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Home My WebLink About20152163.tiff RESOLUTION RE: APPROVE NINE (9) STANDARD FORMS OF AGREEMENTS FOR VARIOUS OUT-OF-HOME PLACEMENT AND FOSTER CARE SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN AGREEMENTS CONSISTENT WITH SAID FORMS WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board, has been presented with Nine (9) Standard Forms of Agreements for Various Out-of-Home Placement and Foster Care Services between the Weld County Department of Human Services and various providers, as listed on the attached providers lists, and 1. Agreement to Purchase Out-of-Home Placement Services (SS23A) (with various provider lists) 2. Exhibit to SS23A - Additional Provisions for Purchase of Residential Child Care Facility Services (with provider list) 3. Exhibit to SS23A-Additional Provisions for Purchase of Child Placement Agency Services (with provider list) 4. Exhibit to SS23A - Additional Provisions for Purchase of Group Home Care Services (with provider list) 5. Exhibit i to SS23A - Additional Provisions for Purchase of Group Home/Group Center Care Services (with provider list) 6. Addendum to SS23A- Needs Based Care Addendum 7. Child Specific Addendum - Agreement to Purchase Out-of- Home Placement Services (SS23B) (with various provider lists) 8. Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility Agreement (with provider list) 9. Exhibit A to CWS-7A - Additional Provisions for Purchase of Foster Care Services and Foster Care Facility Agreement (with provider list) CC �" -n l 8 2015-2163 ��3 HR0086 APPROVE NINE (9) STANDARD FORMS OF AGREEMENTS FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS PAGE 2 WHEREAS, after review, the Board deems it advisable to approve the Nine (9) Standard Forms of Agreements for Various Out-of-Home Placement and Foster Care Services, copies of which are attached hereto and incorporated herein by reference, and to delegate standing authority to the Chair of the Board of County Commissioners to execute individual agreements between the Department of Human Services and various providers. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that these standard forms between the Weld County Department of Human Services and various providers be, and hereby are, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign any agreements consistent with said form. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 20th day of July, A.D., 2015. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST:die/ i v• ;4. L /,( 1L Barbara Kirkrneyer, Chair Weld County Clerk to the Board ' I • Mike Freeman, Pro-Tern BY: D:p y Clerk to the Bard F j�, 1 . L �� ) j '-,ian P. Conway O D A 11.61 eta)* Q(9 A. Cozad Count orney g JI Steve Moreno Date of signature: 2015-2163 HR0086 MEMORANDUM DA II-:: June 26,2015 c-, TO: Board of County Commissioners—Pass-Around FR: Judy A.Griego, Director, Human Services o ,J N T-Y, RE: Weld County Department of Human Services' Child Welfare Request for 2015-2016 SFY Out-of-Home Provider Rate Increase with Templates Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval for the Departments'Child Welfare Request for 2015-2016 SFY Out-of-Home Provider Rate Increase with Templates(attachment 1).Counties are authorized, with a methodology that is approved by the State Department,to negotiate rates, services,and outcomes with providers to provide out-of-homes services to youth in custody. As approved on the methodology, Weld County utilizes State base anchor rates in Trails to pay Residential Child Care Facilities(RCCF)and individually negotiates foster care rates on a needs based care system that is tied to the Weld County rate table. The General Assembly in the 2015 legislative session approved a 1.7% increase to out-of-home provider rates for the FY 2015-2016. Due to the legislative approval and based on the current approved rate methodology,the Department is requesting that effective July 1,2015,a 1.7% increase be passed on to all Residential Child Care Facilities,Child Placement Agencies,and Weld County Certified Foster Care/Kinship providers.Currently Weld County has approximately 122 children that would be eligible for the increase.The estimated cost to initiate the 1.7%rate increase would be approximately$49,000.00 per year funded through a combination of Federal, State and County dollars. Attached are the contract templates for the out-of-home providers.These have been reviewed by County Attorney Frank Haug and have been approved for in the 2015-2016 contract year. I do not recommend a Work Session. I recommend approval of this Increase with Templates. Approve Request BOCC Agenda Work Session Sean Conway Steve Moreno ({� Barbara Kirkmeyer Mike Freeman Julie Cozad Pass-Around Memorandum; June 26, 2015 Page 1 2015-2163 AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23A ❑ CHILD PLACEMENT AGENCY SERVICES(CPA) ❑CHILDREN'S HABILITATION RESIDENTIAL PROGRAM(CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY(RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE(RCCF) ❑ OTHER: THIS IS AN AGREEMENT, made this day of , 20 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County,"and «Agency»,whose address is«Agency_Mailing_Address», «Agency_City_State_Zip», hereinafter referred to as, "Contractor." THIS AGREEMENT: Shall include all children placed by County with Contractor. A child specific addendum, identifying individual service needs, must be completed and attached to supplement this agreement for each child being served by the Contractor. If this is a CPA placement, the child specific addendum should also address how administrative services will be provided in the event the child is placed for adoption in a foster home supervised by the CPA. WHEREAS, the Colorado State Department of Human Services, hereinafter referred to as, "State Department," is authorized to provide social services to individuals and families of individuals through its agent, County Departments of Human 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, Residential Child Care Facility, certified Psychiatric Residential Treatment Facility, or meets the requirements for other licensed service types. NOW THEREFORE, it is hereby agreed that in consideration of the mutual undertakings the County and Contractor agree as follows: TERM: A. This Agreement shall be in force from July 1,2015, until the end of the Colorado fiscal year,June 30,2016. Any child may be removed from the facility prior to the end of the fiscal year by the county department. SS-23A Agreement to Purchase I Revised 6/2015 B. 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. Except as otherwise provided above, either 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. C. This Agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and services herein described. DESCRIPTION OF SERVICES TO BE PURCHASED: A. County and Contractor agree and understand that the reasons for referral, which necessitate purchasing services for children, are specified in the Child Specific Addendum (SS23B) and Family Services Plan. Any other relevant information concerning these children that does not necessitate purchasing services is also included in the Child Specific Addendum (SS23B). B. The terms of this Agreement are contained in the terms recited in this document and in Exhibit , each of which forms an integral part of this agreement. Exhibit are specifically incorporated herein by this reference. County and Contractor acknowledge and agree that this Agreement, including specifically Exhibit define the performance obligations of Contractor and Contractor's willingness and ability to meet those requirements. Exhibit consists of C. County and Contractor shall develop an Initial Individual Plan of Care that addresses the immediate and/or emergency needs of the child within 72 hours of admission for children in RCCFs or group homes, except PRTF. County and Contractor shall formulate an Individual Plan of Care within 14 calendar days after admission for children in RCCFs or group homes, except PRTF. The placement date is that date noted in the Child Specific Addendum (SS23B)with this contract. The Child's Family Service Plan may be utilized as an Individual Plan of Care for this purpose for facilities. Modifications to this plan shall be agreed to in writing on the plan or as a supplemental document. D. County and Contractor shall formulate an Initial Individual Plan of Care for children in PRTFs within 72 hours. For children in a PRTF, a comprehensive Individual Plan of Care must be completed by the multidisciplinary team within 14 calendar days from the placement date. The placement date is that date noted in the Child Specific Addendum (SS23B) included with this contract. Modifications to the Individual Plan of Care must be agreed to in writing on the plan or as a supplemental document. E. The Individual Plan of Care shall be goal oriented and time-limited and shall: SS-23A Agreement to Purchase ? Revised 6/2015 1. Address all areas listed in Section 7.714.4, C, 2, (12 CCR 2509-8)together with clinical and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan. 2. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow up services criteria to be met for termination of treatment. 3. Specify the type, frequency, and duration of clinical therapy services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific goals. . 4. Specify that all therapeutic services are necessary to meet the needs of the child and to treat the child's current diagnosis. 5. Identify the provision of, or the referral for, services other than RCCF services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment. 6. Specify the anticipated living arrangement for the child at the date of discharge. 7. Specify the anticipated educational arrangement for the child at the time of discharge. 8. Specify the anticipated date for discharge from treatment purchased for the child. 9. Specify a permanency goal for the child. F. Monthly, Child Placement Agencies, RCCFs and all other Contractors, other than PRTF, shall conduct a monthly review of each Individual Plan of Care to evaluate whether the short-term and long-term goals have been achieved or not achieved. These Contractors shall provide County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the treatment plan. Further, Contractor agrees to sequence reports to be received by County fifteen (15) calendar days prior to judicial or administrative hearings or reviews when provided with thirty (30) calendar days advance notice of such review dates by County. G. Every fourteen (14)days, PRTFs shall provide County with written reports which address changes to the child's physical condition, psychological and social functioning, changes in the child's family situation, educational progress, significant incidents or disciplinary actions, and progress made to achieve goals specified in the Individual Plan of Care. H. Contractor 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 SS-23A Agreement to Purchase 3 Revised 6/2015 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. 2. Maintain a current license and maintain license requirements as specified under State law and rule. 3. Not charge any fees to 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- Agreement without the express written approval of the Director of the County Department 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 in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 6. Maintain at all times during the term of this Agreement a liability insurance policy of at least $25,000 for CPAs ($400,000 for PRTFs and RCCFs) for property damage liability, $150,000 for injury and/or damage to any one person, and $600,000 for total injuries arising from any one accident. Contractor shall provide a certificate of insurance provided by its insurer upon request by County. 7. Maintain during the terms of this Agreement a fidelity bond of at least $25,000 or two (2)months gross receipts, whichever is greater, covering the activities of any of its officers, agents or employees responsible for the implementation and/or administration of this Agreement in order to make reparations for any wrongful acts, omissions, or any other defalcations of Contractor. 8. Indemnify County, the Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, 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 Agreement 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. (Paragraphs 6, 7 and 8 do not apply to agreements between County and the University of Colorado.) 9. In regards to University of Colorado Contractors only, Contractor shall be responsible for its own wrongful or negligent acts or omissions or those of its officers, agents, or employees while performing their professional duties to the full extent allowed by law. Notwithstanding the foregoing, nothing in this Agreement is a limitation or waiver of the application of the Colorado Governmental Immunity Act set forth in §24-10-101 to §24-10-120, C.R.S., any claims resulting from the performance of the University of Colorado, its employees or agents under this Agreement. SS-23A Agreement to Purchase 4 Revised 6/2015 10. 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, Colorado Department of Human Services, Colorado Department of Health Care Policy& Financing, or county personnel, and other persons authorized in writing by the Executive Director of the Colorado Department of Human Services. 11. In any instance of a potential adoption by a foster parent, provide the initial home study, the SAFE study update, annual certification updates and related materials when requested by the County within fourteen working days of the request. At all other times Contractor shall make home studies and related materials available to the County for review, at a location agreed upon by the County and Contractor, during regular business hours. 12. Invoice the County for services rendered, using the required form. This form is to be mailed to the County by the last day of the month of care. Billings for PRTFs shall be made to the MMIS System only. Billings for RCCF fee-for-service and CHRP shall be made to either the MMIS System or the County. Billings for RCCFs daily rate, CPAs and other Contractor types shall be made to the County only. Contractor will not be paid by the county when billing is not received by the County within thirty(30) calendar days following the billing due date. 13. Attend and participate in Administrative Reviews for children in placement with Contractor pursuant to two (2)weeks written notice by the County. Contractor shall encourage children over the age of twelve to attend their Administrative Reviews. Participation may be in person or by teleconference. 14. Contractor shall pay the foster parent the amount agreed upon with the county as the child maintenance or room and board. Any payment to the foster parent in excess of the child maintenance or room and board amount shall be treated as income to the foster parent. I. Audit and financial requirements. The purpose of these requirements is to provide minimum assurance that Contractor has adequate accounting and budgeting information available to allow management to maintain a financially viable enterprise and to demonstrate financial accountability to County and to the State of Colorado Department of Human Services for the use of public funds. 1. Contractor must have in place a double entry accounting system and all financial transactions must be posted to this system. Financial statements, prepared from information provided by this system, shall be presented in conformity with U.S. generally accepted accounting principles (GAAP). Contractor must also have adequate time keeping and cost allocation systems to allocate salary cost and indirect cost to appropriate cost centers. Books and records of Contractor shall be subject, at any reasonable time, to inspection, audit or copying by appropriate Federal, State or county personnel, or such independent auditors or accountants as may be designated by these personnel. 2. All billing by Contractor must be in a format approved by the fiscal agent or county. Contractors must bill the fiscal agent and county at least once a month. Contractors may bill twice a month, on the 15th and last day of the month, for SS-23A Agreement to Purchase 5 Revised 6/2015 services rendered. Bills will be returned unpaid if the bills do not conform to the approved format or the documentation is inadequate. 3. All Contractors whose total annual expenditures are $100,000 or more shall submit an annual audit of their financial statements by an independent certified public accountant. Contractors with total annual expenditures less than $100,000 may submit an audit as described above or may submit compiled or reviewed financial statements, prepared in accordance with generally accepted accounting principles. If Contractor is a government agency that has an independent audit done by another agency of that government, its audited financial statements, prepared in accordance with generally accepted accounting principles for state and local governments meet this requirement. The audited, compiled or reviewed financial statements of PRTFs, RCCFs, and CPAs must be completed and a copy provided to the Colorado Department of Human Services(Attn: Administrator for PRTFs, and RCCFs and Attn: Audit Division Director for CPAs) within 180 days after Contractor's fiscal year end. The audited financial statements and supplementary information defined in regulation for various agencies shall be presented as described in Section VI, B (1), above and must contain sufficient detail to provide evidence of financial accountability under the terms of this Agreement and controlling state regulations. Contractors that are a subsidiary of a parent organization must submit separate financial statements for the subsidiary that detail each of Contractor's facilities and/or programs that provide services for the Colorado Department of Human Services and also must provide a reconciliation of these financial statements to the consolidated financial statements of the organization as a whole. When applicable, Contractor must comply with the audit requirements found in the Single Audit Act of 1984 and the Single Audit Act Amendments of 1996 and U. S. Office of Management and Budget (OMB)Circular A-133, Audits of States, Local Governments, and Non- Profit Organizations including subsequent revisions, and appropriate audit and financial reporting requirements as defined in State laws, rules, and regulations. 4. If Contractor does not submit their annual audit or refuse to disclose financial information regarding the operation of the program in a timely manner, the Fiscal Agent may withhold payment until the audit and/or requested information is submitted. If Contractor is a CPA, then sanctions of Contractor may occur for failure to submit. 5. In cases where documentation does not exist to support audit information or services provided, Contractor will be required to repay all funds received for which documentation does not exist. 6. In cases where audit deficiencies are noted, a plan of corrective action shall be submitted to the State Department's Audit Division for approval within four(4) months of the date of the audit. 7. Failure to comply with any of these requirements, including items on the addendum is justification for the County to impose possible fiscal sanctions, penalties, or cancel the Agreement. II. PAYMENT TO CONTRACTOR: SS-23A Agreement to Purchase 6 Revised 6/2015 ' I A. The total rate of payment for care and services under this Agreement shall not exceed: the established rate for the PRTF; for CPA placements, the negotiated rate or the approved vendor rate; for RCCF placements, the established Fee-for-Service rate and the negotiated rate or the approved vendor rate; and, for CHRP placements, the agreed upon service proposal rate. The total rate of payment for care and services for other service types will be as negotiated between the County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. Any child may be removed from the facility prior to the end of the term by County. The amount paid for purchased care and services for less than a full month will be based upon the daily rate. B. 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 (12 CCR 2509-5)and County Policy. C. All invoices from contractor shall be submitted to and approved by the appropriate County staff. Payment for placement services shall be paid from the date of admission up to, but not including,the day of discharge. Medicaid payments for PRTF and CHRP placements are permitted on the day of discharge in compliance with regulations promulgated by the Colorado Department of Health Care Policy and Finance. Fee for Service will be reimbursed as per Medicaid regulations. Medicaid funds shall not be limited to funds encumbered in this Agreement and shall also include Medicaid funds for PRTF and RCCF therapeutic services and CHRP services paid by the Department of Health Care Policy and Financing. Payment for placement services will not be provided for clients on "runaway" status unless the County has previously approved it. Invoices for therapy costs for clients enrolled in PRTF, RCCF, and CHRP programs shall be submitted to the Medicaid Fiscal Agent in accordance with instructions provided by such Fiscal Agent. Contractor shall forward copies of such billings to the County on a monthly basis. D. In the event that a Contractor receives payment for a per diem discharge day, regardless of funding source, Contractor shall refund those dollars forthwith. E. In the event this Agreement is terminated, final payment to Contractor may be withheld at the discretion of the County until final audit. Incorrect payments to Contractor due to omission, error, fraud, or misuse of funds shall be recovered from Contractor either by deduction from subsequent payments under this Agreement or other Agreements between the County and Contractor or by the County, as a debt due to both the State of Colorado,the Colorado Department of Human Services and the County. The waiver of any violation shall not be construed as a waiver of any other or subsequent violation of this Agreement or appropriate statutes and regulations. F. If this Agreement covers an initial placement for a child, Contractor may receive a clothing allowance in accordance with State Department rules. G. Reimbursement rates that are negotiated between the County and Contractor shall be for allowable costs in one or more of four primary components: child maintenance, administrative services, administrative maintenance, and treatment. Contractor type will determine which of these four components will be included in the reimbursement rate. • SS-23A Agreement to Purchase 7 Revised 6/2015 i III. TRANSPORTATION: A. 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 Contractor's facility, County shall provide transportation to either return the child to the facility or to other care as arranged by County. County has responsibility for the decision to return the child to the facility, with input from Contractor. B. All other transportation associated with Contractor's proposed services shall 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 Family Service Plan/ Individual Plan of Care. C. Any transportation costs to be incurred on behalf of a child in placement, which are to be borne by persons, or agencies, which are not a party to this Agreement, shall be specified in the treatment/service plan, and those persons shall acknowledge their responsibility by signing the treatment/service plan. D. Transportation may include, but is not limited to; visitation with family members, medical/dental or mental health appointments, extracurricular activities, court hearings or other specialized programming. Transportation expectations will be documented on the Child Specific Addendum, SS23B. IV. LEGAL STATUS AND AUTHORIZATIONS: A. Such permission as is held by the County is hereby granted to Contractor to authorize routine or emergency medical and dental treatment, except that: 1. Medical or dental care shall be provided by personnel duly licensed by law as required by the State of Colorado. 2. It is mutually understood hereto that hospital expenses, surgery, ophthalmology services, eyeglasses, orthodontia or other unusual expenses are not included in the monthly rate. 3. The cost of any items not covered by Medicaid will be negotiated between County and Contractor. Medicaid rules shall govern activities to be covered in the daily rate paid to PRTFs. B. County and Contractor shall insure that the child(ren) is enrolled in the Early and Periodic Screening, Diagnosis and Treatment Program. C. It is agreed and permission is granted for the child(ren) 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 guardian 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/service plan. Further, Contractor and County will also secure, where possible, permission SS-23A Agreement to Purchase 8 Revised 6/2015 v from parents or guardians of the child placed with Contractor. Any planned absence of more than 24 hours for children placed in a PRTF is not Medicaid reimbursable. D. 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. E. Contact by Contractor with County regarding emergency medical, surgical or dental care will be made in person-to-person communication, not through phone mail messages. During regular work hours, 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, Contractor will contact the Screening Department at (970) 346-7670. V. RESPONSIBILITIES OF COUNTY: A. County shall: 1. Determine eligibility of the children under this Agreement for placement and medical coverage. Medicaid rules and regulations shall govern determination of Medicaid eligibility. 2. Assess and collect fees in accordance with the rules and regulations of the Colorado Department of Human 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 when billing is submitted as described in Section IV, Number 10 (above). 4. Abide by all the rules and regulations of the Colorado Department of Human 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 children's progress in accordance with the treatment/family services plan and the requirements of Colorado Department of Human Services rules and provide consultation to Contractor in relation to the services purchased under this Agreement. 6. Invite Contractor to administrative reviews at least two (2)weeks prior to the scheduled review. 7. Involve Contractor in planning for the child and give Contractor a copy of the Family Services Plan at time of placement or as soon as completed and when updated or revised. 8. Seek recovery from the RCCF, CPA or other Contractor type for any non- Medicaid payment amounts that have been misused as defined in rules. The County may withhold subsequent payments to recover any funds misused by the RCCF, CPA or other Contractor type. The County shall seek recovery of any remaining funds as a debt due the County for the benefit of the state. The RCCF SS-23A Agreement to Purchase 9 Revised 6/2015 or CPA may appeal the decision to recover or withhold subsequent payments as defined in rules. 9. Identify the amount agreed upon with Contractor to be paid to the foster parent for the child's room and board. Such amount will be the same as shown in Trails for the child's maintenance. VI. 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 the child specific addendum and the family services plan 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 the family services plan or appending a count designed addendum to this agreement. E. The State of Colorado Department of Human Services 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 may provide consultation to 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. SS-23A Agreement to Purchase 10 Revised 6/2015 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 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. SS-23A Agreement to Purchase 11 Revised 6/2015 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 County find and determine that Contractor has substantially failed to satisfy the scope of work found in this Agreement, Exhibit,the child specific addendum SS23B, 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 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, SS-23A Agreement to Purchase 12 Revised 6/2015 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. SS-23A Agreement to Purchase 13 Revised 6/2015 WHEREFORE,the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board WELD COUNTY, COLORADO By: Deputy Clerk to the Board Barbara Kirkmeyer, Chair APPROVED AS TO SUBSTANCE: Elected Official or Department Head CONTRACTOR: «Agency» «Agency_Mailing_Address» «Agency_City_State_Zip» By: Contractor's (or designee's) Signature and Date I SS-23A Agreement to Purchase 14 Revised 6/2015 a d d• r, ri Ln LD d' Ln N LD d' v1 Ln LD 0 d' d' d' Ln d- d' d• d' d' d• 01 Ln Ln LO LD LD M M4 N M M M M M d d- 0 m L.0 0 00 M 01 01 01 cr 01 01 01 d' m m n N N LT Ol a> 01 01 Ol d' Ol m Ol .--1 00 Ni Ni 61 n M M M m m m d' 01 01 N N-: 00 00 co_.,... 00 00 00 co00 00 Ln N4 N 00 LD LDCOCO0 V1 CO00 CO0O 00 00 00 00 CO00 CO0O 00 00 v. c-1 <-1 r N,--I i--1 c--1 e-1 N--1 i--I r-I e I 1-I ,--I e--I i--I r-I r-I c-1 ri t I ,--I r-1 c-I c-1 t-I i--i r I c-1 c-I a--I ri { VI- VI- �' tn- V1- cn- tn. tn. tn. t/} tn. in. IA- tn. t!1 tn. tn• tn. t/} in. -in. tn. 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O O M _ U 0 C O ‘4. 4J -a co Q -c U T ns LL U x-1 T N O. o up T u ,n Co LL 46 4-, G1 Q E f6 Z 71 OD L (13 U EXHIBIT to the SS23A Additional Provisions for the Agreement to Purchase Out-of-Home Placement Services SS23A For the Purchase of Residential Child Care Facility Services The following additional provisions apply to the agreement entitled, "Agreement to Purchase Out-of-Home Placement Services SS23A, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services,"hereinafter referred to as, "County,"and«Agency», hereinafter referred to as, "Contractor." 1. County agrees to purchase and Contractor, ID#«Facility_ID»,agrees to provide: a. Child Maintenance, Administrative Maintenance and Services, which are listed in this Agreement at a rate of$«Agency_Rate» per day unless otherwise negotiated based on the needs of the individual child placed within the Residential Child Care Facility. b. Additional services not covered by Medicaid or considered within the above vendor rate. These additional services/rates may be negotiated on a child by child basis, based on the needs of the child and in accordance with the Colorado Department of Human Services Agency Letter CW-06-11-I dated June 8, 2006. 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. 2. County considers the agreed upon rate, outlined in the Weld County Addendum to this contract, to be all inclusive and shall not pay for additional treatment fees; i.e. Drug/Alcohol and Sex Offender services. 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 provider. Reimbursement rates for bed hold days may not exceed the state standard rate for administrative maintenance and administrative services or may be a reduced rate that is mutually agreed upon. 4. The services purchased under this Agreement as Child Maintenance, Administrative Maintenance and Services for Residential Child Care Facilities include, but are not limited to: Food, shelter, clothing, personal needs and allowance, administration, administrative overhead, support staff, support overhead, sleep-over staff, direct child care, transportation, therapeutic recreation, service delivery staff, parent training for teens, independent living training, mentor/advocate, supervised visitation and all other services as outlined in the Child Specific Addendum. The anticipated minimum percentage for each item is as follows and will be subject to County monitoring as outlined in Section VI of this contract: a. Food, including meals and snacks(25%). b. Clothing(3%). Exhibit to the SS23A 1 Revised 6/2015 c. Shelter, including utilities and use of household furnishing and equipment and daily supervision, including those activities that a parent would normally carry out to assure protection, emotional support and care of the child (30%). d. Personal items and grooming care for the child, such as toothpaste,toothbrushes, soap, combs, haircuts, and other essentials(2%). e. Other/miscellaneous items considered usual in the care and supervision of the child, include, but are not limited to, transportation, recreation and overhead (40%). 5. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 6. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, that is not provided within the vendor rate or attached Scope of Service, will need be negotiated and authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 7. Contractor agrees to have appropriate personnel available to attend or participate in Family Engagement or Team Decision making meetings. Provider shall be notified by County staff of the dates and times attendance is requested. 8. Contractor agrees to cooperate with any vendors hired by the Weld County Department of Human Services to shorten the duration of placement. 9. Contractor agrees to have physical examinations scheduled within 14 days and dental examinations scheduled within 8 weeks of the child being placed with Contractor. All documentation of these examinations shall be forward to the County. 10. Contractor agrees to arrange a full evaluation of an Individualized Educational Plan (LEP) for youth designated as a Special Education Student every 3 years and coordinate reviews 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. 11. Children in Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Human Services Policy and Procedure Manual. Exhibit to the SS23A 2 Revised 6/2015 as M NY >, r, LD Li") s. 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Q i i CC ✓ a.1 CU a, C C U U ✓ a C — >- T O O ro co a a u co CtA C C L L D I- I- N m 1.11 t0 m m m m m EXHIBIT to the SS23A Additional Provisions for the Agreement to Purchase. Out-of-Home Placement Services SS23A For the Purchase of Child Placement Agency Services The following additional provisions apply to the agreement entitled, "Agreement to Purchase Out-of-Home Placement Services SS23A, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services,"hereinafter referred to as, "County,"and«Agency», hereinafter referred to as, "Contractor." 1. County and Contractor agree that a child specific Needs Based Care Assessment, designated in this exhibit, 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 in this exhibit, for children placed within the CPA identified as Provider ID#«FACILITY_ID». 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. If a child is deemed eligible for the Children's Habilitation Residential Program (CHRP) waiver, Contractor agrees to accept the assessed waiver service rate billable through the MMIS system and the federal SSI rate billable through the County. 4. 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 County's Department Administrator before payment will be release to provider. 5. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished by the Contractor under this contract for facilities that provide sex offender treatment. 6. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 7. Contractor agrees to have appropriate personnel available to attend or participate in Family Engagement or Team Decision making meetings. Contractor shall be notified by County staff of the dates and times attendance is requested. 8. Contractor agrees to cooperate with any vendors hired by the County to shorten the duration of placement. Exhibit to the SS23A I Revised 5/2015 9. Contractor agrees to 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 shall be forward to County. 10. Contractor agrees to arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement, the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. Children in Psychiatric Residential Treatment Facilities, Residential Child Care Facilities and Child Placement Agencies are not eligible to receive clothing allowances as outlined in the Weld County Department of Human Services Policy and Procedure Manual. Exhibit to the SS23A 2 Revised 5/2015 imormei- 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 Cl Substance Abuse Select One ❑ Presence of Psychiatric Symptoms/Conditions Select One ❑ Enuresis/Encopresis Select One ❑ Runaway Select One Cl Sexual Offenses Select One ❑ Inappropriate Sexual Behavior Select One Cl Disruptive Behavior Select One O 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 to the SS23A 3 Revised 6/2014 VINES Needs Based Care Assessment WELD COUNTY DHS Requested Services from Agency Please indicate the services that are requested for this child. The following information will be reflected on the child specific contract. (Please be specific) ❑ Adoption Services ❑ Medical Services ❑ Other: NA ❑ Doctor/Dentist Appointment Coordination ❑ Provider agrees to work with family ❑ Medication Evaluation(not covered under fee for service) ❑ Therapeutic Services funded through Medicaid Fee for ❑ Medication Monitoring Service: (TRCCF) ❑ Individual Therapy ❑ Nursing Services/Coordination ❑ Group Therapy ❑ Physician Services/Coordination ❑ Interactive Group Therapy ❑ Occupational Therapy ❑ Family Therapy ❑ Speech Therapy ❑ Psychological Testing 0 Child Find ❑ Pharmacological Management 0 Other: ❑ Treatment not funded by Medicaid Fee for Service: 0 Education: E Home Based Intervention ❑ On-Grounds School ❑ MST Multi-Systemic Therapy 0 Coordinate Assessment for Special Education ❑ Offense Specific Treatment 0 Public School Attendance ❑ Occupational Therapy ❑ Drug and Alcohol Treatment 0 Speech Therapy 0 Attend Special Education Meetings ❑ Urine Analysis/Drug Screening/Breathalyzer 0 Other: D Sexual Abuse Victimization Treatment ❑ Visitation Coordination ❑ Independent Living Skills Training ❑ Monitor phone calls and correspondence ❑ Anger Management ❑ Transportation for family/parent/child visits ❑ Behavior Modification Services ❑ Other: ❑ Behavioral Assessment ❑ Other: ❑ Recreation Services ❑ Interpreter Services ❑ Case Management ❑ Other: ❑ Attend Court Hearings ❑ Transportation: To include: ❑ Other: Levels of Care: Provider Level: Case Management Level: • Therapy Level: Date Staffed: Participants: Comments: Exhibit to the SS23A 4 Revised 6/2014 • Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEVEL OF CHILD ADMINISTRATIVE 1DMINISTRATIVE MEDICAL SERVICE MAINTENANCE RI.SPPI L MAINTENANCE SERVICES NEEDS Level Daily Rate Daily Rate Daily Rate Daily Rate Daily Rate $12.35 County Basic Age 0-10...$17.01 $0.00 $.66 No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover CPA involvement one face-to- Rate Age 15-21...$20.09 under Medicaid. face visit with child per month. $15.77 $5.14 Minimal crisis intervention as Regularly Scheduled $20.56 5.66 f needed,one face-to-face visit 's1 I therapy up to 4 per month with child,2-3 hours/month. contacts per month IV: 4. $23.99 5.66 $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled $27.42 -�''' needed,two face-to-face visits therapy 5-8 hours a w-L�� with child,2-3 contacts per month with 4 hours of month group therapy. 2 $30.85 S.66 $20.91 $22.62 $15.42 Regularly scheduled { Ongoing crisis intervention as weekly,multiple 3 ,, y 66 needed,weekly face-to-face sessions,can include ' $6.50 visits with child,and intensive more than 1 person, coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 I'2 $37.69 -r,r, $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high Care S4 I I' r)i, level of case management and Negotiated Negotiated Drop Down CPA involvement with child and provider and 2-3 face-to face contacts per lyeek minimum. 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O L Q Q m U V1 0 W 2 Y Y U J CC C Z Z Q Z VI 0_ VI (n V1 f- O ,-I N M d- V1 Up r CO 01 0 .-4 N .-I N M d' V1 LD n). co Ol I .-I .-I .-I .-I a-I .-I .-1 r1 .--I .-I N N N EXHIBIT A to the SS23A Additional Provisions for the Agreement to Purchase Out-of-Home Placement Services SS23A For the Purchase of Group Home Care Services The following additional provisions apply to the agreement entitled, "Agreement to Purchase Out-of-Home Placement Services SS23A, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services,"hereinafter referred to as, "County,"and«Agency», hereinafter referred to as, "Contractor." 1. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement at a rate of$«Agency_Rate», per day for children placed within the Group Home identified as Provider ID#«Agency_ID». 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. 2. 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 County's Department Administrator before payment will be release to provider. 3. The services purchased under this Agreement for Group Home services may include, but are not limited to: Basic 24-hour care and child maintenance(food, shelter, clothing, educational supplies and allowance), direct child care, transportation, administrative overhead, support overhead, service delivery staff, which may include but are not limited to: Parent training for teens, independent living training, and mentor/advocate services. 4. Contractor agrees to have appropriate personnel available to attend or participate in Family Engagement or Team Decision making meetings. Contractor shall be notified by County staff of the dates and times attendance is requested. 5. Contractor agrees to actively participate in achieving the child's Permanency Goal and cooperate with any vendors hired by the Weld County Department of Human Services to shorten the duration of placement. 6. Contractor agrees to 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 group home placement binder. 7. Contractor agrees to meet with the Department of Human Services Group Home Coordinator for a minimum of two hours weekly (7.709.21). 8. Contractor agrees to work collaboratively with Department staff, mental health professionals, GAL's, CASA volunteers, and other service providers in arranging times that Contractor's home is open to professional visits. Contractor also understands that the County Department Caseworker and GAL have the right to make unannounced home visits to check the child's safety, needs, and environment. Exhibit to the SS23A I Revised 6/2015 9. Contractor agrees to ensure that hired staff are completing training specific to the children they service, and are current on all trainings and other requirements as mandated by CDHS Volume 7 Policy and Procedure Manual section 7.700. 10. Contractor agrees to accompany key professionals to school conferences, IEP meetings, school-related staffings, Foster Care Reviews and Court Hearings. 11. Contractor agrees to immediately report any significant issue, regarding the youth,to the youth's assigned caseworker. Issues may be medical, behavioral, legal/criminal, or educational in nature. If a youth becomes a threat to him/herself or others, appropriate "critical incident"documentation must be prepared by the specialized group home parent according to State guidelines(7.701.52), in addition to notification to the caseworker. While specialized group home parent attempts to maintain the youth at the group home level of care,the specialized group home parent will be familiar with Weld County's continuum of care and understand when a child needs to be forwarded or regressed through the continuum. 12. Contractor agrees to immediately report to the County and/or local law enforcement any known or suspected child abuse or neglect as set forth in Section 19-3-304, C.R.S. Exhibit to the SS23A 2 Revised 6/2015 a) ce c4 N co 4. O _ up `u CO LL 0. m GJ v1 O O U U T rl +4. 0- ai O = a, E N ro N O CS= M LL C7 • W • C vi O aJ C7 O < 4' 00 • O 00 • N .0 O aJ N fl. r-1 U_ N C aJ E E O _ U Z a ++ o L •5 O ra 2 LL 06 U - ++ O1 LL EXHIBIT to the SS23A Additional Provisions for the Agreement to Purchase Out-of-Home Placement Services SS23A For the Purchase of Group Home/Group Center Care Services The following additional provisions apply to the agreement entitled, "Agreement to Purchase Out-of-Home Placement Services SS23A, by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services,"hereinafter referred to as, "County,"and«Agency», hereinafter referred to as, "Contractor." 1. County agrees to purchase and Contractor agrees to provide the care and services, which are listed in this Agreement at a rate of$«Agency_Rate», per day for children placed within the Group Home/Group Center identified as Provider ID#«Facility_ID». 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. 2. Contractor agrees to accept the assessed waiver service rate billable through the MMIS system for Children's Habilitation Residential Program (CHRP)waiver eligible children and the federal SSI rate billable to the County. 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 provider. 4. A minimum of one polygraph test per Colorado fiscal year, if needed by the child, will be furnished under this contract for facilities that provide sex offender treatment. 5. Any additional costs for specialized services, which include, but are not limited to; polygraph tests, plethysmographs, and urinalysis screens, which are not provided within the negotiated provider rate, will need to be authorized, in writing by the County, prior to the service being performed. Any payment for specialized services not authorized in writing will be denied. 6. The services purchased under this Agreement for Group Home/Center services may include, but are not limited to: Basic 24-hour care and child maintenance (food, shelter, clothing, educational supplies and allowance), direct child care,transportation, administrative overhead, support overhead, service delivery staff, which may include but are not limited to: Parent training for teens, independent living training, and mentor/advocate services. 7. Contractor agrees to have appropriate personnel available to attend or participate in Family Engagement or Team Decision making meetings. Contractor shall be notified by County staff of the dates and times attendance is requested. Exhibit to the SS23A 1 Revised 6/2015 oar 8. Contractor agrees to actively participate in achieving the child's Permanency Goal and cooperate with any vendors hired by the Weld County Department of Human Services to shorten the duration of placement. 9. Contractor agrees to 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 shall be forward to the County. 10. Contractor agrees to arrange a full evaluation of an Individualized Educational Plan (IEP) for youth designated as a Special Education Student every 3 years and coordinate reviews every year. If the IEP is due while the child is in placement,the Contractor shall complete or obtain a completed IEP. A copy will then be forwarded to the County. 11. 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CO OL M T v 0 co co 0. > Lil4- > U aJ (N 01 C 'u a oco co ) > 00 CLc, O to Q E on ti t O E a D N E V co L L C Z cLu CL .r co 2 �O N E a Z In • -, vi r-- 2 Q V1 cn Q ,-1 en ,-I O N o In is, en •I' 3 ,--1 al O N c' (N CT) ,—I 0) O O N O 0 m In ,--I ,--I 00 00 (V 'a ,--I N C) L LC) m N d l m ,--IN ,-1 l ' O -I <1- ,--I e-I irl l74 i I Q ›, 0J a U 3 f0 v) c.,Z L- au E a 0 E o E ,- o = 0 0 I 0_ u = — a 3 Ii 0_ 0) L 3 O 0 a) 3 C ay., O2 W 4- O aJ C U N p vVI N c 3 v 0 U CU n a) _i _ O 2 ,_ co = cu X Q u 3 = m N W 3 O C Q (Ti rL. a 0 N -0 00 cu (9 0 Q1 S O cu cp 'L r0 c0 0 0 IL Z La) U U 1n 2 2 >- 0 00 UD N 0 Ni V) < C M M CO < N C 0J M Q .-1 a ifl U H J -0 J U Y C Il) a.U - °d) ° 3 ..1744 O C 0 C co U C 0 0 Q 3 @ N a, 0 4.4 (^ _Y p V E C r 0 N 0 cc Y 0 tD 1, 00 Ol O ,-I N M .7 V) VD N N N N N M M M M M M in M v f WELD COUNTY DEPARTMENT OF HUMAN SERVICES NEEDS BASED CARE ADDENDUM This addendum supplements the Placement Agreement Form SS-23A dated 7/1/2014 between the above County Department of Human Services and «Agency»/«Facility», provider#«Facility ID». The provider(s) hold(s) a valid and current full certificate as a certified provider. This Addendum is effective from «PlacementDate» to 6/30/2016, unless otherwise negotiated. I. THE ABOVE COUNTY AGREES TO: • Pay the provider a rate of$«Total2» per day, prorated for the days in care, for the care of child «Childs Name», State ID# «State ID», Case ID# «Case ID». The agreed upon rate is based upon the following: SERVICES LEVEL DAILY RATE Child Maintenance «RatesRLevel» (Provider Services) $«Child Maint» Respite NA $0.66 Admin. Maintenance «Rates 1RLevel» (Case Management) $«Admin Maint» Admin. Services NA �0 Special Medical Needs «Rates 2RLevel» $«Med Needs» Total $«Total2» Comments: «Add Comment» • Provide support and supervision to such placement as specified in the Family Service Plan and Needs Based Care Assessment. Involve the provider in case planning, staffing or other meetings concerning the child, and service delivery as specified in this child's Family Service Plan and Needs Based Care Assessment. II. THE PROVIDER HAS MET THE PLACEMENT REQUIREMENTS OF: ❑Family Foster Care ❑ Gateway ❑ Child Placement Agency Group Care ❑ Specialized Group Care ❑ Child Placement Agency Foster Care III. THE PROVIDER AGREES TO: Meet the service needs as identified by the Needs Based Care Assessment and Family Service Plan. Keep weekly records of this child's behavior and progress, submit monthly written reports to the county department, and retain copies for own files. Submit the required forms for payment in a timely manner. The provider's signature on the monthly payment form signifies that the above services have been provided for this child during the month. Provide the services identified by the Needs Based Care Assessment and Individual Plan. Meet additional requirements: IV. This addendum shall be reviewed at least every six months in conjunction with the review of the Family Service Plan or Needs Based Care Assessment. It shall be revised if there are agreed upon changes in the child's service plan. It shall expire the date the child is removed, upon the renegotiation of a new addendum, or upon the termination of the SS-23A Placement Agreement. The conditions of this contract may be renegotiated at any time during the term of the contract based upon the changing service needs of the child. Provider Signature/Date Negotiator Signature/Date Provider Signature/Date Other Signature/Title/Date Revised 6/2015 CHILD SPECIFIC ADDENDUM AGREEMENT TO PURCHASE OUT-OF-HOME PLACEMENT SERVICES SS23B This child specific addendum is to be used in conjunction with the general contract(SS23A)for all providers. This is an agreement between Weld County, Department of Human Services and«Agency» «Agency Mailing Address»«Agency City State Zip» 1. County agrees to purchase and Contractor agrees to provide the care and services which are listed in this agreement,the Family Services Plan,and the Contract at a specific rate of payment for: «Childs Name» «DOB» Child's Name Date of Birth «Client ID» «Case ID» Trails Client ID Trails Case ID hereinafter called"Child"who has been deemed eligible for social services under the statutes,and rules and regulations of the State of Colorado. 2. This agreement will be effective from date of placement,«PlacementDate»,and is authorized until June 30,2016,or until the end of the Colorado fiscal year,June 30,2016,or until child is removed by the county department, or if the child's behavior would cause harm to himself or other children and provider seeks approval in writing to terminate this Agreement and the county department agrees,whichever occurs first.Authorized date is estimated length of stay determined by the county department. 3. This agreement may be renewed only by entering into a new agreement signed by the authorized representatives of the parties. Except as otherwise provided in paragraph 2 above, either party shall have the right to terminate this contract by giving the other party thirty days notice by registered mail,return receipt requested. If notice is so given,this agreement shall terminate on the expiration of the thirty days or until the eligible child can be placed elsewhere,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. 4. This agreement is in lieu of and supersedes all prior agreements between the parties hereto and relating to the care and service herein described. 5. Provider will provide the purchased care and services at the address above or at the following facility, foster home,or group home: «Facility» License#«Facility ID» «Facility Address» «Facility City State Zip» License/Certificate Expiration Date(must be valid for payment) SS23B Child Specific Addendum 1 Revised 6/2015 The services purchased under this agreement will be provided in: O CHILD PLACEMENT AGENCY SERVICES(CPA) ❑ CHILDREN'S HABILITATION RESIDENTIAL PROGRAM(CHRP) ❑ GROUP HOME/GROUP CENTER CARE ❑ INDEPENDENT LIVING ❑ PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY(PRTF) ❑ RESIDENTIAL CHILD CARE FACILITY(RCCF) ❑ RESIDENTIAL DRUG/ALCOHOL PROGRAM ❑ SHELTER CARE ❑ SUBSIDIZED ADOPTION ❑ TRANSITION/HOME BASED AFTER-CARE(RCCF) El OTHER: PAYMENT The total rate of compensation for the care and services provided to the child under this agreement, determined on a daily rate basis that includes administrative overhead O Foster or Group Home/Center—If different from Trails Base Anchor Rate $«GH Admin Maintenance» Administrative Maintenance $0«GH Admin Services» Administrative Services $«GH Child Maintenance» Child Maintenance $0 Respite amount $**See Needs Based Care Addendum«GH Total»SSI Benefit Total Daily Rate ❑ RCCF—If different from Trails Base Anchor Rate $0«RCCF Adm in Maintenance»Administrative Maintenance $0«RCCF Admin Services» Services $0«RCCF Child Maintenance» Child Maintenance $0 Treatment $0 Respite amount $0«RCCF Total»Total Daily Rate 0 Child eligible for CHRP funding ❑ Child eligible for PRTF funding ❑ Child eligible for Fee for Service Medicaid funding SS23B Child Specific Addendum 2 Revised 6/2015 Services Services will include but are not necessarily limited to the following services to be provided by the provider: Out-Of-Home Other Provider agrees to work with family Therapeutic Services funded through Medicaid Fee for Service: Individual Therapy Group Therapy Family Therapy Psychological Testing Pharmacological Management Treatment NOT funded by Medicaid Fee for Service: Home Based Intervention MST Multi-Systemic Therapy El Offense Specific Treatment Drug and Alcohol Treatment Urine Analysis/Drug Screening/Breathalyzer Sexual Abuse Victimization El Independent Living Skills Training Anger Management ❑X Behavior Modification Services EI Behavioral Assessment SS23B Child Specific Addendum 3 Revised 6/2015 Case Management Attend Court Hearings Recreation Services ❑ Other Medical Services: Doctor/Dental Appointment Coordination Medication Evaluation(not covered by Fee for Service) Medication Monitoring Nursing Services/Coordination ❑X Physician Services/Coordination Occupational Therapy Child Find ❑ Other Education: On-grounds School Coordinate Assessment for Special Education Public School Attendance a Occupational Therapy Speech Therapy 111 Attend Special Education Meetings Other SS23B Child Specific Addendum 4 Revised 6/2015 Visitation Coordination: Monitor phone calls and correspondence ❑X Transportation for family/parent/child/visits n Other • Other Transportation to Include: ❑X Other All doctor,dental,therapy,court and visitation appointments. Other Interpreter Services ▪ Other Respite SS23B Child Specific Addendum 5 Revised 6/2015 LEGAL STATUS AND AUTHORIZATIONS 1. Check one of the following for child's legal status: ❑ Child is in placement through a placement contract;a voluntary placement agreement signed by the parent/guardian under conditions established by the County and according to the Children's Code,with an expiration date of and signed by: Name Address City, State,Zip, Phone El Child in placement through a court order,and temporary legal custody or guardianship of the child is held by the county. ❑ Child is in placement through a petition for review of need for placement,with custody retained by: the County or person named below. Name Address City, State,Zip, Phone Relationship to Child: 2. Permission for emergency medical and dental treatment is at the discretion of the County. The contractor is required to abide by county specific practices as to emergency medical and dental procedures. 3. Notice of medical and emergency treatment shall be provided to the county caseworker as soon as reasonably possible but no later than 24 hours following treatment. The county should be called for authorizations for all life and limb threatening emergencies unless authorization is given by the medical professional(s)on duty. County Department: Provider: Weld County Department of Name: «Agency» Human Services Phone: (970)352-1551 Phone: Address: PO Box A Address: «Agency Mailing Address» Greeley, CO 80632 «Agency City State Zip» Social Caseworker's Signature/Date Contractor's Signature/Date County Director/Designee Signature/Date Print Name of Person Authorized to Sign Agreement for Contractor Print Name of Person Authorized to Sign for County Director SS23B Child Specific Addendum 6 Revised 6/2015 +� go gC >,, d- d- ci c-I Ln LO v Lf1 I, L.0 L l In LD O v v v L I Cr Cr v Cr Cr CI' O1 Ir1 In LO LO LLD M M . . 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O > 01) u C 0- 0 Ln 0 CC Y cM LD N 00 Q1 0 a-1 N m cr LA LO N N N N N 01 en en M M en M en U a) CD 2 ra >, CC ID T '� C V u it CI) b.0 u1 QsZr ui L O G1LSD N � O D aJ O i a O t0 f0 O U vi fy N >, O � L • fr1 u tZ iff E C LL "a 4-0 CI) i O _O H +' O f6 U +' O C N vi a GJ of 13 cu • T -a Y co Q L — L _ O CO t tai M N a _ up T U Lf1 fD LL 4-0 f6 41) CL E crs = Z v c 8_ u N RS L LL (B U a INDIVIDUAL PROVIDER CONTRACT FOR PURPOSE OF FOSTER CARE SERVICES AND FOSTER CARE FACILITY AGREEMENT THIS AGREEMENT is made this day of , 20 , by and between the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, whose address is P.O. Box A, Greeley, CO, 80632, hereinafter referred to as, "County," and«Facility_Name»,whose address is «Facility_Address», «Facility_City_State_Zip», 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 July 1,2015,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. CWS-7A Individual Provider Contract 1 Revised 6/2015 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. 11. 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 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 11. 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. [II. 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. E. 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 WHEREFORE, the parties have herein set their hands and affixed their seals the day and date first written above. COUNTY: ATTEST: BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board WELD COUNTY, COLORADO By: Deputy Clerk to the Board Barbara Kirkmeyer, Chair APPROVED AS TO SUBSTANCE: Elected Official or Department Head CONTRACTOR: «Agency» «Agency_Mailing_Address» «Agency_City_State_Zip» By: Contractor's (or designee's) Signature and Date By: Contractor's (or designee's) Signature and Date CWS-7A Individual Provider Contract 9 Revised 6/2015 ,• v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM fO CO f0 a0 c0 c0 f0 f0 f0 f0 o c0 c0 f0 N f0 a0 o N c0 a0 f0 c0 aO [O o c0 f0 f0 N f0 c0 fO f0 c0 a0 H F— H H H H H F-- H F— F— H F— H H F— H H H H H H H H H H H H H F— H H H H H H v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y 4—, Y Y Y Y f0 a0 CO f0 CO CO CO CO f0 CO CO CO CO CO Co CO CO CO CO CO CO Co CO CO CO CO CO CO CO CO CO CO CO CO CO CO CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC CC fY CC CU v v v v v v v v v v v v v v v v v v v v v v v v v CU v CU v v v v v v v CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO CO Co Co CO CO CO CO CO CO f0 U U u U (J u U u U U u U U U U U O U U U U U U U U U U u U U U U U U U U -o a s -O a -0 -0 a -0 -0 -O a -0 a -o a s -0 -o a a a a a a a a a a a a a a a a a v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v v V1 V) VI 3/1 N VI V1 V1 VI VI VI VI VI VI VI VI 1A VI V) Vf VI VI VI VI V) V) VI VI VI V) VI VI VI VI VI N CO CO CO Co CO Co CO CO CO CO CO CO CO CO CO CO CO CO Co CO CO Co CO CO CO Co Co CO CO CO CO CO CO CO CO CO CO m m 00 00 00 CO m LY) Lb m m 00 00 0] m m 0 00 00 0 00 00 m 00 00 00 m 0303 00 CO CO C003 00 N N V) VI VI V1 V) VI V) VI VI V) V) VI V) V) V) V) VI V) V) VI VI V1 VI VI N VI LA V) V) VI VI VI N VI d a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a a . 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IA LD N. 00 01 O .-1 N M in LO N Co M m M Tr Tr Tr Tr Tr Tr d' CT Tr Tr in in in Ln in in in in Ll1 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«Agency», hereinafter referred to as, "Contractor." GENERAL PROVISIONS 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#«Agency_ID». 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 4`" 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. Exhibit A to the CWS-7A 1 Revised 6/2015 iv v 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: I. 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. Exhibit A to the CWS-7A 2 Revised 6/2015 ay 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. 1 1. 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. Exhibit A to the CWS-7A 3 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 theral 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 El 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 A to the Additional Provisions 4 Revised 6/2014 I Needs Based Care Rate Table Weld County Department of Human Service (Effective 7/01/2015) LEVEL CHILD ADM1INISTRATIVE 1[MIN ISTRATIVE MEDICAL SERVICE MAINTENANCE RESPITE MAINTENANCE SERVICES NEEDS Level Daily Rate Daily Rate Daily Rate Daily Rate Daily Rate County Basic Age 0-10...$17.01 $12.35 $0.00 �!�i, No crisis intervention,Minimal Maintenance Age 11-14...$18.81 Not needed or cover CPA involvement,one face-to- Rate Age 15-21...$20.09 face visit with child per month. under Medicaid. 41 $15.77 $5.14 — Minimal crisis intervention as Regularly Scheduled I $20.56 ,,!,!' needed,one face-to-face visit therapy up to 4 e S—t s per month with child,2-3 hours/month. contacts per month 1 %i $23.99 5!,c, $17.48 $19.20 $10.28 Occasional crisis intervention as Weekly scheduled $27.42 !'' needed,two face-to-face visits therapy 5-8 hours a S 1.)' with child,2-3 contacts per month with 4 hours of month group therapy. 2 'i $30.85 c,hi, $20.91 - $22.62 $15.42 Regularly scheduled Ongoing crisis intervention as weekly,multiple 3 $34.27 s,!,,, needed,weekly face-to-face sessions,can include 'ti6.S0 visits with child,and intensive more than I person. coordination of multiple i.e.family therapy,for services. 9-12 hours/monthly. 3 1/2 4 $37.69 y hi, $24.34 $26.05 4 Ongoing crisis intervention as Congregate needed,which includes high Care ',I I I ,,!'!, level of case management and Negotiated Negotiated II CPA involvement with child and Drop Dow n provider and 2-3 face-to face contacts per week minimum. 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