HomeMy WebLinkAbout920919.tiff RESOLUTION
RE: APPROVE CONTRACT WITH COLORADO DEPARTMENT OF HEALTH FAMILY AND COMMUNITY
HEALTH SERVICES DIVISION AND AUTHORIZE CHAIRMAN TO SIGN
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 a Contract between Colorado
Department of Health Family and Community Health Services Division and Weld
County Health Department, commencing October 1, 1992, and ending September 30,
1993, with the further terms and conditions being as stated in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said
contract, a copy of which is attached hereto and incorporated herein by
reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Contract between Colorado Department of Health Family
and Community Health Services Division and Weld County Health Department be, and
hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by� the following vote on the 23rd day of September, A.D. , 1992.
�o/U gag EBOARD OF COUNTY COMMISSIONERS
ATTEST: r WEL�Y, COLORADO
Weld County Clerk to he Board yy !
7 Geor e Ke:tiiedy, Chairman +
BY:
I _r0":7 2'a-%. r
Deputy Clerk to the Boa d Constance L. Harbert, Pro-Tem
APPROVED AS T FORM:
C. W. Ki by
County Attorney Gor . L cy
1
W. H. Webster
920919
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•
DEPARTMENT OR AGENCY NUMBER
260000 -- FAA
CONTRACT ROUTING NUMBER
CONTRACT
THIS CONTRACT, Made this 3rd day of September 199 , by and between
the State of Colorado for the use and benefit of the Department of •1 Health.
Family and Community Health Services Division. Handicapped Children's
Program/Children With Special Health Care Needs. 4210 East 11th Avenue. Denver.
Colorado 80220 hereinafter referred to as the State or Program, and •z Weld
County Health Department . 1517 16th Aveune Court. Greeley. Colorado 80631
hereinafter referred to as the contractor,
WHEREAS, authority exists in the Law and Funds have been budgeted,
appropriated and otherwise made available and a sufficient unencumbered balance
thereof remains available for payment in Fund Number 100 , APPR code 607 ,
Contract Encumbrance Number FAA HCP 930426 ; and
WHEREAS, required approval, clearance and coordination has been
accomplished from and with appropriate agencies; and
WHEREAS, *3 the State has formulated a comprehensive State Plan to carry
out the Handicapped Children's Program/Children With Special Health Care Needs
(HCP) , funded by Federal Health and Human Services funds; and
WHEREAS, said comprehensive State Plan and Federal budget allocates funds
to be utilized for the implementation of the Program through various agencies in
order to provide these health care services to the people of Colorado; and
WHEREAS, the Contractor is considered by the State to be an appropriate
agency to provide the services to the Program as herein set forth.
NOW THEREFORE, it is hereby agreed that for and in consideration of their
mutual promises to each other, hereinafter stated, the parties hereto agree as
follows:
1. *4 The Contractor will provide the following services on behalf of
the Handicapped Children's Program:
A. Casefinding and community outreach as described in the Public
Health Nursing Process Standards for Handicapped Children's
Program, Attachment A, which by this reference is made a part
hereof.
B. Assure that all children who are Medicaid eligible are
enrolled in Title XIX Medicaid. Contractor will review all
children for Medicaid eligibility and assist those who appear
eligible but are not enrolled in completing and facilitating
the application process.
Page 1 of 7 pages
*(Sias instructions an reverse of last pass) 920919
C. Management of existing HCP clinics; participation with HCP
clinics and patients as described in Attachment A.
D. Evaluation of appropriateness of caseload and other related
HCP activities as described in Attachment A.
E. Provide case management services to selected HCP patients as
described in Attachment A.
2. The Contractor will serve a caseload of 269 children to include
clinic and nursing services.
3. The Contractor will submit a final review report, as requested by
the State, due by August 1, 1993.
4. The Contractor will cooperate with and provide all requested
records regarding recipients for whom services were provided under
this contract at the time that periodic chart audits occur.
5. The Contractor will submit data to the State utilizing the ADD's:5
data system.
6. Title V funds may not be used to pay for any item or service
(other than an emergency item or service) furnished by an
individual or entity convicted of a criminal offense under the
Medicare or any State health care program (i .e. , Medicaid,
Maternal and Child Health, or Social Services Block Grant
programs) .
7. The State will , in consideration of said services by the
Contractor, cause to be paid to the Contractor an amount not to
exceed THREE THOUSAND EIGHT HUNDRED SEVENTY-THREE DOLLARS AND ZERO
CENTS ($3,873.00) in the following manner:
Upon receipt of signed monthly statements, submitted in duplicate,
to FAMILY AND COMMUNITY HEALTH SERVICES DIVISION. HANDICAPPED
CHILDREN'S PROGRAM requesting reimbursement, Attachment B, and by
this reference made a part hereof, and conditioned upon
affirmation by the State Handicapped Children's Program that
services and reports were rendered in accordance with this
contract.
8. Contractor agrees to provide services to all program participants
and employees in a smoke—free environment. Smoking may not be
permitted in waiting areas, examination rooms, formal sessions
providing education, therapy, or similar services. Designated
smoking areas may be established for staff, program participants,
family members, and visitors. These designated areas should be
well ventilated in order that the waiting area and the service
environment remains smoke—free.
9. A. No charges will be made to families for care coordination/
case management regardless of income.
Page 2 of 7 pages 920919
B. Charges for services including attendance at specialized
clinics must conform to the HCP Clinic Charge Schedule,
Attachment C, and by this reference made a part hereof.
10. A. No Federal appropriated funds have been paid or will be paid
by or on behalf of the State, to any person for influencing
or attempting to influence an officer or employee of any
agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in
connection with the awarding of any Contract, and the
extension, continuation, renewal , amendment, or modification
of any Contract, grant, loan or cooperative agreement that
utilizes Federal funds.
B. If any funds other than Federal appropriated funds have been
paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency,
a Member of Congress, an officer or employee of Congress in
connection with this Federal Contract, grant, loan, or
cooperative agreement, the Health shall complete and submit
Standard Form - LLL, "Disclosure Form to Report Lobbying",
in accordance with its instructions.
11. The Contractor certifies, by submission of this Contract, that
neither it nor its principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal
department or agency.
12. The Contractor shall protect the confidentiality of all applicant/
recipient records and other materials that are maintained in
accordance with this contract. Except for purposes directly
connected with the administration of this Program/Project, no
information about or obtained from any applicant/recipient shall
be disclosed in a form identifiable with the applicant/recipient
without the prior written consent of the applicant/recipient or
a minor's parent or guardian or as otherwise properly ordered by
a court of competent jurisdiction. The Contractor shall have
written policies governing access to duplication and dissemination
of all such information. The Contractor shall advise its
employees, agents, servants, and subcontractors, if any, that they
are subject to these confidentialities.
13. The term of this contract is beginning October 1, 1992 and ending
September 30, 1993.
Page 3 of 7 pages 920919
•
COLORADO DEPARTMENT OF HEALTH - hereinafter, under the General Provisions referred to as
"Health" .
GENERAL PROVISIONS -- page 1 of 2 pages
I. The contractor shall performIts duties hereunder as an independent contractor and
not as an employee. Neither the contractor nor any agent or employee of the contractor
shall be or shall be deemed to be an agent or employee of the • state. Contractor shall
pay when due all required employment taxes and income tax withholding. shall provide and
keep in force worker's compensation (and show proof of such insurance) and unemployment
compensation insurance in the amounts required by law. • Contractor will be solely
responsible for its acts and the acts of its agents, employees, servants and
subcontractors during the performance of this contract.
2. Contractor authorizes Health, or its agents, to perform audits and to make
inspections for the purpose of evaluating performance under this contract.
3. Either party shall have the right to terminate this agreement by giving the ocher
party thirty days notice by registered mail, return receipt requested. If notice is so
given, this agreement shall terminate on the expiration of the thirty days, and the
liability of the parties hereunder for the further performance of the terms of this
agreement shall thereupon cease, but the parties shall not be relieved of the duty co
perform their obligations up to the dace of termination.
4. This agreement is intended as the complete integration of all understandings
between the parties. No prior or contemporaneous addition, deletion, or ocher amendment
hereto shall have any force or effect whatsoever, unless embodied herein in writing. No
subsequent novation, renewal, addition, deletion, or other amendment hereto shall have
any . force' or effect unless embodied in a written contract executed and approved pursuant
• .co the Scare Fiscal Rules: '
5. If this contract involves the expenditure of federal funds, this contract is
contingent upon continued availability of federal funds for payment pursuant co the
terms of this agreement. Contractor also agrees to fulfill the requirements of:.
a) Office of Management and Budget Circulars A-87, A-21 or A-122, and A-102 or
A-110, whichever is applicable;
b) the Hatch Act (5 USC 1501-1508) and Public Law 95-454 Section 4728. These
statutes state that federal funds cannot be used for partisan political purposes of any
kind by any person or organization involved in the administration of federally-assisted
programs;
c) the Davis-Bacon Act (40 Scat. 1494, Mar. 3, 1921, Chap. 411, 40 USC
276A-276A-5) . This act requires that all laborers and and mechanics employed by
contractors or sub-contractors to work on construction projects financed by federal
assistance must be paid wages not less than those established for the locality of the
project by the Secretary of Labor;
d) 42 USC 6101 et seq, 42 USC 2000d, 29 USC 794. These acts require that no
person shall, on the grounds of race, color, national origin, age, or handicap, be
excluded from participation in or be subjected to discrimination in any program or
activity funded. in whole or in part, by federal funds; and
Page 4 of 7 Pages
Rev. 06/01/92
920919
' GENERAL PROVISIONS--Page 2 of 2 pages
e) the Americans with Disabilities Act (Public Law 101-336; 42 USC 12101, 12102,
12111 - 12117, 12131 - 12134, 12141 - 12150, 12161 - 12165, 12181 - 12189, 12201 - 12213
and 47 USC 225 and 47 USC 611.
f) if the contractor is acquiring real property and displacing households or
businesses in the performance of this contract, the contractor is in compliance with the
Uniform Relocation Assistance and Real Property Acquisition Policies Act, as amended
(Public Law 91-646, as amended and Public Law 100-17, 101 Stat. 246 - 256) ;
g) .when applicable, the contractor is in compliance with the provisions of the
"Uniform' Administrative Requirements for Grants and Cooperative Agreements to State and
Local Governments (Common Rule) .
• 6. By signing and submitting this contract the contractor states chat:
a) the contractor is in compliance with the requirements of the Drug-Free
Workplace Acc (Public Law 100-690 Title V, Subtitle D, 41 USC 701 et seq.) ;
b) ' the contractor ' is not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from covered transactions by any federal
department or agency; and
• 7. To be considered for payment, billings for payment pursuant to this contract must
be received within 60 days after the period for which payment is being requested and
final billings on the contract must be received by Health within 60 days after the end
of the contract term.
8. If applicable, Local Match is co be submitted on the monthly payment statements, in
the column provided, as required by• the funding source.
9. -. If Contractor receives $25;000.00 .or more per year in federal funds in the
aggregate from Health, Contractor agrees to have an annual audit, by an independent
certified public accountant, which meets the requirements of Office of Management and
Budget Circular A-128 or A-133, whichever applies. If Contractor is required co submit
an annual indirect cost proposal to Health for review and approval, Contractor's auditor
will audit the proposal in accordance with the requirements of OMB Circular A-87, A-21
or A-122. Contractor agrees to furnish one copy of the audit reports to the Health
Department Accounting Office within 30 days of their issuance,. but not later than nine
months after the end of Contractor's fiscal year. Contractor agrees co take appropriate
corrective action within six' months of the report's issuance in instances of
noncompliance with federal laws and regulations. Contractor agrees co permit Health or
its agents to have access to its records and financial statements as necessary, and
further agrees to retain such records and financial statements for a period of three
years after the date of issuance of the audit report. This contract does
contain federal funds as of the date it is signed. This requirement is in addition to
any other audit requirements contained in other paragraphs within this contract.
' 10. Contractor agrees to not use federal funds to satisfy federal cost sharing and
matching requirements unless approved in writing by the appropriate federal agency. .
Page 5 of 7 Pages
920919
Rev. 06701/92
•
Peres 01-AC-021I
SPECIAL PROVISIONS •
•
CONTROLLER'S APPROVAL
1. This contract shall not be deemed valid until it shall have been approved by the Contmllerofthe State of Colorado or such assistant as he may designate.This
provision is applicable to any contract involving the payment of money by the State. _
FUND AVAILABILITY
2, Financial obligations of the Sate payable after die current fiscal year are contingent upon funds for that purpose being appmpfated budgeted and otherwise
made available. -
BOND REQUIREMENT •
3. Ifthis contract involves the payment of more than fifty thousand dollars for the construction,erection,repair.maintenance,or improvement of any building,
road bridge,viaduct tunnel.excavation or other public works for this State,the contractor shall,before entering the performance of any such work included in this
contract,duly execute and deliver to and file with the official whose signature appears below for the State,a good and sufficient bonds other acceptable surety to be
approved by said official in a penal sum not less than one-half of the total amount payable by the terms of this contract.Such bond shall be duly executed by a
qualified corporate surety,conditioned for the due and faithful performance of the contract,and in addition,shall provide that lithe contractor or his subcontractors
fail to duly pay for any labor,materials,team hire,sustenance.provisions.provendor or other supplies used orconsumed by such contactor or his subcontractor in
performance of the work contracted to be done,the surety will pay the same in an amount not exceeding the sum specified in the bond,together with interest at the
rate of eight per cent per annum.Unless such bond,when so required,is executed,delivered and filed,no claim in favor of the contractor arising under this contract
shall be audited,allowed or paid.A certified or cashiers check or a bank money order payable to the Treasurer of the State of Colorado may be accepted in lieu of a
bond.This provision is in compliance with 38-26-106 CRS, as amended.
INDEMNIFICATION
4. To the extent authorized by law,the contractor shall indemnify,save and hold harmless the State,its employees and agents,against any and all claims,
damages,liability and court awards including costs,expenses,and attorney fees incurred as a result of any act or omission by the contractor,or its employees.
agents,subcontractors,or assignees pursuant to the terms of this contract.
DISCRIMINATION AND AFFIRMATIVE ACTION
5. The contractor agrees to comply with the letter and spirit of the Colorado Antidiscrimination Act of 1957,as amended,and other applicable law respecting
discrimination and unfair employment practices(24-34-402.CRS 1982 Replacement Vol.),and as required by Executive Order.Equal Opportunity and Affirma-
tive Action,dated April 16, 1975.Pursuant thereto, the following provisions shall be contained in all State contracts or sub-contracts.
During the performance of this contract.the contractor agrees as follows:
(1) The contractor will not discriminate against any employee or applicant for employment because of race,creed.color,national origin,sex,marital status,
religion,ancestry,mental or physical handicap,or age.The contractor will take affirmative action to insure that applicants are employed,and that employees are
treated during employment,without regard to the above mentioned characteristics.Such action shall include,but not be limited to the following:employment,
upgrading,demotion,or transfer,recruitment or recruianent advertising;lay-offs orterminationr rates of pay or other forms of compensation;and selection for
training,including apprenticeship.The contractor agrees to post in conspicuous places,available to employees and applicants for employment.notices to be pro-
vided by the connoting officer setting forth provisions of this noa4isabnination clause.
(2) The contractor will,in all solicitations or advertisements for employees placed by or on behalf of the contractor.state that all qualified applicants will receive
consideration for employment without regard to race,creed color,national origin,sex,marital status, religion. ancestry, mental or physical handicap,or
age.
(3) The contractor will send to each labor union or representative of workers with which he has collective bargaining agreement crochet contracorunderstand-
ing,notice to be provided by the contracting officer,advising the labor union or workers'representative of the contractor's commitment under the Executive
Order.Equal Opportunity and Affirmative Action,dated April 16, 1975,and of the riles,regulations,and relevant Orders of the Governor.
(4) The contractor and labor unions will furnish all information and reports required by Executive Order,Equal Opportunity and Affirmative Action of April l6.
1975.and by the riles,regulations and Orders of the Governor.orpursuant thereto,and will permit access to his books,records,and accounts by the contracting
agency and the office of the Governor or his designee for purposes of investigation to ascertain compliance with such rules,regulations and orders.
(5) A labor organization will not exclude any individual otherwise qualified from full membership rights in such labor organization.or expel any such individual
front membership in such labor organization or discriminate against any of its members in the full enjoyment of work opportunity,because of race.creed,color.
sex,national origin.or ancestry.
(6) A labor organization,or the employees or members thereof will not aid,abet,incite,compel or coerce the doing of any act defined in this contract to be dis-
criminatory or obstruct or prevent any person from complying with the provisions of this contract or any order issued thereunder or attempt either directly or
indirectly,to commit any act defined in this contract to be discriminatory.
•
39543.01-1022
•
Revised 1/88 page of—2_pages Oero-]}essaa
920919
•
Form 6-AC-02C
(7) In the event of the contractor's non-compliance with the non-discrimination clauses of this contractor or with any of such rules,regulations.or orders.this
contract may be cancelled,terminated or suspended in whole or in part and the contractor may be declared ineligible for further State contracts in accordance
with procedures,authorized in Executive Order,Equal Opportunity and Affirmative Action of April 16.1975 and the rules,regulations,or orders promulgated
in accordance therewith,and such other sanctions as may be imposed and remedies as may be invoked as provided in Executive Order,Equal Opportunity and
Affirmative Action of April 16. 1975,or by rules,regulations, or orders promulgated in accordance therewith;or as otherwise provided by law.
(8) The contractor will include the!envisions of paragraph(1)through(8)in every sub-contract and subcontractor piuthase order unless exempted by ruin.
regulations,or orders issued pursuant to Executive Other,Equal Opportunity and Affirmative Action of
upon each subcontractor or vendor.The contractor will take such action withApril ng or purchase rcs so that such Pro ntrans will a binding
respect to any ided,however,
int order axone actor a co agency
dircR as a meant of enforcing such provisions,including sanctions for ton-comphianeat provided, that in the event the contractor becomes involved
in.or is threatened with,litigation with the subcontractor or vendor as a result of such direction by the contracting agency,the contractor may request the State
of Colorado to enter into such litigation to protect the interest of the State of Colorado.
COLORADO LABOR PREFERENCE
6a. Provisions of 8-17-101&102,CRS for preference of Colorado labor are applicable to this contract if public works within the State are undertaken hereun-
der and are financed in whole or in pan by State funds.
b. When construction contract for a public project is to be awarded to a bidder,a resident bidder shall be allowed a preference against a non-resident bidder
from a state or foreign country equal to the preference given or required by the stain or foreign country in which the non-resident bidder is a resident.If it is deter-
mined by the officer responsible for awarding the bid that compliance with this subsection.06 may cause denial of federal funds which would otherwise be avail-
able or would otherwise be inconsistent with requirements of federal law,this subsection shall be suspended,but only to the extent necessary to prevent denial of
the moneys or to eliminate the inconsistency with federal requirements(section 8-19-101 and 102.CRS).
GENERAL
7. The laws of the State of Colorado and rules and regulations issued pursuant thereto shall be applied in the interpretation,execution and enforcement of this
contract.Any provision of this contract whether or not incorporated herein by reference which provides for arbitration by any extra-judicial body or person or
which is otherwise in conflict with said laws,rules and regulations shall be considered null and void.Nothing contained in any provision incorporated herein by
reference which purports to negate this or any other special provision in whole or in part shall be valid or enforceable or available in any action at law whether by
way of complaint.defense orotherwise.Any provision rendered null and void by the operation of this provision will not invalidate the remainder of this contract to
the extent that the contract is capable of execution.
8. At all times during the performance of this Contract,the Contractor shall strictly adhere to all applicable federal and state laws,rules and regulations that
have been or may hereafter be r.r.hluhM
9. The signatories hereto aver that they are familiar with 18-8-301,a.seq.,(Bribery and Corrupt Influences)and 18-8.401,et.seq.,(Abuse of Public Office),
CRS 1978 Replacement Vol., and that no violation of such provisions is present.
10. The signatories aver that to their knowledge, no state employee has a personal or beneficial interest whatsoever in the service or property
described herein:
IN WITNESS WHEREOF,the parties hereto have executed this Contract on the day first above written.
Contractor.
(Full Legal Name) Weld County Board
STATE OF COLORADO
of Co 'oners ROY ROMER, GOVERNOR
BY for
B EXECV77VE DIRECTOR.
Position(Tide) Chairman
84-6000813
Sant Maker or Fears LD.Mann,c)/ o t a- DEPARTMENT
(If Corporation:)
OF HEALTH
WELD CO HEALTHDEPARTMENT
Aaest (Seal)
BY: A
By Randolph rdon, M.D. , M.P.H.
Connect Seeman.a Egan ,Ta.a/CuwCwwr Clerk Director
APPROVALS
ATTORNEY GENERAL CONTROLLER
By By
PROGRAM APPROVAL:/7/L7Ce
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M X72091
COLORADO DEPARTMENT OF HE. CH
HANDICAPPED CHILDREN'S PROGRAM/
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
ANNUAL NURSING REPORT
COUNTY DATE
REPORTING PERIOD TO
1. # Current open cases Target Population
2. # Cases opened past 12 months: New Reopen
3. # Cases closed past 12 months:
4. # Clients in county requiring complex PHN intervention:
Total current
Opened past 12 months
Closed past 12 months
5. # HCP clinics staffed by PHN's in past 12 months and time required:
CLINIC TYPE DATES TIME/CLINIC INCLUDING
PRE & POST TIME
Page 5 of 10 pages 920919
6. Time (if available ipent in follow-up of chil an not seen in HCP clinics.
•
7. Please list any activities you or your agency have performed in your
community on behalf of HCP this past year (newspaper articles, speeches,
posters, legislative/county commissioner contacts, etc.) . Include examples:
8. Please list 2 - 3 suggestions for changes in HCP which you would like to see
us attempt to implement (clinics, changes in eligibility requirements and
diagnoses covered, etc. ) :
9 . Please give 2 - 3 goals or objectives which you would like to achieve for.
clients in your HCP caseload during the upcoming years:
10. After reviewing the goals and objectives which you established for your HCP
Program last year and the HCP portion of the MCH Block grant, please comment
on your successes as well as the goals and objectives you were unable to
meet.
Thank you!
Page 6 of 10 pages szosis
COLORADO DEPARTMENT OF HEI H
HANDICAPPED CHILDREN'S PROGRAM/
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
Record Audit Tool: for use with all nursing records for HCP registered children.
County HCP Chart #
PME Child's Birth date
Reviewer Primary Physician
Review Date Diagnosis
HCP Clinics attended (if applicable #:
Type:
AUDIT CRITERIA YES NO N/A COMMENTS
FORMS/GENERAL INFORMATION
Completed registration; includes
brief summary of nursing assess-
ment, diagnosis and plan.
Copy of Acceptance letter
Past Medical Record
Current Medical Evaluation of
Handicapping Condition
Consent forms signed
Current Information:
Lab Reports
Therapy Reports
Other Agencies Reports
School Reports
Medication (i.e. , flow charts for
anticonvulsants)
Clinic Reports with Worksheets
Attached
PRIMARY CARE:
Well Child Care
Source (CHC, MD, HMO identify)
Growth, HC Graphs
Immunizations current
Nutrition evaluation
Dental screen
Other screening as age appropriate
Page 7 of 10 pages 920919
COLORADO DEPARTMENT OF HEA H
HANDICAPPED CHILDREN'S PROGRAM/
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
AUDIT CRITERIA YES NO N/A COMMENTS
NURSING CARE:
Initial assessment in SOAP Format
(includes psychosocial and family
assessment) PHN-5c, 7, 11, or
HCP 1000 may be used) *
Assessment updated yearly or as
appropriate in SOAP Format
Documentation of PHN Follow-up
(i.e. , phone calls, home visits,
chart review)
Referrals as appropriate
Contact with other agencies
Documentation of communication
with other health care team members
RECORD ORGANIZATION:
According to suggested HCP format
A tracking system consistent with
records for follow-up care
Cross reference to other clinic
files
920919
Page 8 of 10 pages
COLORADO DEPARTMENT OF HE rH
HANDICAPPED CHILDREN'S PROGRAM/
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
PUBLIC HEALTH NURSE REPORT
FROM: (PHN) COUNTY DATE
RE: B.D. PARENTS
ADDRESS: PHONE: M.D.
DIAGNOSES: Nursing SSI YES NO
Medical Medicaid YES NO
FOR PERIOD: / / to / / NUMBER OF VISITS: Home
Clinic
Agency
(See directions on back for completion)
ASSESSMENT:
STRENGTHS & PROBLEMS IDENTIFIED INTERVENTIONS & RESULTS (past 6 months)
PLANNED INTERVENTIONS (next 6 months)
NUTRITION ASSESSMENT: RESULTS & PLAN
Done
Not Done
CARE PROVIDERS AND DATE LAST SEEN (if nown) COMMUNITY AGENCIES INVOLVED
MEDICATIONS IMMUNIZATIONS HOSPITALIZATIONS/SURGERIES (past 6 months)
Complete
Incomplete
PHN SIGNATURE
Page 9 of 10 pages 920919
Directions for complet_ ,n of HCP Complex Nursing .report (suggested areas to
evaluate/address) .
I. NURSING CARE PLAN
A. ASSESSMENT: STRENGTHS & PROBLEMS IDENTIFIED
1. Treatment regime: status and outcome or progress.
2 . Growth and development.
3 . Psychosocial adjustment of client and family, and family coping.
4 . Parent - child relationship.
4 . Primary care status of client - including well-child care, nutrition,
and dental care.
B. INTERVENTIONS AND RESULTS FOR PREVIOUS 6 MONTHS
1. Include nursing interventions attempted related to teaching of client
and family regarding handicapping condition, anticipatory guidance
provided, referrals made, coordination of services, and efforts related
to primary care service.
C. PLANNED INTERVENTIONS FOR NEXT 6 MONTHS
1. List 1-2 desired outcomes and specific objectives for obtaining these
outcomes based on problems identified in (A) . Try to be realistic in
number and scope of interventions selected. The client and family
should be involved in setting these outcomes and objectives.
II. OTHER PERTINENT INFORMATION
A. MEDICATIONS
1. List current prescription and regularly utilized over the counter
drugs.
B. NUTRITION ASSESSMENT
1. Refers to HCP Nutrition Assessment tool (not pre-screen questionnaire) .
If not done, please state why under "Results and Plan. "
C. CARE PROVIDERS & DATE LAST SEEN
1. Include specialty and routine medical care, well child clinics, HCP
clinics, physical and occupational therapy, etc.
D. COMMUNITY AGENCIES INVOLVED
1. List any known including BOCES, parent support groups, community
boards, etc.
Page 10 of 10 pages 920919
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ATTACHMENT C
CLINIC CHARGE SCHEDULE
HANDICAPPED CHILDREN'S PROGRAM/
Children With Special Health Care Needs
(HCP/CSHCN)
Families at and above a +7 financial eligibility level are charged
a fee at the clinic site for attending the HCP/CSHCN clinics.
Checks and/or money orders are to be made payable to "Colorado
Department of Health" and are to be forwarded to the Handicapped
Children's Program/ Children With Special Health Care Needs.
The current schedule of clinic fees to be collected is as follows:
CLINIC TYPE FEE
Pediatric Cardiology Clinic $ 35.00
Pediatric Neurology Clinic $ 35. 00
Orthopedic Clinic including $ 27.00
Scoliosis and Cerebral Palsy
Hearing Clinic $ 27. 00
Plastic Clinic $ 27.00
Developmental Evaluation Clinic $ 27.00
The Handicapped Children's Program will provide funding for all
diagnostic and laboratory tests ordered in the first clinic visit
only. Families at and above a +1 financial eligibility level are
responsible for the payment of diagnostic and laboratory tests
ordered in clinic, as of the second clinic visit. Payment for
these tests is made by the family directly to the provider of these
services.
920919
mEmoRAnDum
W I` e To George Kennedy, Chairman
Board of County Commissioners Date September 15, 1992
I
)i)o_np)E
COLORADO From Jeannie K. Tacker, Business Manager, Weld County Health Dept. ,
SubjectHandicapped Children's Program Contract
Enclosed for Board approval is a contract between the Weld County Health
Department and the Colorado Department of Health for the Handicapped Children's
Program(HCP) .
The Health Department will receive $3,873 for the period of October 1,1992
through September 30, 1993. This constitutes a decrease of $2,039 over the prior
years contract.
The funds are used to cover the costs of nurse activities and services given to
HCP patients, case finding, assisting with registrations, doing home visits,
clinic management and follow-up to children who require intensive care.
If you have any questions, please feel free to contact me.
JKT/sjh
77 920919
�,� (O/7(
ROY ROMiiR 1..rfaa Numbers:
Governor Main Building, Denver
I4, (303)322-9076
PATRICIA A. NOLAN, MD, MPH Ptarmigan Place, Denver
(303)320.1529
Executive Director
First National Bank Building, Denver
(303)355-6559
4210 East 11th Avenue Grand Junction Office
t Denver, Colorado 80220-3716 (303)248-7198
COLORADO Phone (303) 320-8333 (i blo Office
DEPARTMENT
OFAHEALTH
Handicapped Children's Program/
Children With Special Health Care Needs
(303) 331-8777
September 3, 1992
Randy Gordon, M.D.
Director
Weld County Health Department
1517 16th Aveune Court
Greeley, Colorado 80631
Dear Dr. Gordon:
Enclosed you will find the new contract for nursing services provided by your
health department for the Handicapped Children's Program/Children With Special
Health Care Needs (HCP/CSHCN) for the effective dates of October 1, 1992 through
September 30, 1993 .
Turing the period October 1, 1992 through September 30, 1993 , if you wish,
please bill us one-twelfth of the contract amount for each month or one-fourth
of the contract amount if you prefer to bill by the quarter.
We appreciate your cooperation in providing care to children with special health
care needs under this contract. Should you have any questions, please feel free
to contact me.
Yours very truly,
Michael F. McGuire
Administrative Officer
(303) 331-8405
Enclosures
920919
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