6282-0 - RFA - Attachment for Application Packet.pdf

RFA 6282 - Professional Consultant For Residential Care Facility Providers - Attachments Page 1 of 11

ATTACHMENT A

RFA S-10000-00017902

APPLICANT IDENTIFICATION AND CERTIFICATION STATEMENTS

Applicant Name

Applicant Address

Contact Name

Phone:

Email:

1. Applicant understands and accepts the requirements of this RFA S-10000-00017902. Applicant agrees to be bound by the Agreement Standard and Federal terms and conditions in the RFA and as modified by Addendum, except for those terms and conditions that Agency has reserved for negotiation in the RFA.

2. Applicant acknowledges receipt of all Addenda or notices for this RFA posted in OregonBuys.

3. Applicant statements and documentation is considered a firm response for 60 days following the deadline the Applicants are due found in Section 1.2 of RFA S-10000-00017902.

4. If selected as an Approved Consultant, Applicant agrees to perform the work and meet the performance standards set forth in this RFA.

5. Under penalty of perjury, Applicant certifies that Applicant is aware of and complies with the requirements found in OAR 125-246-0330, concerning Taxes, and Transacting Business in Oregon.

Upon request of Agency, Applicant shall provide supporting documentation.

6. Applicant does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, sexual orientation or national origin. Nor has Applicant or will Applicant discriminate against a subcontractor in the awarding of a subcontract because the subcontractor is:

• a minority, women or emerging small business enterprise certified under ORS 200.055, or

• a business enterprise that is owned or controlled by or that employs a disabled veteran, as defined in ORS 408.225

7. Applicant and its employees and agents are not included on the list titled “Specially Designated Nationals and Blocked Persons” maintained by the Office of Foreign Assets Control of the United States Department of the Treasury and currently found at:

https://www.treasury.gov/ofac/downloads/sdnlist.pdf .

https://www.treasury.gov/ofac/downloads/sdnlist.pdf

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8. Applicant certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Applicant, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFA. Applicant shall provide prompt written notification to the State of any change occurring with respect to Applicant’s business or interests which is reasonably likely to result in (or has resulted in) an actual or potential conflict between the business or economic interests of the Applicant and those of the State, arising out of, or relating in any way to, the subject matter of the RFA. In its notice, Applicant will describe the nature of such actual or potential conflict of interest or remuneration in question in reasonable detail.

9. Applicant certifies that all contents of the Applicant (including any other forms or documentation, if required under this RFA) and this Applicant Certification Sheet, are truthful and accurate and have been prepared independently from all other Applicants, and without collusion, fraud, or other dishonesty.

10. Applicant understands that any statement or representation it makes in response to this RFA, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, of being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS

180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

11. Applicant acknowledges these certifications are in addition to any certifications required in OregonBuys, the Attachments, and the final Statement of Work at the time of execution of any Agreement made between the parties.

Authorized Signature Date

(Print Name and Title)

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ATTACHMENT B

CONSULTANT KEY PERSON AND ADMINISTRATION

APPLICANT’S STAFF AND TRAINING QUALIFICATIONS SHEET

Applicant as a residential care and assisted living facility (RCF and ALF) Consultant must have provider experience and have Key Persons who are qualified to provide the services of a Consultant.

Please describe any experience you have with Oregon RCFs and ALFs, including memory care communities. Please give details of your experience for both Key Person and general RCF and ALF Consultant experience.

B1

Key Person (Note: Copy this section for each Key person)

Key Person Name

Key Person Relevant Experience ____________________(Please attach resumes for each Key person)

Key Person Education (area of study) Degree level:

Bachelor’s Masters Doctorate Licensure RN or Other ______________________ Type Of license ______________________________ (Please attach diploma or certificate for each Key person.)

Key Person Formal Classes and Training

Describe Other Related Experience (formal classes or project related training) (Please attach a copy of licensure)

B1

Key Person Professional Performance Responsibilities

Has Key Person ever been substantiated for abuse of a client? Yes No If yes, provide date and details related to investigation.

(Attach related materials if needed)

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RCF and ALF Consultant Administration Applicant Specific Requirements

B2

RCF and ALF Consultant Administration Application Focus

RCF and ALF Consultant Services Identification. This Section is used to describe the area of expertise that Applicant is choosing to provide Consultation Support as part of their official Application Focus of Service.

Administration (such as: Executive Director, Fiscal Management, Personnel) Key Persons (Nursing RN, BSN, PA) Programs for resident support such as Life Enrichment/Activities Mental Health (Programs and Key Persons MSW, Behavioral Health Specialist) Dementia Care (Programs and Key Persons MSW, Behavioral Health Specialist) Dietary/Nutrition. Please Attach a copy of business licensure

Applicant Focus Statement, I am choosing this focus because of:-

(Attach related materials in support of focus of service)

B2

Applicant RCF and ALF Consultant Administration Experience and Mandatory Training.

RCF and ALF Consultant experience description in conjunction with Focus Statement above.

(Attach additional pages if needed in response to this requirement)

Has the Administrator named in the RCF and ALF Consultants Application received a Residential Care Facility Administrator’s license from the Health Licensing Office ?

Yes No

(Attach current licenses for all administrators)

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B3

Applicant RCF and ALF Consultant Administration Writing Example

RCF and ALF Consultant will include a writing sample of 350-700 words that will demonstrate Applicant’s ability to communicate key topics in a real RCF and ALF Consultant setting in writing. This must be an original work created by the Applicant.

The specific topic of this writing assignment is up to the Applicant but should focus on one of the following topics:

➢ Person-centered direct resident care

➢ Responsibilities of a Residential Care Facility Administrator

➢ Operations Improvement in Residential Care Facility settings

➢ Key Personnel retention in Residential Care Facilities

B4 Applicant RCF and ALF Consultant Administration

RCF and ALF Consultant confirmation that all Key Persons and other mandatory personnel have approved background checks. . Yes No In-progress (Please provide a summary related to any in-progress background checks)

B5

Applicant RCF and ALF Consultant Administration

RCF and ALF Consultant Key Person utilization will require professional care personnel as described in B1.

Applicant may require other Key Persons who act to support Consultations services. Describe here the types of Key Persons utilized.

Office Support, Clerical, Accounting, Administrative.

Subcontractors, Third Party Consultants

Other (Please Describe)

B6

Disclosure of other facilities

Please disclose any facilities that you own or operate or manage. Please list the licensed name of each facility along with its address:

1.

2.

3.

4.

Applicant statements provided are in support of both Key Person and RCF and ALF Consultant Qualifications in response to this Request for Application S-10000-00017902 hereby signed by an authorized representative for the Applicant.

Signature: Date:

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ATTACHMENT C

APPLICANT CONSULTANT

BUSINESS AND CONTACT INFORMATION

C2

Contact Name:

Title:

Phone:

Fax:

Email:

C3

Applicant Business Information

C4

Business Designation

Oregon SOS registered __________ Other State Registry #______________

Professional Corporation Nonprofit Corporation Limited Partnership

Corporation Partnership Governmental Organization type_____________________

Note: Applicant by signing this Attachment agrees to provide as a RCF and ALF Consultant consultation support to those RCFs and ALFs identified by APD that need assistance as described in this RFA.

Applicant Signature

Name Title Date

C1

IRS registered Business Name

Address

City, State, Zip

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ATTACHMENT D

RESPONSIBILITY INQUIRY

Bidder must complete and return this Responsibility Inquiry with its Bid. Agency will determine responsibility of a Bidder prior to award and execution of a Contract. In addition to this form, Agency may notify Bidder of other documentation required, which may include but is not limited to recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate responsibility may result in an Agency finding of non-responsibility and rejection.

Does Bidder have available the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to demonstrate the capability of Bidder to meet all contractual responsibilities?

YES / NO .

Within the last five years, how many contracts of a similar nature has Bidder completed that, to the extent that the costs associated with and time available to perform the contract remained within Bidder′s control, Bidder stayed within the time and budget allotted, and there were no contract claims by any party?

Number: ____

How many contracts did not meet those standards? Number: ____ If any, please explain.

Response:

Within the last three years has Bidder (incl. a partner or shareholder owning 10% or more of Bidder’s firm) or a major subcontractor (receiving 10% or more of a total contract amount) been criminally or civilly charged, indicted, or convicted in connection with:

1. Obtaining, attempting to obtain, or performing a public (federal, state, or local) contract or subcontract,

2. Violation of federal or state antitrust statutes relating to the submission of bids, or

3. Embezzlement, theft, forgery, bribery, falsification, or destruction of records, making false statements, tax evasion, or receiving stolen property?

YES / NO .

If "YES," indicate the jurisdiction, date of indictment, charge or judgment, and names and summary of charges in the response field below.

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Response:

Within the last three years, has Bidder had:

1. Any contracts terminated for default by any government agency, or

2. Any lawsuits filed against it by creditors or involving contract disputes?

YES / NO .

If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

Response:

Does Bidder have any outstanding or pending judgments against it? YES / NO .

Is Bidder experiencing financial distress or having difficulty securing financing? YES /

NO .

Does Bidder have sufficient cash flow to fund day-to-day operations throughout the proposed Contract period? YES / NO

If "YES” on the first question or second question of the three questions immediately above, or “NO” on the third question, please provide additional details.

Response:

Within the last three years, has Bidder filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES / NO .

If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

Does Bidder have all required licenses, insurance and/or registrations, if any, and is Bidder legally authorized to do business in the State of Oregon? YES /NO .

If "NO," please explain.

Response:

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Pay Equity Certificate. Does a current authorized representative of Bidder possess an unexpired Pay Equity Certificate issued by the Department of Administrative Services? YES

/ NO / N/A . If applicable, submit a copy of the certificate with this form.

Response:

AUTHORIZED SIGNATURE: By signature below, the undersigned Authorized Representative on behalf of Bidder certifies to the best of their knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

Bidder Name: ITB:

Project Name:

By: ___________________________________________ Date: _________________________ Authorized Representative

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Attachment E Disclosure Exemption Affidavit

____________________ (Affiant), being first duly sworn under oath, and representing _______________ (hereafter “Applicant”), hereby deposes and swears or affirms under penalty of perjury that:

1. I am an employee of the Applicant, I have knowledge of the Request for Application referenced herein, and I have full authority from the Applicant to submit this affidavit and accept the responsibilities stated herein.

2. I am aware that the Proposer has submitted a Application, dated on or about ___________ (the “Application”), to the State of Oregon (State) in response to Request for Application S-10000-00017902, for Consultant and Management Entity Approval, and I am familiar with the contents of the RFA and Application.

3. I have read and am familiar with the provisions of Oregon’s Public Records Law, Oregon Revised Statutes (“ORS”) 192.311 through 192.478, and the Uniform Trade Secrets Act as adopted by the State of Oregon, which is set forth in ORS 646.461 through ORS 646.475. I understand that the Proposal is a public record held by a public body and is subject to disclosure under the Oregon Public Records Law unless specifically exempt from disclosure under that law.

4. I have reviewed the information contained in the Application. The Applicant believes the information listed in Exhibit A is exempt from public disclosure (collectively, the “Exempt Information”), which is incorporated herein by this reference. It is my opinion that the Exempt Information is exempt from disclosure under Oregon’s Public Records Law under the specifically designated sections as set forth in Exhibit A or constitutes “Trade Secrets” under either the Oregon Public Records Law or the Uniform Trade Secrets Act as adopted in Oregon because that information is either:

A. A formula, plan, pattern, process, tool, mechanism, compound, procedure, production data, or compilation of information that:

i. is not patented,

ii. is known only to certain individuals within the Proposer’s organization and that is used in a business the Proposer conducts,

iii. has actual or potential commercial value, and

iv. gives its user an opportunity to obtain a business advantage over competitors who do not know or use it.

or B. Information, including a drawing, cost data, customer list, formula, pattern, compilation, program, device, method, technique or process that:

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i. Derives independent economic value, actual or potential, from not being generally known to the public or to other persons who can obtain economic value from its disclosure or use; and

ii. Is the subject of efforts by the Proposer that are reasonable under the circumstances to maintain its secrecy.

4. I understand that disclosure of the information referenced in Exhibit A may depend on official or judicial determinations made in accordance with the Public Records Law.

Affiant’s Signature

State of ___________) ) ss:

County of ________)

Signed and sworn to before me on ___________ (date) by ______________________ (Affiant’s name).

Notary Public for the State of _________________

My Commission Expires: ________