ذدà،±ل>‏ے 9<‏ےےے678ےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےى¥ءgہ ù؟dbjbjکظکظ dzْ³ْ³ض6Qےےےےےے·w w w w w $ےےےے› › › Pë ¤ڈ!ü› ²>¨‹%Dد*ه*ه*ه*ہ+êھ.l0¸ا9p7=7=7=7=7=7=$Z@²C"[=w خ0ہ+ہ+خ0خ0[=w w ه*ه*غl>آ7آ7آ7خ0Fw ه*w ه*ا9آ7خ0ا9آ7آ7#8K8ه*ےےےےPïٌذ}Hجےےےے1ژ;8³9‚>0²>C8.D¢1.DK8.Dw K8hخ0خ0آ7خ0خ0خ0خ0خ0[=[=²4خ0خ0خ0²>خ0خ0خ0خ0ےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےےے.Dخ0خ0خ0خ0خ0خ0خ0خ0خ0=: ASSESSMENT FOR DETERMINATION OF CARE FOR MEDICALLY FRAGILE CHILDREN IN FOSTER CAREMichigan Department of Human ServicesCase NameLog Number FORMTEXT FORMTEXT FORMTEXT Case NumberCountyDistrictSectionUnitLast Assessment/Level/Date FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT Date of BirthBegin DateEnd Date FORMTEXT FORMTEXT FORMTEXT Foster Home Name FORMTEXT Legal StatusPermanency Goal FORMTEXT FORMTEXT This form is used when a child has a documented medical condition which threatens health, life or independent functioning. Documentation of the medical condition must be in the case file.A foster care provider or supervising agency/DHS staff may initiate a request for review of a DOC at any time. The request must be done in writing. Action must be taken within 30 days of the receipt of the request. If the foster care provider or the agency disagrees with the level of care determination, an administrative review process may be initiated within 30 calendar days of the decision. See FOM 903-3. When a DOC supplement is due to a physical or mental disability screen the youth for SSI eligibility: see FOM 902-10 SSI Benefits Determination.Section I - If at least 2 of the following characteristics or care needs are checked in section 1A and/or 1B the youth qualifies for a Level I DOC.If 3 or more Items in Section 1A and/or 1B are checked go to Section II.1A.PHYSICAL or MEDICAL IMPAIRMENTS1. FORMCHECKBOX Any physical or medical impairment or combination of impairments requiring an average of at least ½ to 1 hour of daily medically prescribed therapy or procedures performed by the foster parents (i.e. respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medication, failure to thrive).2. FORMCHECKBOX Colostomy care.3. FORMCHECKBOX Ileostomy care.4. FORMCHECKBOX Daily injections (i.e. insulin, allergies).5. FORMCHECKBOX Feeding problems requiring an additional 30 minutes of preparation or feeding time (i.e. difficulty swallowing, cleft pallet, nasal difficulties, tongue thrust).6. FORMCHECKBOX Special diet (i.e. diabetic, asthmatic, allergy, mild Cystic Fibrosis, and/or need for special formulas, additives).7. FORMCHECKBOX Hearing problems requiring encouragement and monitoring (i.e. hearing-aid use).8. FORMCHECKBOX Vision problems requiring encouragement, visual exercises, patching.9. FORMCHECKBOX Sporadically active infectious diseases requiring sterile procedures when active, such as Herpes-type viruses.10. FORMCHECKBOX Out-of-home bi-weekly or weekly therapy or medical appointments (i.e. PT, OT, ST, etc.), or medical training involving the foster parents.11. FORMCHECKBOX In-home therapy (i.e. PT, OT, ST). Every two weeks nursing, or teacher appointments requiring foster parent involvement.1B.BEHAVIORAL or EMOTIONAL PROBLEMS1. FORMCHECKBOX Weekly counseling or therapy appointments requiring monthly foster parent participation and/or every two weeks schedule of foster parent programming (i.e. behavior charts, etc.) for problems such as depression, hyperactivity, encopresis, enuresis, eating disorders, night trauma.2. FORMCHECKBOX Special Education (EI, LD, TMI, EMI) requiring monthly school contact and/or up to ½ hour of daily foster parent programming.3. FORMCHECKBOX Regular Education requiring every two weeks to weekly school contact (i.e. meetings, teacher conferences to monitor attendance, behavior).4. FORMCHECKBOX Documented supervision or attention needed to prevent the child from causing minor injury to self, others, or property – including clothing, glasses.5. FORMCHECKBOX Documented increased attention needs which prevent or interfere with therapy or sleep (i.e. child wakes up 3-4 times a night, intolerance of tactile stimulation).Foster Parent Activities for any item checked. FORMTEXT Section II If any 1 characteristic or care need is checked in Section 2A the youth qualifies for Level II DOC.If any two items are checked in Section 2B or 2C the youth qualifies for a level II DOC.If only 1 item in section 2B or 2C is checked and none in section 2A the youth qualifies for a level I DOC.If 3 or more Items are checked in Section II, go to Section III.If 3 or more Items are checked in Section I and none in Section II the youth qualifies for a level I.2A.AT RISK PHYSICAL or MEDICAL IMPAIRMENTS1. FORMCHECKBOX Seizures uncontrolled by medication, requiring hospitalization 3-4 times per year.2. FORMCHECKBOX Heart monitor (i.e. for apnea and to prevent Sudden Infant Death Syndrome).3. FORMCHECKBOX Oxygen while sleeping (for Broncho Pulmonary Dysplasia).4. FORMCHECKBOX Tube feedings.5. FORMCHECKBOX Severe heart problems, such as ‘blue baby”.6. FORMCHECKBOX Respiratory problems (asthma or allergies) requiring major dietary and/or environmental restrictions. Examples include no pets, no carpeting or overstuffed furniture, no smoking, no perfume or heavy scents, daily vacuuming and dusting with wet cloth, the use of allergy-proof bedding or allergy-proof covers on pillows and bedding and the use of an air purifier and/or air conditioner.7. FORMCHECKBOX Chemotherapy.8. FORMCHECKBOX Body cast (Spica cast).9. FORMCHECKBOX Other activities, specify: FORMTEXT 2B.PHYSICAL or MEDICAL IMPAIRMENTS1. FORMCHECKBOX Any physical or medical impairment or combination of impairments requiring an average of at least 1 to 2 hours of daily medically prescribed therapy or procedures performed by the foster parents (i.e. respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medications, failure to thrive, etc.).2. FORMCHECKBOX Legal blindness in both eyes or severe vision impairments requiring exercises, minor environmental modifications.3. FORMCHECKBOX Hearing impairment requiring foster parent to know sign language and encourage and monitor hearing-aid or auditory-training device use.4. FORMCHECKBOX Twice weekly out-of-home therapy or medical appointments (i.e. PT, OT, ST, etc.) requiring foster parent involvement.5. FORMCHECKBOX Twice weekly in-home therapy (i.e. PT, OT, ST, etc.), nursing or teacher appointments, requiring foster parent involvement.6. FORMCHECKBOX Child age two or over weighing 20 to 30 pounds with mobility impairments causing partial dependence, requiring assistance in transfer from wheelchair to bed, chairs.2C.BEHAVIORAL or EMOTIONAL PROBLEMS1. FORMCHECKBOX Weekly therapy or counseling appointments requiring bi-weekly to weekly foster parent participation and/or a daily schedule of foster parent programming for problems such as depression, hyperactivity, encopresis, enuresis, eating disorders, night traumas, etc.2. FORMCHECKBOX Special Education (EI, LD, TMI, EMI, SMI) requiring school contact every two weeks and/or up to one hour per day in-home foster parent programming.3. FORMCHECKBOX Documented supervision and attention needs in daily hygiene skills in excess of age-appropriate developmental levels (i.e. bathing, clothing, feeding) for children to monitor age five or over who are not in regular therapy.Foster Parent Activities for any item checked. FORMTEXT Section III If any one or two of the following characteristics and/or care needs are checked the youth qualifies for a level III DOC. If three or more are checked, complete Section IV with additional documentation/justification for a level IV DOC (negotiated rate).3A.PHYSICAL or MEDICAL IMPAIRMENTS1. FORMCHECKBOX Any physical or medical impairment or combination of impairments requiring an average of 3 or more hours of daily prescribed therapy or procedures performed by the foster parents (i.e. for respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medication, failure to thrive).2. FORMCHECKBOX Any life-threatening medical needs or conditions.a. FORMCHECKBOX Oxygen 24 hours per day (for BPD, etc.)b. FORMCHECKBOX Tracheotomy.c. FORMCHECKBOX Hemophilia.d. FORMCHECKBOX Respiratory problems (asthma or allergies) requiring a complete sterile environment. In addition to all the examples listed in Section II, the child is not able to be in public settings. Anyone interacting with the child must wash his/her hands and wear a gown and mask. e. FORMCHECKBOX Other, specify FORMTEXT 3. FORMCHECKBOX Seizures uncontrolled by medication, occurring daily or more often.4. FORMCHECKBOX Child age two or over weighing 31 pounds or more with mobility impairments causing partial dependence, requiring assistance in transfer from wheelchair to bed, chairs, etc.5. FORMCHECKBOX Child age two or over weighing 20 pounds or more who is totally dependent, without use of own limbs for mobility.6. FORMCHECKBOX Child age four or over without self-care skills (i.e. cannot dress, feed, or bathe self) requiring total care due to physical impairments.7. FORMCHECKBOX Child age four or over who is more than 50% behind age level in more than 3 areas of development due to physical impairments.8. FORMCHECKBOX Child age four or over without self-care skills (i.e. cannot dress, feed or bathe self) requiring total care due to mental retardation or emotional impairments.9. FORMCHECKBOX Child age four or over who is more than 50% behind age level in more than 3 areas of development due to mental retardation or emotional impairments.10. FORMCHECKBOX Child who is totally blind requiring mobility training and/or major environmental modifications.11. FORMCHECKBOX Child with major behavior problems that may or may not be due to physical impairment (i.e. self-stimulating, head banging, removes medical apparatus at least 3 times a week); refusal to comply with medical procedures (i.e. taking meds at prescribed times).12. FORMCHECKBOX Any active, chronic infectious disease requiring complete sterile procedures.Foster Parent Activities for any item checked. FORMTEXT Section IV This section is required for Level IV requests. 4A.Document the current DOC Status, and why/how the scenario has changed, or necessitates an increase in level. FORMTEXT 4B.Document the extraordinary behaviors and needs of the child. FORMTEXT 4C.Explain how the reimbursement amount was determined. Document the extraordinary care, activities and supervision required by the foster parent. Include a list of specific activities, and time required for each activity, for the foster parent to meet the child s needs. 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Attach any additional supporting documents: (i.e. medical reports/records, therapy reports, IEP s, etc.). Please ensure that all required signatures and dates have been obtained on all documents: foster parents, services specialist, services supervisor and county director. Once completed submit packet to: Field Operations Administration 235 S. Grand Ave., Suite 415 P.O. Box 30037 Lansing, MI 48909Case NameLog Number REF GranteeFirstName REF GranteeLastName REF LogNumber 5. Level I $8.004ًAge Appropriate Rate5A $ FORMTEXT Level II $13.00Determination of Care (if appropriate)5B $ FORMTEXT Level III $18.00 Level IV approved rateTOTAL FOSTER PARENT RATE (5A + 5B):5C $ FORMTEXT Begin DateEnd DateADMINISTRATIVE RATE: (if appropriate)5D $ FORMTEXT REF BeginDate REF EndDate Approval not to exceed 6 monthsTOTAL PER DIEM RATE (4C + 4D): $ FORMTEXT FORMCHECKBOX Due to the foster parent s extensive activities a level IV exception is being requested. 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(Required for all levels)DateDHS County Director Signature (Required for Level III & IV)DateDHS Monitor Supervisor SignatureDateField Operations Director or designee Signature (Required for Level IV)DateDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: PA 280 of 1939 COMPLETION: Is required by policy. CONSEQUENCE: Correct reimbursement may not be received by the foster parent. DHS-1945 (Rev. 8-11) Previous edition obsolete. 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