HomeMy WebLinkAbout20140497.tiff MEMORANDUM
ik
X861 `°k
��� ----"
DATE: February 13, 2014
rte,
TO: Douglas Rademacher, Chair, Board of County Commissioners
E
1074--- 70
o---51)N T � FROM: Judy A. Griego, Director, Human S ices e� e
RE: Individual Provider Contract for B ose o Foster Care
Services and Foster Care Facility between the Weld
County Department of Human Services and Jeremy and
Haley Dreweck for Consent Agenda
Enclosed for Board approval is an Individual Provider Contract for Purpose of Foster
Care Services and Foster Care Facility Agreement between the Department and Jeremy
and Haley Dreweck. This was reviewed under the Board's Pass-Around Memorandum
dated January 21, 2014, and approved for placement on the Board's Agenda.
The major provisions for this Agreement are as follows:
No. Provider/Term Facility Type/Location Daily Rate
1 Dreweck, Jeremy and Haley Foster Home $16.32 - $40.11
November 27, 2013 —June 30, 2014 Loveland, Colorado
If you have questions, please give me a call at extension 6510.
Ray-A-1d0.O 2014-0497
2' 19 - N eCH..%d(usan r) Hee°5S
a/aa//9
INDIVIDUAL PROVIDER CONTRACT
FOR PURPOSE OF FOSTER CARE SERVICES
AND
FOSTER CARE FACILITY AGREEMENT
THIS AGREEMENT is made and entered into this ).7 day of 06u er 20 l 3,
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 ; Jeremy & Haley Dreweck,whose address is 2759
Empire Ave, Loveland, CO 80534,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 ,to and until
June 30,2014, 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 I Revised 6/2013
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 6/2013
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 6/2013
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 $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.
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:
1. To share all available information about the child, including relevant social,
medical and educational history, behavior problems, court involvement, parental,
sibling and relative visitation plans, and other specific characteristics of the child,
with the provider before placement and to share additional information when
obtained.
2. To inform the provider of expectations regarding the care of the child, such as
meeting medical needs, handling special psychological needs, and separation/loss
issues.
CWS-7A Individual Provider Contract 4 Revised 6/2013
3. To arrange for a medical examination of the child before placement or within 14
days after placement and give a copy of the completed form to the out-of-home
provider.
4. To give the provider a written record of the child's admission to the home at the
time of placement.
5. To give the provider a written procedure or authorization for obtaining medical
care for the child.
6. To involve the provider in service planning for the child as part of the overall
treatment team.
7. To give the provider a copy of the Family Services Plan for the child at the time
of placement or as soon as it is completed following placement.
8. To give at least two weeks notice of plans to remove a child from the facility. The
two-week notice may be waived by mutual consent to allow immediate removal
of said child for placement elsewhere, or without such waiver in the event of an
emergency. An emergency is defined as any situation in which a provider's
inability to provide services threatens the health, safety or welfare of children.
9. To pay the provider at the rates established by the State Department of Human
Services or as negotiated between the provider and the county. The rate of
payment per month shall be based on the type of facility and individual rates.
Payment shall be by warrant drawn by the duly authorized county officer.
10. To provide or arrange through statewide contracted training a minimum of twelve
hours of core certification training for family foster homes. The county
department is responsible for providing information on county specific
procedures.
11. To invite the provider to Administrative Reviews for Children in placement.
12. To incorporate provider information in planning for the child.
13. To assure that the service described herein has been accomplished and a record
made thereof on a case by case basis.
14. To provide notice of hearings.
C. At such time or as soon as possible after the acceptance of a child for services, the
County Department and the Provider shall verify foster care placement of each child
in writing on the required form, which shall become an addendum to this contract,
subject to all the terms and conditions hereof.
CWS-7A Individual Provider Contract 5 Revised 6/2013
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 Exhibits A, B, and C 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 and Exhibits A, B,
and C in writing, if agreed to by both parties. This Agreement and Exhibits A, B, and
C 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.
CWS-7A Individual Provider Contract 6 Revised 6/2013
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:
1. Are not presently debarred, suspended, proposed for debarment, and declared
ineligible or voluntarily excluded from covered transactions by a federal
department or agency.
2. Have not, within a three-year period of preceding this Agreement,been convicted
of or had a civil judgment rendered against them for commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, state, or local)transaction or contract under a public transaction;
violation of federal or state antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
3. Are not presently indicted for or otherwise criminally or civilly charged by a
government entity (federal, state, or local) with commission of any of the offenses
enumerated in paragraph (B) above.
4. Have not within a three-year period preceding this Agreement, had one or more
public transactions (federal, state, and local) terminated for cause or default.
CWS-7A Individual Provider Contract 7 Revised 6/2013
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 and Exhibits A and B. 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 6/2013
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: W. / , 1 • of Human Services
aC/do• ,
ir. 11
_�
D- uty Clerk to the :� ex .*�r�r �'nou ids Rad macher, Chair 1 g Z®,4
'J' ., : RACTOR:
Approval as to Substance: '' �o �'� ,1 ,t--_• ---- ll I I Zi(1
WELD COUNTY DEPARTM "N� temy & Haley Dreweck
OF HUMAN SERVICES 2759 Empire Ave /7/4
/ a Z /71/2-7/3
Loveland, CO 80534
n
By:Jil
Athit daer ,A 5 any:
C. jnty D#rector's or de'/gnee'r�) / •y Directors (or designee's) Signature
ig ature land Da and Date
2►oit -oa1
CWS-7A Individual Provider Contract 9 Revised 6/2013
EXHIBIT "A"
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 Jeremy & Haley Dreweck, hereinafter referred to as,
"Contractor."
GENERAL PROVISIONS
1. County and Contractor agree that a child specific Needs Based Care Assessment,
designated as Exhibit B, shall be used to determine levels of care for each child placed
with Contractor unless the child is placed in a County certified kinship foster care home
or if the child is placed in 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 on the Needs Based Care Rate Table, designated 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 each level of service, as
indicated by the Needs Based Care Rate Table, designated as Exhibit C, for children
placed within the Weld County Certified Foster Care Home identified as Provider
ID#1639704. 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 3 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.
C. Placement service reimbursement shall be paid from the date of placement up to,
but not including the day of discharge.
Exhibit"A"to the CWS-7A 1 Revised 6/2013
D. Transportation reimbursement shall be for visitation purposes only. If medical
transportation is needed, Contractor will arrange reimbursement through
Medicaid. Any other special requests for transportation reimbursement shall
require prior approval by the Resource Manager or the Department Administrator.
E. Clothing allowance reimbursement shall be approved and reimbursed as indicated
on the clothing allowance form accessed through the Foster Parents Database On-
line System (FIDOS).
6. It is expressly understood and agreed that the enforcement of the terms and conditions of
this Agreement, and all rights of action relating to such enforcement, shall be strictly
reserved to the undersigned parties or their assignees, and nothing contained in this
Agreement shall give or allow any claim or right of action whatsoever by any other
person not included in this Agreement. It is the express intention of the undersigned
parties that any entity other than the undersigned parties or their assignees receiving
services or benefits under this Agreement shall be an incidental beneficiary only.
7. No portion of this Agreement shall be deemed to constitute a waiver of any immunity the
parties or their officers or employees may posses, nor shall any portion of this Agreement
be deemed to have created a duty of care that did not previously exist with respect to any
person not a party to this Agreement. The parties hereto acknowledge and agree that no
part of this Agreement is intended to circumvent or replace such immunities.
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
have not been performed and which due to circumstances caused by the
Contractor cannot be performed or if performed would be of no value to the
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.
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.
Exhibit"A"to the CWS-7A 2 Revised 6/2013
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 the Foster Parents Internet Database
On-line System (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
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;
Exhibit"A"to the CWS-7A 3 Revised 6/2013
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 6/2013
EXHIBIT"B"
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE ASSESSMENT
ANSWERS TO THE FOLLOWING QUESTIONS WILL DETERMINE THE NEEDS BASED CARE PAYMENT
• For each question below,please select the response which most closely applies to this child.
THE FOLLOWING SEVEN QUESTIONS ARE MUTUALLY EXCLUSIVE:
P 1. How often does the child require transportation by the foster care Contractor for the following: Therapy; Medical
Treatment; Family Visitation; Extraordinary Educational Needs; etc.,as outlined in the treatment plan?
❑Basic Maint.)Less than one round trip a week 01)One round trip a week ❑I'h)2 round trips a week
02)3-4 round trips a week. ❑2'/:)5 round trips a week 03)6 round trips a week
❑3'%)7 round trips or more
Comments:
P 2. How often is the foster care Contractor required to participate in child's therapy or counseling sessions?
❑ Basic Maint.)No participation required 01)Once a month 01%)Two times month
❑2)Three times a month ❑2%:)Once a week ❑3)Two times a week
03%)Three times a week or more
Comments:
P 3. How much time is the Contractor required to intervene at home and/or at school with the child in conjunction with a regular
or special education plan?
❑ Basic Maint.)No educational requirements ❑1)Less than a'G,hour per day 011/2) 1/2 hour a day
❑2) 1 hour a day 02 1/2) 1'/z-2 hours per day 03)2'h-3 hours per day
03%)More that 3 hours per day
Comments:
P 4. How often does the child require special and extensive involvement by the Contractor in scheduling and monitoring of time
and/or activities and/or crisis management?
❑ Basic Maint.)No special involvement needed ❑1)Less than 5 hours per week ❑1'/n)5 to 7 hours per week
02) 8 to 10 hours per week ❑2'/) 11 to 14 hours per week
❑ 3)Constant basis during awake hours 03%)Nighttime hours
Comments:
P 5. How much time is the Contractor required to assist the child because of impairments beyond aee appropriate needs with
feeding,bathing,grooming,physical,and/or occupational therapy?
0 Basic Maint.)0-2 hours per week ❑1)3 to 4 hours per week ❑1'/)5 to 7 hours per week
❑2)8 to 10 hours per week ❑2'/:) 11 to 15 hours per week ❑3) 16 to 20 per week
❑3'%)21 or more hours per week
Comments:
A 1. How often is CPA/County case management required? (Does not include therapy)
0Basic Maint.)Face-to-face contact one time per month with child and no crisis intervention.
(i.e. mutual care placements.)
01)Face-to-face contact one time per month with child and minimal crisis intervention.
❑1%:)Face-to-face contact one time per month with child and occasional crisis intervention.
02)Face-to-face contact two times per month with child and occasional crisis intervention.
❑2%)Face-to-face contact three times per month with child and occasional crisis intervention.
03)Face-to-face contact weekly with child and occasional crisis intervention.
❑3'/)Face-to-face contact weekly with child and ongoina crisis intervention which may include intensive
coordination of multiple services.
**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 Contractor.
T 1. How often are therapy services needed to address child's individual needs per NBC assessment?
❑0)Not needed or provided by another source(i.e.Medicaid) ❑I)Less than 4 hours per month
❑2)4-8 hours per month ❑3)9-12 hours per month
Exhibit"B"to the Additional Provisions 5 Revised 6/2013
EXHIBIT"B"
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
BEHAVIOR ASSESSMENT
Please rate the behavior/intensity of conditions which create the need for services that a.ply to this child.
TMlllg 1 ? �¢ '�IIS ° ors, •.+ is »v
eck ma
b tegd r
Y�SS
1\O110 � f r8tt '1t
r
,� . � tray .
''.E
. Pte' yk r _w
. . . . .� ., r..._ 1 * "^� k,.. ..
Aggression/Cruelty to
Animals ❑ ❑ ❑ ❑ ❑ ❑ ❑
Verbal or Physical
Threatening ❑ ❑ ❑ ❑ ❑ ❑ ❑
Destructive of
Property/Fire Setting ❑ ❑ ❑ ❑ ❑ 0 ❑
Stealing
❑ ❑ ❑ ❑ ❑ 0 ❑
Self-injurious Behavior
❑ ❑ 0 0 ❑ ❑ ❑
Substance Abuse
❑ ❑ ❑ 0 ❑ 0 ❑
Presence of Psychiatric
Symptoms/Conditions ❑ ❑ ❑ ❑ ❑ ❑ 0
Enuresis/Encopresis
❑ ❑ ❑ ❑ 0 ❑ 0
Runaway
❑ ❑ ❑ ❑ ❑ ❑ ❑
Sexual Offenses
❑ ❑ ❑ ❑ ❑ ❑ ❑
Exhibit"B"to the Additional Provisions 6 Revised 6/2013
EXHIBIT"B"
WELD COUNTY DEPARTMENT OF HUMANS SERVICES
NEEDS BASED CARE
BEHAVIOR ASSESSMENT CONTINUED
Please rate the behavior/intensity of conditions which create the need for services that apply to this child.
- ' {`` Rating of„conditions : *- "
6e ea 1
., „ ,may t �'# 4'
Wit.
1.
N v h x ever ��.
Inappropriate Sexual
Behavior ❑ El ❑ ❑ El 0 ❑
Disruptive Behavior
❑ Cl ❑ ❑ ❑ El ❑
Delinquent Behavior
❑ ❑ ❑ 0 0 0 0
Depressive-like
Behavior ❑ ❑ ❑ El ❑ ❑ ❑
Medical Needs
(lf condition is rated ❑ ❑ ❑ ❑ ❑ ❑ ❑
"severe",please complete the
Medically fragile NBC)
Emancipation
❑ ❑ ❑ ❑ El ❑ El
Eating Problems
❑ ❑ ❑ ❑ ❑ ❑ ❑
Boundary Issues
❑ ❑ ❑ ❑ ❑ ❑ ❑
Requires Night Care
❑ ❑ ❑ ❑ ❑ ❑ El
Education
❑ ❑ ❑ El El ❑ ❑
Involvement with
Child's Family ❑ El El ❑ ❑ ❑ El
1 CHILD'S OVERALL LEVEL OF NEED FROM BEHAVIOR ASSESSMENT:
(check level of need) ❑ 0 ❑1 ❑ 1'/ ❑ 2 ❑ 2'/ ❑ 3 ❑ 31/2
Exhibit"B"to the Additional Provisions 7 Revised 6/2013
EXHIBIT "C"
WELD COUNTY DEPARTMENT OF HUMAN SERVICES
NEEDS BASED CARE
RATE TABLE
LEVEL' tr RVICE k r.1.4 etv , oRkv 10.
x- - P5 ,!
� r�� vb Y N 'Mk}' •.
' aievei y + „ Chid t1 .nrcatl 6 tl 4. 414
Age 0-10...$16.32/day
County Basic Age 11 -14...$18.05/day
Maintenance = `
Rate
Age 15-21 ...$19.27/day
+ Respite Care $.66/day
$19.73
1 +$.66 Respite Care
($20.39 day)
$23.01
1 1/2 :£ +$.66 Respite Care
(523.67 day)
$26.30
2 +$.66 Respite Care
($26.96 day)
$29.59
2 1/2 +$.66 Respite Care
($30.25 day)
$32.88
3 +$,66 Respite Care
jv ($33.54day)
$36.16
a.
3 1/2 't +$.66 Respite Care
($36.82 day)
4 $39.45
RCCF Drop Down +$.66 Respite Care
($40. 11 day)
$29.59
Assessment/Emergency +$.66 Respite Care
Rate ($30.25 day)
Effective 7/01 /2008
Exhibit "C" to the Additional Provisions 8 Revised 6/2013
Hello