PLACEMENT AGREEMENT
CLIENT'S NAME EFFECTIVE DATE
First Middle Last
This Agreement is entered into as of the effective date first written above by and between the "Facility", the "Parents", and the Placing "Placing Agency".
Definitions:
Facility: Catholic Charities St. Cloud Children's Home (SCCH)
Parents: The Parents or Legal Guardian of the Client first written above
Placing Agency: County Social Service Agency, Parents, Insurance Provider, School District, or Tribal Council that is financially responsible for services
Whereas, the Facility operates a residential treatment program and shelter licensed by the Minnesota Department of Human Services for boys and girls with emotional disturbances; and,
Whereas, the Facility has approved for admission and intends to accept this Client into its program for the purpose of providing residential treatment services and/or assessment services, according to the Facility's admission criteria; and,
Whereas, the Parents and/or Placing Agency have requested and approved this Client's admission into the Facility's program and has provided the Facility with the following admission materials;
1. Referral materials, including a current social history and list of previous services/placement and dates;
2. Medical history of the Client;
3. Physician’s orders for any and all medications Client is on;
4. Physical examination completed within thirty (30) days prior to admission;
5. Verification of the Client's age;
6. Complete immunization history, including tetanus and mantoux results;
7. Assurance that the Client cannot be maintained in a less restrictive environment within the community;
8. The legal status of the Client;
9. The Placing Agency's service plan to the Parents;
10. Educational materials of the Client;
11. Current psychological and/or psychiatric evaluations and reports;
12. A court order, if appropriate, on the Client;
13. A tentative discharge plan and living resource for the Client; and,
14. Verification of the Parent's application for social services from the Placing Agency, verification of insurance coverage from insurance company, or verification of parent ability to pay;
Whereas, the Facility believes services can most effectively be provided when certain agreements are understood and accepted by all the parties;
Thus, the parties mutually agree to the following:
I. GENERAL CONDITIONS of AGREEMENT:
A. Assurances: The Facility commits itself to the following assurances in its relationship to the Client, Parents and Placing Agency;
1. No Client shall be admitted to the Facility if in the judgment of the Facility the presence of the Client to be admitted will be damaging to the ongoing functioning of the group and/or the Clients already in care;
2. The Facility will not admit into its program or continue placement of any Client whose needs cannot adequately be met in its program;
3. The Facility will ensure that each Client, upon placement, is evaluated for communicable diseases, fever, rashes, bruises and injury; the Client will be asked if s/he has any health concerns and the results of these assessments shall be documented and maintained in the Client's records and utilized in designing a specific medical care plan;
4. The Facility will provide treatment services which are carefully planned in accordance with overall objectives of the Parents and which will appropriately serve the needs of the individual Client;
5. The Facility shall work together to the extent possible with the Parents as "partners" in its treatment delivery system;
a. The Facility shall have as its prime goal the return of the individual Client to the Parents and the community as quickly as possible and to provide the best possible care and assessment/treatment of the Client in order to increase the opportunities for successful program completion;
6. Each Client shall be assigned a Therapist at the Facility who will be the primary treatment coordinator for the Client's daily living program and who will be the primary contact person for the Parents and Placing Agency;
7. The Facility does not discriminate in its admission procedures on the basis of race, creed, color, religion, sex or national origin;
8. Assessment Service: The Facility will conduct a comprehensive assessment of the Client during the first 30 days of placement for adolescent residents and during the first 45 days of placement for preadolescent residents. A written assessment report will be developed within five business days of the end of the assessment period. The Client will be allowed to remain in Assessment services a maximum of 45 days without prior approval; Residential Treatment Service: The Facility will conduct a comprehensive assessment of the Client upon admission and on the basis of this assessment will develop, within ten (10) days of admission, a written, specific and goal-oriented individual treatment plan for the Client. This treatment plan shall be finalized in the Admission Assessment and Treatment Plan (AATP) and these plans and assessments shall be sent to the Placing Agency and Parents, as requested. These shall be reviewed and revised as frequently as necessary and at least quarterly during the Client's stay at the Facility;
9. The Facility will use methods and procedures in assessing the Client that are sensitive to the Client's age, ability, and cultural background;
10. The Facility prohibits all cruel and unusual punishment of children, including but not limited to the following:
a. The use of aversive conditioning techniques;
b. Locked seclusion room for reasons other than the Client's personal safety or the safety of those around the Client;
c. Punishments including any type of physical hitting;
d. Physical exercise used solely as a means of punishment;
e. Requiring the Client to take an uncomfortable position or forcing the Client to repeat physical movements when used solely as a punishment;
f. Withholding of any scheduled meal;
g. Denial of sufficient sleep;
h. Denial of clothing, shelter or bedding;
i. Extensive withholding of emotional response or stimulation;
j. Chemical or mechanical restraint;
k. Exclusion of the Client from entry to the Facility;
l. Assignment of unduly physically strenuous or harsh work;
m. Punishment which subjects the Client to verbal abuse, ridicule or humiliation;
11. The Facility will only use physical restraint to be documented in the Client's case record if the following situations warrant its use:
a. To end a disturbance that threatens physical injury to the Client;
b. To end a disturbance that threatens physical injury to others;
12. The Facility will not use psychotropic medications as a means of punishing or disciplining the Client;
13. The Parents and/or Placing Agency shall be involved in the decision to therapeutically use any psychotropic medication with the Client; the Facility shall obtain prior, informed consent for the use of any psychotropic medication from the Parents and/or Placing Agency;
14. All use of medications shall be authorized only by a licensed medical professional and recorded in the Client's case record;
15. The Facility shall allow all children the opportunity to participate in spiritual activities and services in accordance with the Client's faith or that of the Parents; the Facility shall provide or arrange transportation, when possible;
a. Clients shall not be coerced to participate in any spiritual activities, but may be encouraged to do so;
16. With prior arrangements, parents are encouraged to visit their Client at the Facility unless prohibited by a court order;
17. The Facility shall protect the confidentiality of the Parents, Client, and records and shall only release information to others when authorized to do so, in writing, by the Parents and/or Placing Agency, unless court ordered to do otherwise. The Facility conforms to the Minnesota Data Practices Act and HIPAA;
18. The Parents and/or Legal Guardians agree that for billing purposes, the Placing Agency and the Facility may use the family name. The Parents and/or Legal Guardian also agree to allow the Facility to release any and all information the Facility has obtained on the Client to insurance companies as required for processing insurance claims.
B. Client's Rights: The Facility adheres in its policies and procedures to certain rights of children receiving treatment services at the Facility. These rights are explained and distributed in the Resident/Parent Handbook at admission.
C. Parents' Rights: The Facility adheres in its policies and procedures to certain principles of the rights of Parents. These rights are explained and distributed in the Student/Parent Handbook at admission.
D. Basic Services: The basic services provided for by this Agreement shall be as follows:
1. Residential milieu treatment;
2. Special education services;
3. Assessments;
4. Individual assessment/treatment planning;
5. Recreational and social programming;
6. Title I, Speech and Occupational Therapy services, if indicated;
7. Psychiatric, psychological, medical and nutritional consultation, if indicated;
8. Casework services and family communication;
9. Routine (yearly) medical and dental checkups, to be the financial responsibility of the Parent or Placing Agency, if indicated;
10. Routine health care, nutritious meals and adequate clothing;
11. Individual, group and family therapy.
E. Additional Services: The following services may be provided by the Facility upon written authorization and acceptance of responsibility for payment by the Parents and/or Placing Agency.
1. Off-campus psychiatric, psychological or medical diagnosis, testing, or counseling;
2. Home visitation beyond insurance authorization;
3. Aftercare counseling services.
4. Additional clothing items needed to complete the basic wardrobe requirements at the time of admission (See Clothing Agreement).
5. Additional staff coverage in the event of a need for more individualized service plan to meet the specific needs of the Client and or/family.
F. Compensation:
1. According to the Master Lead County Contract, the Placing Agency is responsible to the Facility for the total cost of service incurred by the resident. Medical and Remedial care are an integral part of the Service Cost;
2. The unit cost for January1, 2014, through December 31, 2014, is as follows
(Intake Supervisor will insert rates here):
County Rate / Insurance RateResidential Treatment
Secure Residential Treatment
Assessment Services
3. Any financial arrangements or obligations on the part of the Client's Parents to the Placing Agency will be between the Client's Parents and the Placing Agency and will not involve the Facility;
4. Collection of applicable third party payments will be the responsibility of the facility unless otherwise specified at the time of placement by all parties;
5. The Agency of financial responsibility shall, within thirty (30) days of the date of receipt of the invoice, make payment to the Facility;
6. That vendor payments relative to the Client's medical, dental, optical care or “Additional Services” will be billed from the vendor to the responsible financial agency;
7. All educational costs are the financial responsibility of the Client's resident school district and will be billed separately to the resident school district.
8. When Placing Agency is an insurance company,
a. The Parents are responsible themselves or through their insurance company for all costs of medical, dental and optical services and/or prescriptions connected with these services;
b. The Parents are responsible themselves or through their insurance company, for the payment of the per diem fee;
c. The Parents are responsible for all initial clothing costs;
d. The Parents are responsible for seeking alternative funding if they or their insurance company are unable to cover all the costs. Insurance will not cover cost of placement after aging out of care coverage;
e. Prior to the commencement of services, a written statement from the insurance company will need to be received by the Facility indicating these costs will be covered;
f. The Facility will submit all costs incurred by the Client to the insurance company and the insurance company will submit payment to the assignee (St. Cloud Children's Home).
g. The Parents are responsible to see that all necessary intake materials are supplied to the Facility for evaluation. The Parents are responsible to sign all appropriate intake and placement forms prior to the placement.
G. Length of Agreement:
1. This Agreement, and as amended, shall remain in force for the duration of the Client's stay at the Facility;
2. The Parents authorize and agree that the Client will not be removed from the Facility without prior approval of the Facility and the Placing Agency unless determined by law enforcement;
3. As stated in the Master Lead County Contract, the Lead County Contract takes precedence over other County Agreements.
H. Changes: All parties may request changes in the provisions of this Agreement. Such changes, which are mutually agreed upon by and among all parties, shall be incorporated in written amendments to the original Agreement.
II. MEDICAL SERVICES
A. The Parents and Placing Agency agree to and authorize the following medical services and provisions:
1. Medical and dental care and planned surgery, in the best interest of the Client's health, as determined by the Facility's consulting physician and/or dentist;
2. Any emergency medical or dental treatment that may be necessary for the Client; the Facility shall always attempt to gain prior approval for any emergency treatment but all parties agree that this may not always be possible and, therefore, in the best interest of the Client's health, the Facility is authorized to provide for emergency care without prior approval if such approval cannot be reasonably gained and the Facility agrees to notify and gain approval of the Parents and/or Placing Agency as immediately as feasible without endangering the Client;
3. That similar medications the Client may be taking at the Facility be available to the Client at home visits and dispensed according to the physician's instructions by the Parents or custodian of care.
B. The Facility hereby agrees and confirms that it shall adhere to the following procedures and practices regarding medical services;
1. That the Client shall receive timely and competent medical care routinely, and when ill, that s/he will continue to receive necessary follow-up medical care;
2. That every effort will be made to maintain the Client in his/her normal environment during an illness;
3. That every effort will be made to ensure that if the Client requires glasses, a hearing aid, a prosthetic device or a corrective device, the necessary equipment or device will be provided;
4. To use competent, professional and qualified licensed medical or dental professionals to provide care or consultation regarding the Client's health needs;