. Level 4...34.56 a
Drop 4 (S40.11) f; ,and provider,including on-going more than 1 person,i.e.family Down ' crisis intervention and face to therapy for 8-12 hours/monthly.)
' 3 face contact 2-3 times per
week minimum.) '
44
Assess.
ssess Assessment >;r
Assessment
Period Period $2630 Assessment Period $11.51 Assessment Period $0
d(Includes Respite) �` Period $466 i
ax1
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATT T: 4ts/411/4/1
lc,
� `Weld County Clerk to the Board
•► /4)
1 04: �` WELD COUNTY BOARD OF SOCIAL
11861 ( =' S SERVICES,ON BEHALF OF THE
'%;A.1. ` WELD COUNTY DEPARTMENT OF
N.-- �•e SOCIAL SERVICES
r
4�.. tr
SZL 6�Gi7 /&2, Byt•eputy Clerk to the Rob D.Masden,Chair
APPROVED AS TO FO • JUN 2 8 2004
CONTRACTOR
County ltorney
Creative Beginnings
7100 N. Broadway Unit 6-0
Denver, CO 80221
By: gad
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: cjitetko a
Directo
Agreement to Purchase
14
CPA Foster Care Services
aeo4/-/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
a
THIS AGREEMENT made this, W day ofQimu, 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soul Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Eagle Homes, 1225 Redwood St,
Fort Collins, CO 80524-2052, hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS,County is authorized to purchase certain services for eligible children under
State Department rules,and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS,Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. A child specific Needs Based Care Assessment, designated as Attachment B, shall be
used to determine levels of care for each child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services,which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#31058. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
•
3. This Agreement shall be in force from July 1,2004,until the end of the Colorado fiscal
year,June 30,2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees,in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
aoas/—/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter,clothing,educational supplies and allowance), Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy,Polygraph,
Plethysmograph,Parent Training for Teens,Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility,including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 31058
Eagle Homes
1225 Redwood St
Fort Collins, CO 80524-2052
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72, 2.710.73,2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131),the contractor may obtain: 1)Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical,surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s)should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County,the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening,Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen (15)days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury,including death,to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance,or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
ti.
' Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
•
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them,contemplated by
this Agreement is that of employer-independent contractor. No agent, employee,or
servant of Contractor shall be deemed to be an employee, agent,or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part,is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission,error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PI'04/O5-SS-23A-CPA
of Colorado,Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
Legal Status of Child. (Mark appropriate box)
❑ Placed through a Vohmtary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child am:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes ❑No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ hi home services O Placement with Relative O Cty CC Foster Care 0 Shelter Care ❑ Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC O Cty regular Foster Care
❑ Day Treatment ❑ Kinship Care 0 Group Home O hid.living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
0 Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
Individual O Family 0 Group
'Appropriate Treatment:
0 Sex Offender O Aggressive/Violent 0 Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression
❑ Self-destructive O Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
0 Special Ed. ❑ Public School 0 Day Treatment
❑ On-grounds School ❑ Additional Tutoring 0 Independent living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 it has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
g>Dt_ D6e.of clear/4
Gloria Romansik,Administrator Signature of Person Auth ed ign A®c..un.nt
✓f"/�/pfr
Date Date
Agreement to Purchase 9
CPA Foster Care Services
Contract No: FY 04/05-SS-23A-CPA
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# DATE OF ASSESSMENT
AGENCY NAME IPROVIDER 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?
O0)one a month ❑1)twice a month O2)once a week ❑3)2 or more times a week
P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special
education Ian?
00)less than e%hour per day 01)'A 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 O 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming, hysical,and/or occupational therapy?
00)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 2 Transportation
P 2 ThenpY/Connsding
P 3 Educational Intervention
P 4 Behavior Management ❑ O O
A 5 Personal Care
[] [�
A 1 Case Management ❑ ❑
T 1 Therapeutic Services O O
Agrcvnn..nt to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
• NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE
SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: [Initial Assessment ORe-Determination -Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING.
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ 0 ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ 0 0 0
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ 0 0 ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ 0 ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: D ❑ 1 0 0
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
• (ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD I:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(TI)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
•
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 SO
Age 11-14...$12.89 (Minimal CPA involvement,no
p (Therapy not needed or provided (None)
crisis intervention. Only doing by another source,i.e.mental
0 Age 15.21._$13.91 ? what is necessary to maintain , 1 health.)
monthly responsibility.) I:
+$.66 Respite Care i.-;
�
. ;
Level 1 $8.22 HI Level 1 $4.93
1 $19.07 I Level 1 $2.99
4.66 Respite Care Level 1...$4.56 (Low level of case management ' (Regularly scheduled therapy,
($19.73) _ - minimal crisis intervention,2-3 4 hourshnonth.)
i 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 ('M (Weekly scheduled therapy, Level $4.47
4.66 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, rr
Face to face contact 1 time
Per month.)
Level3 $14.79 Level 3 $14.79
$32 22 (High level of case management - (Regularly scheduled weekly
3 +j,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.)
3 ti
Level 4 $18.08 {Level 4 $14/9
4 539.45 :(High level of case management (Regularly scheduled weekly Level 4 Neg.
RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child , multiple sessions,can include
Drop ($40.11) 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.)
7
Assess. Assessment
Period Period......$26.30 ,- ASSBSSrrl$4 ?.Assessment Period $11 51 r Assessment Period $0
(Includes Respite) ., Period $4.56 4
Effective 10/01/01
Agreement to Purchase
13
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
a
ATTEST: r
'-_` Weld County Clerk to the Board
Art I
WELD COUNTY BOARD OF SOCIAL
�,�.1 I` SERVICES,ON BEHALF OF THE
1861 WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
V- Pit`Cse O otri-- \h\kb
,4aU' r -Zl«� By:
k --
eputy Clerk to the Board o .Masden,Chair
JUN 2 8 2004
APPROVED AS TO FO •
CONTRACTOR
County Att rney
Eagle Homes
1225 Redwood St
• Fort Collins, CO 80524-2052
By: .e--
Dmeant or oMC4T1os6
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: , / Q
DirtAit
Agreement to Purchase
14
CPA Foster Care Services
a oo l- /7S7
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
not
THIS AGREEMENT made this(ges day of jg 2004 between the Board of Weld
County Commissioners, sitting as the Board of So Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Emily Griffith Center- Chins
Up, 14142 Denver West Pkwy, Suite 225,Lakewood, CO 80401,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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#1510565. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30,2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30)days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
ceoov_/73;
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance),Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. My transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/ease plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 1510565
Emily Griffith Center- Chins Up
14142 Denver West Pkwy, Suite 225
Lakewood, CO 80401
Agreement to Purchase
2
CPA Foster Care Services
•
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible, permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and •
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15)days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
CPA Foster Care Services 5
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee,or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative Involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA O RTC O Cry regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O Ind.Living ❑ Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender O Aggressive/Violent O Substance Abuse ❑ Truancy O Victim Behavior O Depression
❑ Self-destructive ❑ Delinquency O Special Medical Needs O Behavior Modification ❑ Anger Management
❑ Other (Explain)
A propriate Educational Services:
0 Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# EX trails Case ID IDOB
I Sex
WORKER COMPLETING ASSESSMENT rI# 1DATE OF ASSESSMENT
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 ❑I)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
DO)one a month ❑l)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 Ian?
O0)less than a'''hour per day 01)'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 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 O1)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) I face to face contact per month and/or no crisis intervention
O 1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 ❑ 0 ❑
P 3 Educational Intervention ❑ ❑ ❑ ❑
P 4 Behavior Management 0 0 0 0
P 5 Personal Care 0 0 0 0
A 1 Case Management [ 0 0
T 1 Therapeutic Services [ ❑ 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
F� � = t
1
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ 0 0 ❑
Delinquent Behavior ❑ ❑ ❑ ❑ .
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 Di ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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)
agreement to Purchase
TA Foster Care Services 12
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
L.1 Ws11
0 i., Age 0-10...$11.47 Level 0...$4.56 r. Level 0 $4.93 C Level 0 $0 Level o $0
o .• Age 11-14...$12.89 � (Minimal CPA involvement,no i (Therapy not needed or provided , (None)
I t crisis intervention. Only doing by another source,i.e.mental
Age 15-21...$13.91 - what is necessary to maintain , health.)
o monthly responsibility.) t
+$.66 Respite Care , 's
i Level 1 $8.22 ALevel 1 $4.93
1 $19.07 `� 'III rt Levell $2.99
+$,66 Respite Care Level 1...$4.56 ;.(Low level of case management, (Regularly scheduled therapy,
- minimal crisis Intervention,2-3 4 hours/month.) it
($19.73 .. contacts/month,minimal crisis �1 r^
Intervention
2-3 contacts/month.)
l Ni
?Level2 $11.51 &Level2 $9.86 r
ri
2 ,.F $25.64 d (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47
+$.66 Respite Care Level 2...$4.56 �! Management including RI 4-8 hours a month with 4 hours of
kl
($26.30) Weekly support services, ' Group therapy.)
Occasional crisis intervention, u.k
Face to face contact 1 time •4
•
Per month.)
w
Level 3 $14.79 Level 3 $14.79
I '
I '(High level of case management ; (Regularly scheduled weekly LI
3 i $32.22 e.4 . and CPA involvement with child .( multiple sessions,can include b Level 3 $6.02
, +$,66 Respite Care . Level 3...$4.56
and provider including ongoing more than 1 person,i.e.family
3 ($32.88) '? crisis intervention and face to therapy,for 8-12 hours/monthly.) ;,..
'� `. face contactl-2 time per week .a 1:
I ,, minimum.) °{9{ ;'a
ii I 3
( Level 4 $18.08 ,_, Level 4 $14.79
i
4 ,(High level of case management (Regularly scheduled weekly '7,.ii Level 4 Neg.
RTC $39.45 £ 'r and CPA involvement with child '1 multiple sessions,can include '?
+$.66 Respite Care Level 4...$4.56 '
Drop ($40 11) and provider,including on-going:,I more than 1 person,I.e.family 's
Down crisis intervention and face to .4 therapy,for 8-12 hours/monthly.) 4
face contact 2-3 times per I ' I
,4,, - week minimum) 1
Assess. A Assessment Assessment pp
Period Period $26.30 Assessment Period $11.51 Assessment Period $0 F
F1 (Includes Respite) Period $456 _,,,
3
Effective 10/01/01
Agreement to Purchase
13
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: Midetth
Weld County Clerk to the Board
WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
1e61 ( = _ =' WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
By: l ?,,,,S) e6 ‘Wel).\).----
eputy Clerk to the Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FORM-
CONTRACTOR
County Atto Bey
Emily Griffith Center- Chins Up
14142 enver West Pkwy, Suite 225
woo , •
: 4 tj'Itl(�I
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:, Ad)
Direct
-
Agreement to Purchase
CPA Foster Care Services 14
aoa y—/737
Contract No: PY 04/05-SS-23A-CPA
• AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made thistday o 2004 between the Board of Weld
County Commissioners, sitting as the Board of So I Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Foster Care Connection, 4860
Robb St., Suite 203, Wheatridge, CO 80033, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. A child specific Needs Based Care Assessment, designated as Attachment B, shall be
used to determine levels of care for each child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services,which
are listed in this Agreement,based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#45079. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
0760'i-7737
Contract No: PY 04/05-SS-23A-CPA
_ earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider]D#: 45079
Foster Care Connection
4860 Robb St., Suite 203
Wheatridge, CO 80033
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
•
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure, where possible, permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports, which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further,the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
O Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative ❑ Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
O RTC
O CORE Services O Receiving Home O CPA
O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home
O Ind.Living (Spe
cify)
O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
O Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID rOB
ISex
WORKER COMPLETING ASSESSMENT HH# IDATE OF ASSESSMENT
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?
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'/:hour per day ❑1)%:hour a day
O2)more than'/hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming,physical,and/or occupational therapy?
❑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) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 0 0 0
P 3 Educational Intervention 0 0 0 0
P 4 Behavior Management ❑ 0 O 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
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
4141i Wikiiiiirtratigi ;:with itiovv4; Trtmaypitir, --r-.9.40.imimu,•,lama", gx,„,,,-„,„„w, „cm , , ,
'3. , P'1-cili ?,;,-!.,.. 'law t 0 .groped i irtio ri Air s -1 ; it.44 t;Iteraprorcronnti;tit
1 ! i 14i ! I '
,4,,dip dr,', 1,pki, qi d:€-'i; Iffelettilati t
i 71-14'4i i i}ill so WeaMMISTORWlatill, rir+144 41;"}142!1:nagleali:L.itis!i. 1; " 4 g.1111.- ' 47 , Ala L
iFirm t lot ol
' - J6 a9 1lffil 1 diYii 1 ti '
Aggression/Cruelty to Animals El El ❑ ❑
Verbal or Physical Threatening El El ❑ El
Destructive of Property/Fire Setting ❑ El El El
Stealing El El El El
Self-injurious Behavior ❑ El El El
Substance Abuse El El ❑ ❑
Presence of Psychiatric El El El El
Enuresis/Encopresis El El El El
Runaway El El El El
Inappropriate Sexual Behavior El El El El
Disruptive Behavior El El El El
Delinquent Behavior El ❑ ❑ ❑
Depressive-like Behavior El El El ❑
Medical Needs ❑ El El El
Emancipation El El El ❑
Education El El El El
Involvement with Child's Family El El El El
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 El ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
CPA Foster Care Services 11
Contract No: PY 04/05-SS-23A-CPA
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: itial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
' (Attachment C)
6 0 6 0 1. t1111. 1:111 1 O.' 711 .. I. e o t r t w Y s , �qa '
il;;i4:1:1, ..:111.il.;;;;;,,:gia. II;
`t t�, � v31i 9� I.
,d
i I
- 111i t •i•It� ° t ,°
t I33t e3�old tt S" It° ° 'I
3
3 M� 3�" it . . . - ° 3�34I tl.`k 31st}
a � i9it 1411
0 Age 0-10...$11.47 Level 0...$4,56 Level 0 OE
$4.93 Level 0 $0 Level 0 $0
aill
Age 11-14...$12.89 (Minimal CPA involvement,no )
o fri crisis intervention. Only doing (Therapy not needed or provided (None)
n by another source,i.e.mental ,11
0 Age 15-21...$13.91 : what is necessary to maintain health.)
monthly responsibility.)
+$.66 Respite Care it PE Mi.
tad thi
ira
It§ Level 1 $8.22 Level 1 $4.93
1 $19.07pp
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 VI 4 hours/month.)
contacts/month,minimal crisis 101 r
intervention,
qii, 2-3 contacts/month.)
Levell $11.51 Level $9.86
2 igo $25.64 (Moderate level of case (Weekly scheduled therapy, Ito
4,1
+$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of Level 2 $4.47
ll
i!il ($26.30) Weekly support services, Group therapy.) gli
rt
IN Occasional crisis intervention, RIF
rtg Face to face contact 1 time ll
Per month.)
Level 3 $14.79 Level 3 $14.79 1,1
3 $32.2211: (High level of case management (Regularly scheduled weekly
+$.66 Respite Care Level 3...$4.56 go 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 pa
crisis intervention and face to therapy,for 8-12 hours/monthly.) 31,
face contactl-2 time per week DO
IP ir
minimum.)
Fri
4.
s is
Et Level4 $18.08 L Level4 $14.79'.In
mi
4 .3 1 (High level of case management (Re ularl scheduled weekly Level 4 Neg.$39.45 9 Y
+$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include IN
Drop ($40.11) and provider,including on-going more than 1 person,i.e.family TA
Down crisis intervention and face to igi therapy,for 8-12 hours/monthly.) IN
I. face contact 2-3 times per
iti
week minimum.) Illa
PI Assess. Assessment IL Assessment1141
Period Period $26.30 Period $4 56 Assessment Period $11.51 Assessment Period $0
(Includes Respite)
Pi aid
lit thit
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTE T: "'lidf
I ,ass`eld County Clerk to the Board
e �‘
I �':�•�f� ` WELD COUNTY BOARD OF SOCIAL
I
t.J �,� SERVICES,ON BEHALF OF THE
`r Ff `� SOCIAL SERVICES
D COUNTY DEPARTMENT OF
J /
:— '4i _ C / By:
Deputy Clerk to the Board Robert D.Masden,Chair
APPROVED AS TO FORM: JUN 2 8 2004
CONTRACTOR
County Atto ey
Foster Care Connection
4860 Robb St., Suite 203
Wheatrid e, CO 800
J„—By: kJ
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: , jat ,
irector r
U v
Agreement to Purchase
CPA Foster Care Services 14
d o0 1—/7'37
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
tt
THIS AGREEMENT made this xi lay of 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soci Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Hope and Homes, 620
Southpointe Ct., Colorado Springs, CO 80906,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. A child specific Needs Based Care Assessment, designated as Attachment B, shall be
used to determine levels of care for each child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services,which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#29867. These services will be for
children who have been deemed eligible for social services under the statutes, rules and
regulations of the State of Colorado.
3. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
c-Veo
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include, but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 29867
Hope and Homes
620 Southpointe Ct.
Colorado Springs, CO 80906
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening,Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports, which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which maybe
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected far visits? 0
Will transportation for visits be provided by the facility/provider listed below? 0 Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative 0 Cty CC Foster Care 0 Shelter Care 0 Substance Abuse Treatment
❑ CORE Services 0 Receiving Home 0 CPA 0 RTC 0 Cty regular Foster Care
❑ Day Treatment 0 Kinship Care 0 Group Home 0 Ind.Living 0 Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) 0 Secure 0 Other(Explain)
Appropriate Counseling:
❑ Individual 0 Family ❑ Group
Appropriate Treatment:
❑ Sex Offender 0 Aggressive/Violent 0 Substance Abuse 0 Truancy 0 Victim Behavior ❑ Depression
❑ Self-destructive 0 Delinquency 0 Special Medical Needs 0 Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. 0 Public School 0 Day Treatment
❑ On-grounds School 0 Additional Tutoring 0 Independent Living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child Is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) 0 Yes 0 No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID 1DOB
Sex
WORKER COMPLETING ASSESSMENT HH# 1ATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME rROVIDER 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 ❑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?
DO)one a month DI)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?
❑0)less than a 1/2 hour per day 01)'A hour a day
02)more than'/2 hour per day,up to 2 hours per day 03)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑l)5 to 10 hours per week 0 2)at least daily 03)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming„pphysical,and/or occupational therapy?
ION)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week 03)21 or more hours per week
A 1. How often is CPA case management required?
00) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
02) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0 0 0
P 2 Therapy/Counseling 0 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
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
if 4 f: 1 I - ) t h, 11 N° 9 -� {"' i s alb• :11,'•••ltIPI ,,;I ;ay l i r " ell ;rt ''' :
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+Maes:� .,.a: :a �.i a w ,ad.'+. i , d.s vua� i ��_e,, ,,,,,,trs l"5:#v. J A S,:
klir> R, a § r i .v,11 _ Celia. e ' ;I ' AV
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a 1/4i .AI n x,
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4A; u.— d�,iway....,�1 !�: do i. 9..,.R w 2;13. .1 .3 t r
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 El ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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: ritial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
• Calculated as Dally Rates
(Attachment C)
v^, n h .;n u ' }°-• �F Ilia" - �}, i I p h�. it i , v 3"so- ,ry '9 ht;
ill!!!� 1 j•,i y .� 1* q r t ,,,s,*,t i4 i , J €.il J1 tLL11
;ill} , � �.r, , t� „�0. 60, r 'd- ' �) 1 igi 1449 ra6ix_.. I ull r r 1 a pi l :" . O i3; k � I,, I,f t: ,y�,�,t t !,: , ° . 'u 4 J " ' li E d illigi ' °5'
tL1
il ' '" . eiiirasrJprsaamllaLI
, f,�;x ,a t
q Pa
0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 1,4 Level 0 $0 J:ti
Level 0 $0
r Age 11-14...$12 89 f' y (Minimal CPA involvement,no 1.4 )
0 bi$ a" (Therapy not needed or provided (None)
ri! k crisis intervention. Only doing by another source,i.e.mental "a,:
0 Age 15-21...$13.91 .R what is necessary to maintain ii; health.)
: Ill
1 monthly responsibility.) (� ra.
i, +$.66 Respite Care { I°I r:p
s., iq
lli
i - Level t $8.22 J*.:Level l $4.93 i
1 `r ien• $19.07 ( i it a Level 1 $2.99
+5.66 Respite Care Level 1...$4.56 ,i'(Low level of case management,tiq
(Regularly scheduled therapy, l ti
lit' ($19 73) :;S minimal crisis intervention,2-3 J 4 hours/month.)
I contacts/month,minimal crisis N
9Ill
1 }Pi intervention, na
;. 2-3 contacts/month.) r1 }
i
r" 'i
y.:Level 2 $11.51 •-.Level 2 $9.86.,,
p
2 • $25.64 1 (Moderate level of case (Weekly scheduled therapy,
)p r Level 2 $4.47
+5.66 Respite Care it Level 2...$4.56 r Management including a 4-8 hours a month with 4 hours of r
($26.30) y Weekly support services, 4 Group therapy.)
nl Occasional crisis intervention, ;h Iti
1.
' ,I;. Face to face contact 1 time ri i
J.,,
P. Per month.) f
Eii o¢ Yi v as
Level 3 $14.79 '! Level 3 $14.79 f G
•1 t r, f
; 03
1: $32.22 ;(High level of case management l c, (Regularly scheduled weekly ik
3 +$.66 Respite Care Level 3...$4.56 iii and CPA involvement with child tit multiple sessions,can include y„ Level 3 $6.02
($32.88)iff t and provider including ongoing ir,i
} more than 1 person,i.e.family Of
crisis intervention and face to i, therapy,for 8-12 hours/monthly.) t
pa } face contactl-2 time per week ,
". t, minimum.) a`+
i t
It
l' CPI
1.1
a Level4 $18.08 i; Level4 $14.79 .I
p, 1)3
4 $3945 d (High level of case management;II (Regularly scheduled weekly Level 4 Neg.
RTC .J 1 and CPA involvement with child i multiple sessions,can include it
+5.66 Respite Care 0 Level 4...54.56 :.I
Drop wie.. ($40 11) �I ` • and provider,including ongoing more than 1 person,i.e.family 44
Down I crisis intervention and face to :} therapy,for 8-12 hours/monthly.) la
fp
c face contact 2-3 times per141
week minimum.)
y
qt9
it r til
Assess. Assessment ' Assessment
Period a Period
(Includes Respite) I0 , Period rt4 56 ,t Assessment Period $11.51 Assessment Period $0
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEs•
40� Si,eld County Clerk to the Board
may, •O,
' ' WELD COUNTY BOARD OF SOCIAL
I SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
Pr"' S SOCIAL SERVICES
(
1-:17,711 By: \!\k„,,D.__
Deputy Clerk to the Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FORM:
CONTRACTOR
County Attomey
Hope and Homes
620 Southpointe Ct.
Colorado Springs, CO 80906
By:
WELD COUNTY DEPARTMENT fit"-a_
OF SOCIAL SERVICES
By:
irector�
C VVVVVV VV
Agreement to Purchase
CPA Foster Care Services 14
Goo 51—/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made thisaK day o 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. 1 Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Jacob Family Services, 1819
Birch Ave, PO Box 160, Greeley, CO 80632,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given,this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase 1
CPA Foster Care Services
O2005/-1737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management,Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 71260
Jacob Family Services
1819 Birch Ave,PO Box 160
Greeley, CO 80632
Agreement to Purchase 2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition, psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase 4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase 6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? ❑ Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative ❑ Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
O CORE Services O Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family ❑ Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
O Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan Is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID 1DOB
Sex
WORKER COMPLETING ASSESSMENT HH# 1DATE OF ASSESSMENT
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 ❑l)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 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'A hour per day ❑l)'A hour a day
O2)more than%,hour per day,up to 2 hours per day ❑3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑l)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, hysical,and/or occupational therapy?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week O3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
❑2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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) ❑l)less than 4 hours per month
❑2)4-8 hours per month ❑3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ 0 ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention ❑ 0 0 0
P 4 Behavior Management ❑ 0 0 ❑
P 5 Personal Care 0 ❑ 0 ❑
A 1 Case Management ❑ 0 ❑ ❑
T 1 Therapeutic Services ❑ 0 0 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY
SS
DSS
NEEDS BASED CARE ASSEMENT
(ATTACHMENT B)
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.
-fly WIPP,fs. 134,1,T
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4!r i ' ll ill ITO liltP 41,141 itil if filliANIPtrit ir,'hill it!" t, IV i F;
a
aw pliktatioasina IN
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ID El ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing El LI El III
Self-injurious Behavior ❑ Ell ❑ ❑
Substance Abuse El LI ❑ ❑
Presence of Psychiatric ❑ El ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway El ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior III ❑ ❑ ❑
Medical Needs III LI ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: El 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase 11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED(Average of PI through P5)
PERIOD 1:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED (Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daly Rates
(Attachment C)
i .•. 2i it viii{. � � i
mtt - a _ o , i i o ti:oL `'eEr 9 p ri. p # qr �qsa
it ( ; ' .(n V r , � v'f e� y.,i�.$4.409,04414040
ill
`qK C. didi(� '4 I;�i i . qii i �if i F.4; ° • B1Rr iXi d i'�A )7 p� rip,_!? a r �t i ! .'� i� r i ' o i 4
t :.if a {i �i i
8t��,a'. °: il..i� _! .I' l l6. 4 Ti.' !,I,l k .., _ :i.a, :I:-"prn.clipatPiropttrogiiirpfpitkipt).4.... .p.s.„ Isaf.,:in, ?i.ii, . :,,i, f141.„3":7 Qi; .:Aviki..i 1. Fir. .. i 717 illi el%it lin Plc!.liiiirlaitiSr
9 5Age 0-10...$11.47 P.,i0 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0
9 pi Age 11-14...$12.89 nr il (Minimal CPA involvement,no la (Therapy not needed or provided III (None)
it
crisis intervention. Only doing by another source,i.e.mental IL
0 Age 15-21...$13.91 what is necessary to maintain health.)
1,0 dia monthly responsibility.)
+$.66 Respite Care gg, 111
OggLevel 1 $8.22 Level 1 $4.93
$19.07 Level t $2.99
pl +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, pi
($19.73) lilPit gig minimal crisis intervention,2-3 4 hours/month.)
contacts/month,minimal crisis
51 intervention, 11
Ill lill
el 2-3 contacts/month.)
iiri N4
tin 4;01
N. NJP
114
Level2 $11.51 Level2 $9.86
2 I $25.64iiii
(Moderate level of case (Weekly scheduled therapy, Level 2 $4.47
4.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of
($26.30) Weekly support services, Group therapy.) Or
g WI Occasional crisis intervention, 15
Face to face contact 1 time
fpf
tt fill Per month.) In
110
ur Level3 $14.79 5 Level 3 $14.79
$32 22 (High level of case management ' (Regularly scheduled weekly
3 V.
and CPA involvement with child multiple sessions,can include Level 3 $6.02
+$.66 Respite Care Level 3...$4.56 and provider including ongoing more than 1 person,i.e.family it
($32.88) crisis intervention and face toIII
therapy,for 8-12 hours/nwnthly.)
face contactl-2 lime per week
P gill ill 11
..i., i;;i ...Iiiiii'l:i
ill 4t3
WI gin
minimum.)
Level4 $18.08 pi Level $14.79 Nil
rr
4 (High level of case management (Regularly scheduled weekly Level 4 Neg.
RTC $39.45 and CPA involvement with child multiple sessions,can include
Drop +$.66 Respite Care Level 4...$4.56 and provider,including on-going more than 1 person,i.e.family
($40.11)
Dowii n crisis intervention and face to iiii therapy,for 8-12 hours/monthly.)
gp face contact 2-3 times per
week minimum.)
gig
k II la ag
Assess. A Assessment 5nit Assessment •
Period Period $26.30 Period $4.56 Assessment Period $11.51 1 Assessment Periodpi. $0
14 (Includes Respite)
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: Ati4114/114,
iirsar3/4„,, Weld County Clerk to the Board
'e f jilWELD COUNTY BOARD OF SOCIAL
r1661 �p SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
r ;y. ,! SOCIAL SERVICES UC--13t / By: 4(,N--- -
Deputy Clerk to the Board Robbrt D.Masden,Chair
JUN 2 S 2004
APPROVED AS TO FORM:
CONTRACTOR
County Attomg
Jacob Family Services
1819 Birch PO Box 160
Greeley, 80 32
By: L r.
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Direct
Agreement to Purchase
14
CPA Foster Care Services
&OO5/—/7S7
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
• THIS AGREEMENT made thisijg day of 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Kids Resources Network Inc, 898
Racquet Ln, Boulder, CO 80303-2935, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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#45183. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
0706 9—/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 45183
Kids Resources Network Inc
898 Racquet Ln
Boulder, CO 80303-2935
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
I. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure, where possible, permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. It is expressly understood and agreed that the enforcement of the teens 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.
8. 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, which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home ❑ Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
O Individual O Family O Group
Appropriate Treatment:
d Sex Offender O Aggressive/Violent O Substance Abuse O Truancy O Victim Behavior O Depression
O Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID IDOB
Sex
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
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 Ian?
00)less than a'/:hour per day ❑1)'/:hour a day
❑2)more than'4 hour per day,up to 2 hours per day 03)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑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, hysical,and/or occupational therapy?
00)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
❑2) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation ❑ ❑ ❑ ❑
P 2 Therapy/Counseling ❑ ❑ ❑ ❑
P 3 Educational Intervention 0 0 0 ❑
P 4 Behavior Management 0 0 0 ❑
P 5 Personal Care 0 0 0 ❑
A 1 Case Management 0 0 0 ❑
T 1 Therapeutic Services 0 ❑ 0 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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 fa•{ b l
i
tr:It O4014:O i E 3 O i 8 i w' ' 1
anitNE•r fit. ,'s '1 4
lN,Terwa liFir.r.„,,,„.0„,r, „,1 a.al beilsaftl:'4 Filii4fill q
�
I s VW 1 Ate hE
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
•
tat+ iil9 Y3'•€ ;r
pG! {a s a.,. . o r inialttilarill w,, d,f- g, e o - e , - 3 i'L� 6, -e , qen
' ! X .,...111;11:1:11,i,::,. .1)1611111011101111
L l5(h' ' � Y G�i i fly
roi
-. . . a .®. -
. ; ^. tai stf" G'=a 'aa".
3i 6. *,. _ - -- ti,4"
o fk Age 0-10...$11.47 Level 0...$4.56IN
Level 0 $4.93 Level 0ill $0 Level 0 $0
0 0. Age 11-14...$12.89 (Minimal CPA involvement,no (Therapy not needed or provided (None)
ill crisis intervention. Only doing by another source,i.e.mental
la
iti
iii fa
o Age 15-21...$13.91 what is necessary to maintain health.)
monthly responsibility.)
+ma $.66 Respite Care
is
pli
Level 1 $8.22 IMW Level 1 $4.93
If* IN t ill ill 1
$19.07 Level 1 $2.99
+$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy„.n,
p. ($19 73) minimailt l crisis intervention,2-3 4 hours/month.)
contacts/month,minimal crisisIX
at
intervention,
air
lila
2-3 contacts/month.) lite
1 EN fly
Level ii IS ill $11.51 Level 2 $9.86iii
2 $25.64 Pi
(Moderate level of case (Weekly scheduled therapy,lid agil
fool olo
lik II
to
Level 2 $4.47
+$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of
Ikti
~` ($26.30) it tiaiWeekly support services, 41 Group therapy.)
Oil Occasional crisis intervention, 10 pi
Pi P Face to face contact 1 time
Per month.)
Illi
ilit
IL It
ill tp,i,
iis
iii
to p
Level3 $14.79 Level 3 Lai
$14.79 ag
(High level of case management (Regularly scheduled weekly
3 $32.22 and CPA involvement with child multiple sessions,can include Level 3 $6.02
+$.66 Respite Care Level 3...54.56 gr and provider including ongoing more than 1 person,i.e.family
'' ($32.88) la crisis intervention and face to therapy,for 8-12 hours/monthly.) it
Da: face contactt-2 time per week
'a minimum.)
I Ed l; RE
Level4 $18.08 Level $14.79 iiii
11
q ;�.;; (High level of case management (Regularly scheduled weekly4% III Level 4 Neg.
RTC ;°v. + $39.P5 and CPA involvement with child0. multiple sessions,can include
Dro $.66 Respite Care Level 4...$4.56 and provider,including on-going more than I person,i.e.family
Down !),Ii 00.11)
crisis intervention and face to therapy,for 8-12 hours/monthly.)
face contact 2-3 times perid
6! Elli wee minimum.)
It
a IC
it nem
fill
Assess. 66
Assessment Assessment
lig ES
Period Period......$26.30 period $4.56 Assessment Period $11.51 Assessment Period $0
w (includes Respite)
Pli
Effective 10/01/01
Agreement to Purchase 13
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: 4.41,"/L4
Weld County Clerk to the Board
E �1
® WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
It61 tt$S
WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
By: 0..k4.
Deputy Clerk to the Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FORM:
CONTRACTOR
Co my Attorn y
Kids Resources Network Inc
898 Racquet Ln
Boulder CO 80303-2935
By:
WELD COUNTY DEPARTMENT Sl z4al•
OF SOCIAL SERVICES
By:
Direc o
Agreement to Purchase 14
CPA Foster Care Services
4aoy-/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made this tday of 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and ICidz Ark, Inc, PO Box 1725,
Sterling, CO 80751,hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing,to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30)days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
670.01—/7,97
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens,Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 40900
Kidz Ark, Inc
PO Box 1725
Sterling, CO 80751
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131),the contractor may obtain: 1)Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s)and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor,including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible, permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral)or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2) weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04!05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement,if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation,it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. • The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? 0 Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services O Receiving Home O CPA ❑ RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O hid.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
0 Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual 0 Family 0 Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truancy O Victim Behavior 0 Depression
❑ Self-destructive 0 Delinquency O Special Medical Needs O Behavior Modification 0 Anger Management
❑ Other (Explain)
Appropriate Educational Services:
0 Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring 0 Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) 0 Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agccnient
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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 DATE OF ASSESSMENT
AGENCY NAME (PROVIDER NAME (PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS JII WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY
THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or
social counseling,etc.,as outlined in the treatment plan or approved by the caseworker?
❑0)one trip a week or less ❑I)2-3 trips a week ❑2)4-5 trips a week ❑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 lan?
00)less than a'/,hour per day DI)'4 hour a day
02)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 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?
UI0)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?
00) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
02) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P I Transportation 0 ❑ 0 0
P 2 Therapy/Counseling 0 L�rJil 0
P 3 Educational Intervention
P 4 Behavior Management C 0 0
P 5 Personal Care 0 0 0 0
A 1 Case Management 0 0 0
T 1 Therapeutic Services 0 0 0 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
,,4yii, .gig g i i($,g,.r4 l.33 um' .`
9 x- s� �
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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 PS)
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)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
ad .
_. _ ... .z..!:".'.,;,.., ( ' 517" ' ) 1 1 0. I I ti-.;-1,K,1'. b
{�,. �X 7 .:".7;A:("
t
.•:-477'
F a�i..d '‘'...777E.:
�b.,s..�. ..?1�LC' sW�7w..: ... ,�. �.,..... .
0 Age 0-10...$11.47 i. Level 0...54 56 p Level 0 $4.93 Level 0 $0 Level 0 $0
0 Age 11-14..,$12.89 r,. (Minimal CPA involvement,no ,, (Therapy not needed or provided (None)
I,• crisis intervention. Only doing •� by another source,i.e.mental
0 •4 Age 15-21...513.91 tIII , what is necessary to maintain - health.)
monthly responsibility.)
+5.66 Respite Care a y'(Iy
..
i 4 -ej
ri! c."4 it 1 $8.22 Level l $4.93
1 'II Level l$2.99
$19O7 (Low level of case management, I (Regularly scheduled therapy,
+5.66 Respite Care Level 1...$4.56 minimal crisis intervention,2-3 - 4 hours/month.)
;,` ($19.73) ' contacts/month,minimal crisis =-#
�' intervention,
•=₹ 2-3 contacts/month.)
4 Irk
G"1 Level 2 $11.51 I Level 2 $9.86 ,
tix14e':
2 ,)it $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47
1 +8.66 Respite Care Level 2...5456 ri Management including 4-8 hours a month with 4 hours of
($26.30) Weekly support services, Group therapy.)
l.
i =F Occasional crisis intervention,
Face to face contact 1 time
Per month.)
!':•P P
71 Level 3 $14.79 Level 3 514.79
1 83222 a(High level of case management • (Regularly scheduled weekly
and CPA involvement with child multiple sessions,can Include Level 3 $6.02
:,) +8.66 Respite Care Level 3...54 56 • and provider including ongoing ,, more than 1 person,i.e.family
-: ($32.88) crisis intervention and face to I.. therapy.for 8-12 hours/monthly.)
'.; face contactl-2 time per week
t*� minimum.)
?tit
t- Level 4 $18.08 +',Level 4 $14.79 it q . ii, f(High level of case management• j (Regularly scheduled weekly Level 4 Neg.
RTC $3905 i and CPA involvement with child multiple sessions,can include
Drop ��' *5.66 Respite Care . Level 4...84 56 ..„and provider,including on-going -, more than 1 person,i.e.family
)
Down p,q (540.11 •; crisis intervention and face to therapy,for 8-12 hourslmonthly.)
face contact 2-3 times per )
*, d week minimum.) •
;
Assess. 2, Assessment
I"
k Assessment
Period s Period 526.30 :: Period $4 56 Assessment Period $11.51 1 Assessment Period $0
(Includes Respite) `
1.
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month,and year first above written.
Al lEST: Avia
�, ► l ! �,� WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
1 1 l�1nu1
l / 1'
``®� r� / By:
Rot .Masden,Chair
Deputy Clerk to e Board
JUN 2 8 2004
APPROVED AS TO FORM:
CONTRACTOR
Coun tto y
ICidz Ark,Inc
PO Box 1725
Sterling, C 80751 1
By: __ �f J
WELD COUNTY DEPARTMENT 5/�',/
OF SOCIAL SERVICES YJ
By:s l�'� CCAT
Direct°
C
Agreement to Purchase 14
CPA Foster Care Services
aoo4-/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made this,02 day of anti 2004 between the Board of Weld
County Commissioners, sitting as the Board of Soc. Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Lost and Found Inc., 6700 44th
Ave, Wheatridge,CO 80033,hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follow&
1. 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
dett,unined. 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#57351. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
4OO.V-/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility,the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility, with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 57351
Lost and Found Inc.
6700 44th Ave
Wheatridge, CO 80033
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/O5-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131),the contractor may obtain: 1)Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County,the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973,Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death,to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute,ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase 6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement,if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation,renewal, addition, deletion,or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports,on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
•
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? ❑ Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative 0 Cty CC Foster Care 0 Shelter Care 0 Substance Abuse Treatment
❑ CORE Services 0 Receiving Home ❑ CPA 0 RTC 0 Cty regular Foster Care
❑ Day Treatment 0 Kinship Care 0 Group Home ❑ Ind.Living 0 Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
• Therapeutic(Behavior Modification) ❑ Secure 0 Other(Explain)
Appropriate Counseling:
❑ Individual 0 Family 0 Group
Appropriate Treatment:
❑ Sex Offender 0 Aggressive/Violent ❑ Substance Abuse 0 Truancy 0 Victim Behavior 0 Depression
❑ Self-destructive 0 Delinquency 0 Special Medical Needs 0 Behavior Modification ❑ Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. ❑ Public School 0 Day Treatment
❑ On-grounds School 0 Additional Tutoring 0 Independent Living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) 0 Yes ❑ No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PD Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase 9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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 IHH# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME 1PROVIDER 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 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 Ian?
50)less than a 1/2 hour per day 01)%f hour a day
O2)more than%1 hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
DO)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 ❑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) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
❑3) at least 1 face to face contact 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) 01)less than 4 hours per month
❑2)4-8 hours per month O3)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation
P 2 Therapy/Counseling 0
P 3 Educational Intervention 0 0
P 4 Behavior Management 0 0 0 0
P 5 Personal Care [ 0 ❑ 0
A I Case Management C 0 0
T 1 Therapeutic Services 0 0 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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 w fir- i i `TT* v r ". ..+� ` �3.
it,'11, °, t i r,f ( , $' S xa
d k. 3 . .`.' Ti
a
4 2$' _.aI .E i �.., t 1 K
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of PI through P5)
PERIOD 1:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED(Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(T1)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
•
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
•
Calculated as Daily Rates
(Attachment C)
Age 0-10...$11.47 Level 0...$4 56 'o Level 0 $4.g3 Level 0 $0 Level 0 $0
0 Age 11-14...$12.89 (Minimal CPA involvement,no ", (Therapy not needed or provided _ (None)
crisis intervention. Only doing by another source,i.e.mental
74 Age 15-21...$13.91 , what is necessary to maintain -' health.)
monthly responsibility.) r
+$.66 Respite Care rh,
Level l $8.22 „Level l $4.93
1 ' $19.07 r Level l $2.99
+$.66 Respite Care Level 1...$4 56 s(Low level of case management, (Regularly scheduled therapy,
($19.73) minimal crisis intervention,2-3 4 hours/month.)
contacts/month,minimal crisis
intervention, ,
S d 2-3 contacts/month.)
# Level 2 $11 51 :Level 2 $9.86
2 `t $25.64 t (Moderate level of case (Weekly scheduled therapy,
Management including 4-8 hours a month with 4 hours of Level 2 $4.47
+$.66 Respite Care Level 2...$4.56 9 r,
($26.30) a'` Weekly support services, i: Group therapy.)
Occasional crisis intervention, a
Face to face contact 1 time
Per month.) .,
F
,,
II I
m
Level 3 $14.79 Level 3 $14.79
(High level of case management (Regularly scheduled weekly
3 � $32.22 •e and CPA involvement with child � ! multiple sessions,can include ! Level 3 $6.02
+$.66 Respite Care Level 3...$4.56 and provider including ongoing more than 1 person,i.e.family
($32.68) . crisis intervention and face to i therapy,for 8-12 hours/monthly.)
Ol face contactl-2 time per week
al . minimum.)
.01
Level 4 $18.08 Level 4 $14.79
q
4 $39.45 g(High level of case management (Regularly scheduled weekly Level 4 Neg.
RTC +$.66 Respite Care Level 4...$4.56 # . and CPA involvement with child . multiple sessions,can include
Drop $. ($40.11) and provider,including on-going'ii more than 1 person,i.e.family
Down crisis intervention and face to , 3 therapy,for 8-12 hours/monthly.)
r? face contact 2-3 times peritidoit
week minimum.) ( -.
j
Assess. Assessment
Assessment
Period Period $26.30 s Assessment Period $11.51 Assessment Period $0
• (Includes Respite) Period $4 56 l�
Effective 10/01/01
Agreement to Purchase 13
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF,the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: -"eg��"�.'/
Weld County Clerk to the Board
®
WELD COUNTY BOARD OF SOCIAL
ISM = •'� j SERVICES, ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
\in n
i eputy Clerk to e Board Robert D. asden,Chair
JUN 2 8 2004
APPROVED AS TO FO •
CONTRACTOR
County A omey
Lost and Found Inc.
6700 44th Ave
Wheatridge, CO 80033
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By: ,dueLt0a
Direct
Agreement to Purchase
CPA Foster Care Services 14
X0651-1737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
•
THIS AGREEMENT made this*day o C 2004 between the Board of Weld
County Commissioners, sifting as the Board of So 'al Services, on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Loving Homes Inc., 212 W 13th
St,Pueblo, CO 81003,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services, hereinafter called"State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. A child specific Needs Based Care Assessment, designated as Attachment B, shall be
used to determine levels of care for each child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services,which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated as Attachment C, for children
placed within the CPA identified as Provider ID#72767. These services will be for
children who have been deemed eligible for social services under the statutes,rules and
regulations of the State of Colorado.
3. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given,this contract shall terminate on the expiration of
the thirty(30)days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
doe 41-/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up,Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization,will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 72767
Loving Homes Inc.
212 W 13th St
Pueblo, CO 81003
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
• sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening,Diagnosis and Treatment Program.
Agreement to Purchase 3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission maybe in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral)or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition, psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment .
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30)day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered,using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
lb. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appi up,late box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care
❑ CORE Services O Receiving Home ❑ CPA O RTC O Substance r Abuse Care
Treatment
❑ Day Treatment O Kinship Care O Group Home0 Cty regular Foster Caro
O Ind.living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
0 Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truant urnY O Victim Behavior O Depression
❑ Self-destructive O Delinq
uency cY O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan Is:
ARRANGEMENT (If other,please explain)
Ifthe outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Soda!Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,r
(Worker Name) Date
Gloria Romansik,Administrator ature offerson Auth ized to Si greement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX Trails Case ID (DOB
Sex I I _
WORKER COMPLETING ASSESSMENT IHH# DATE OF ASSESSMENT
AGENCY NAME (PROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES 1 DAY
THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for one of the following: therapeutic or medical treatment,emotional or
social counseling,etc.,as outlined in the treatment plan or approved by the caseworker?
❑0)one trip a week or less ❑1)2-3 trips a week ❑2)4-5 trips a week ❑3)6 or more trips a week
P 2. How often is the provider required to participate in child's therapy or counseling sessions?
❑0)one a month 01)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 Ian?
00)less than a%hour per day ❑I)'4 hour a day
02)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 monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily 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, hysical,and/or occupational therapy?
Ull 0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2) 11 to 20 hours per week 03)21 or more hours per week
A 1. How often is CPA case management required?
❑0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include I face to face)and/or minimal crisis intervention
02) 2 face to face contacts per month and/or occasional crisis intervention
03) at least I face to face contact 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
02)4-8 hours per month 03)8-12 hours per month
RATING OF SERVICE AREAS Initial Assessment Date:
SERVICE AREAS 0 1 2 3
P 1 Transportation 0 0
[] 0
P 2 Therapy/Counseling 0
❑ 0
P 3 Educational Intervention 0 J 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
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
d :
Aggression/Cruelty to Animals ❑ ❑ ❑ 0
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ 0 ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ 0 ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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: itial Date:
(maximum of 6 month intervals)
Agreement to Purchase
CPA Foster Care Services 12
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
•
.
, k w'': r'1'
2
T
1 p yn 1
I
!”m,
p Age 0.10...$11.47
Level 0...$4.56 it Level 0 34,93 Level 0 $0 Level 0 $0
5r x
0 Age 11-14...$12.89 - (Minimal CPA involvement,no (Therapy not needed or provided (None)
{ 3 crisis intervention. Only doing i z.; by another source,i.e.mental
0 . Age 15-21...$13.91 `1 ',; what is necessary to maintain Hi
+ "- health.)
monthly responsibility.) t
+$.66 Respite Care -
k, Wil
rr' Level 1 $8.22 Level 1
1 5 :y. ,a $4,93 :
519.07 ,) ; Level 1......$2.99
+$.66 Respite Care i.; Level 1...$4.56 ,i„ (Low level of case management (Regularly scheduled therapy, (`;
($19.73) minimal crisis Intervention,2-3 4 hours/month.) .,,,
contacts/month,minimal crisis
11
intervention, )::-
r. 2-3 contacts/month.) hi
' ,Level2 $11.51 Level 2
:Y j pi E9.86�..,
Sa
TA 2 + $25.64 ',n (Moderate a level of case (Weekly scheduled therapy, i Level 2 $4.47
5.66 Respite Care Level 2...54.56 Bement Including - 4-8 hours a month with 4 hours of
.a ($26.30) a Weekly support services, Group therapy.)
ahs 1.4 Occasional crisis intervention, 5;:3
Face to face contact 1 time b2
. .. Per month.) „ ::
S
r
l r
A Level3' $14.79;.1 Level 3 $14.79 ;
i
3 d $32.22 ' M(High level of case management (Regularly scheduled weekly ,r ::
_: +$.66 Respite Care i^' Level 3.,,34,56 and CPA involvement with child t multiple sessions,can include -_; Level 3 $6.02
($32.88) p and provider including ongoing P more than 1 person,I.e.family r a
s `':', crisis intervention and face to therapy,for 8-12 hours/monthly.)
t, t ; face contactl-2 time per week t 5
minimum,) P,4
L.
'i Level 4 $18,08 `d Level 4 $14.79
4
j (High level of case management
RTC R $39,45 (Regularly scheduled weekly Level 4 Neg.
+Sss Respite Care Level 4...$4.56 } and CPA involvement with child 2+1 multiple sessions,can include
Drop ($40.11) '.and provider,including on-going kj more than 1 person,i,e.family �-i
Down Ki crisis intervention and face to therapy,for 8-12 hours/monthly.)
face contact 2.3 times per ',Iii
na r. ,, week minimum,) i"
,r_
Assess. Assessment - _„ r9
Period , Period $26.30 Assessment s.ilAssessment Period $11.51 ; Assessment Period
(Includes Respite) ' Period $4 56 $0 ,;;
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: cs
Weld County Clerk to the Board
'��`
y a WELD COUNTY BOARD OF SOCIAL
Ibl ��� %. SERVICES,ON BEHALF OF THE
:.5:_
;141‘ WELD COUNTY DEPARTMENT OF
r ?PT' SOCIAL SERVICES
V '
By:
Deputy Clerk to the :oard Robert D.Masden,Chair
APPROVED AS TO FORM• JUN 2 8 2004
CONTRACTOR
County A e�e
Loving Homes Inc.
212 W 13th St
Puebl , CO 81003
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Directo
Agreement to Purchase
14
CPA Foster Care Services a70D•y-/737
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made thisa8 day of 2004 between the Board of Weld
County Commissioners, sitting as the Board of So al Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and PATH, 6355 Ward, Suite 305,
Arvada, CO 80004, hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
CPA Foster Care Services 1
&'a'51-/737
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease, but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management, Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological,Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation, Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However, provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 1502692
PATH
6355 Ward, Suite 305
Arvada, CO 80004
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective, non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s) must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological (mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports, which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen (15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds, whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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, which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? 0 Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative 0 Cty CC Foster Care 0 Shelter Care 0 Substance Abuse Treatment
❑ CORE Services 0 Receiving Home 0 CPA 0 RTC 0 Cty regular Foster Care
❑ Day Treatment 0 Kinship Care 0 Group Home 0 Ind.Living 0 Other(Specify)
( p fy)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
• Therapeutic(Behavior Modification) 0 Secure 0 Other(Explain)
Appropriate Counseling:
❑ Individual 0 Family 0 Group
Appropriate Treatment:
❑ Sex Offender 0 Aggressive/Violent 0 Substance Abuse 0 Truanc
y 0 Victim Behavior 0 Depression
❑ Self-destructive 0 Delinquency 0 Special Medical Needs 0 Behavior Modification 0 Anger Management
❑ Other (Explain)
Appropriate Educational Services:
• Special Ed. 0 Public School 0 Day Treatment
❑ On-grounds School 0 Additional Tutoring 0 Independent Living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) 0 Yes 0 No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
CHILD'S NAME STATE ID# SEX krails Case ID IDOB
Sex J
WORKER COMPLETING ASSESSMENT HH# DATE OF ASSESSMENT
AGENCY NAME rROVIDER 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?
O0)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 Ian?
O0)less than a''/S hour per day ❑1)'A hour a day
O2)more than'A hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily ❑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) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 0 0 0
P 2 Therapy/Counseling ❑ 0 0 0
P 3 Educational Intervention 0 0 0 0
P 4 Behavior Management ❑ 0 0 0
P 5 Personal Care 0 0 0 0
A 1 Case Management 0 0 0 0
T 1 Therapeutic Services 0 0 0 0
Agreement to Purchase 10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
'RATE THE BEHAVIOR CONDITIONS WHICH CREATE THE NEED FOR SERVICES THAT APPLY TO THIS CHILD THAT ARE
SIGNIFICANT IN TERMS OF DURATION AND INTENSITY.
Assessment Period: ❑Initial Assessment ❑Re-Determination - Months in Care
THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING.
1: -,74m: rit ratvertris
ralftwilt . . 7.61 441 11 tat!IL
04 r 138 11 '
Fil air Mt { i . 1 . 4 y; l!hi PI W 41 V l! 1* 'illf ;PS 3•=4iy...
' ' 141TWITRRAMTI3411 ' lc p frIPpriTtilirrI iriM, lip illieSill1/441, 1
: ..Iiiiih lfr' lariat, Y.10 glib aitatafil iiildWilthr, . l 'i. %Eta sii 1 I %Pi, .11.
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ ❑ ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
11
CPA Foster Care Services
Contract No: PY 04/05-55-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
SUMMARY-Please identify all specific requirements and expectations which support Level of Care.
LEVEL OF PROVIDER SERVICES NEEDED (Average of PI through P5)
PERIOD 1:LEVEL#
Comments:
LEVEL OF CASE MANAGEMENT SERVICES NEEDED (Al)
LEVEL #
Comments:
LEVEL OF THERAPY SERVICES NEEDED(Ti)
LEVEL #
Comments:
SPECIAL MEDICAL NEEDS: (Medically Fragile Children Only)
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: itial Date:
(maximum of 6 month intervals)
Agreement to Purchase 12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
in'ggiuggrg4414 4 Ira "'''g 'gilt PRIM; .11; M�6 3 - 4tl., A0 .., 8' f 9 [ i' I .434ll/ tlr 8 0.:
.. ,.t I sC'!i{('3f�I, ,i #
r t ' l'i - f ! ... - ii �llig II 6 ,tbi §.I i p4,
�1 i E c:s
Arri
�„ �r s��I I dtl��� [ �Ioi t I s.., �Irag
a� g h,3i a',.,.,°�i . , ri�i�031���,:. �'i i i I g �� 4�d M'i 43 �4 "clot, �iri
b11:14411.0,'
1 E. 'I I ;'i e °� '� I '' i 4,' i�3 `1�`�)d44 t H , »t, Ftg>>pF(,4I i I In"
"I ` I r' �?'., `E',.,1 i Ailirc g.. E f � v v .'hi, q I, 9 dr:I,I ,I ���,3�h i '4,NI , d';',!wt e ! �,
..xj, 'aE '.,6i1 i 3.lii�,,f,° ,. !'. �� �� III .L 'a�i.7�..�,. 6 '11040 RR7 ,E�I�_° �i �, .:.3, iq4444414434.3341.
;iP �b Ali_ .` 133�I e. � �!�+4.3044444. '
Age 0-10...$11.47 Level 0...$4.56Level 0 o Level 0 $4.93 $0 Leve10 $0
tikU I Age 11-14...$12.89 (Minimal CPA involvement,no (Therapy not needed or provided (None)
crisis intervention. Ony doing by another source,i.e.mental
'A. Age 15-21...513.91 what is necessary to maintain
0 , . health)
,''+ liti "PI
14
monthly responsibility.) If
+$.66 Respite Care EtiE
lit
il rid,
i 61.
Leven $8.22 Levell $4.93.l:.
Level t $2.99
ir
lid $espit (Low level of case mana ement, li. (Regularly scheduled theca
+$.66$19 7te Care Level 1...$4.56 minimal crisis Intervention,2-3 ( g 4 hours/month.) Py,
($19.73) contacts/month,minimal crisis
doil Intervention, 14
2-3 contacts/month.)NI
Iill Li
Levell $11.51 Level ii 4 $9.86 iii
Iii
2 il $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) ill Weekly support services, Group therapy.)
2. Occasional crisis intervention, t ggig
bIlrFace to face contact 1 time
Ili
Per month.) .ii.,Iiii, poll
gig
gE
Igki
lill
iFt
Level 3Vil $14.79- Level 3 $14.79
3II ll$32 22 (High level of case management (Regulady scheduled weekly
+$.66 Respite Care Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02
02
($32.88) and provider including ongoing1,1
more than 1 person,i.e.family dii Fil crisis intervention and faILA
ce to3 therapy,for 8-12 hours/monthly.)
IIiiiI face contactl-2 time per week
Ig
minimum.)
54
f 04Level4 $18.08 Level4 $14.79.
4 $39 45 ylilti rif(High level of case managementF (Regulady scheduled weekly Level 4 Neg.
RTC +$.66 Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can inGude
Drop ($40.11) ol
and provider,including on-going more than 1 person,i.e.family
Down crisis intervention and face to lilt therapy,for 8-12 hours/monthly.) iiii
ttI
face contact 2-3 times per rip
On
ft Jo;
ififweek minimum.)
iiiiAssess. Assessment it Assessment iiii
iiii
Period Period......$26.30 Penal $4.56 Assessment Period $11.51 Assessment Period $0
(Includes Respite)
ilill
NI
Effective 10/01/01
Agreement to Purchase
CPA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: S,CJ® 44
•
-�Weld Coiut[y 1 to'ffe 1�E1�d
WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
1861 4182 1 WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES ��p
j!� e at 1 W—�By:
Deputy Clerk to lie Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FO •
CONTRACTOR
oun Attq ey
PATH
6355 Ward, Suite 305
Arvada, CO 80004
By: A
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Director Aler
Agreement to Purchase 14
CPA Foster Care Services
aoo 5/-/z'7
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
THIS AGREEMENT made this,day of 2004 between the Board of Weld
County Commissioners, sifting as the Board of Soct 1 Services,on behalf of the Weld County
Department of Social Services,hereinafter called "County" and Trinity Foster Care, 8120
Sheridan Blvd, Suite C-200, Westminster, CO 80003,hereinafter called "Contractor".
WHEREAS, the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
1. 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#104702. 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. This Agreement shall be in force from July 1, 2004,until the end of the Colorado fiscal
year,June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing,to terminate this Agreement,whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30)days notice by registered mail,return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
�ea1—/7.37
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance(food,
shelter, clothing, educational supplies and allowance),Administrative Overhead, Case
Management, Direct therapy and evaluation,which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy,Polygraph,
Plethysmograph,Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care,Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility, including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 104702
Trinity Foster Care
8120 Sheridan Blvd, Suite C-200
Westminster, CO 80003
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies (2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2) Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication, not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact, authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State,provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven (7)days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure,where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status, which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological(mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports,which address the child's physical condition,psychological and
social functioning,the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services,the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least$25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and $400,000 for total injuries arising from any one accident.
8. Indemnify County, the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death, to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records, which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection,review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received,payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two (2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held, participation maybe by
teleconference.
Agreement to Purchase
5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agee to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
•
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein,when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual,Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee, or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement,if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation, it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever, unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion,or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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,which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
SECTION VII. ATTACHMENTS
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
1: Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative involvement? 0 Yes 0 No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? 0 Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services 0 Placement with Relative 0 Cty CC Foster Care 0 Shelter Care 0 Substance Abuse Treatment
❑ CORE Services 0 Receiving Home 0 CPA 0 RTC 0 Cry regular Foster Care
❑ Day Treatment 0 Kinship Care 0 Group Home 0 Ind.living 0 Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
Appropriate Setting:
❑ Therapeutic(Behavior Modification) 0 Secure 0 Other(Explain)
Appropriate Counseling:
O Individual 0 Family 0 Group
Appropriate Treatment:
O Sex Offender 0 Aggressive/Violent 0 Substance Abuse 0 Truancy 0 Victim Behavior 0 Depression
❑ Self-destructive 0 Delinquency 0 Special Medical Needs 0 Behavior Modification 0 Anger Management
O Other (Explain)
Appropriate Educational Services:
O Special Ed. 0 Public School 0 Day Treatment
O On-grounds School 0 Additional Tutoring 0 Independent living Training 0 Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
0 It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) 0 Yes 0 No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
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# DATE OF ASSESSMENT
AGENCY NAME PROVIDER NAME PROVIDER CWEST ID
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT FOR CHILDREN AGES I DAY
THROUGH 18 YEARS OLD.
• For each question below,please select the response which most closely applies to this child.
• Please check the number for that response in the corresponding box below.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does this child require transportation by the provider for 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?
00)less than a''/2 hour per day ❑1)'/2 hour a day
O2)more than'/2 hour per day,up to 2 hours per day O3)more than 2 hours per day
P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming,physical,and/or occupational therapy?
00)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?
O0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 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 ❑ ❑ ❑ ❑
P 4 Behavior Management ❑ ❑ ■ ❑
P 5 Personal Care El ❑ ❑ ❑
A 1 Case Management U 0 ❑ ❑
T 1 Therapeutic Services ❑ 0 ❑ 0
Agreement to Purchase
10
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
v _3E _
Aggression/Cruelty to Animals El ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis ❑ ❑ O ❑
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation El ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
Agreement to Purchase
CPA Foster Care Services 11
Contract No: PY 04/05-SS-23A-CPA
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)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daly Rates
(Attachment C)
, El.
z E
rq� �
. ., ... ,..- ._ _ ` , .:. _. ,.x . w..w,.: ._, .e..,_. ....a.....
o Age 0-10...$11.47 Level O...$4 56 Level 0 $4.93 Level 0 30' Level 0 $0
o Age 11-14...$12.89 `: (Minimal CPA involvement,no s (Therapy not needed or provided (None)
crisis intervention. Only doing r; by another source,i.e.mental
°; Age 15-21...$13.91 what is necessary to maintain health.)
0
monthly responsibility.)
+3.66 Respite Care ,. ,41
Level 1 $8.22 ,. Level 1 34.93
1 . Level 1......$2.99
$19.07 •
a +3.66 Respite Care Level 1...$4.56 (Low level of case management,s (Regularly scheduled therapy,
} ($19.73) minimal crisis Intervention,2-3 r 4 hours/month.) t
! contacts/month,minimal crisis ;
intervention, �
2-3 contacts/month.) t'( F-
: Level 2 $11.51 Level 2 $9.86
2 $25.64 _ (Moderate level of case [ (Weekly scheduled therapy, Li
+. Level 2 $4.47
+3.66 Respite Care Level 2...$4.56 Management including ;t 4-8 hours a month with 4 hours of
($26.30) Weekly support services, Group therapy.) E:
u Occasional crisis intervention,
Face to face contact 1 time
Per month.)
{ Level 3 $14.79 1 Level 3 $14.79
Pi(High level of case management . (Regularly scheduled weekly
3 $32.22 and CPA involvement with child 1 multiple sessions,can include p. Level 3 36.02
+3.66 Respite Care Level 3...34 56
($32.88) I 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 a
, minimum.) e"
'' Level 4 $18.08 Level 4 $14.79
4 (High level of case management , (Regularly scheduled weekly Level 4 Neg.
$39.45 3a
RTC : ti and CPA involvement with child : multiple sessions,can include
+$66 Respite Care Level 4...$4 56
Drop '1 ($40.11) s..and provider,including on-going ; more than 1 person,i.e.family +J1
Down ) crisis intervention and face to :: therapy,for 8-12 hours/monthly.) 4
' face contact 2-3 times per #:
week minimum.) . .
0-1
Lt
I
Assess. Assessment
Period Period 326.30 Assessment Assessment Period $11Z1 Assessment Period 30
(Includes Respite) . Period $4.56
Effective 10/01/01
Agreement to Purchase
13
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
ATTEST: """"4 14d
- �s • County Clerk to the Board
WELD COUNTY BOARD OF SOCIAL
1861 SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
SOCIAL SERVICEScat. & ----)
tkOZ
B B . �:�. By: .
eputy Clerk to the Board Robert D.Masden,Chair
JUN 2 8 2004
APPROVED AS TO FORM.
CONTRACTOR
ounty A tomey
Trinity Foster Care
8120 Sheridan Blvd, Suite C-200
V,_,L‘2Westminster, CO 80003
By: _.-
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
irector
Agreement to Purchase
14
CPA Foster Care Services
avo`/—/73 7
Contract No: PY 04/05-SS-23A-CPA
AGREEMENT TO PURCHASE
CHILD PLACEMENT AGENCY SERVICES
!t
THIS AGREEMENT made thisotic day of 2004 between the Board of Weld
County Commissioners, sifting as the Board of Soc 1 Services, on behalf of the Weld County
Department of Social Services, hereinafter called "County" and Youth Ventures LLC,4785
Granby Cir, Colorado Springs, CO 80919, hereinafter called "Contractor".
WHEREAS,the Colorado State Department of Social Services,hereinafter called "State
Department" is authorized to provide social services to individuals and families of individuals
through its agents, County Departments of Social Services, and
WHEREAS, County is authorized to purchase certain services for eligible children under
State Department rules, and
WHEREAS, County wishes to provide these services by purchasing them from
Contractor, and,
WHEREAS, Contractor is licensed as a Child Placement Agency.
NOW THEREFORE, it is hereby agreed that in consideration of the mutual Undertakings
County and Contractor agree as follows:
•
1. 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#78356. 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. This Agreement shall be in force from July 1, 2004, until the end of the Colorado fiscal
year, June 30, 2005; or until the child is removed by the County; or if the child's behavior
would cause harm to himself or other children, and Contractor seeks approval from the
County and the County agrees, in writing, to terminate this Agreement, whichever event
occurs first.
4. This Agreement may be renewed only by entering into a new written Agreement, such as
this Agreement, signed by the authorized representatives of the parties. In addition to the
termination provisions in Paragraph 3 above, either party shall have the right to terminate
this contract by giving the other party thirty(30) days notice by registered mail, return
receipt requested. If notice is so given, this contract shall terminate on the expiration of
the thirty(30) days or until the eligible child can be placed elsewhere,whichever occurs
Agreement to Purchase
1
CPA Foster Care Services
07401,/—/73
Contract No: PY 04/05-SS-23A-CPA
earlier, and the liability of the parties hereunder for further performance of the terms of
this Agreement shall thereupon cease,but the parties shall not be released from the duty
to perform their obligations up to the date of termination.
5. This Agreement is in lieu of and supersedes all prior agreements between the parties
hereto and relating to the care and services herein described.
SECTION 1. DESCRIPTION OF SERVICES TO BE PURCHASED.
1. The services purchased under this Agreement are Child Placement Agency services and
may include,but are not limited to: Basic 24-hour care and child maintenance (food,
shelter, clothing, educational supplies and allowance), Administrative Overhead, Case
Management,Direct therapy and evaluation, which may include but are not limited to:
Psychological and/or Neurological, Medication and follow-up, Family Therapy,
Individual Therapy, Group Therapy, Sex Offender Evaluation and/or Sex Offender
Treatment as prescribed by the Sex Offender Management Board Policy, Polygraph,
Plethysmograph, Parent Training for Teens, Independent Living Training,
Mentor/Advocate, Supervised Visitation,Direct Child Care, Therapeutic Recreation,
Transportation, and Special Needs (requires SS-22).
2. Payment for a child's temporary absence from the facility,including absence due to
hospitalization, will be made in accordance with State Department rules in Staff Manual
Volume VII, 7.406.1 (F).
3. Transportation shall be furnished by County between the child's residence and
Contractor's facility for the initial placement and return after the treatment plan is
completed. If the child runs away from the Contractor's facility, the County shall provide
transportation to either return the child to the facility or to other care as arranged by the
County. The County will make the decision to return the child to the facility,with input
from the Contractor.
4. All other transportation associated with the Contractor's proposed services will be
provided by Contractor. Any transportation costs not covered or contemplated in the
original treatment plan must be negotiated between County and Contractor and are not
subject to reimbursement under this Agreement. However,provisions for payment of
other transportation may be provided for in the treatment/case plan.
5. Any transportation costs to be incurred on behalf of this child which are to be borne by
persons or agencies which are not a party to this contract shall be specified in the
treatment/case plan, and those persons shall acknowledge their responsibility by signing
the treatment/case plan.
6. Contractor will provide the purchased care and services at:
Provider ID#: 78356
Youth Ventures LLC
4785 Granby Cir
Colorado Springs, CO 80919
Agreement to Purchase
2
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
7. Contractor shall not charge any additional fees to children or families of children referred
by County for services provided under this Agreement.
8. Contractor agrees not to assign the obligations under this Agreement nor enter into any
sub-contracts without the express written approval of the Executive Director of the
Colorado Department of Social Services or his appointed designee.
SECTION II. MEDICAL CARE
1. In accordance with the Weld County Department of Social Services policies(2.710.70,
2.710.71, 2.710.72, 2.710.73, 2.710.74) and Colorado Department of Human Services
Child Care Licensing Division policy(7.714.131), the contractor may obtain: 1) Ordinary
medical care, and 2)Emergency medical, surgical or dental care for said child after
making reasonable efforts to contact the County to obtain consent. Emergency care is
defined as any medical treatment as recommended by a licensed medical authority to
protect the life and health of a child and treatment cannot be delayed without placing the
child at risk.
2. Contact by the Contractor with the County regarding emergency medical, surgical or
dental care will be made in a person-to-person communication,not through phone mail
messages.
3. 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.
4. The County will be notified by the facility no later than the following working day of any
administration of emergency medical, surgical or dental services provided under this
authorization.
5. Prior to any elective,non-routine or non-emergency medical, surgical or dental services
being provided, authorization must be obtained from the assigned caseworker or
supervisor. If parental rights are intact,•authorization or attempts to obtain authorization
from the parent(s) should also be documented. If the placement is made through a
voluntary placement agreement between the parent(s) and the County, the parent(s)must
be contacted for authorization.
6. The Contractor is required to maintain a complete record of all medical, surgical or dental
services provided and the medications administered to the child.
7. The Contractor will provide an up-to-date copy of the medical record to the County at the
time of submittal of each progress report, including the discharge report at the time of the
child's termination from the care of the Contractor.
8. County and Contractor shall insure that the Child is enrolled in the Early and Periodic
Screening, Diagnosis and Treatment Program.
Agreement to Purchase
3
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
9. It is agreed and permission is granted for the child to participate in planned recreational
and social activities of Contractor, including supervised off grounds excursions and
extended trips within the State, provided that Contractor has written permission from
County and legal custodian for any trips out of Colorado for any reason and any planned
absence from the facility of over seven(7) days within a consecutive 30-day period. Such
written permission may be in the treatment/case plan. Further, Contractor and County
will also secure, where possible,permission from parents or guardians of the child placed
with the Contractor.
10. County and Contractor shall inform each other and the local school district of any
changes in parental residence affecting educational status,which comes to their attention.
SECTION III. REASONS FOR REFERRAL AND TREATMENT PLAN
1. Attachment A will be designated as the Placement Referral form. This referral will be
child specific and shall include the initial Treatment Plan that shall be goal oriented and
time-limited.
2. The Treatment Plan shall include the anticipated living arrangement and the anticipated
educational arrangement for the child upon completion. Also included will be the
anticipated date for discharge from treatment purchased as well as provisions concerning
the involvement of the child's family in treatment of the child.
3. County and Contractor agree and understand that the psychological(mental and
behavioral) or physical problems which necessitate purchasing services for this child are
specified in the Attachment A.
4. Modifications to the initial Treatment Plan shall be agreed upon by the County and
Contractor and shall be reflected in the Attachment A.
5. At no longer than three-month intervals after placement, Contractor shall provide County
with written reports, which address the child's physical condition,psychological and
social functioning, the child's family situation, educational progress, significant incidents
or disciplinary actions, and progress made to achieve goals specified in the Treatment
Plan. Further, the Contractor agrees to sequence reports to be received by the County•
fifteen(15) days prior to judicial or administrative hearings or reviews when provided
with thirty(30) day advance notice of such dates by County. Contractor shall participate
in all Foster Care Reviews as scheduled by the County and insure the attendance of the
child.
SECTION IV. CONTRACTOR SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of
Social Services, the State of Colorado and any federal laws and regulations, as such,
which may be amended from time to time, and shall be binding on Contractor and control
any disputes in this Agreement.
Agreement to Purchase
4
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
2. Maintain a current license and maintain license requirements as specified under State law.
3. Not collect any fees from children or families of children referred by county for any
services provided under this Agreement.
4. Not assign the obligations under this Agreement nor enter into any sub-contract without
the express written approval of the Executive Director of the Colorado Department of
Human Services or his/her appointed designee.
5. Abide by all applicable provisions of Title VI and VII of the Federal Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, Title XX of the Social Security Act
of 1975 as revised, and provide confidentiality of information concerning the child and
the child's family.
6. Maintain during the term of this Agreement a liability insurance policy of at least $25,000
for property damage liability, $150,000 for injury and/or damage to any one person, and
$400,000 for total injuries arising from any one accident.
7. Maintain during the term of this Agreement a liability insurance policy of at least
$400,000 for property damage liability, $150,000 for injury and/or damage to any one
person, and$400,000 for total injuries arising from any one accident.
8. Indemnify County,the Colorado Department of Social Services and the State of Colorado
against any and loss against all claims and actions based upon or arising out of damage or
injury, including death,to persons or property caused or sustained in connection with the
performance of this contract or by conditions created thereby, or based upon any
violations of any statute, ordinance, or regulation and the defense of any such claims or
actions.
9. Maintain service program records, fiscal records, documentation and other records,which
will sufficiently and properly reflect all direct and indirect costs of any nature incurred in
the performance of this Agreement. The above shall be subject at all reasonable times to
inspection, review or audit by federal, State Department or county personnel, and other
persons authorized in writing by the Executive Director, Colorado Department of Social
Services.
10. Bill the County for services rendered, using the required Division of Child Welfare
Provider Roster. This roster is to be mailed to the County department by the last day of
the month of care. If Provider Rosters are not received, payments will be held until the
required paperwork is received.
11. Attend and participate in Foster Care Reviews for children in placement longer than 60
days, and any subsequent appeal process, for children in placement with the Contractor
pursuant to two(2)weeks written notice by the County. If the facility is in a different
part of the state from the county in which the review is held,participation may be by
teleconference.
Agreement to Purchase 5
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
12. Agree to cooperate with any vendors hired by Weld County Department of Social
Services to shorten the duration of placement at CPA level.
13. Obtain physical examinations within 14 days of placement and forward all appropriate
information to the County.
14. Obtain Dental examinations within 60 days of placement and forward all appropriate
information to the County.
15. A full evaluation of an Individualized Educational Plan(IEP) for youth designated as a
Special Education Students 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.
16. 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.
SECTION V. COUNTY SHALL:
1. Determine eligibility of the child under this Agreement for placement and medical
coverage.
2. Assess and collect fees in accordance with the rules and regulations of the Colorado
Department of Social Services.
3. Reimburse Contractor by the 15th of the following month in accordance with fiscal
system time frames for services purchased under this Agreement in accordance with the
established rate specified herein, when Provider Rosters are submitted as described in
Section IV,Number 8.
Agreement to Purchase
6
CPA Foster Care Services
Contract No: PY 04/O5-SS-23A-CPA
4. Abide by all the rules and regulations of the Colorado Department of Social Services,
federal rules and regulations and the laws of the State of Colorado, any of which may be
amended from time to time.
5. Monitor child's progress in accordance with the treatment/case plan and the requirements
of State Department Staff Manual, Volume VII, and provide consultation and/or technical
assistance to Contractor in relation to the services purchased under this Agreement.
6. Involve Contractor in planning for the child and give the Contractor a copy of the
Discrete Case Plan at time of placement or as soon as completed and when updated or
revised.
SECTION VI. GENERAL PROVISIONS.
1. The Parties to this Agreement intend that the relationship between them, contemplated by
this Agreement is that of employer-independent contractor. No agent, employee,or
servant of Contractor shall be deemed to be an employee, agent, or servant of County.
Contractor will be solely and entirely responsible for its acts or of any agent, employee,
servants and sub-contractors during the performance of this Agreement.
2. Payment pursuant to this Agreement, if in State of Colorado or federal funds,whether in
whole or in part, is subject to and contingent upon the continuing availability of State of
Colorado and federal funds for the purpose thereof.
3. It is agreed that if, after investigation,it is shown that reasonable care was given to guard
and protect personal items brought to Contractor by the Child, Contractor will be released
from responsibility for loss or damage to such personal items.
4. This Contract is intended as the complete integration of all understandings between the
parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall
have any force or affect whatsoever,unless embodied herein in writing. No subsequent
notation, renewal, addition, deletion, or other amendment hereto shall have any force or
effect unless embodied in a written Agreement.
5. The Contract shall permit the Colorado Department of Social Services and the County to
monitor the service program, fiscal books and other records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the
aforementioned child through program reports, on-site visits where applicable and other
contracts as deemed necessary. The Contractor understands that the Colorado
Department of Social Services will provide consultation and technical assistance to
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
6. In the event this contract is terminated, final payment to the Contractor may be withheld
at their discretion of the County until final audit. Incorrect payments to the Contractor
due to omission, error, fraud, or misuse of funds shall be recovered from the Contractor
either by deduction from subsequent payments under this contract or other contracts
between the County and the Contractor or by the County, as a debt due to both the State
Agreement to Purchase
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
of Colorado, Colorado Department of Social Services and the County. The waiver of any
violation shall not be construed as a waiver of any other or subsequent violation of this
contract or appropriate statutes and regulations.
7. 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.
8. 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, which 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.
9. 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;
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.
10. 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.
Agreement to Purchase
8
CPA Foster Care Services
Contract No: PY 04/o5-SS-23A-CPA
SECTION VII. ATTACHMENTS
•
PLACEMENT REFERRAL
FOR CPA SERVICES
(Attachment A)
Child's Name: State ID No: Date of Placement:
I. Legal Status of Child. (Mark appropriate box)
❑ Placed through a Voluntary Placement Contract signed by(Fill in Name).
❑ Placed through court order and legal custody/guardianship is held by Weld County DSS.
❑ Placed through a Petition for Review of Need for Placement with custody retained by(Fill in Name).
❑ Other (please explain)
2. Reasons for purchasing services for this child are:
REASON (If Other,please Explain)
3. Expected parent/guardian/relative Involvement? O Yes O No
Number of times per week expected for visits? 0
Will transportation for visits be provided by the facility/provider listed below? O Yes ❑No
Number of times per week transportation from facility/provider is expected? 0
Comments:
4. Services already utilized prior to placement. (Mark appropriate box)
❑ In home services O Placement with Relative O Cty CC Foster Care O Shelter Care O Substance Abuse Treatment
❑ CORE Services ❑ Receiving Home O CPA O RTC O Cty regular Foster Care
❑ Day Treatment O Kinship Care O Group Home O Ind.Living O Other(Specify)
5. Services needed within the Initial Treatment Plan. (Mark appropriate box)
A propriate Setting:
d Therapeutic(Behavior Modification) O Secure O Other(Explain)
Appropriate Counseling:
❑ Individual O Family O Group
Appropriate Treatment:
❑ Sex Offender O AggressiveNiolent O Substance Abuse O Truancy O Victim Behavior O Depression
❑ Self-destructive O Delinquency O Special Medical Needs O Behavior Modification O Anger Management
❑ Other (Explain)
Appropriate Educational Services:
❑ Special Ed. O Public School O Day Treatment
❑ On-grounds School O Additional Tutoring O Independent Living Training O Other (Explain)
Estimated date for accomplishing treatment plan goals are June 30,2005,or before.
6. CCAR Level of Care:(for RTC Placements Only) (Level) (copy to Business Office)
O It has been determined that this child is in need of rehabilitative services.
(Check Box if child is placed within a RTC)
Need Based Care Assessment Completed. (CPA Placements Only) O Yes O No (copy to Business Office)
7. The anticipated living arrangement of child upon completion of the Treatment Plan is:
ARRANGEMENT (If other,please explain)
If the outcomes are not achieved in the amount of time as planned,Contractor agrees to meet with the County to revise this plan.
COUNTY FACILITY
Weld County Department of Social Services Facility Name
PO Box A Trails provider ID
Greeley CO 80632 Address
City,State,Zip
Provider Info:
(If applicable) Foster Care Provider
Trails provider ID
Provider Address
Caseworker Signature City,State,Zip
(Worker Name) Date
Gloria Romansik,Administrator Signature of Person Authorized to Sign Agreement
Date Date
Agreement to Purchase
9
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
IDENTIFYING INFORMATION
gimp's NAME STATE ID# SEX Trails Case ID DOB
Sex
WORKER COMPLETING ASSESSMENT IFDI# (DATE OF ASSESSMENT
AGENCY NAME (PROVIDER NAME 1ROVIDER 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 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'A hour per day O1)I/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 monitoring of time and/or activities
and/or crisis management?
❑0)less than 5 hours per week ❑1)5 to 10 hours per week 0 2)at least daily O3)on a constant basis
P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing,
grooming, hysical,and/or occupational therapy?
O0)less than 5 hours per week ❑1)5 to 10 hours per week
❑2)11 to 20 hours per week ❑3)21 or more hours per week
A 1. How often is CPA case management required?
❑0) 1 face to face contact per month and/or no crisis intervention
❑1) 2-3 contacts per month(must include 1 face to face)and/or minimal crisis intervention
O2) 2 face to face contacts per month and/or occasional crisis intervention
O3) at least 1 face to face contact 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 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 ❑
P 4 Behavior Management ❑ ❑
P 5 Personal Care ❑ 0 0 ❑
A 1 Case Management 0 0 0 0
T 1 Therapeutic Services 0 ❑ 0 0
Agreement to Purchase
CPA Foster Care Services 10
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DSS
NEEDS BASED CARE ASSESSMENT
(ATTACHMENT B)
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.
4 c
� �•
v . a s tie;.
i� t4 .a �� ts� ' i � t s !
n 4
Aggression/Cruelty to Animals ❑ ❑ ❑ ❑
Verbal or Physical Threatening ❑ ❑ ❑ ❑
Destructive of Property/Fire Setting ❑ ❑ ❑ ❑
Stealing ❑ ❑ ❑ ❑
Self-injurious Behavior ❑ ❑ ❑ ❑
Substance Abuse ❑ ❑ ❑ ❑
Presence of Psychiatric ❑ ❑ ❑ ❑
Enuresis/Encopresis 0 ❑ 0 0
Runaway ❑ ❑ ❑ ❑
Inappropriate Sexual Behavior ❑ ❑ ❑ ❑
Disruptive Behavior ❑ ❑ ❑ ❑
Delinquent Behavior ❑ • ❑ ❑ ❑
Depressive-like Behavior ❑ ❑ ❑ ❑
Medical Needs ❑ ❑ ❑ ❑
Emancipation ❑ ❑ ❑ ❑
Education ❑ ❑ ❑ ❑
Involvement with Child's Family ❑ ❑ ❑ ❑
CHILD'S OVERALL LEVEL OF AVERAGE LEVEL:
NEED: ❑ 0 ❑ 1 ❑ 2 ❑ 3
(check level of need)
4greement to Purchase
SPA Foster Care Services 11
Contract No: PY 04/05-SS-23A-CPA
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 It
Comments:
LEVEL OF THERAPY SERVICES NEEDED(T1)
LEVEL #
Comments:
SPECIAL MEDICAL NEED& (Medically Fragile Children Only) •
LEVEL #
Comments:
NEXT SCHEDULED RATE REVIEW: Initial Date:
(maximum of 6 month intervals)
Agreement to Purchase
12
CPA Foster Care Services
Contract No: PY 04/05-SS-23A-CPA
WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
NEEDS BASED CARE RATE TABLE
Calculated as Daily Rates
(Attachment C)
V
t
t X
A -, },?icei 3rtr ' n4.4 } k�
1 'c',..,7:4:411,-,I, tr 7 a J
. i ev rfa'?.W,T'u a" ..a vn...
--
g Age 0-10...$11.47 t z
4 Level 0...$4.56 ' Level 0 $4.93 :;,4 Level 0 $0 Level 0 $0
0 Age 11-14...$12 89 ::.; ! (Minimal CPA involvement,no k (Therapy not needed or provided (None)
R; ' . crisis intervention. Only doing by another source,i.e.mental
0 Age 15-21...$13 91 ( - what is necessary to maintain e
_i monthly responsibility.) health.) 6.''
+$.66 Respite Care ii ' !� ill
b) )'�.
R 6
1 ' Level 1 $8.22 il Level 1 - $4.93
$19.07 FLevel 1 $2.99
4.66 Respite Care ,;, Level 1...$4.56 s(Low level of case management,d. (Regularly scheduled therapy, F�
I minimal crisis intervention,2-3 i.
($19.73) r.. 4hours/nwnlhJ
a _ contacts/month,minimal crisis r',
t 4 intervention, a'.
2-3 contacts/month.) reil
); rty f4
Pi
4. `Level 2 $11.51 'Level 2 $9.86
I
2
525.64 -'. (Moderate level of case (Weekly scheduled therapy, ".
?, +5.66 Respite Care ,; Level 2...$4.56 Management including P 4-8 hours a month with 4 hours of ,. Level 2 $4.47
($26.30) := Weekly support services, .^: Group therapy.)
Occasional crisis intervention 's
k s Face to face contact 1 time �, a;i
S Per month.) I.3
i,,
i
! e.
Level 3 $14.79 I r Level 3 $14.79 ' ,
i
i (High level of case management a (Regularly scheduled weekly i
3 $32.22
••; +$.66 Respite Care i+,!
Level 3...$4.56 and CPA involvement with child multiple sessions,can include G"< Level 3 $6.02
($32.88) �, and provider including ongoing 1.4 more than 1 person,i.e.family i
i. . crisis intervention and face to _ therapy,for 8-12 hours/monthly.) r''
face contact)-2 time per week ',.r.'
minimum.) I:t t'7
`,,z
. 413, :.
-
a Level 4 $18.08 a Level 4 $14.791I,.
4 r f4
RTC $39.45 a(High level of case management (Regularly scheduled weekly Level 4 Neg.
+5.66 Respite Care Level 4...54.56 and CPA involvement with child ;:4, multiple sessions,can include
Drop ,. ($40 11) u,l and provider,including on-going`w more than 1 person,i.e.family
Down :k„ crisis intervention and face to i..'.:, therapy,for 8-12 hours/monthly.) -;
_, face contact 2.3 times per ca.
week minimum.) "-
r.,,.:LI
Assess. Assessment *t ;rf
Period Period $26.30 y1 Assessment t Assessment Period $11.51 Assessment Period
(Includes Respite) -, Period $4.56 `'u $0 ,
Effective 10/01/01
kgreement to Purchase
PA Foster Care Services 13
Contract No: PY 04/05-SS-23A-CPA
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day,
month, and year first above written.
MAIM
ATTEST:
��T`! •.,. ,ty Clerk to the Board
J' I` WELD COUNTY BOARD OF SOCIAL
SERVICES,ON BEHALF OF THE
WELD COUNTY DEPARTMENT OF
SOCIAL SERVICES
(By: .- : . By: Z? k
Deputy Clerk to the Board Robert D.Masden,Chair
APPROVED AS TO FO • JUN 2 8 2004
CONTRACTOR
County Attorney
Youth Ventures LLC
4785 Granby Cir
Colorado Springs CA 80919
By:
WELD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
Ili ector
•
Agreement to Purchase
CPA Foster Care Services 14
awes/—/737
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