214830 Housing Stability Support Transitional Application form~2.docx

The Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health 250 Washington Street, Boston, MA 02108-4619 Rev 8

APPLICATION RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

For use with the M03/MM3 RFR

General Instructions:

1. See the RFR and COMMBUYS posting for complete procurement specifications.

2. All responses are to be submitted using the online submission tools available to Vendors registered in COMMBUYS. There is no charge to register in COMMBUYS. To Register go to www.COMMBUYS.com and click on the “Register” link on the front page.

Bidders are solely responsible to monitor COMMBUYS for Bid amendments, if any. Bidders may monitor the record by frequently checking the Amendment Section on the Summary screen for the BID in COMMBUYS.

3. All Bidders are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume. DPH is not responsible for delays encountered by Bidders or their agents, or for a Bidder’s local hardware failures, such as computers or related networks, associated with bid compilation or submission. Bids submitted via COMMBUYS are time stamped by the COMMBUYS system clock which is considered the official time of record.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. Save this document file to your computer.

2. Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard.

3. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

4. Text responses are limited to a maximum number of characters and the limits are noted in each question. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character, and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that applicants insert graphics into the responses. Spell-check does not work in text boxes.

5. Delete this instructions page before submitting your proposal.

6. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

RFR #______

TRANSITIONAL HOUSING APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE: Housing Stability Support

RFR # _ 214830

Organization Organization Name: [ ]

Address:

City: [ ] State: [ ] Zip: [ ]

Vendor Code: [ ]

CEO (Chief Executive Officer) First Name: [ ] Last Name: [ ]

Telephone: ( ) - E-Mail: [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ]

Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Organization Information

Is your agency pre-qualified to conduct business with the Commonwealth? |_| Yes |_| No

If so, which Massachusetts Department is your Principal Purchasing Agent (PPA): [ ]

Location of Proposed Service Program Name: [ ]

Program Address:

City: [ ] State: [ ] Zip: [ ]

RFR #___ 214830 ___

A note about the text boxes: Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box.

Enter your response in the text boxes using Microsoft Word.

1. (a) Attach an organizational chart that shows the location of the proposed program within your agency.

|X| Organization Chart uploaded to COMMBUYS. (2 Points)

(b) Describe how the proposed program will link with the mission and programs described in your agency’s mission statement (text input limit 1,250 characters, approximately 200 words).

A note about the text boxes: Type or paste text into the gray areas. Text input is limited to a maximum number of characters. MS Word will not allow more than this limit. Spaces, commas, line breaks, etc. are counted as characters. The spell-check feature does not work in a text box. (2 Points)

Enter text here: text limit 1,250 characters

Attach a copy of your organization’s most recent mission statement to this response.

|_| Most recent mission statement is uploaded to COMMBUYS. (1 Point)

(c) Supplier Diversity Plan form for POS (posted in the COMMBUYS Bid Attachment Section): Bidders are to submit a copy of their most recently submitted “SDP Plan Form for POS” with their proposal to signify to the Procurement Management Team that a form has been submitted. Bidders that do not currently hold POS contracts with Commonwealth Departments, Bidders that are exempt from filing a UFR or Bidders who have not yet submitted a SDP Plan Form for POS with their most recent UFR are required to complete the Form and include it with their proposal. (No Points)

|_| Copy of SDP plan form is uploaded to COMMBUYS (original was submitted with UFR) or |_| Original SDP plan form is uploaded to COMMBUYS. (No Points)

2. Provide a brief abstract of the proposed Transitional Housing SCM program (text input limit 1,875 characters, approximately 300 words, 5 Points):

Enter text here; text limit 1,875 characters

Please check which populations the program will be serving:

|_| Single Adults |_| Young Adults |_| Families

3. (a) Provide a percentage breakdown by job category and race/ethnicity of your agency’s staff on the Agency Staff Demographics Table available in the COMMBUYS Bid Attachment Section. Please enter percentages as whole numbers (e.g., 2.3% = 2%).

|_| Agency Staff Demographics Table uploaded to COMMBUYS. (2 Points)

(b) Describe the population your agency serves across all programs, in terms of its racial, ethnic, linguistic, cultural, gender and age characteristics. What neighborhood(s) or town(s) does your agency serve? (text input limit 2,500 characters, approximately 400 words, 3 Points)

Enter text here; text limit 2,500 characters

4. Please describe: type of housing, where housing will be located, how housing is funded/subsidized, and how you will ensure housing is affordable for clients. (text input limit 3,750 characters, approximately 600 words, 4 Points) :

Enter text here; text limit 3,750 characters

5. Briefly describe your experience in providing the type of program proposed in this RFR, including your history of providing SCM services, case management service and a supportive living environment that reinforces recovery through establishing community-based supports to maintain ongoing goals in the recovery process. (text input limit 5,000 characters, approximately 800 words, 10 Points)

Enter text here; text limit 5,000 characters

6. a) Describe how internal and external collaborations have and will enhance your ability to target, plan, provide and evaluate the proposed program. Describe how these collaborations will directly benefit the priority population, promote efficiency and/or improve effectiveness. Identify the top three external collaborations and the number of clients involved in FY 21 (text input limit 3,750 characters, approximately 600 words, 4 Points) :

b) Complete and attach the Levels of Cooperative Activities Chart for this program available in the COMMBUYS Bid Solicitation; File Attachment Section

|_| Levels of Cooperative Activities Chart is uploaded to COMMBUYS. (2 Points)

7. If the proposal being submitted contains subcontracts, name the proposed subcontractors. Describe how the subcontracts will function, including descriptions of responsible parties and structures for operation and accountability. All subcontracts are subject to DPH approval (text input limit 2,500 characters, approximately 400 words, No Points):

If you are proposing to use subcontractors, complete the Direct Care Subcontractor Identification List, found in the COMMBUYS Bid Solicitation; File Attachment Section.

|_| Subcontractor Identification List is uploaded to COMMBUYS (if applicable). (NO POINTS)

8. Federal standards direct agencies to deliver effective, understandable and respectful care that is provided in a manner compatible with a client’s cultural health beliefs and practices and preferred language. Please describe your program’s client population and the strategies your programs have incorporated for delivering culturally competent and linguistically appropriate services. (text input limit 2,500 characters, approximately 400 words, 5 Points):

9. Describe how you will meet the service elements of Supportive Case Management. If you are serving young adults please include how you will meet the food service requirements. If you are serving families, please include those service elements specific to families. (text input limit 5,000 characters, approximately 800 words, 10 Points)

10. Provide a sample weekly chart of staff shift coverage. How does your staffing pattern demonstrate support of the program? How frequently will staff receive individual supervision, by whom, and how will this activity be documented? How does your staffing pattern reflect the diversity of the community you serve with respect to language, culture, and race/ethnicity?(text input limit 5,000 characters, approximately 800 words, 8 Points):

|_| Sample weekly chart of staff shift coverage is attached (2 Points).

11. Describe your training – who provides training, how frequently, and how does staff access continuing education? How do you ensure that all staff receives the required trainings, including training on overdose prevention? (text input limit 2500 characters, approximately 400 words, 6 Points)

12. Articulate the role of a Supportive Case Management program in the recovery process and specifically describe the philosophical perspective for delivering case management within the program being proposed, including risk reduction.(text input limit 5,000 characters, approximately 800 words, 10 Points)

13. Describe your referral and case management process and how your program works with clients to main stable housing, transition to permanent housing, and continue their recovery process. (text input limit 3,750 characters, approximately 600 words, 7 Points)

14. Site control must include a commitment from the property owner that the applicant can site and operate the proposed SCM at the site. Provide address and location, floor plans with number, size, and purpose of rooms. Describe how site and layout is appropriate for the program using criteria from the Specifications section of the RFR (text input limit 5,000 characters, approximately 800 words, 6 points

|_| Floor Plan uploaded to COMMBUYS (2 Points) |_| All documents, such as lease, to demonstrate site control of the proposed facility uploaded to COMMBUYS (2 Points)

15. Describe your quality improvement process. How do you measure the effectiveness of your services? Describe how your program incorporates consumer feedback into the ongoing planning, design, improvement, and implementation of your services. Provide a concrete example of a change that was made to your program as a result of consumer feedback. Attach a sample of client feedback material (questionnaire, feedback form, program evaluation, for example). (text input limit 1,250 characters, approximately 200 words, 5 Points)

|_| Sample of client feedback material (questionnaire, feedback form, program evaluation, for example) is uploaded to COMMBUYS. (2 Point)

QUESTIONS FOR TRANSITIONAL HOUSING APPLICATION RESPONSE

APPLICATION RESPONSE SUBMISSION PAGE

Organization

CERTIFICATION OF ASSURANCE OF COMPLIANCE:

ADA/ 504 and NON-DISCRIMINATION BASED ON DISABILITY

All MDPH- funded projects must certify that the Applicant Organization will comply with all state and federal requirements regarding equal employment opportunity, nondiscrimination and civil rights for persons with disabilities. The Applicant must complete a Certification of Assurance of Compliance-ADA/504/Non-Discrimination based on Disability. By signing, the Applicant formally notifies MDPH that the Applicant is in compliance and shall maintain compliance with all applicable requirements.

· I , certify, that the Applicant is in compliance and shall maintain compliance with all applicable federal and state laws protecting the rights of persons with disabilities, including but not limited to the Americans with Disabilities Act (“ADA”), 42 12131-12134; Section 504 (“504”) of the Rehabilitation Act of 1973, 29U.S.C. §§ U.S.C. § 794; Article CXIV of the Massachusetts Constitution; and Chapter 6, §§ 185-87; Chapter 93, § 103; Chapter 151B; and Chapter 272, §§ 92, 98, and 98A of the Massachusetts General Laws.

· I understand that federal and state laws prohibit discrimination in public accommodations and employment based solely on disability. I recognize that to make goods, services, facilities, privileges, advantages, or accommodations readily accessible to and usable by persons with disabilities, the Applicant, under the ADA, must:

· remove architectural and communication barriers in existing facilities, when readily achievable and, if not readily achievable, must use alternative methods;

· purchase accessible equipment or modify equipment;

· modify policies and practices; and

· Furnish appropriate auxiliary aids and services where necessary to ensure effective communication.

I recognize that Section 504 of the Rehabilitation Act requires recipients of federal funds (either directly or through contracting with a governmental entity receiving federal funds) to make their programs, services, and activities, when viewed in their entirety, accessible to qualified and/or eligible people with disabilities. I understand that reasonable accommodation is required in both program services and employment, except where to do so would cause an undue hardship or burden. I also understand that the Massachusetts Constitution Article CXIV provides that no otherwise qualified individual shall, solely by reason of disability, be excluded from the participation in, denied the benefits of, or be subject to discrimination under any program or activity within the Commonwealth.

· I agree the Applicant shall cooperate in any compliance review and to provide reasonable access to the premises of all places of business and employment and to records, files, information, and employees therein for reviewing compliance with Section 504, the ADA, the Massachusetts Constitution, other applicable state and federal laws, and this Contractual Agreement.

· I agree that any violation of the specific provisions and terms of this Assurance and/or Corrective Action Plan and/or Special Contract Conditions required herein or Section 504 or the ADA, shall be deemed a breach of a material provision of the Contract between the Department and the Contractor. Such a breach shall be grounds for cancellation, termination, or suspension, in whole or in part, of this Contract by the Department.

I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ]

Title: [ ]

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE APPLICATION RESPONSE FORM

All documents listed below must be submitted via COMMBUYS in order for you response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart.

Assign when creating documents

Weekly chart of staff shift coverage provided

Company Name _ 214830 Weekly_Staff_Shift_caverage

Sample of client feedback material

Company Name _ 214830 _Client_Feedback_Material

Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Zipped files will be accepted and must be in a .zip format when saved. Other zip file formats will not be accepted.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation will not be reviewed.

APPLICATION INSTRUCTIONS

1. Save, read and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proof read text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Application Response Form with the attachments according to the application Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes) image1.png