HomeMy WebLinkAbout20142900.tiff RESOLUTION
RE: APPROVE EIGHT (8) STANDARD FORMS OF AGREEMENTS FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND
VARIOUS PROVIDERS AND AUTHORIZE CHAIR TO SIGN AGREEMENTS
CONSISTENT WITH SAID FORM
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 Eight (8) Standard Forms of
Agreements for Services between the Weld County Department of Human Services and various
providers, as listed below, and
A. Agreement to Purchase Out-of-Home Placement Services
(SS23A)
B. Individual Provider Contract for Purpose of Foster Care
Services and Foster Care Facility Agreement(CWS7A)
C. 2013-2014 Residential Child Care Facility (RCCF) Exhibit "A"
to the SS23A and provider list
D. 2013-2014 County Certified Foster Care Exhibit A to the
CWS7A and provider list
E. 2013-2014 Child Placement Agency (CPA) Exhibit A to the
SS23A and provider list
F. 2013-2014 Group Home/Group Center Exhibit A to the
SS23A and provider list
G. 2013-2014 RCCF/Children's Habilitation Residential Program
(CHRP) Exhibit A to the SS23A and provider list
H. 2013-2014 Group Home Exhibit A to the SS23A and
provider list
WHEREAS, after review, the Board deems it advisable to approve the Eight (8)
Standard Forms of Agreements for 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.
2014-2900
HR0085
CC- HSb q/2g
APPROVE EIGHT (8) STANDARD FORMS OF AGREEMENTS FOR SERVICES BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND VARIOUS PROVIDERS
PAGE 2
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 22nd day of September, A.D., 2014.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: ddt 1l jelgo,� (enWDStiAnc.-6ouglq RademChair
Weld County Clerk to the Boar•
IEIsa. EXCUSED
arbara Kirkmeyer, Pro-Tem
BY. 1. . 1. I /.11,_.1!_r" .�Be
De.u�� Clerk to th- Bo- t 'J ° �
n �.ean P. Conway
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ti
AP" • . . . aRM: ®Q���
M eFr an
n y Attorney
illi F. Garcia
Date of signature: 9 in
2014-2900
HR0085
MEMORANDUM
1861
Ix T
DATE: September 18, 2014
.41
1 T Y TO: Douglas Rademacher, Chai , B d AC() Commissioners
GOON T Cole
FR: Judy A. Griego, Director uman ervices epa ent
RE: Weld County Addendums and List of Out-of-Home
Providers to be Submitted to the Board of County
Commissioners for Consent Agenda
Request Board approval of the attached proposed Weld County Addendums and list of out-of-home
providers for SFY 2014-2015. County Attorney Bruce Barker reviewed and revised provider
agreements, exhibits, and provider lists of the out-of-home contractors and is recommending
approval of these boiler-plate agreements. These Addendums were reviewed under the Board's
Pass-Around Memorandum dated July 15, 2014, and approved for placement on the Board's
Agenda.
A. Agreement to Purchase Out-of-Home Placement Services (SS23A). This agreement is the
State prescribed contract containing Weld County additions that are used for all out-of-home
providers excluding County Certified Foster Care.
B. Individual Provider Contract for Purpose of Foster Care Services and Foster Care Facility
Agreement(CWS7A). This agreement is the State prescribed contract containing Weld County
additions that are used for Weld County Certified Foster Care homes only.
C. 2013-2014 Residential Child Care Facility (RCCF) Exhibit "A" to the SS23A and provider
list. Per the Weld County Rate Methodology approved by the State, RCCF rates are based on
the State computed rates that are released every July. The new rates for the 2014-2015 contract
year include a two and a half(2.5%) increase which was approved via pass around
memorandum by the Board of County Commissioner on June 11, 2014.
D. 2013-2014 County Certified Foster Care Exhibit A to the CWS7A and provider list. Rates
are based the Needs Based Care Assessment and rate table as approved by the Board of Weld
County Commissioners. The new rates for the 2014-2015 contract year include a two and a half
percent (2.5%) increase which was approved via pass around memorandum by the Board of
County Commissioner on June 11, 2014.
E. 2013-2014 Child Placement Agency (CPA) Exhibit A to the SS23A and provider
list. Rates are based on the Needs Based Care Assessment and rate table as approved by the Board
of Weld County Commissioners. The new rates for the 2014-2015 contract year include a two and
a half percent (2.5%) increase which was approved via pass around memorar -- ' "--
County Commissioner on June 11, 2014. 2014-2900
F. 2013-2014 Group Home/Center Exhibit A to the SS23A and provider list. Rates are
negotiated per home/center due to highly specialized care for children who are stepping down
from RCCF care or cannot maintain in a foster care home setting.
G. 2013-2014 RCCF/CHRP Exhibit A to the SS23A and provider list. Rates are based on a
negotiated rate per agency due to highly specialized care for children who are not eligible or
who are awaiting approval for Children's Habilitation Residential Program (CHRP).
H. 2013-2014 Group Home Exhibit A to the SS23A and provider list. Rates are based on the
approved rate structure as outlined in DHS policy/procedures manual section 2.325.1 for State
Licensed County Supervised Group Homes. No COLA is being recommended for the 2014-2015
fiscal year.
If you have any questions, please give me a call at extension 6510.
Attachement I
AGREEMENT TO PURCHASE
OUT-OF-HOME PLACEMENT SERVICES
SS23A
❑ CHILD PLACEMENT AGENCY SERVICES (CPA)
LI CHILD RESIDENTIAL HABILITATION 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 (DESCRIBE):
THIS AGREEMENT is made and entered into 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 758, hereinafter referred to
as, "County," and «CENTER_NAME>>, whose address is «MAILING_ADDRESS»,
«CITY_STATE_ZIP», hereinafter referred to as, "Contractor." This Agreement covers all
children placed by County with Contractor.
WITNESSETH:
WHEREAS, the Colorado State Department of Human Services, hereinafter referred to
as, "State Department," is authorized to provide human services to individuals and families
through 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, 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, 2014, to and until June 30,2015.
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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. SERVICES TO BE PROVIDED BY AND REQUIREMENTS OF CONTRACTOR:
A. Services to be provided by Contractor are detailed herein in the document entitled,
"Additional Provisions," which is attached hereto and referred to herein as "Exhibit
A."
B. 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).
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 Child Specific Addendum (SS23B). Modifications to the Individual Plan of
Care must be agreed to in writing.
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). Modifications to the Individual Plan of Care must be agreed to
in writing.
E. The Individual Plan of Care shall be goal oriented and time-limited and shall:
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.
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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
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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.
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
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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.
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.
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I. 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
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
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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.
III. PAYMENT TO CONTRACTOR:
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).
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
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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.
IV. 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 arc 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.
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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.
V. LEGAL STATUS AND AUTHORIZATIONS:
I. Such permission as is held by the County is hereby granted to Contractor to authorize
routine or emergency medical and dental treatment, except that:
a. Medical or dental care shall be provided by personnel duly licensed by law as
required by the State of Colorado.
b. It is mutually understood hereto that hospital expenses, surgery, ophthalmology
services, eyeglasses, orthodontia or other unusual expenses are not included in the
monthly rate.
c. 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.
2. County and Contractor shall insure that the child(ren) is enrolled in the Early and
Periodic Screening, Diagnosis and Treatment Program.
3. 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
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.
4. 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.
S. 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 Emergency Duty Worker
at the pager number (970) 304-2749.
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VI.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
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.
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VII. 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, the SS23B,
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, the SS23B, and the Needs Based
Care Addendum in writing, if agreed to by both parties. This Agreement, Exhibit A,
the SS23B, and the Needs Based Care Addendum are intended to be in lieu of and
supersedes 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 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.
II
SS-23A Revised 6/2014
Attachement I
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental
actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws
of Colorado and be in accordance with the policies, procedures, and practices of
County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further,
Contractor represents, warrants, and agrees that it has verified that Contractor does
not employ any illegal aliens. If it is discovered that Contractor is an illegal
immigrant, employs illegal aliens or subcontracts with illegal aliens, County can
terminate this Agreement and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. 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.
12
SS-23A Revised 6/2014
Attachement
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 A, the SS23B, and 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.
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.
13
SS-23A Revised 6/2014
Attachement I
pa
rties arties have herein set their hands and affixed their seals the day Y and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: of Human Services
By: By:
Deputy Clerk to the Board Douglas Rademacher, Chairman
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT «CENTER NAME»
OF HUMAN SERVICES «MAILING ADDRESS»
«CITY_STATE ZIP»
By: By:
County Director's (or designee's) Director's (or designee's) Signature
Signature and Date and Date
14
SS-23A Revised 6/2014
Attachment II
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into 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 Colorado State Department of Human Services (hereinafter referred to
as "State Department"), has certified or licensed Contractor's facility as a Family Foster
Home/Emergency Shelter Home (hereinafter referred to as "Facility"), and
WHEREAS, Contractor understands and agrees that it must, during the term hereof,hold
a valid certificate/license for the Facility, maintain certification standards, and read and be fully
familiar with the Minimum Rules and Regulations for Family Foster Home issued by the State
Department, 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 Facility's 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, 2014, to and until June 30, 2015,
or until the Facility's 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.
CWS-7A Individual Provider Contract 1 Revised 6/2014
Attachment II
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.
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.
CWS-7A Individual Provider Contract 2 Revised 6/2014
Attachment II
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.
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
CWS-7A Individual Provider Contract 3 Revised 6/2014
Attachment IT
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
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:
I. 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.
CWS-7A Individual Provider Contract 4 Revised 6i2014
Attachment II
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.
S. 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.
1 I. 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.
CWS-7A Individual Provider Contract 5 Revised 6/2014
Attachment 11
III. GENERAL PROVISIONS:
A. Contractor agrees that Contractor is an independent contractor and that neither
Contractor nor Contractor's agents or employees are, or shall be deemed to be, agents
or employees of the County for any purpose. Contractor shall have no authorization,
express or implied, to bind the County to any agreement, liability, or understanding.
The parties agree that Contractor will not become an employee of County, nor is
Contractor entitled to any employee benefits from County as a result of the execution
of this Agreement. Contractor shall be solely and entirely responsible for its acts or
of any agent, employee, servants and sub-contractors during the performance of this
Agreement.
B. Payment pursuant to this Agreement, if in State of Colorado, county, or federal funds,
whether in whole or in part, is subject to and contingent upon the continuing
availability of State of Colorado, county, and federal funds for the purpose thereof.
C. It is agreed that if, after investigation, it is shown that reasonable care was given to
guard and protect personal items brought to Contractor by the children, Contractor
shall be released from responsibility for loss or damage to such personal items.
D. This Agreement is intended to be applied in conjunction with Exhibit A and the
Needs Based Care Addendum as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion or other
amendment hereto shall have any force or affect whatsoever, unless embodied herein
in writing. No subsequent notation, renewal, addition, deletion, or other amendment
hereto shall have any force or effect unless embodied as a part of this written
Agreement. This section shall not be construed as prohibiting the periodic amending
of this Agreement, Exhibit A and the Needs Based Care Addendum in writing, if
agreed to by both parties. This Agreement, Exhibit A and the Needs Based Care
Addendum are intended to be in lieu of and supersede all prior agreements between
the parties hereto and relating to the care and services herein described.
E. The State of Colorado Department of Human Services 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.
P. 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.
CWS-7A Individual Provider Contract 6 Revised 6/2014
Attachment Il
G. Time is of the essence in each and all of the provisions of this Agreement.
H. Neither party to this Agreement shall be liable to the other for delays in delivery or
failure to deliver or otherwise to perform any obligation under this Agreement, where
such failure is due to any cause beyond its reasonable control, including but not
limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental
actions.
I. Any notice required to be given under this Agreement shall be in writing and shall be
mailed or delivered to the other party at that party's address as stated above.
J. This Agreement and the provision of services hereunder shall be subject to the laws
of Colorado and be in accordance with the policies, procedures, and practices of
County.
K. This Agreement is nonexclusive and County may engage or use other contractors or
persons to perform services of the same or similar nature.
L. Contractor certifies that Contractor is not an illegal immigrant, and further,
Contractor represents, warrants, and agrees that it has verified that Contractor does
not employ any illegal aliens. If it is discovered that Contractor is an illegal
immigrant, employs illegal aliens or subcontracts with illegal aliens, County can
terminate this Agreement and Contractor may be held liable for damages.
M. Contractor assures and certifies that it and its principals:
I. 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.
CWS-7A Individual Provider Contract 7 Revised 6/2014
Attachment II
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
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.
CWS-7A Individual Provider Contract 8 Revised 6/2014
Attachment II
WHEREFORE, the parties have herein set their hands and affixed their seals the day and
date first written above.
COUNTY:
The Board of County Commissioners of Weld
County, on behalf of the Weld County Department
ATTEST: of Human Services
By: By:
Deputy Clerk to the Board Douglas Rademacher, Chairman
CONTRACTOR:
Approval as to Substance:
WELD COUNTY DEPARTMENT «Facility_Name»
OF HUMAN SERVICES «Facility_Address»
«Faci lity_City_State_Zip»
By: By:
County Director's (or designee's) Director's (or designee's) Signature
Signature and Date and Date
CWS-7A Individual Provider Contract 9 Revised 6/2014
Attachment III
EXHIBIT A 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#«Agency_ID», agrees to provide:
a. Child Maintenance, Administrative Maintenance and Services, which are listed in this
Agreement at a rate of S«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-I 1-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 A to the SS23A I Revised 6/2014
Attachment III
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 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 (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 will complete
or obtain a completed IEP. A copy will then be forwarded to the County.
1 I. 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 A to the SS23A 2 Revised 6/2014
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Attachment IV
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
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated within this exhibit as Exhibit B, 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 forChild
Maintenance as indicated on the Needs Based Care Rate Table, designated in this exhibit
as Exhibit C, 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
as Exhibit C, 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 4th of each month following the month of service. If the
reimbursement request is not submitted within twenty-five(25) calendar days of
the month following service, it may result in forfeiture of payment.
Exhibit A to the CWS-7A 1 Revised 6/2014
Attachment IV
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
the Foster Parents Database form accessed through
on the clothing allowance
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.
8. The Director of Human Services or designee may exercise the following remedial actions
should s/he find that the Contractor substantially failed to satisfy the scope of work found
in this Agreement. Substantial failure to satisfy the scope of work shall be defined to
mean incorrect or improper activities or inaction by the Contractor as outlined in the State
Department Staff Manual Volume VII and/or County Department Policy and Procedure
Manual. These remedial actions are as follows:
A. Withhold payment to the Contractor until the necessary services or corrections in
performance are satisfactorily completed;
B. Deny payment or recover reimbursement for those services or deliverables which
performed and which due to circumstances caused b have not been by the
Contractor cannot be performed or if performed would be of no value to the
Human Services. Denial of the amount of payment shall be reasonably related to
the amount of work or deliverables lost to Human Services;
C. Recover from the Contractor any incorrect payment due to omission, error, fraud,
and/or defalcation by deducting from subsequent payments under this Agreement
or other agreements between Human Services and the Contractor, or by Human
Services as a debt to Human Services or otherwise as provided by law.
9. Contractor shall promptly notify Human Services in the event in which it is a party
defendant or respondent in a case, which involves services provided under the agreement.
Exhibit A to the CWS-7A 2 Revised 6/2014
Attachment IV
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 Human Services'
Director. The term "litigation" includes an assignment for the benefit of creditors, and
filings in bankruptcy, reorganizations and/or foreclosure.
CONTRACTOR SHALL:
10. 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.
11. 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.
12. Actively participate in achieving the child's permanency goal, cooperate with any
contractors hired by Weld County Department of Human Services or Weld County
Department of Human Services staff to preserve placement in the least restrictive
placement appropriate, and comply with the treatment plan of the child.
13. 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.
14. Attend all necessary school meetings and support any plan that is developed regarding
the child in order to promote educational success.
15. 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.
16. Maintain, access and review information weekly on FIDOS.
17. 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.
18. 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.
19. Maintain/update medication logs on a daily basis, if child is taking medications.
20. Maintain behavior observation notes as required by the level of care assessed for each
child.
21. Assure and certify that it and its principals:
A. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal department
or agency.
B. Have not, within a three-year period of preceding this Agreement, been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
Exhibit A to the CWS-7A 3 Revised 6/2014
Attachment IV
offense in connection with obtaining, attempting to obtain, or performing a public
(federal, state, or local)transaction or contract under a public transaction;
C. 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;
D. 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.
E. 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.
22. 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 4 Revised 6/2014
Attachment IV
EXHIBIT B
NBC NEEDS BASED CARE ASSESSMENT)
question below please select the
Answers to the following questions will determine the NBC Care Payment. For each
II
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
complete the Medically fragile NBC)
❑ Emancipation Select One
❑ Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
❑ Education Select One
❑ Involvement with Child's Family Select One
Exhibit B to the Additional Provisions 5 Revised 6/2014
Attachment IV
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
zw
I
r " —R
F't..
1� }- 4 �- 1 i
{
County Basic �s Age 0I0...$16.73 $1214 ' $0.00
$.66 , No crisis intervention,Minimal ,x Not needed or cover
Maintenance - Age II-14...$18.50 A •r. CPA involvement,one face-to
Rate w Age 15-21...$19.75 s;_y ,r- under Medicaid : ,
_ F . face visit with child per month. ' (- .
It:,. rs�;
1z: $15.51
',..•,.
it $5.05 _.
c Minimal crisis intervention as :t x
(E, Regularly Scheduled , : $3.39
1 $20.22 t- $66 needed,one face-to-face visit Ir therapy up to 4
n, per month with child,2-3 " �- hours/month.
contacts per month
1 'A $23.59 $66 $17.19
e $18.88 $10.11
' r Occasional crisis intervention as Weekly scheduled �i�'"�
2 ''‘<
$26.96 , $66 needed,two face-to-face visits 7 therapy 5-8 hours a -4 $4.89
°}x with child,2-3 contacts per : month with 4 hours of 't
, group therapy.
o .�?. month ;::
2%, tak,, $30.33 $66 $20.56 ' +
'1s os
tr: $22.24 k $15.16 ra
r ,r"; `.' Regularly scheduled
' ''' r* Ongoing crisis intervention as weekly,multiple t'
r needed,weekly face-to-face
3 " $33.70 ` $66 sessions,can include .` $6.39
visits with child,and intensive
x .- more than I person Er
`. coordination of multiple '
`aa i.e.family therapy.for
;,_ services. 9-12 hours/monthly "-
3 1/2 $37.06 I' $66 3 $23.93 "_ - .-
O'.
C•. ,"
T $25 61 {
/' Ongoing crisis intervention as 1
4 x. 3d ca needed,which includes high
' Negotiated
RCCF $40.44 �A. $66 r level of case management and /. g
Drop Down �. ,; �': CPA involvement with child and
V', provider and 2-3 face to face ak '
contacts per week minimum. r
Assessment/ ''. a°. '.
Emergency $26.96 $66 $18.88 "a:
,y��
Level Rate •
Exhibit C to the Additional Provisions 6 Revised 6/2014
Attachment IV
County Foster Care Providers
2014-2015
PRiDUID R:M %ks 'PROVIDER ,ID MAILING Si® SCI «ATE Sa
1 Adams, Matthew and Karen 1647841 7917 Holly Springs Road Raleigh, NC 27606
2 Arnett, Casey and Lindsay 1614609 1545 Chickadee St. Loveland, CO 80537
3 Brown, Rachel 1640956 2809 W E. Street Greeley, CO 80631
4 Buck,Jamie and Lynne 1643264 6455 Chardonnay St. #3 Evans,CO 80620
5 Bunton, Sammy and Stephen 1642868 3405 Burlington Ave Evans, CO 80621
6 Calvillo,Vanessa and Jaebker, Ryan 1652850 4179 Plum Creek Loveland,CO 80538
7 Counts,Jessica and Lustgraaf, Bradley 1620400 6317 Union St. Arvada,CO 80004
8 Crews, Paul and Kimberly 1648992 407 7th Street Mead, CO 80542
9 Dreweck,Jeremy and Haley 1639704 2759 Empire Ave Loveland, CO 80534
10 Eckhardt, Shawna and Mitchell 1644218 505 54th Ave. Greeley, CO 80634
11 Egbert, Katie 1650079 214 14th Street SE Auburn, WA 98002
12 Erbacher, Dan and Hallie 1546381 3850 Cheyenne Dr Greeley,CO 80634
13 Fisher, Matthew and Claire 1532312 5022 W 2nd St Rd Greeley,CO 80634
14 Fitzpatrick,Thomas and Cheryl 1620996 324 Saturn Dr. Fort Collins, CO 80525
15 Fritz, Nancy and Aughe, Christopher 1539167 3925 Stampede Dr. Evans, CO 80620
16 Froggatte, Grant and Shelly 1601426 213 N 52nd Ave Greeley, CO 80634
17 Granquist, Derek and Jacqueline 1631597 281 E. Ilex Street Milliken, CO 80543
18 Grizzle, Phillip and Nicole 1629745 4380 W 23rd Street Dr. Greeley, CO 80634
19 Gutierrez, Elisa and Hoffer, Christopher 1519595 10101 W 13th St Rd Greeley, CO 80634
20 Hadley-Risler,Tamara and Risler,Jason 1631808 3717 Soderburg Dr Fort Collins, CO 80526
21 Hartness, Richard and Marlaena 1643348 15716 CR 40 Platteville, CO 80651
22 Hastings, Charles and Tambra 1646607 8436 Nashua Circle Wellington, CO 80549
23 Heard, John and Kimberly 1624256 109 Hunters Cove Dr. Mead, CO 80542
24 Heimer, Sara 1547292 3000 W 19th St Greeley, CO 80634
25 Hernandez, Roberto and Margarita 1520297 912 Elm Ct Fort Lupton, CO 80621
26 Hoeft, Kimberly 1603004 720 E. 3rd Street Eaton, CO 80615
27 Irwin,Jeremiah and Kasi 1644260 4544 Sunshine Circle Loveland, CO 80538
28 Johnson, Darrell and Linda 1625927 577 Voiles Dr. Brighton, CO 80601
29 Kirchoefer,John and Erin 1631599 1420 Snipe Lane Fort Collins, CO 80524
30 Kusluski, Gary and Selinda 1586228 4457 Firehawk Ct. Windsor, CO 80550
31 Land, Brad and Molly 1543324 1831 25th Ave Greeley, CO 80634
32 Maronek, Dennis and Patricia 1520627 2929 56th Ave Greeley, CO 80634
33 McCreery,James and Tammy 1612890 120 Maple Ave Eaton, CO 80615
34 Means, Nathan and Lisa 1601788 2632 15th Ave Greeley, CO 80631
35 Mena, David and Marie 1510691 2905 41st Ave Greeley, CO 80634
36 Miller, Linda 1628214 2034 Birch Ave Greeley, CO 80631
37 Miller, Pamela 1587465 5151 W 29th Street, Unit 2004 Greeley, CO 80634
38 Moran, Mitzi and Fisher, Jeff 1653562 40 Caballo Trail Greeley, CO 80634
39 Pierce, Larry and Kris 1586620 3017 54th Ave. Greeley, CO 80634
40 Pluma, Mike and Annette 35126 PO Box 34 Kersey, CO 80644
41 Roderick, Douglas and Kelli 10994 3110 57th Ave Greeley CO 80634
Attachment IV
y..?tom 'r u ; F^^�E"t t h .f R (�t$y((g. X r"�y °,
+2 .t. -, " f'{1 k DJZ,X�.�+1.� i < /., rR ,,,,, t 1L. j ,,,, H" ..g.,;1,4,! ..
��r �! ..org- �✓.,
,. :` �" art::
,{. X7�'� 4.,,„4.,,,,..,,4
4r �°
42 Serna, Leo and Carol 1597453 1020 Cottonwood Ave Windsor, CO 80550
43 Simmons, Michael and Hava 1645970 1117 Alpine Ct. Windsor,CO 80550
44 Sims, Mildred 1613448 5604 Troy Villa Blvd Dayton, OH 45424
45 Smith, Stephanie and Pults, Mark 1645696 25 Yukon St. Lakewood,CO 80226
46 Tauber, Nicole and Wright,Jon 1639129 3919 W. 22nd Street Greeley, CO 80634
47 Terry, Royce and Michael 1640696 166499E 42 Rd. Ringwood, OK 76768
48 Van Den Elzen, Dawn 44282 5819 W 16th St Ln Greeley, CO 80634
49 Wade, Michael and Jodyne 1554152 1016 Cottonwood Dr Windsor,CO 80550
50 Walker, Kurt and Jennifer 1546248 519 Trout Creek Ct Windsor, CO 80550-3194
51 Willert, Melody D and Lee, Kimberly 1540372 219 N 4th St LaSalle, CO 80645
52 Wurtz, Drew and Workman-Wurtz, Katherine 1633330 1901 15th Street Greeley, CO 80634
53 Wyatt,Justin and Tracy 1601806 418 Dogwood Ct. Eaton, CO 80615
54 Yearous, Lorilee and Courtney 1639678 1007 N 3rd Street iJohnstown,CO 80534
55 Yingling, David and Nicole 1639142 50151 County Road 15 Wellington,CO 80549
Attachment V
EXHIBIT A 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 «CPA_NAME», hereinafter referred to as, "Contractor."
I. County and Contractor agree that a child specific Needs Based Care Assessment,
designated in this exhibit as Exhibit B, shall be used to determine levels of care for each
child placed with Contractor.
2. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement, based on the Needs Based Care Assessment levels
determined. The specific rate of payment will be paid for each level of service, as
indicated by the Needs Based Care Rate Table, designated in this exhibit as Exhibit C, 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. For Children's Habilitation Residential Program (CHRP) waiver eligible children,
County agrees to pay the federal SSI rate to Contractor and all other service costs will be
billable under the CHRP program.
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.
agrees to cooperate with any vendors hired by County to shorten the duration
8. Contractor
g p
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 County.
Exhibit A to the SS23A 1 Revised 6/2014
Attachment V
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 Social Services Policy and Procedure Manual.
Exhibit A to the SS23A 2 Revised 6/2014
EXHIBIT B
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.
Pl. 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.
TI. How often are[hers, 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
o Verbal or Physical Threatening Select One
❑ Destructive of Property/Fire Setting Select One
❑ Stealing Select One
WM Self-injurious Behavior Select One
LeSubstance Abuse Select One
Presence of Ps chiatric S m.toms/Conditions Select One
• Enuresis/Encopresis Select One
o Runaway Select One
❑ Sexual Offenses Select One
❑ Inappropriate Sexual Behavior Select One
❑ Disruptive Behavior Select One
❑ Delinquent Behavior Select One
o Depressive-like Behavior Select One
Medical Needs-(If condition is rated"severe",please Select One
❑ complete the Medically fragile NBC)
❑ Emancipation Select One
IIII Eating Problems Select One
❑ Boundary Issues Select One
❑ Requires Night Care Select One
O Education Select One
O Involvement with Child's Family Select One
Exhibit A to the SS23A 3 Revised 6/2014
EXHIBIT B
WELD COUNTY DHS
Requested Services from Agency
Please indicate the sen ices that are requested for this child.
The following information will he reflected on the child specific contract.
(Please he 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 0 Physician Services/Coordination
❑ Interactive Group Therapy 0 Occupational Therapy
❑ Family Therapy ❑ Speech Therapy
❑ Psychological Testing Er Child Find
❑ Pharmacological Management ❑ Other:
❑ Treatment not funded by Medicaid Fee for Service: U Education:
❑ Home Based Intervention 0 On-Grounds School
❑ MST Multi-Systemic Therapy 0 Coordinate Assessment for Special Education
❑ Offense Specific Treatment ❑ Public School Attendance
0 Occupational Therapy
❑ Drug and Alcohol Treatment 0 Speech Therapy
❑ Attend Special Education Meetings
❑ Urine Analysis/Drug Screening/Breathalyzer 0 Other:
❑ Sexual Abuse Victimization Treatment 0 Visitation Coordination
❑ Independent Living Skills Training ❑ Monitor phone calls and correspondence
❑ Anger Management 0 Transportation for family/parent/child visits
❑ Behavior Modification Services ❑ Other:
❑ Behavioral Assessment ❑ Other:
❑ Recreation Services ❑ Interpreter Services
0 Case Management ❑ Other:
0 Attend Court Hearings
❑ Transportation: To include: ❑ Other:
Levels of Care:
Provider Level:
Case Management Level:
Therapy Level:
Date Staffed:
Participants:
Comments:
Exhibit A to the SS23A 4 Revised 6/2014
EXHIBIT C
Weld County Department of Human Service
Needs Based Care
Rate Table
(Effective 7/01/2014)
i.i,',3sii rit 4 r to s ,, . sor
� F ' 5i4da' t .,Y,. I: s
Y a" $12.14 ,
County Basic Age r: $0.00 g $66 1 No crisis intervention,Minimal Not needed or cover `,'-
Maintenance Age 11-14...$18.50 a- {. CPA involvement,one face to it
Rate --s. Age 15 21...$19.75 under Medicaid
' ' j,l
. face visit with child per month. -
. $15.51 $$ $5.05 ^h Minimal crisis intervention as a
Regularly Scheduled
1 . $20.22 .: $66 S., needed,one face-to-face visit therapy up to 4 ` $3.39
»'�ir; , "' per month with child,2 3 "`` hours/month m°1
•;
Yr, . contacts per month -
I '/ - $23.59 $.66 I. $17.19
": $18.88 : $10.11
Occasional crisis intervention as Weekly scheduled
2 $26.96 $66 ° therapy 5-8 hours a $4.89
needed,two face-to-face visits
'' + month with 4 hours of
with child,2-3 contacts per
1.! month ti group therapy.
2'/, $30.33 $.66 1 $20.56 .
4 $22.24 41k $15.16
le s'
Regularly scheduled
c Ongoing crisis intervention as it weekly,multiple s
needed,weekly face-to-face
3 e $33.70 $66 4 sessions,can include $6.39
Ifs, visits with child,and intensive more than 1 person.
r coordination of multiple
� i.e.family therapy,for
' , services. .,g} 9-12 hours/monthly.
3 1/2 si $37.06 Q $66 $23.93 I:tt P* g' �'$25.61 * {�
fit Ongoing crisis intervention as
4 needed,which includes high
RCCF $40.44 * $66 level of cast management and ` Negotiated
Drop Down s' F CPA involvement with child and D_ �'
provider and 2-3 face-to face ':
N
contacts per week minimum. .;
+y*+f , t k ? +z' .+ '{ $ e tY` ^f �yt 4,r4 ,r "s,k ". :kr . . q ' 'r t.
V,x}7'rt ..a'.n :',"'4-' a.,<, fi-; e ,e. . v ti:. r' �a'1� ".,, ? �a�.
Assessment/ Irii '�
Emergency • $26.96 $66 $18.88
t' ict
Level Rate
Exhibit A to the SS23A 5 Revised 6/2014
Attachment V
Child Placement Agency Providers
''1.,. 2014-2015 a
r h a ` ° S .t K us 't'{� I „ S, l' ., ,..i„,,_ ; ;,,,.,tYEx �. 5'�` ' 'z ti 11 74iJaP. f,s, hY:r ea x Y.a kE�d4 _4.::1..0,%;;;;7-14c
1 Adoption Options 45078 13900 East Harvard Ave,Suite 200 Aurora,CO 80014
2 Ariel Clinical Services 90205 4660 Wadsworth Blvd Wheat Ridge, CO 80033
3 Commonworks D.B.A. Synthesis 104085 9520 E.Jewell Ave,Suite C Denver, CO 80247
4 Denver Area Youth Services 45069 1530 W. 13th Ave Denver, CO 80204
5 Frontier Family Services 38041 1290 Boston Ave Longmont, CO 80501-5810
6 Hope & Home 29867 4945 N 30th Street,Suite 300 Colorado Springs, CO 80919-3152
7 Imagine! 21369 1400 Dixon Ave Lafayette,CO 80026
8 Kids Crossing 79752 1440 E Fountain Blvd Colorado Springs, CO 80910-3502
Kids Resource Network of
9 1508602 6285 Leham Dr.,Suite 101 Colorado Springs, CO 80918
Colorado Springs
Lutheran Family Services Rocky
10 45080 2032 Lowe Street, Suite 200 Fort Collins, CO 80525
Mountains
11 Maple Star Colorado 90967 2250 S Oneida Street, Suite 200 Denver, CO 80224-2557
12 New Start Youth Services LLC 1528224 PO Box 1932 Pueblo, CO 81002
13 North Metro Community Services 1613245 1185 W 124th Avenue Westminster, CO 80234
14 Parker Personal Care Homes Inc. 1512100 5394 Marshall Street Arvada, CO 80002
15 Quality Life Services LLC 32066 11975 Reed Street Broomfield, CO 80020
16 Smith Agency Inc. 44882 14394 E. Evans Ave Aurora, CO 80014-1408
17 Special Kids Special Families 43184 424 W Pikes Peak Ave Colorado Springs, CO 80905
18 Strong Foundations, LLC 1594056 1702 68th Ave Greeley,CO 80634
19 Whimspire CPA 19562 9540 E. Jewell Ave Denver, CO 80247
Attachment VI
EXHIBIT A 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."
I. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement at a rate of S«Ageney_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. County and Contractor agree that for Children's Habilitation Residential Program
(CHAP) waiver eligible children, the County agrees to pay the federal SSI rate to
Contractor and all other service costs will be billable under the CHRP program.
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 A to the SS23A 1 Revised 6/2014
Attachment VI
8. Contractor agrees to actively participate in achieving the child's Permanency Goal and
cooperate with any vendors hired by 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.
Y
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 A to the SS23A 2 Revised 6/2014
r
Attachment Vt
Group Home/Center Providers
2014-2015
i CE B NAME FACroITY' " IvfAII IISG AD13_4. 5' 44 C �' ; iPrier i
1 A Kidz Hope Homes Inc. 1531611 1401 W Colorado Ave Colorado Springs,CO 80904 $95.00
2 A Kidz Hope Homes Inc. 1531612 1401 W Colorado Ave Colorado Springs,CO 80904 $95.00
3 Evergreen Child Placement Agency 61317 1436 Hilltop Dr. Longmont,CO 80501 $131.77
4 Frontier Family Services 84655 1290 Boston Ave Longmont,CO 80501-5810 $73.01
5 Frontier Family Services 1526756 1290 Boston Ave Longmont,CO 80501-5810 $73.01
6 Griffith Center for Children 1531601 1724 Gilpin Street Denver,CO 80218 $115.00
7 Griffith Center for Children 1543863 1724 Gilpin Street Denver,CO 80218 $115.00
8 Kids Crossing 1534441 1440 E Fountain Blvd Colorado Springs,CO 80033 $92.05
9 Kids Crossing 1541496 1440 E Fountain Blvd Colorado Springs,CO 80033 $92.05
10 Kids Crossing 1551132 1440 E Fountain Blvd Colorado Springs,CO 80033 $95.34
11 Kids Crossing 1552984 1440 E Fountain Blvd Colorado Springs, CO 80033 $95.34
12 Kids Crossing 1590619 1440 E Fountain Blvd Colorado Springs,CO 80033 $92.05
13 Kids Crossing 1594381 1440 E Fountain Blvd Colorado Springs,CO 80033 $88.77
14 Kids Crossing 1597038 1440 E Fountain Blvd Colorado Springs, CO 80033 $92.05
15 Kids Crossing 1621890 1440 E Fountian Blvd Colorado Springs, CO 80033 $118.36
16 Kids Crossing 1623469 1440 E Fountain Blvd Colorado Springs, CO 80033 $92.05
17 Maple Star Colorado 13416 2250 S.Oneida Street,Suite 100 Denver,CO 80224 $86.00
18 Parker Personal Care Homes 1564088 5394 Marshall Street Arvada,CO 80002 $151.12
19 Parker Personal Care Homes 1598368 5394 Marshall Street Arvada,CO 80002 $146.90
20 Rocky Mountain Kids 1599810 2210 E. LaSalle Street,#219 Colorado Springs, CO 80909 $100.00
21 Rocky Mountain Kids 1599808 2210 E. LaSalle Street, #219 Colorado Springs, CO 80909 $93.67
22 Smith Agency 1540493 14394 E Evans Ave Aurora,CO 80014 $155.30
23 Strong Foundations, LLC 54150 1702 68th Ave Greeley,CO 80634 $71.74
Attachment VII
EXHIBIT A to the SS23A
Additional Provisions for the Agreement to Purchase
Out-of-Home Placement Services SS23A
For the Purchase of
Residential Child Care Facility Services
The following additional provisions apply to the agreement entitled, "Agreement to Purchase
Out-of-Home Placement Services SS23A, by and between the Board of County Commissioners
of Weld County, on behalf of the Weld County Department of Human Services," hereinafter
referred to as, "County," and «RCCF_NAME», hereinafter referred to as, "Contractor."
I. County agrees to purchase and Contractor, ID#«FACILITY_ID», agrees to provide:
A. Child Maintenance, Administrative Maintenance and Services, which are listed in
this Agreement at a rate of$«RCCF_RATE» per day for children placed within
the Residential Child Care Facility unless the child is eligible for the Children's
Habilitation Residential Program (CHRP). If the child is deemed CHRP eligible,
County agrees to pay the federal SSI rate to Contractor and all other service costs
will be billable under the CHRP program.
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 he subject to County monitoring as
outlined in Section VI of this contract:
a. Food. including meals and snacks (25%).
b. Clothing (3%).
c. Shelter, including utilities and use of household furnishing and equipment and daily
Exhibit A to the SS23A 1 Revised 6/2014
Attachment VII
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 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 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 A to the SS23A 2
Revised 6/2014
Attachment VII
RCCF/CHRP Providers
2014-2015
p t v,� f;k. i ,kx A73r i ' i 't' Y a i r3�1d. 3' Y G't
� �.' :' tt.15 ;‘pri-k,.ir+ ..a t .-Yt.-'4 S.t t Sl{ ...a. S.,..
I Smith Agency 6566 14394 E. Evans Ave Aurora, CO 80014 $155.30
2 Smith Agency 96482 14394 E. Evans Ave Aurora, CO 80014 $155.30
3 Roundup Fellowship 45105 3443 South Galena St, Suite 310 Denver, CO, 80231 $159.32
4 Roundup Fellowship 45201 3443 South Galena St, Suite 310 Denver, CO, 80231 $159.32
5 Roundup Fellowship 45211 3443 South Galena St, Suite 310 Denver, CO, 80231 $159.32
6 Roundup Fellowship 45212 3443 South Galena St, Suite 310 Denver, CO, 80231 $159.32
Attachment VIII
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 <<CENTER_NAME», hereinafter referred to as, "Contractor."
I. County agrees to purchase and Contractor agrees to provide the care and services, which
are listed in this Agreement at a rate of$60.82, per day for children placed within the
Group Home 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. 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 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 A to the SS23A I Revised 6/2014
Attachment VIII
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 A to the SS23A 2 Revised 6/2014
' Anaahmenl VIII
Group Home Providers
2014-2015
PROVIDER I lI)a;' AIvfAILTN GADS "x " 5 _ 4 yitoy rRffi '
I C&M Group Home 9875 1920 81st Ave Greeley,CO 80634 $60.82
2 Marie Alirez Group Home 70335 1405 26th Street Greeley,CO 80631 $60.82
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