HomeMy WebLinkAbout20184180.tiffCOLORADO
Office of Children,
Youth 8 Families
Depsrtrnent of Hwnan Services
INDIVIDUAL PROVIDER CONTRACT
FOR PURCHASE OF FOSTER CARE SERVICES IN A FOSTER CARE HOME
1. THIS CONTRACT AND AGREEMENT, made this date, ' p20/d by and between theWeld County
Department of Human Services, P. O. Box A, Greeley, CO 80632, hereinafter cat led "County Department" and
Visser, Ryan and Amanda, 3212 68th Ave. Ct., Greeley, CO 80634, hereinafter called Provider".
2. This Contract and Agreement shall be effective from July 1, 2018 and continue in force until June 30, 2019 or until
the facility certificate is revoked or surrendered. This contract and agreement may be renewed at any time during
the term of the valid facility certificate. This contract and agreement is in lieu of and supersedes all prior purchase
contracts between the parties hereto and relating to the services herein described.
3. The Provider holds a valid certificate as a: ® Foster Care Home or O Kinship Foster Care Home (check
applicable blank). Such certification standards shall be maintained during the term hereof. The provider has
read and is fully familiar with the "Rules Regulating Foster Care Homes' issued by the Colorado Department of
Human Services.
4. The County Department may, but shall not be obligated to purchase foster care home services. The County
Department or any duly authorized agent may request such services to be provided to any child or youth at any
time within the limits of the certificate and without prior notice. At such time or as soon as possible after the
acceptance of a child or youth for services, the County Department and the Provider shall verify foster care
placement of each child or youth in writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
5. The terms of this Agreement are contained in the terms recited in this document and in Exhibit A and Addendum 1
and 2, which form integral parts of this Agreement. Exhibit A and Addendum 1 and 2 are specifically incorporated
herein by this reference.
The Provider agrees:
1. To furnish foster care services to eligible children and youth at the established rate based on the individual
child or youth rates negotiated between the county department and the provider;
2. To safely provide the 24 -hour physical care and supervision of each child or youth until removed or
until the agreement is renewed;
3. To accept a child or youth, only with the approval of the certifying agency;
4. To cooperate fully with the County Department or its representatives, and participate in the
development of the Family Service Plans -for a child or youth in placement, including visits with their
parents, siblings, relatives, or to transition to anotherfoster care facility;
5. To maintain approved standards of care as set by the Colorado Department of Human Services;
6. To maintain the confidentiality of information shared about the child or youth and his/her family;
7. Not to accept money from parents or guardians;
8. Not to make any independent agreement with parents or guardians;
2018-4180
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John W. Hickentooper, Governor I Reggie Bicha, Executive Director
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9.. Not to release the child or youth to anyone without prior authorization from. the County Department;
10. To allow representatives Of the County Department toVisit foster care hOineand to meet with the
child or youth at any reasonable time, including scheduledand unscheduled.visits;.and;
11. To give the County Department a 30 -day notice, except in an emergency, to remove a child or youth'
for placement elsewhere, and to work with the County Department as requested to prepare the child or
youth for another placement:
12. To provide transportation to the child or youth. The amount of transportation to be provided will be
agreed upon at placement and may bechanged upon mutual agreement of theprovider and the
County Department, as recorded in the Family Service Plan. Transportation.must be provided or
arranged:
a. For professional services and/or for school attendancewhen necessary; "and,
b. For children or youth to participate in age or developmentally approprate:extracumcular; •enrichment,
cultural, and social activities.
13. To report promptly to the County Department
a. Any unplanned absence of the child or youth -from providers care
b. Any major illness of the child or youth;
c. Any serious injury to the child or youth
d. Any significant change in the sleeping arrangement for the child or youth;
e. Any contemplated change of address or change of household members;
f. Any conflict the child or youth may have with law enforcement, schooUschool district staff, or otherpersons
in authority;
g. Any emergency;.
h. Any pertinent discussion with parents or guardians about the child or youth or supervising agency; and,.
L Any information received regarding a change of address of the parents or guardians.
14. To comply with the Civil Rights Act of 1964,. Section 504, Rehabilitation Act of 1973, and the ADA-of 1990, concerning
discrimination on the basis of race, color, sex, agejsexual orientation, expression, or identity, religion, political beliefs,
national origin,or handicapping condition.
15. To complete pre -service training prior to the placement of a child or youth.
16. To annually:
a. Update the Training Development Plan withthe County Department:
b. Complete ongoing, quality, and relevant training that will build competencies to meet the needs of the
children and youth served in the foster care home as required by the Colorado Department of Human
Services regulations;and,
c. Obtain certification to use and apply the reasonable,and prudent parent standard for each child or youth'served
in the foster care home.
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17. To attend semi-annual Administrative Reviews for achfld oryouth.in placement
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18. To be knowledgeable of, and comply with the 'Rul sj. g lating Foster Care Homes' and the "General Rules for
Child Care Facilities;
19. Not to enter. into any subordinate subcontract hereunder ?
20. To keep required and necessary records for ai review puipo es by, state and federal personnel. These records
shall document the type of care and dates that care provided for each child or youth. In addition, medical,
educational, and progress summary records shall be: maintained for each childor youth as required pursuant to the
Colorado Department of Human Services' Rules Regulating`Femity Foster Care Homes.
21.. To complete or schedule a medical examination for the child or youth within 14 days after initial placement and a
dental examination within eight weeks of initial placement;
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John. W. Hicientooper, Governor I Reggie Bicha, Executive Director
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The County Department agrees:
1. To share an available information about the child or youth, including relevant social,, medical and educational
history, behavior problems, court involvement, parental, sibling and relative visitation plans, and other specific
characteristics of the child or youth, with the provider before placement and to share additional Information when
obtained while the child or youth Is in placement
2. To inform the provider of expectations regarding the care of the child or youth, such as meeting medical needs,
visitation, special psychological needs, trauma and other grief/loss issues, and the child's or youth's identification
with hi&herfarhly;
3. To give the provider the written admission record Of the child or youth to the foster care homeat the time of
placement; _
4. Togive the provider a written procedure or authorization for obtaining medical care for the child or youth;
5. To involve the provider in family service planning for the child or youth as a member of treatnienttearn;.
6. To give the provider a copy of the Family Service Plan, .as it pertains to their expectations for meeting the needs of
the child or youth in the foster care home, at the time of placement or when it is completed following placement,,
7. To give at least a 30 -day notice of plans to remove a child or youth from the foster care home. The 30 -day notice
may be waived by mutual consent to allow and permit immediate removal of a chilior youth 'for placement
elsewhere, or without such waiver in the event of an emergency. An emergency is defined as any situation in
which a provider's inability to provide services threatens the health, safety or welfare of a child or youth.
8. To pey the provider at the rates established by the Colorado Department of Human Services or as authorized and
negotiated between the provider and the County Department:
a. Payment shall be made by electronic banking transfers (EBT) drawn by the duly authorized county officer and,.
b. Provider shall notify the County Department of any payment or billing dispute within 80days of the month
when service was provided. Failure to do so will result in forfeiture Of the payment The Provider understands
that, pursuant to the Colorado Department of Human Services' Rules for the General Reimbursement for Child
Welfare Services, when reimbursement is warranted current and (2) preceding months.
9. To provide or arrange through statewide contracted training, a minimum of twelve hours of core pre -service
training for foster care homes and 15 hours of pre -service training directed at the needs of the child or youth to be
served in the foster care home.
10. To annually complete the following:
a. Update the Training Development Plan with the provider,
b. Provide or make available quality and relevant training for each foster parent that will build competencies to
meet the needs of the children and youth served in the foster care home;
c. Provide training that prepares each foster parent to use and apply the reasonable and prudent parent
standard; and,
d. Pursuant to the Colorado Department of Human Services' Rules Regulating Family Foster Care Homes,
document that the provider is trained in, and can use and apply the reasonable and prudent parent standard
for each child or youth placed in the foster care home.
11. The County Department is responsible for providing information on county specific procedures.
12. To invite the provider to Administrative Reviews for each child or youth in placement.
1575 Sherman Street, 2nd Floor, Denver, CO 80203 P 303-866-5932 F 303.866.5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor I Reggie Bic&, Executive Director
3
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13. To incorporate provider information in planning for the child or youth placed in the foster care home.
14. To assure that the service described herein has been accomplished and a record made thereof on a case by case
basis.
15. To provide notice of court hearings for each child or youth placed in the foster care home.
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County, au.Human owu>en.aoludy
Weld Human Services
County Department (type or print)
Judy Griego
Signature
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Date
WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first
COUNTY; r�
ATTES .47.1,44)? 'o'(ABOARD OF COUNTY COMMISSIONERS
Weld Eou ty�¢(hrd WELD COUNTY, COLORADO
By:
Deputy C
PROVIDER:
TA are Iii SStr
Provid, r (type or print).Anif441496
Sse_r—
Steve Moreno, Chair
Provider (type or print) Si• - - ure
DEC 282018
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Date
to/ `t
Date
1575 Sherman Street. 2nd Floor, Denver, CO 80203 P 303.866-5932 F 303.866.5536 www.colorado.gov/cdhs
John W. Hickenlooper, Governor I Reggie Bicha, Executive Director
4
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EXHIBIT A to the CWS-7A
Additional Provisions for the Agreement to Purchase
Foster Care. Services and, Foster Care Facility Agreement
CWS-7A
The following additional provisions;in this Exhibit A, and Addendum 1 and Addendum 2, apply to the
agreement entitled, 'Individual Provider. Contract for Purpose of Foster Care. Services and Foster Care
Facility Agreement,' by and between the Weld County Department of Human Services, hereinafter
referred to as., -County; and Visser, Ryan and Amanda,hereinafter referred to as, 'Provider.'
GENERAL PROVISIONS
1.
Each party shall have -the right to terminate this Agreement by giving the other party written notice
received at least thirty (30) days prior to the intended date of termination. If notice is so given,.
this. Agreement, shall terminate upon the expiration of thirty (30) days, or until the eligible
children) may be placed elsewhere; whichever occurs first, and the liability of the parties
hereunder for further performance of the terms of this. Agreement shall thereupon cease;
however, the parties shall not be released from the duty to perform their obligations up to the date•
of termination. This provision does not affect removal of a child In an emergencysituation.
2. Provider agrees that Provider is an independent contractor and that neither Provider "nor
Providers agents or employees are, or shall be deemed to be, agents or employees' of the
County for any purpose. Provider shallhave no authorization, express • or Implied, to:bind Me .
County to any agreement, liability, or understanding. The partiesagree that Provider will not
become an employee of County, nor is Provider entitled to any employee benefits from' County as,
a result of the execution of this Agreement. Provider shall be solely and entirely responsible for
its acts or of any agent, employee, servants and sub -Providers during the performance of this
Agreement. 4
3. Payment pursuant:tothis Agreement, if in State of Colorado, county, or federal funds, whether In
wholeor in part, issubject to and contingent upon the continuing availabilityof State of Colorado,
county,, and federal funds for the purposethereof.
4. This Amendment is intended to be applied in conjunction with attached Agreement and the Needs
Based Care. Addendum as the complete integration of all understandings between the parties.
No prior or contemporaneous addition, deletionor' other amendment hereto shallhave 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 as
a part of this written Agreement. This section shall not be construed as prohibiting the Periodic
amending of this Agreement or the Needs Based Care Addendum in writing, if agreed to by both
parties. The Agreement, this Exhibit A and the Needs Based Care Addendum are intended to be
in lieu of and supersede all prior agreements between the parties hereto and relating to the care
and services herein described. �Q
5. The State of Colorado Department of Human Services and the County shall be and hereby is
permitted to monitor the service program, fiscal and other, records sufficiently to assure the
purchase of services in this Agreement are carried out for the benefit of the aforementioned child
or youth. Monitoring may occur through review of programreports; on -site visits where
applicable and other Agreements as deemed necessary. Provider understands that the State
Department and the County, may provide consultation to Provider to assure satisfactory
performance in the provision of purchased services under this Agreement.
6. County shall have access to Provider's service program, financial and other records, which will
sufficiently and properly reflect all direct and indirect costs of any nature incurred' In the
performance of this Agreement for purposes of audi. Such records shall be complete and
available for audit 90 days after final payment hereunder and shall be retained and available for
audit purposes for at least five years after final paymenthereunder.
Time is of the essence in each and all of the provisions of this Agreement
Exhibit A to the CWS-7A
5. Revised 5/2018
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8' Neither party to this Agreement shall be liable. to the other fordelays in delivery or failure to
deliver or otherwise to perform any obligation under this Agreement, where such failure -is due to
any cause beyond. its. reasonable control, including but not limited to. Acts of God; fires, strikes;
war, flood, earthquakes or Governmental actions.
9. Any notice.required to be given under this Agreement shall tie,in Writing end shall be "mailed or
delivered to the other party at that party'saddress as,statedin thitAgreement
10. This Agreement is nonexclusive:and County may engage or use.ottier'Providers or persons to,
Perform Services of the same or similar nature.
11. Provider certifies, warrants, and agrees that it does hot knowingly employ or contrail with an
illegal alien who will perform work under this contract. Provider Will :confirm the employment
eligibility of all employees wh o are newly hired for employment- in the United States to perform
work under this Agreement, through'participetion in the'E-Verify:program or the State of Colorado
program established pursuant to C.R.S. §8-17:5-102(5)(c)_ Provider shall not knowingly employ
or contract With an illegal alien to perform.work under this Agreement or enter into a contract with.
a sub -contractor• that fails to certify with Provider that. the sub -contractor shall not knowingly
errrploy or'contract with•an illegal alien to perform. work under this -Agreement. Provider shall not
use E -Verify Program or State of Colorado program procedures to: undertake preemployment
, screening or job applicants while this Agreement is being performed: elf Provider obtains actual
knowledge that a sub -contractor performing =work under the public contract for services knowingly
employs or contracts with an illegal alien Provider shall notify the sub -contractor and County
,within three (3),days that Provider has actual knowledge that a sub -contractor is employing or
'contracting with,an illegal alien and shall terminate the subcontract if a sub-contracor does not
stop employing or contracting with the illegal alien within three (3) daysof receiving notice.
Provider shall not terminate the cbntract�if within three days the sub -contractor provides
information to establish that the sub -contractor has not knowingly employed. or: contracted with an
illegal alien. Provider shall comply with reasonable requests Made in the, course of an
investigation, undertaken pursuant to C.R.S.,§8717.5-102(5), bythe Colorado Department of
Labor and, Ermployment. If Provider participates in the -State of Colorado program, Contract ,
Professional shall; within twentydays after hiring a new employee to perform work under the
contract, affirm that. Provider has examined the legal work status of suchiemployee; retained file
copies of the documents; and not altered or'falsified the identification documents for such
employees. Provider shall deliver to County; a written notarised affirmation that it has examined
the legal work status' of such employee, and shall comply with all of the;other requirements of the
State of Colorado program. If Provider fails to comply With any requirement of this: provision or of
C.R.S. §8-17.5-101 et seq., County; may terminate this Agreement for breach, and if so
terminated. Provider shall be liable for actual and'consequentialda-mages.
Except Where exempted by federal law and except as provided in G.R.S. § 2446:8 fp313),:if
Provider receives federal or state funds under the contract, Provider must confirm that any
'individual natural person eighteen (18) years of age or older is lawfully present in the United
States pursuant to C.R.S. § 2476.5-103(4)," if such individual applies for public benefits provided
under the contract. If Provider operates; es a tole proprietor, it hereby swears or affirms under
penalty' of perjury that it: (a) is a'citizen of the United States or is otherwise lawfully present in the
United States pursuant to federal law; (b) shall produce one of the forms of identification required
by C.R.S. § 2476.5-101, et seq.; and (c) shall produce one of the forms of identification required
by C.R.S. § 2446.5-103 prior to the effective date of the contract.
12. Provider assures and certifies that it and its principals:
A. Are not presently debarred, suspended, proposed for debannent, and'declared ineligible
or voluntarily excluded from covered transactions bya federal.departnient or agency.
Exhibit A to the CWS-7A
6 Revised 5/2018
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D:
B: tlavenot. vi2hri a three-year period'of preceding this Agreement:been conyided o or
laid a char pnerni rendered against them for commission of fraud or a crininaf offense
wadi
in connection wobtaining, attempting to obtain. or performing a puti5c (federa `state
ortocai) tnansaction.orcontract wider apub5c transaction. _violation of federal or state
ardlatstor commission of embetheft; forgery, brbery. done or
,destruction of retards. making false statements_ or receiving stolen proper
Are. rot present3y ncfided'for or otherwise crimina2y.;or civibbY'a Boileirment
entity (federal staie..or bra!) with commission of any of the offenses enumerated Inn
PlragraPti On shove -
Have not wfthin: a three -Y' i period preceding this . had one or more pith
transactions (federal; state, and loqinteiminated for cause ordefaufi_
13_ to adiftion to terminating ths.Agreernerd it accordance wfth the, provisions herear,:Cdintm
may ezere use the foftowug remedial actions if the County funds and CletarmineS that the
Provider has sir ly) fated to : satisfy the duties found in this_Agree ent. Exhit T'A our the
Needs Based Care Addendum. Substantial faitu're to satisfy the scope of work shaft be defined_
to mean incorrect or improper activities or inaction' by the Provider. These remedial actions.
include, but are riot &riled to,.any one or moreof the following_
A. Withhold payment to Provider untiTthe necessary services or corrections in
performance are satisfectonly completed.
11 Deny payment or recover reimbursement for those services or dies which Nave
not been performed and which due to circumstances caused by provider cannot tie
performed or if performed would be of no value to County. Denialof the amount of
payment shaft be reasonably related to the amount of work or deliverables lost totality.:
C_ Recover iron: Provider any incorrect payment to Provider due to omission: error, fraud,.
andfor defalcation by deducting from subsequent payments under this AgreemeAgreement, or
other agreements between County and Provider, or as.a debt to County, orotherwise as
provided by law.
14. It is expressly understood and agreed that the enforternerd of the terms and conditions of this
Agreement: and: all rights of action(elatingto such enforcement, shall be strictly reserved to the
undersigned parties or their assignees: and nothing contained in this Agreement shall give or
all any claim, or nght.of action whatsoever by any other person notincluded: in this Agreement
ft 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 shaft be an
incidental beneficiary only.
15. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the parties
or their officers or employees may possess. nor shall any portion of this. Agreement be deemedto
have created a duty of care that did not previously exist with respect to any person riot a party to
this Agreement The parties hereto admowtedge and agree that no part of this Agreement is
intended to circumvent or replace such immunities..
16. Provider shall promptly notify County in the event in which it is a party defendant orriespondent in
a case, which involves services provided under the agreement The Provider, 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.CountfD►rector. The term 'litigation' includes an assignment for the benefit
of creditors, and:frlings in bankruptcy, reorganizations and/orforectosure:
17. This Agreement and the provision of services hereunder shall be subject to the laws of Colorado
and be in accordance with the policies, procedures, and practices of County Provider shall
strictly comply with all applicable federal and. State laws, rules and regulations in effect or
hereafterestablished.
18. Financial obligations of the County payable after the current fiscal year are contingent upon funds
Exhibit A to the CWS-7A 7 Revised 5/2018
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for that purpose being appropriated, budgeted and otherwise made available: Execution of this
Agreement by County does not create an obligation on the part of County to expendfundsnot
otherwise:appropriated in each -succeeding year.
19. County, and Provider agree that a child specific. Needs Based,CareAssessment; designated as
Addendum 1 shall be used to determine the Child. Maintenance. and Medical Needs; if applicable,
for each child placed with Provider unless _otherwise;negotiated'and approved by the_County.
20: County agrees to purchase and Provider 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 tie paid for the Child Maintenance level of service, as indicatedby
the Needs Based Care Rate Table, designated as Addendum 2, for children placed within the
Weld County Certified Foster Care Home identified as Provider ID# 1673369. These
services will be for chiildrenwho have been deemed eligible for social services under the
statutes, rules, and regulations of the State of Colorado. ,:
21. All bed hold authorizations and payments are subject to a.7 -day maximum for a child's temporary
absence from a facility, including hospitalization., Bed:hold requests must have prior written
authorization from the Department Administrator before payment will be release to Provider.
22 Any additional costs for specialized services, which may include but are not limited to; Co -pays,.
deductibles; or services not covered by Medicaid, will need to be authorized, in writing by the
Department Administrator, prior to the service being performed. Any payment for specialized
services not authorized in writing may be denied.
23: All reimbursement requests shall:
A. Be submitted in a,format approved by the County. Ifsubmitted, in an unapproved format
or inadequate documentation is provided, the County reserves the right to deny payment.
B. Be submitted by the 40 of each month following the month of service: If the
reimbursement request is not submitted within twenty -fire (25)'calendar.days ofthe
month following service, it may result in forfeiture ofpayment.
C. Placement service reimbursement shall be paid from the date of placement up to, bid riot
including the dayy of discharge.
Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed; Provider will arrange reimbursement through Medicaid. Any
other special requests for transportation reimbursement shall require prior approval by•
the Resource Manager orthe DepartmentAdministrator.
E. Clothing allowance reimbursement shalt be approved and reimbursed as indicated on the.
clothing allowance form accessed through the Foster Parents Database On-line System
(FIDOS). �:s: - E- . ,et`5" : _.•
24. It is agreed that if, after investigation, it is shown that reasonable care was given to guard and
protect personal items broughtjo revider by the children, Provider shall, be released from
responsibility for loss or damage, to such personal items.
D.
PROVIDER SHALL:
1. Conform with and abide by all rules and regulations of the Colorado Department of Human
Services; the Colorado Department of Health Care Policy and Financing (if appropriate), the State
of Colorado and any applicable federal laws and regulations, as such, which may be amended
from time to time, and shallbe binding on Provider and control any disputes in this Agreement.
2. Not charge any fees to children or families of children, referred by County for any services
provided under this Agreement.
3. Not assign the obligations under this. Agreement nor enter into any sub -Agreement without the
Exhibit A. to the CWS-7A
8 Revised 5/2018
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•,f.4
express wiitten approval of the Director of the County Department or his/her appointed
' designee. `1 E
4.. Maintain at all times during the term of this Agreement a liability insurancepolicy of atleast
$25,000 for property damage liability, $150,000 for injury and/or damage to any one person and
$500,000 for total injuries arising from, any one accident. Provider shall'prove a cert�cate of
insurance- provided by its insurer upon request by County.:
5. Indemnify the County 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. Agreement or by conditions: created: thereby, or based
upon any violations of any statute, ordinance, or regulationand the defense of any such;claims or
actions.
6. Attend or participate in Ice Breaker, Family Engagement or Team Decision making -meetings, if
requested by the Department County staff shall notify the Provider of thedates and times
attendance is; requested.
7. Request a staffing if considering givingnotice to remove a child, except in eniergencysituations.
These requests shall be made through the child's caseworker and/or.the Providers, Foster Care
Coordinator.
8. Actively participate in achieving the chili's permanency goal, cooperate with any contractors
hired by the Weld County Department of Human Services to preserve placement in theleast
restrictive placement appropriate, comply with the treatment plan of the child; and attendcourt
hearings as requested
9. Have physical examinations completed within 14 days and dental examinations completed Within
8 weeks of the child being placed with Provider.. All documentation of these, examinations will be,
placed in the foster child's placement binder.4 14t
r. • 10. Attend all necessary school meetings and support any plan that is developed regarding. the child '
in order to promote educational success.
11. Immediately report to the County Department and/or local law enforcement any known or
suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S.
12. Maintain; access and review information weekly on FIDOS.
,....
13. Maintain/update information in the foster child's binder. The binder will be reviewed on amonthiy
basis and signed off by child's caseworker and/or the Providers Foster Care. Coordinator.
"'"re -"'"A•
14. Maintain/update medication logs on a daily basis, if child`is takingmedications.
15. Maintain behavior observation notes asrequired by the level of care assessed for each child.
-11;01..0.-.77,, P }
16. Comply with all County and Statercertfiication requirements as set forth in the State Department
rules,. Staff Manual Volume VII and :the Weld County Department of Human Services Policy and
''
Procedure manual. a . • i -',
Exhibit A to the CWS-7A
9 • Revised 5/2018
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ADDENDUM 1
Needs Based Care Assessment
NBC (NEEDS BASED CARE ASSESSMENT)
Answers to the following questions willdetermine the NBC Care Payment. -For each question: below please select the
closest_rating-for this child. The following seven (7) questions.are mutually exclusive.
P1. How often does the child require transportation by the foster care provider for the, -
following:
Therapy;: Medical Treatment; Family Visitation; Extraordinary Educational Needs; etc., as.
outlined in the treatment plan?'
Select.One
P2. How often is the foster care provider required to participate in child's therapy or
counseling sessions? _
P3. How much time is the provider required to intervene at home.and/or a_ teschool-with the
child in conjunction with a regular or special education plan?
Select One
Select One
P4. How often dose the child require special and ,'extensive; jnvolvement by the crovider in
scheduling and monitoring of time and/or activities and/or crisis management?
Select One
P5. 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?
Select One
Al. How often is-CPA/County case management required? (Does not include therapy)
"Please Note: The Case Management level may be assessed on a combined basis
If a sibling group0r more than one County foster child Is with the same provider.
Select One
11. How often are therapy services needed to address child's individual needs per NBC'
assessment?
NBC (NEEDS BASED CARE ASSESSMENT) - Behavioral Assessment
Select One
Assessment Areas:.
Aggression/Cruelty to Animals
Verbal. or Physical Threatening
Destructive of Property/Fire Setting
Stealing
Self -injurious Behavior --
Substance Abuse
Presence of Psychiatric Symptoms/Conditions
Enuresis/Encopresis
Runaway
Sexual Offenses
Inappropriate Sexual Behavior
Disruptive Behavior
Delinquent Behavior
Depressive -like Behavior
Comment:
Rating:
Select One
Select One
Select One
Select One
Select One
Select One — -
. Select One ___
Select One —
Select One
Select One
Select One -
Select One
Select One
Select One
O
Medical Needs - (If condition is rated *severe%
please complete the Medically fragile NBC)
�— Emancipation —
Select One
Select One
•
Eating Problems
Select One
■
Boundary Issues
Select One _-
■
Requires Night Care
Select One
ucation
Select One
y
Involvement with Child's Family
Select One
Addendum 1
10
Revised 5/2018
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ADDENDUM 2
Needs Based Care Rate Table:
Weld County Department of Human Services
(Effective 7/0172018),
Addendum 2
Q.
•
,LEVELyOF r
SERVICE
•
MAINTENANCE,
r,RESPTfE
MEbLCAL
NEEDS;
Level, ,
Daily Ratec °
County,
Basic
Maintenance
Rate
$35.70-
Daily'Rate
S.66
Daily_R�e�`
1
s-33.76
S.66
$3.54
$35.70
$.66
2
$35.70
$.66.
$5.09
2;'h
$38.99
$.66
3:
1•
$42.28.
S.66
•t
3 1/2
$45.57
$.66
4
Congregate
Care
Drop Down
$48.86
$.66
Negotiated.
Assessment/
Emergency
Level Rate
S35.70
$.66
11
Revised 8/2018
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