242032 Application Clinical Stabilization Services.doc

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

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE _Clinical Stabilization Services ___

RFR # 242032

Organization

Organization Name: [ ] Address:

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

Vendor Code: [ ]

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

FEIN: [ ]

Contact Person

First Name: [ ] Last Name: [ ]

Title: [ ]

Telephone: ( ) - FAX: ( ) -

E-Mail: [ ] Contact Person Address (if different):

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

Location of Proposed Service

Program Name: [ Program Address:

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

QUESTIONS FOR RESPONSE

Enter your response in the text boxes using Microsoft Word.

1. Prior to entering into a contract with DPH a bidder must demonstrate that it meets minimum administrative and fiscal standards established through the Executive Office of Health and Human Services (EOHHS) provider qualification policy. Potential bidder’s new to the state system must upload completed provider qualification application materials as part of the response to this RFR. See the Provider Qualification Folder (PROQUAL) for instructions and forms. Bidders with current human and social services contracts (MM3/M03 contracts) must have filed their Uniform Financial Statements and Independent Auditor's Report (UFR) with the Operational Services Division EFile system.

New provider – Uploaded requested documents to COMMBUYS.

Existing provider – UFR on file at the OSD EFile website.

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

Organization Chart uploaded to COMMBUYS.

(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.

Enter text here: text limit 1,250 characters

3. (a) Bidders are required to make a meaningful financial commitment (“SDP Commitment”) by partnering with one or more SDO-certified or recognized diverse business enterprise or non-profit organization. It is desirable that Providers aim to direct at least 1% of their Commonwealth contract revenue toward spending with SDP Partners. The Provider’s percentage of spending with SDP Partner(s) for the prior fiscal year can be seen as “PERCENT (%) OF POS SPEND” on the completed “SDP Plan Form for POS” for that fiscal year. (15 points).

Bidders can

· upload a copy of the SDP Plans most recently filed through the Uniform Financial Reporting (UFR) system

· upload an updated SDP Plan using the SDP Form for POS found in the attachment section on COMMBUYS

· if a new provider completes the SDP Plan for POS and upload with your response

Contractors seeking assistance in the development of their SDP Plans or identification of potential SDP Partners may visit the SDP webpage, www.mass.gov/sdp, or contact the SDP Help Desk at sdp@mass.gov SDP plan form for POS uploaded to COMMBUYS

(b) Describe how current or planned operations of your organization support racial/health equity. How have you/will you incorporate racial equity in relation to the services proposed?

Enter text here: text limit 1,250 characters

4. Provide an abstract of the Clinical Stabilization program including location of the program, number of licensed beds and gender(s) served. (Text input limit 1,875 characters, approximately 300 words):

Enter text here; text limit 1,875 characters

5. (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.

(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)

Enter text here; text limit 2,500 characters

6. Briefly describe your experience in providing Clinical Stabilization Services-ASAM Level 3.5. (Text input limit 1,250 characters, approximately 200 words):

Enter text here; text limit 1,250 characters

7. Describe how internal and external collaborations have and will enhance your ability to target, plan, provide and evaluate the proposed program. Note how these collaborations will directly benefit the priority population, promote efficiency and/or improve effectiveness.

Enter text here; text limit 2,500 characters

8. Complete and attach the Levels of Cooperative Activities Chart for this program available in the COMMBUYS Bid Attachment Section.

Levels of Cooperative Activities Chart uploaded to COMMBUYS.

9. 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. If you are proposing to use subcontractors, complete the Direct Care Proposed Subcontractor Identification List, found in the COMMBUYS Bid Attachment Section. (text input limit 2,500 characters, approximately 400 words):

Enter text here; text limit 2,500 characters Proposed Subcontractor Identification List uploaded to COMMBUYS (if applicable).

10. Federal standards direct agencies to deliver effective, understandable, and respectful care that is provided in a manner compatible with a patient’s cultural health beliefs and practices and preferred language. Please describe your program’s patient population and your strategies for delivering culturally competent and linguistically appropriate services. For assistance in developing strategies to provide culturally and linguistically appropriate standards of care, please see the Cultural and Linguistic Appropriate Services Standards and Guidelines attachment available at the COMMBUYS Bid Attachment Section. (Text input limit 2,500 characters, approximately 400 words):

Enter text here; text limit 2,500 characters

11. Describe your admission process including where the majority of your referrals come from. Include what staff are involved in facilitating admissions and how you ensure admissions occur during the day, evening, and overnight shifts. Describe how referrals are managed and how program handles referrals when program is at capacity. Include how the program ensures access for referrals from community based programs along with referrals from patients transitioning from 24 Hour Diversionary Withdrawal Managment programs (ATS). (text input limit 4,000 characters)

Enter text here; text limit 4000 characters

12. Describe how program ensures patient is appropriate for Clinical Stabilization Services-ASAM Level 3.5 Describe how treatment goals are established and how patient’s feedback is incorporated. (text input limit 2,500 characters) Enter text here; text limit 2,500 characters

13. Describe how clincial progamming is provided, including what evidence based practices are utilized. What groups are provided, including therapeutic, psycho-educational, peer recovery support and health ediucation? How often do patients meet for individual counseling? Include a copy of current group schedule. (text input limit 2,500 characters) Enter text here; text limit 2,500 characters

14. Describe how patients receiving medication for addiction treatment at time of admission continue to receive their medication whille in the CSS program. What linkages and referrals are in place to faciliate the treatment experience and to ensure patients have ability to be maintained on MAT/MOUD both while in the program and upon discharge? Describe the program’s abiliy to induct patients on all forms of FDA approved medication for addiction treatment. (text input limit 2,500 characters) Enter text here; text limit 2,500 characters

15. Describe how aftercare and discharge planning occurs in your program? How are patients’ needs and preferences taken into account? What services does your agency offer in regards to aftercare and what services do external partners provide? Does your program provide any follow up? (text input limit 2,500 characters) Enter text here; text limit 2,500 characters

16. How does the program ensure all staff are trained in overdose prevention? Is traning provided internally or by an external provider?Are patients connected to resouces for Naloxone? (text input limit 2,500 characters)

Enter text here; text limit 2,500 characters

17. How does the program address staff shortages? What positions are currently vacant and how do you ensure patient safety and care amid the workforce challenges? (Text input limit 2,500 characters)

Enter text here; text limit 2,500 characters

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, 29(U.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 polices 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: [ ]

FORMTEXT

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 your response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart.

Document Title

File Name

Assign when creating documents

Application Response Form

Company Name _ 242032 _App Resp Form

Organization Chart

Company Name _ 242032_Org Chart

Supplier Diversity Program (SDP) Form for POS

Company Name _ 242032 _SDP Form for POS

Agency Staff Demographics Table

Company Name _ 242032 _Agency Staff Demo

Mission Statement

Company Name _ 242032 _Mission Statement

Levels of Cooperative Activities Chart

Company Name _ 242032 _Coop Act Chart

Subcontractor List for Direct Services

Company Name _ 242032_ Sub Cont List

Program Budget

Company Name _ 242032 _Program Budget

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. Attachments must be uploaded individually and cannot be combined in a zipped file.

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. Proofread 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)

RFR #______

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