260734_Application~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. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

RFR #______

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE: Family Residential Treatment Services

RFR # 260734

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: [ ]

RFR #______

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.

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.

|X| New provider – Uploaded requested documents to COMMBUYS.

|X| 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.

|X| 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 complete 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) Bidders should describe how the current or planned operations of their organization support racial/health equity (10 points).

Enter text here: text limit 1,250 characters

4. Provide a brief abstract of the proposed program, including location, number of rooms and proposed number and size of families, whether you will serve male or female-headed families and how you will incorporate pregnant women. Please describe your ability to respond to the needs of families of varying sizes and children of varying ages. (text input limit 2,500 characters, approximately 400 words, (5 points):

Enter text here; text limit 2,500 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. (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)

6. Briefly describe your experience in providing the type of program proposed in this RFR (text input limit 1,250 characters, approximately 200 words): (5 points)

Enter text here; text limit 1,250 characters

7. The Department expects health and human service providers and residents to come together to collaboratively identify local and regional health priorities, design community-based prevention plans, and track success in achieving healthier communities through collaborations both internal and external and by participation in a local Coalition that meets the minimum requirements established in the 2015 DPH Coalition Principles and Guidelines.

https://www.mass.gov/service-details/healthy-communities-and-community-engagement-capacity-building.

a) 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. (3 points)

b) Name a coalition that that you plan to participate in and describe how this participation will enhance the work of the proposed program. Participation in a coalition is a requirement of DPH funding. To find coalitions in your area visit http://www.hriainstitute.org/coalitions. (2 points)

c) 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. (2 points)

8. 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): (No Points)

|_| Proposed Subcontractor Identification List uploaded to COMMBUYS (if applicable).

9. 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 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): (5 points)

10. Describe how you will ensure your ability to respond to referrals from the Central Intake Coordinator by promptly admitting new residents, including those located outside your usual catchment area. Describe your ability to provide or arrange for transportation as needed. Program entry should occur within a maximum of 7 days of the program receiving all intake materials from Central Intake, unless the need to transfer medication assisted treatment requires more time. Describe the community networks that will allow your program to expedite transfer of medication assisted treatment and other needed services to your geographic area. (text input limit 5,000 characters, approximately 1000 words, (8 points):

Enter text here; text limit 5,000 characters

11. Describe your agency’s history of/ability to recruit a diverse workforce qualified to serve the anticipated population for FRT. Name each staff position you anticipate will be hired for this program. Describe your weekly supervision plan indicating supervision channels for each required staff position, frequency and duration of supervision, and how documentation of supervision is maintained. (text input limit 5,000 characters, approximately 800 words, (8 points):

12. Describe your program’s history of/ability to appropriately assess and treat families within a residential setting using ASAM criteria. How will you ensure consumer input into treatment planning? Describe how you will implement the required service elements. How will you combine clinical and case management services that address relapse prevention and appropriately serve clients with trauma histories, resistance to treatment, and cognitive impairments including FASD? How will you incorporate parenting skills training for all residents into the program’s scheduled services and milieu? (text input limit 5,000 characters, approximately 800 words, (8 points)

13. Describe your program’s ability to provide services to both parents and children. How will Family Life Advocacy services address and incorporate the elements listed on Page 10 and 11 of the RFR? How will your program ensure that care is coordinated both within the program and with off-site services? (text input limit 5,000 characters, approximately 800 words, (8 points)

Enter text here; text limit 5,000 characters

14. As pregnant and postpartum women are a priority population, please describe how you will address their needs for:

· Prenatal care, support and education

· Hospital arrangements for obstetric/gynecological services

· Care at the program for Substance Exposed Newborns

· Support for new mothers and their infants in building attachment and connection

· Family planning education/counseling

· Pediatric care

· Needed medication assisted treatment for opiate addicted pregnant women

· HIV/AIDS counseling and testing

· Assistance in accessing community services.

(text input limit 5,000 characters, approximately 800 words, (8 points)

15. Describe your experience and capacity in working with those on Medication Assisted Treatment, including methadone, buprenorphine, suboxone, subutex.

· Describe your policies and procedures regarding MAT in FRT settings and affirm your program’s willingness to serve those clients.

· Attach MOUs/linkage agreements with any programs practicing MAT in your immediate area.

· If applicable, indicate number of persons your program served last year on MAT in an FRT setting (text input limit 5,000 characters, approximately 600 words, 6 points):

16. Provide a sample seven day schedule of activities, showing how staff are assigned to each activity including the overnight shifts. Demonstrate that your proposed staffing plan supports the implementation of the program model including individual and group services, services for parents and for children of all ages, and both clinical and case management services. Refer to the DPH regulations at 105 CMR 164.000. (text input limit 2,500 characters, approximately 400 words, (5 points):

|_| Sample seven-day week schedule of activities is uploaded to COMMBUYS. (2 Points)

|_| Staffing Chart of staff shift coverage uploaded to COMMBUYS (2 Points)

Applicants not currently licensed to provide Family Residential Substance Abuse Treatment Services must demonstrate site control of facility and capacity to gain licensure and initiate programming in a timely fashion. Currently BSAS licensed and operating family residential substance abuse treatment services programs need not respond to questions (15), (16), and (17) below and will not be penalized.

17. Site control must include a commitment from the property owner that the applicant can site and operate the proposed FRT 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 and the Facility Checklist (www.mass.gov/dph/healthyaging, see the ADA Compliance Coordination link. (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)

18. Provide an implementation plan and timeline that includes specific milestones toward gaining of licensure and initiation of programming and services. At a minimum, the implementation plan must include the following activities with associated dates and responsible persons: construction, renovations and furnishing of facility; hiring of key staff; facility inspections; licensing of program; and, establishing policies, procedures and linkages. (text input limit 5,000 characters, approximately 800 words, 5 points)

19. Start-up cost-reimbursement: If you are requesting funding for start-up costs, please provide a line-item budget using the Program Budget form on the Forms and Terms screen. For a list of position codes for the form go to: www.mass.gov/anf/docs/osd/forms/attachmts/postitles.doc.

DPH anticipates funding the purchase of capital items under this RFR. Capital items are defined in 808 CMR 1.00 as “an asset or group of assets of nonexpendable personal property having a useful life of more than one year and an acquisition cost which equals or exceeds the capitalization level established and certified by the Contractor.” Only movable items will be reimbursed through this capital purchase process. If your proposal includes capital items, complete the Capital Budget form available at the COMMBUYS Bid File Attachments Section. Capital items must be specifically and individually approved by the DPH program prior to the purchase of the item. These must be purchased within the start-up period.

Capital items must be specifically and individually approved by the DPH program prior to the purchase of the item. These must be purchased within the 3-month start-up period.

|_| Capital Budget form is attached. (No Points) |_| Program Budget form is attached. (No Points)

Provide a program budget justification narrative with the attachments reflecting each line in the Program/Capital Budget form. Demonstrate how each budget item supports the overall program. (6 points) (text input limit 6,000 characters, approximately one page):

Enter text here; text limit 6,000 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, 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 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: [ ]

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

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. 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