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FAMILY BASED SERVICES
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SOLICITATION DHHS91021
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 EVALUATION SCORE SHEET
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Vendor:
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Evaluator:Date:
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Mandatory Minimum RequirementPass/Fail
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1Offeror must have a current license from the Division of Licensing and Background Checks (“DLBC”) for a Child Placing Foster Care license (“CPF”) and Outpatient Treatment (“OT”) or Day Treatment (“DT”) license and if applying for Service Code DAC, the Offeror must have a Residential Support License.
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Documentation RequirementsPass/Fail
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2Offeror completed Attachments A-D.
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3Offeror must hold or subcontract with another provider that has a CETW contract for minimally mentoring and additional staffing service.
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4Offeror submits a W-9 and conflict of interest form.
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5Offeror provided a program manual and an organizational chart.
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Technical CriteriaPass/Fail
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1The providers has submitted documentation to support how their program meets the SOW requirements for their treatment model, type and structure of treatment and interventions, including behavioral interventions. Also including program completion and transition planning (Section 5.1).
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2Did the vender submit a target population and is serving multiple populations. Did they address how they would adhere to the mixing population portions of the SOW (Section 5.2).
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4Did the provider submit a sample treatment plan. Does the treatment plan incorporate the following: Identifiable goals, incorporate the family, family visitation, transition planning as defined in the SOW (Section 4.3-5). Either provide a mock treatment plan with fictitious names or have all names substituted with a pseudonym to protect confidentiality.
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5Did the provider submit a training and onboarding process for families involved in placement of clients per the SOW (Section 3.5).
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6The Offeror's program manual identifies how the Offeror will maintain fidelity to its identified program model(s)/treatment model(s), including but not limited to staff training, certifications, and outcome measures; including specific examples per the SOW (Section ???).
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Specific Services CodesPass/Fail
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DIB/TIB/ DPB/TPB/ PC1/PC2/ BACProvided list of certified level 4 foster homes and home locations on SAFE form.
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DAC/YACProvided independant living program structure that differenciates its homes from traditional DPB.
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DHBProvided list of each professional parent, years on experience and home location. (must also have applied for DIB/TIB/ DPB/TPB/ PC1/PC2/ BAC) - This service code requires a copy of a step down plan.
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DHDBe a current Services for DHHS Clients including People with ID.RC and/or ABI contract holder and provided list of each professional parent, years on experience and home location.
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