The URL can be used to link to this page

Browse Search

Home My WebLink About20041773.tiff Contract No: PY 04/05-SS-23A-CPA AGREEMENT TO PURCHASE CHILD PLACEMENT AGENCY SERVICES a THIS AGREEMENT made this,;,Q day of; in(' . 2004 between the Board of Weld County Commissioners, sitting as the Board of So 1 Services, on behalf of the Weld County Department of Social Services, hereinafter called "County" and Hope Family Services, 1115 11th St, Greeley, CO 80631, 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#42942. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. 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 &Z'5//7J3 Contract No: PY 04/05-SS-23A-CPA the thirty(30) days or until the eligible child can be placed elsewhere, whichever occurs 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#: 45080 Lutheran Social Services of Colo. 3800 Automation Way, Suite 200 Fort Collins, CO 80525 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 Agreement to Purchase 3 CPA Foster Care Services Contract No: PY 04/05-SS-23A-CPA Screening, Diagnosis and Treatment Program. 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 B 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) El 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 ❑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 ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ CORE Services 0 Receiving Home ❑ CPA El Cty Substance regular Fose Treatment ❑ Da Treatment ❑ RTC ❑ Oth (Sp Foster Care Day ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify) 5. Services needed within the Initial Treatment Plan. (Mark appropriate box) Appropriate Setting: ❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain) Appropriate Counseling: ❑ Individual ❑ Family ❑ Group Appropriate Treatment: El Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy Victim Behavior ❑ Self-destructive ❑ ❑ Depression ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification CI Other (Explain) 111 Anger Management Appropriate Educational Services: El Special Ed. ❑ Public School ❑ Day Treatment ❑ On-grounds School ❑ Additional Tutoring ❑ Independent epdent Living Training ❑ 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) ❑ 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) ❑ 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 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 tHH# DATE 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? 90)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? 90)one a month ❑1)twice a month 92)once a week 93)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 V2 hour per day 01)1/4 hour a day O2)more than '/2 hour per day,up to 2 hours per day 93)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑I)5 to 10 hours per week 9 2)at least daily ❑3)on a constant basis P 5. Flow much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing, grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week O2) II to 20 hours per week ❑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 ❑l) 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) 91)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 9 ❑ 0 P 2 Therapy/Counseling 0 9 9 0 P 3 Educational Intervention 0 9 0 ❑ P 4 Behavior Management ❑ ❑ ❑ 9 P 5 Personal Care ❑ ❑ ❑ ❑ A I Case Management ❑ 0 ❑ ❑ T I Therapeutic Services 0 0 9 9 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. • .............................. t.. ..f.......t n. ASSESSMENT: A$.. None. Mild Moderate Severe Comments: 0 1 2 3 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ J ❑ 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 (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) • • LEVEL OF RECOMMENDED RECOMMENDED AGENCY RATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE .. • A') ':.:o;;:::, ' .. Tt ADDENDUM P1-P5 Level Rate Admin.Overhead Case Management Therapy (Admin.Maint.) (Admin.Maint.) (Admin.Services) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 $0 Level 0 $0 Age 11-14...$12.89 (Minimal CPA involvement, no ) 0 (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 1 Level 1 $8.22 Level 1 $4.93 $19.07 Levell $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, +$.66 Respite Care Level 2...$4.56 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, Face to face contact 1 time Per month.) Level3 $14.79 ! Level3 $14.79 $32.22 (High level of case management (Regularly scheduled weekly 3and CPA involvement with child multiple sessions,can include +$.66 Respite Care Level 3...$4.56 and provider including ongoing more than1 person,i.e.family Level 3 $6.02 ($32.88) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 4 $39.45 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC +$,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.) Assess. Assessment Assessment Period Period $26.30 Period $4.56 Assessment Period $11.51 Assessment Period $0 (Includes Respite) 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: Lialle 4f Weld County Clerk to the Board '� w` E 11,,t` WELD COUNTY BOARD OF SOCIAL ` SERVICES,ON BEHALF OF THE 1861 creadiszo...... WELD COUNTY DEPARTMENT OF ` `� SOCIAL \V�(S\JERRJ(1VIC 1ESSy\ 1/44_ BY �� v, ! By: Deputy Clerk to the oard Robert D.Masden,Chair APPROVED AS TO FORM: JUN 2 8 2004 CONTRACTOR County tto ru y Hope Family Services 1115 11th St Greele , O 8 31 By: WELD COUNTY DEPARTMENT OF SOCIAL SERVICES By: irector Agreement to Purchase 14 CPA Foster Care Services 62 oe y -/77 Contract No: PY 04/05-SS-23A-CPA AGREEMENT TO PURCHASE CHILD PLACEMENT AGENCY SERVICES ptit THIS AGREEMENT made this; !1 day of C /1qk, 2004 between the Board of Weld County Commissioners, sitting as the Board of So 1 Services, on behalf of the Weld County Department of Social Services, hereinafter called "County" and Lutheran Social Services of Colo., 3800 Automation Way, Suite 200, Fort Collins, CO 80525, 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#45080. These services will be for children who have been deemed eligible for social services under the statutes, rules and regulations of the State of Colorado. 3. 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 Agreement to Purchase CPA Foster Care Services 1 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#: 42942 Hope Family Services 1115 11th St Greeley, CO 80631 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: 1W 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? ❑ Yes ❑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 ❑ Placement with Relative ❑ Cty CC Foster Care ❑ Shelter Care ❑ Substance Abuse Treatment ❑ CORE Services ❑ Receiving Home ❑ CPA ❑ RTC ❑ Cty regular Foster Care ❑ Day Treatment ❑ Kinship Care ❑ Group Home ❑ Ind.Living ❑ Other(Specify) 5. Services needed within the Initial Treatment Plan. (Mark appropriate box) Appropriate Setting: ❑ Therapeutic(Behavior Modification) ❑ Secure ❑Other(Explain) Appropriate Counseling: ❑ Individual ❑ Family ❑ Group Appropriate Treatment: ❑ Sex Offender ❑ AggressiveNiolent ❑ Substance Abuse ❑ Truancy ❑ Victim Behavior ❑ Depression ❑ Self-destructive ❑ Delinquency ❑ Special Medical Needs ❑ Behavior Modification ❑ Anger Management ❑ Other (Explain) Appropriate Educational Services: ❑ Special Ed. ❑ Public School ❑ Day Treatment ❑ On-grounds School ❑ Additional Tutoring ❑ Independent Living Training ❑ 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) ❑ 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) ❑ 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 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 1FIH# 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 ❑l)twice a month ❑2)once a week ❑3)2 or more times a week P 3. How much time is the provider required to intervene at home and/or at school with the child in conjunction with a regular or special education plan? ❑0)less than a V2 hour per day O1)1/2 hour a day ❑2)more than '/2 hour per day,up to 2 hours per day ❑3)more than 2 hours per day P 4. How often does the child require special and extensive involvement by the provider in scheduling and monitoring of time and/or activities and/or crisis management? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑ 2)at least daily ❑3)on a constant basis P 5. How much time is the provider required to assist the child because of impairments beyond age appropriate needs with feeding,bathing, grooming,physical,and/or occupational therapy? ❑0)less than 5 hours per week ❑1)5 to 10 hours per week ❑2) 11 to 20 hours per week ❑3)21 or more hours per week A 1. How often is CPA case management required? ❑0) 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 ❑2) 2 face to face contacts per month and/or occasional crisis intervention ❑3) 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) ❑1)less than 4 hours per month ❑2)4-8 hours per month ❑3)8-12 hours per month RATING OF SERVICE AREAS Initial Assessment Date: SERVICE AREAS 0 1 2 3 P 1 Transportation ❑ ❑ ❑ ❑ P 2 Therapy/Counseling ❑ ❑ ❑ ❑ P 3 Educational Intervention ❑ ❑ ❑ ❑ P 4 Behavior Management ❑ ❑ ❑ ❑ P 5 Personal Care ❑ ❑ ❑ ❑ A 1 Case Management ❑ ❑ ❑ ❑ T 1 Therapeutic Services ❑ ❑ ❑ ❑ 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 nRe-Determination - Months in Care THE BEHAVIOR ASSESSMENT IS USED ONLY TO IDENTIFY CHILD NEEDS AND ASSIST IN TREATMENT PLANNING. . (e6i4 ne.box for : rye. ASSESSMENT AREAS Non 0 1 e,. Mild Moderate Severe Comments:..... '' 2 3 Aggression/Cruelty to Animals ❑ ❑ ❑ ❑ Verbal or Physical Threatening ❑ ❑ ❑ ❑ Destructive of Property/Fire Setting ❑ ❑ ❑ ❑ Stealing O ❑ ❑ Self-injurious Behavior El ❑ U Substance Abuse ❑ Presence of Psychiatric ICI CI CI CI Enuresis/Encopresis ❑ ❑ ❑ ❑ Runaway ❑ ❑ ❑ ❑ Inappropriate Sexual Behavior ❑ ❑ ❑ ❑ Disruptive Behavior El ❑ ❑ ❑ Delinquent Behavior ❑ ❑ ❑ ❑ Depressive-like Behavior ❑ ❑ ❑ ❑ Medical Needs ❑ ❑ ❑ Emancipation ❑ ❑ ❑ Education ❑ ❑ ❑ ❑ Involvement with Child's Family ❑ ❑ ❑ ❑ CHILD'S OVERALL LEVEL OF AVERAGE LEVEL: NEED: 0 n 1 n2 El (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 (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) LEVEL OF RECOMMENDED RECOMMENDEDAGENCrRATE INTERVENTION RATE MEDICAL NEEDS SERVICE PROVIDER RATE •:::::::•.•:;.-•':-:- .:::.:Al : >: '»>:,,... : •'. . TI ADDENDUM P1 -P5 ;_., Level Rate Admin.Overhead Case Management `'?' Therapy (Admin.Services}.• (Admin.Maint.) (Admin. Maint.) 0 Age 0-10...$11.47 Level 0...$4.56 Level 0 $4.93 Level 0 SO Level 0 $0 Age 11-14...$12.89 (Minimal CPA involvement, no 0 crisis intervention. Only doing (Therapy not needed or provided (None) by another source,i.e.mental 0 Age 15-21...$13.91 what is necessary to maintain health.) monthly responsibility.) +5.66 Respite Care • Level 1 $8.22 Level 1 $4.93 1 $19.07 Level1 $2.99 +$.66 Respite Care Level 1...$4.56 (Low level of case management, (Regularly scheduled therapy, ($19.73) minimal crisis intervention,2-3 4 hours/month.) contacts/month,minimal crisis intervention, 2-3 contacts/month.) Level2 $11.51 Level2 $9.86 2 $25.64 (Moderate level of case (Weekly scheduled therapy, Level 2 $4.47 +$.66 Respite Care Level 2...$4.56 Management including 4-8 hours a month with 4 hours of ($26.30) Weekly support services, Group therapy.) Occasional crisis intervention, • Face to face contact 1 time Per month.) ✓• Level 3 $14.79 Level 3 $14.79 3 • $32 22 (High level of case management (Regularly scheduled weekly +$.66 Respite Care : Level 3...$4.56 and CPA involvement with child multiple sessions,can include Level 3 $6.02 ($32.88) and provider including ongoing more than 1 person,i.e.family ... crisis intervention and face to therapy,for 8-12 hours/monthly.) face contactl-2 time per week minimum.) Level4 $18.08 Level4 $14.79 • 4 • $39.45 (High level of case management (Regularly scheduled weekly Level 4 Neg. RTC Respite Care Level 4...$4.56 and CPA involvement with child multiple sessions,can include Drop +$.66 and provider,including on-going more than 1 person,i.e.family Down • ($40'11) crisis intervention and face to therapy,for 8-12 hours/monthly.) face contact 2-3 times per week minimum.) Assess. Assessment Assessment Period Period $26.30 Period $4 Assessment Period $11.51 Assessment Period $0 (Includes Respite) .56 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: ,mat_ Weld Coun C er c to the Boa d ,t 1 / 4 % A �� WELD COUNTY BOARD OF SOCIAL Al Ifr-1 SERVICES,ON BEHALF OF THE 1461 (1 �i 4;in* ` WELD COUNTY DEPARTMENT OF r pro . , SOCIAL SERVICES Z� - _� i z�-i,- /` LL By: --, . •. ty Clerk to the Board rtC(i Masden, Chair JUN 2 8 2004 APPROVED AS TO FORM: CONTRACTOR Coupty Att mey Lutheran i• Services of Colo. 3800 to ationW Suite Fo n CO Fo� Co s, CO 80505 2' • WELD COUNTY DEPARTMENT /Jo � y7 OF SOCIAL SERVICES �c By: Direeto Agreement to Purchase 14 CPA Foster Care Services orlon 9- /773 Hello