HomeMy WebLinkAbout20160593.tiff INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made this /Qday of , 20/6O , by and
between the Board of County Commissioners of Weld County, on be if of the Weld County
Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter
referred to as, "County," and Easley,Allison and Eric,whose address is 6827 Autumn Ridge
Drive,Ft. Collins,CO 80525, hereinafter referred to as, "Contractor." This Agreement covers
all children placed by County with Contractor.
WITNESSETH:
WHEREAS,the Provider has read and is fully familiar with the Minimum Rules and
Regulations for Family Foster Homes and/or Specialized Group Care Facilities issued by the
Colorado Department of Humans Services and holds a valid certificate/license as a Family Foster
Home with which such certification standards that shall be maintained during the term hereof
and
WHEREAS, County may, but shall not be obligated to, purchase foster care services, and
the County or any duly authorized agent may request such services to be provided to any child at
any time within the limits of the certificate/license and without prior notice.
NOW, THEREFORE, in consideration of the mutual promises and covenants made
herein, County and Contractor agree as follows:
I. TERM:
A. The term of this Agreement shall be from November 25,2015,to and until June 30,
2016, or until the facility certificate/license is revoked or suspended.
B. 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 child(ren) 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.
II. AGREEMENTS OF THE PARTIES:
A. Contractor agrees:
1. To furnish foster care services to eligible children at the established rate based on
type of facility and individual child rates negotiated between the county and the
provider.
2. To safely provide the 24-hour physical care and supervision of each child until
removed or until the agreement is renewed.
e471,44(/t C.e;• I4SPC& 2016-0593
CWS-7A Indivi al Provider Contract I ReviM2015
3. To accept children only with the approval of the certifying/licensing agency.
4. To cooperate fully with the County Department or its representatives, and
participate in the development of the Family Service Plans for children in
placement, including visits with their parents, siblings, and relatives, or transition
to another foster care facility.
5. To maintain approved standards of care as set by the State Department of Human
Services.
6. To keep confidential the information shared about the child and his/her family.
7. Not to accept money from parents or guardians.
8. Not to make any independent agreement with parents or guardians.
9. Not to release the child to anyone without prior authorization from the
Department.
10. To allow representatives of the County Department to visit the foster home and to
see the child at any reasonable time.
1 l. To give the County Department two weeks notice, except in an emergency, to
remove a child for placement elsewhere and to work with the County Department
as requested in preparing the child for the next placement.
12. To provide transportation to the child to enable the utilization of professional
services when necessary. The amount of transportation to be provided will be
agreed upon at placement and may be changed upon mutual agreement of the
provider and the County Department, as recorded in the Family Services Plan.
13. To report promptly to the Department:
a. Any unplanned absence of the child from provider's care.
b. Any major illness of the child.
c. Any serious injury to the child.
d. Any significant change in the child's sleeping arrangement.
e. Any contemplated change of address or change of household members.
f. Any conflict the child may have with law enforcement, school officials, or
other persons in the authority.
g. Any emergency.
h. Any pertinent discussion with parents or guardians about the child or
supervising agency.
i. Any information received regarding a change of address of the parents or
guardians.
CWS-7A Individual Provider Contract 2 Revised 6/2015
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, age, religion, political beliefs, national origin, or handicap, and to provide
confidentiality of information concerning the child in compliance with the Health
Insurance Portability and Accountability Act(HIPAA).
15. To attend core certification training prior to the placement of any child.
16. To attend on-going training as required by State Department regulations.
17. To attend Administrative Reviews for children in placement.
18. To fully comply with the Minimum Rules and Regulations for Foster Family
Homes or Specialized Group Facilities.
19. Not to enter into any subordinate subcontract hereunder.
20. To keep such records as are necessary for audit purposes by state and federal
personnel. The records shall document the type of care and the term during which
care is provided for each child. In addition, medical, educational, and progress
summary records shall be maintained for each child in accordance with Volume 7
requirements.
21. To maintain medical, dental and educational records for each child/youth and
supply updated information to the County Department.
22. To 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 shall
be binding on Contractor and control any disputes in this Agreement.
23. To maintain a current license and maintain license requirements as specified
under State law and rule.
24. Not to charge any fees to children or families of children referred by County for
any services provided under this Agreement.
25. Not to assign the obligations under this Agreement nor enter into any sub-
Agreement without the express written approval of the Director of the County
Department or his/her appointed designee.
26. To maintain at all times 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 $500,000 for total injuries arising from any
one accident. Contractor shall provide a certificate of insurance provided by its
insurer upon request by County.
27. To indemnify County and the State Department 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
CWS-7A Individual Provider Contract 3 Revised 6/2015
I
any statute, ordinance, or regulation and the defense of any such claims or
actions.
28. To 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
State Department Executive Director.
B. County agrees:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues. •
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child 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 children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
CWS-7A Individual Provider Contract 4 Revised 6/2015
1 1. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child in
writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or of
any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. 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 children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum 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 as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, 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.
E. The State of Colorado Department of Human Services and the County shall be and
hereby is permitted to monitor 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 client. Monitoring may occur through review of program reports, on-
site visits where applicable and other Agreements as deemed necessary. Contractor
understands that the State Department and the County may provide consultation to
CWS-7A Individual Provider Contract 5 Revised 6/2015
Contractor to assure satisfactory performance in the provision of purchased services
under this Agreement.
F. County shall have access to Contractor's financial records as they relate to this
Agreement for purposes of audit. 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 payment hereunder.
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays 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.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. 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.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contract Professional certifies, warrants, and agrees that it does not knowingly employ
or contract with an illegal alien who will perform work under this contract. Contract
Professional will confirm the employment eligibility of all employees who are newly
hired for employment in the United States to perform work under this Agreement,
through participation in the E-Verify program or the State of Colorado program
established pursuant to C.R.S. §8-17.5-102(5)(c). Contract Professional shall not
knowingly employ or contract with an illegal alien to perform work under this
Agreement or enter into a contract with a subcontractor that fails to certify with
Contract Professional that the subcontractor shall not knowingly employ or contract
with an illegal alien to perform work under this Agreement. Contract Professional
shall not use E-Verify Program or State of Colorado program procedures to undertake
pre-employment screening or job applicants while this Agreement is being performed.
If Contract Professional obtains actual knowledge that a subcontractor performing
work under the public contract for services knowingly employs or contracts with an
illegal alien Contract Professional shall notify the subcontractor and County within
three(3)days that Contract Professional has actual knowledge that a subcontractor is
employing or contracting with an illegal alien and shall terminate the subcontract if a
subcontractor does not stop employing or contracting with the illegal alien within
three(3)days of receiving notice. Contract Professional shall not terminate the
contract if within three days the subcontractor provides information to establish that
the subcontractor has not knowingly employed or contracted with an illegal alien.
Contract Professional shall comply with reasonable requests made in the course of an
investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado
Department of Labor and Employment. If Contract Professional participates in the
State of Colorado program, Contract Professional shall, within twenty days after hiring
an new employee to perform work under the contract, affirm that Contract
Professional has examined the legal work status of such employee, retained file copies
of the documents, and not altered or falsified the identification documents for such
employees. Contract Professional shall deliver to County, a written notarized
CWS-7A Individual Provider Contract 6 Revised 6/2015
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
Contract Professional 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, Contract Professional shall be liable for actual and consequential
damages.
Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-
103(3), if Contract Professional receives federal or state funds under the contract,
Contract Professional 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. § 24-
76.5-103(4), if such individual applies for public benefits provided under the contract.
If Contract Professional operates as a sole 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. § 24-76.5-101, et seq., and (c) shall produce one of
the forms of identification required by C.R.S. § 24-76.5-103 prior to the effective date
of the contract.
M. Contractor assures and certifies that it and its principals:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. 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;
3. 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.
4. 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.
N. In addition to terminating this Agreement, in accordance with the provisions of
Section I., above, County may exercise the following remedial actions if the County
finds and determines that the Contractor has substantially failed to satisfy the scope
of work found in this Agreement, Exhibit A or the Needs Based Care Addendum.
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 include,
but are not limited to, any one or more of the following:
1. Withhold payment to Contractor until the necessary services or corrections in
performance are satisfactorily completed.
2. Deny payment or recover reimbursement for those services or deliverables which
have not been performed and which due to circumstances caused by Contractor
CWS-7A Individual Provider Contract 7 Revised 6/2015
cannot be performed or if performed would be of no value to County. Denial of
the amount of payment shall be reasonably related to the amount of work or
deliverables lost to County.
3. Recover from Contractor any incorrect payment to Contractor due to omission,
error, fraud, and/or defalcation by deducting from subsequent payments under this
Agreement, or other agreements between County and Contractor, or as a debt to
County, or otherwise as provided by law.
O. 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.
P. 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 deemed to have created a duty of care.that did not previously exist
with respect to any person not a party to this Agreement. The parties hereto
acknowledge and agree that no part of this Agreement is intended to circumvent or
replace such immunities.
Q. Contractor shall promptly notify County in the event in which it is a party defendant
or respondent in a case, which involves services provided under the agreement. The
Contractor, within five(5)calendar days after being served with a summons,
complaint, or other pleading which has been filed in any federal or state court or
administrative agency, shall deliver copies of such document(s)to the County
Director. The term "litigation" includes an assignment for the benefit of creditors,
and filings in bankruptcy, reorganizations and/or foreclosure.
R. Any amendments or modifications to this agreement shall be in writing signed by
both parties.
S. Neither party to this Agreement shall be liable to the other for delays 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.
T. Contractor shall strictly comply with all applicable federal and State laws, rules and
regulations in effect or hereafter established
U. Financial obligations of the County payable after the current fiscal year are
contingent upon funds 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 expend funds not otherwise appropriated in each
succeeding year.
CWS-7A Individual Provider Contract 8 Revised 6/2015
11lb
WHEREFORE,the parties have herein set their hands and affixed their seals the day nil
date first written above.
� COUNTY:
ATTF.ST:d� v' ;i1 BOARD OF COUNTY COMMISSIONERS
Weld -. nt'Clerk to the Bo:rd WELD COUNTY, COLORADO
By: _ `�!� . I�
Deputy C rk to tom- :•,� Mike Freeman, Chair FEB 1 0 2016
SIII j� APPROVED AS TO SUBSTANCE:
• 1/6.PLC a ( JGC-Or
1861 11,$ 2I ElectSII Officia or Depa ent Head
fr
CONTRACTOR:
Easley,Allison and Eric
6827 Autumn Ridge Drive
Ft.Collins, CO 80525
By: '" ^t:a Y �1.ILV,t�' 11/24/2015
Contractor's (or designee's)Signature
and Date
B yJ-- - --II/24/2015
Contractor's(or des' nee's)Signature
and Date
CWS-7A Individual Provider Contract 9 Revised 6/2015
oZb/6 - D -
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 apply to the agreement entitled, "Individual Contractor
Contract for Purpose of Foster Care Services and Foster Care Facility Agreement,"hereinafter
referred to as, "County," and Easley,Allison and Eric, hereinafter referred to as, "Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit shall be used to determine the Child Maintenance and
Medical Needs, if applicable, for each child placed with Contractor unless the child is
placed in a County certified kinship foster care home or a County foster/adoption home
as a pre-adoptive placement. Kinship foster care homes and pre-adoptive placements will
be reimbursed at the County Basic Maintenance level for Child Maintenance as indicated
on the Needs Based Care Rate Table, designated in this exhibit as, regardless of the
child's level of need.
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 the Child Maintenance level of
service, as indicated by the Needs Based Care Rate Table, designated within this exhibit,
for children placed within the Weld County Certified Foster Care Home identified as
Provider ID# 1674424. 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. 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 Contractor.
4. 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.
5. All reimbursement requests shall:
A. Be submitted in a format approved by the County. If submitted in an unapproved
format or inadequate documentation is provided, the County reserves the right to
deny payment.
B. Be submitted by the 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25)calendar days of
the month following service, it may result in forfeiture of payment.
CWS-7A Individual Provider Contract 10 Revised 6/2015
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. 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.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
CONTRACTOR SHALL:
1. Attend or participate in Family Engagement or Team Decision making meetings, if
requested by the Department. County staff shall notify the Contractor of the dates and
times attendance is requested.
2. Request a staffing if considering giving notice to remove a child, except in emergency
situations. These requests shall be made through the child's caseworker and/or the
Contractor's Foster Care Coordinator.
3. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by the Weld County Department of Human Services to preserve
placement in the least restrictive placement appropriate,and comply with the treatment
plan of the child.
4. Have physical examinations completed within 14 days and dental examinations
completed within 8 weeks of the child being placed with Contractor. All documentation
of these examinations will be placed in the foster child's placement binder.
5. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
6. 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.
7. Maintain, access and review information weekly on FIDOS.
CWS-7A Individual Provider Contract 11 Revised 6/2015
8. Read, be familiar with and agree to the terms and conditions as set forth in the Foster
Parent Handbook which can be accessed through FIDOS.
9. Maintain/update information in the foster child's binder. The binder will be reviewed on
a monthly basis and signed off by child's caseworker and/or the Contractor's Foster Care
Coordinator.
10. Maintain/update medication logs on a daily basis, if child is taking medications.
11. Maintain behavior observation notes as required by the level of care assessed for each
child.
12. Comply with all County and State certification 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.
CWS-7A Individual Provider Contract 12 Revised 6/2015
Needs Based Care Assessment
NBC(NEEDS BASED CARE ASSESSMENT)
Answers to the following questions will determine 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: Select One
Therapy;Medical Treatment; Family Visitation; Extraordinary Educational Needs;etc.,as outlined
in the treatment plan?
P2. How often is the foster care provider required to participate in child's therapy or counseling Select One
sessions?
P3. How much time is the provider required to intervene at home and/or at school with the child in Select One
conjunction with a regular or special education plan?
P4. How often does the child require special and extensive involvement by the provider in scheduling Select One
and
monitoring of time and/or activities and/or crisis management?
P5. How much time is the provider required to assist the child because of impairments beyond age Select One
appropriate needs with feeding,bathing,grooming,physical,and/or occupational therapy?
Al. How often is CPA/County case management required?(Does not include therapy) Select One
**Please Note: The Case Management level may be assessed on a combined basis if a sibling
group
or more than one County foster child is with the same provider.
T1. How often are thera• services needed to address child's individual needs .er NBC assessment? Select One
NBC (NEEDS BASED CARE ASSESSMENT) — Behavioral Assessment
Assessment Areas: Comment: Rating:
❑ Aggression/Cruelty to Animals Select One
❑ Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
❑ Self-injurious Behavior Select One
❑ Substance Abuse Select One
❑ Presence of Psychiatric Symptoms/Conditions Select One
❑ Enuresis/Encopresis Select One
❑ Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
❑ Depressive-like Behavior Select One
❑ Medical Needs-(If condition is rated"severe",please Select One
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
❑ Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 13 Revised 6/2014
a
Needs Based Care Rate Table
Weld County Department of Human Service
(Effective 7/01/2015)
LEVEL OF CIIIL.D ADMINISTRATIVE ADMINIS 'ATIV . ,MEDICAL
SERVICE MAINTENANCE RESP[IL MAINTENANCE SERVICES NEEDS
Level *,< Daily Rate � � - e .�,ra Daily Rate
i.. t. ds
$12.35 4
County Basic Age 0-10...$17.01y t t No crisis intervention,Minimal �1 $0.00
Maintenance Age 11-14...$18.81 Not needed or cover
CPA involvement,one face-to-
Rate Age 15-21...$20.09 lace visit with child per month. under Medicaid.
B
$15.77 $5.14
Minimal crisis intervention as Regularly Scheduled
I $20.56 $•66 needed,one face-to-face visit
$3.45
therapy up to 4
per month with child,2-3 hours/month.
contacts per month
1 Y, $23.99 $.66 $17.48
$19.20 $10.28
Occasional crisis intervention as Weekly scheduled
2 2-X22 5.66 needed,two face-to-face visits therapy 5-8 hours a S-1.97
with child,2-3 contacts per month with 4 hours of
month group therapy.
2 Yz g?0 R- `,66 $20.91
$22.62 $15.42
Regularly scheduled
Ongoing crisis intervention as weekly,multiple
1 3 'O-l.?7 y,t,f, needed,weekly face-to-face sessions,can include $6.50
visits with child,and intensive more than 1 person,
7 coordination of multiple i.e.family therapy,for
services. 9-12 hours/monthly.
i,
3 1/2 S-;7.69 66 $24.34
$26.05
,I Ongoing crisis intervention as
(oogrcatc needed,which includes high
Care I' level of case management and Negotiated Negotiated
Drop Don n CPA involvement with child and
provider and 2-3 face-to face
contacts per week minimum.
sk. moor
Assessment/ §'.
1 Emergency $27.42 `i.66 S19 20
Level Rate
CWS-7A Individual Provider Contract 14 Revised 6/2015
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