Application Requirements Amended and Restated.docx

APPLICATION REQUIREMENTS AMENDED AND RESTATED

NOTE: Separate Application must be filed for Site Only, Mobile Only, Blended Capacity and Peer Respite. If an Applicant wants to qualify for more than location for Site Only, Blended Capacity and/or Peer Respite or for more than one DMH Site Office for Mobile Only, it will be necessary for the Applicant to complete certain parts of the Application multiple times (one for each location or Site Office). Please watch for instructions in these Requirements as to when this must be done.

1. Application Cover Sheet: The Applicant must submit a completed Application Cover Sheet that is located in the COMMBUYS File of this Bid. The Cover Sheet must be signed by an individual authorized to negotiate for and execute the contract on behalf of the Applicant. The Cover Sheet must specify which of the 4 Service Models the Bidder wants to be qualified to provide under the Master Agreement. The Applicant must also state in the Cover Sheet what capacity it is proposing to provide. It the Application is a re-application, the Cover Sheet needs to include a summary of what is new or different in the application. If the Application is to add capacity or a new location to an already approved model, the Cover Sheet must include a summary of the proposed addition and an update of the information provided in the original application, if needed. See Cover Sheet and Evaluation Tool Worksheet for more information on re-applications and additions.

2. Application Format: The Application must be in the following format

· type-written 12 point Times New Roman Font

· 8 ½ X 11 inch paper

· fully justified (print fully abuts both margins)

· single-spaced

· one inch margins

· page numbers at the bottom of each page

· Include a Table of Contents

3. Design of the Application All applicable information requested must be provided. The Application Requirements Chart has been divided into Categories. The Application must be divided into the same Categories and the information provided in each Category must be in the order it is asked for in the Chart. The title of the Category must be inserted in bold on a separate line, before responding to any questions/request for information in that Category. The number and the header of the question/request for information must be inserted before the response; for example:

Category I Applicants Background and Organizational Structure I.A Background

1. Response……..

2. Response….

I.B Mission and Philosophy Response……..

4. Page Limits. An Application may not exceed 25 pages; provided, however, that for Site Only, Blended Capacity and Peer Respite, an Applicant gets four (4) additional pages for each location it is seeking to qualify for over one (e.g., if an applicant is proposing three (3) locations, it would get an extra 8 pages). Similarly, for Mobile Only, an Applicant gets four (4) additional pages for each Site Office it is seeking to qualify for over one. The page limit does not include allowable attachments.

Department of Mental Health Amended and Restated Respite Services – Master Agreement Request For Applications

DMH # 2017-DMH-3048-03

July, 2020

APPLICATION REQUIREMENTS CHART

An Applicant must respond to all relevant questions and requests for information set forth below. It is important that the Application demonstrate that the Applicant understands and can meet the requirements of the RFA. The Application must be in compliance with the requirements as identified above. The Applicant must provide details in its Application. It is not enough to say that you will meet requirements; you must describe how you intend to do it. In completing the Application, you should address the service model you have selected and your proposed capacity. Note: Blended Capacity and Peer Respite has specific capacity requirements that must be met.

Before completing the Application, Applicants should review the RFA Evaluation Tool Worksheet.

CATEGORY I: APPLICANT’S BACKGROUND AND ORGANIZATIONAL STRUCTURE

Questions/Requests For Information

A. Background

Subsections 1.2, 1.3 and 1.4; Sections 4, 5, 6, 7 and 8

· Identify the length of time your organization has served adults who have serious and/or long term mental illness and identify the types of services provided to these individuals.

Preference will be given to Applicants with 5 or more years of experience providing respite or services similar to Respite.

Preference will be given to Applicants with 5 or more years of experience in providing recovery based services to individuals with serious mental illness.

· Identify if you organization is on any other Master Service Agreement involving Human and Social Services, and what those agreements are. Further describe if you have received any statement of works and/or purchase agreements under those Master Service Agreements and how your agency has been able to address the additional business.

If you are unable to provide this information, describe why you feel your organization is qualified to manage a Master Service Agreement.

· Identify what could be barriers to you entering into Purchase Agreements and/or commencing services quickly once a Purchase Agreement is signed. Indicate how such barriers could be minimized.

B. Mission and Philosophy

Subsections 1.3, 1.4 and 7.3 and Section 3

· Describe your organization’s mission and philosophy and how Respite Services will fit within the overall mission and direction of your organization.

· Describe how your organization’s mission and philosophy are consistent with DMH’s vision and mission (Section 3) and the description, principles and goals of Respite Services as set forth in Subsections 1.3 and 1.4 and 7.3

C. Organizational Culture

Subsection 1.3 and Sections 3 and 4

· Describe how Recovery, Trauma Informed Care, Person Centered and Strength Based services and peer support are incorporated into the culture of your organization.

· Give specific examples such as corporate policies and procedures, employee trainings, staff positions, assessment of staff competencies, staff supervision, and quality management to demonstrate your organizational culture.

Preference will be given to Applicants that have incorporated recovery principles into their mission statements and policies and that submit documentation of such as attachments to their responses.

D. Applicant’s Organizational Support

· Describe how your organization will provide oversight, consultation and support for the Respite Services.

· Attach an organizational chart depicting how the Respite Services will fit in your organizational structure. Describe the advantages this structure will provide the Respite services.

E. Other Qualifications, if Applicable

Other, if applicable. Describe other qualifications of your organization that DMH should consider in determining if your organization is qualified to provide this service.

F. Risk Mitigation

Subsections 6.14 and 7.10

Attach your organization’s proposed Risk Mitigation Protocol for Respite Services.

G. Information Technology Requirements

Subsection 8.5

Indicate if your organization meets the Information Technology (IT) requirements set forth in Subsection 8.5. If it does not, describe the steps your organization will take to ensure compliance and the expected timeframe to meet these requirements.

H. Privacy and Data Security

Subsection 8.2

I. EOHHS Qualified Corrective Action Plan/Audit Resolution Agreement

Subsection 8.1

Indicate if your agency is EOHHS Qualified or the date your agency submitted information to be Qualified to DMH.

J. Corrective Action

Subsection 8.1

If your organization is under a Corrective Action Plan (CAP) or Audit Resolution Agreement (ARA), indicate the current status and why this should not be considered in determining if your organization can successfully undertake providing services under the MA.

K. Debarment

Subsection 8.1

Indicate if your agency is now or has ever been subject to a state or federal debarment order. If your organization has been subject to a debarment order, specify the date and the circumstances surrounding it.

L. Complaint Process

Subsections 6.4, 6.10, 7.7 and 7.11

Attach your proposed complaint process.

M. For Peer Respite

Section 7

· Identify the length of time your organization has served adults who self-identify as having been diagnosed with a serious mental illness or as having experienced emotional distress, trauma, or significant mental health challenges and who may also have or have had substance use issues and identify the types of services provided to these individuals.

Preference will be given to Bidders who have five or more years or experience providing Peer Lead and Operated Services as defined in the RFR

· Describe your organization’s governance structure.

· Describe your organization’s current Board of Directors. Include overall number and the number of Persons with Lived Experience on your Board, and indicate whether there are any requirements for including Persons with Lived Experience on your organizational board.

· Describe any peer advisory committees your organization currently convenes.

· Describe any policies or procedures used by your organization to support staff in sharing personal information or lived experience.

CATEGORY II. STAFF POSITIONS, QUALIFICATIONS, AND REQUIREMENTS

COMPLETE A SEPARATE CATEGORY II RESPONSE FOR EACH PROPOSED LOCATION FOR SITE ONLY; BLENDED CAPACITY AND PEER RESPITE OR DMH SITE OFFICE FOR MOBILE ONLY FOR WHICH YOU ARE SEEKING TO BE QUALIFIED FOR THE PURPOSE OF THE MASTER SERVICE AGREEMENT

Notes: (1) For all Models in responding to these Questions/Request For Information assume that you are providing services at your stated capacity level for each location or DMH Site Office; (2) for Mobile Only if the response for each Site Office will be identical, just indicate that on the additional Category II Responses; (3) For Blended Capacity include in the staffing for a location the staff that will also be responsible for the required mobile respite capacity and be sure to indicate in your response how the two roles will be addressed by the different staff members; (4) For Peer Respite indicate the staff who will be responsible for outreach when resources permit.

Questions/Requests For Information

A. Availability

· For Site Only; Blended Capacity or Peer Respite identify each location you are proposing for site-based respite and the capacity of each location for referrals from DMH under a Purchase Agreement. For Blended Capacity also indicate your mobile respite capacity.

· For Mobile Only. Identify each DMH Site Office you are proposing to serve and the capacity for each.

B. Staff Positions

Subsections 5.1, 5.2, 5.3, 6.12, 7.1, 7.4 and 7.10 Sections 4, 5, 6 and 8

· Describe your proposed staffing for this location/Site Office assuming you have enrollment up to your stated capacity.

· Include as attachments job descriptions, including education training and experience requirements, for all Direct Care Supervisors, all Direct Care Program Staff and managerial and executive staff.

· Describe how the staffing meets the applicable requirements in Subsection 6.12 or Subsection 7.10.

· Describe how staff resources will be managed to achieve maximum flexibility to respond to the needs of Person Served.

· Describe what you believe will be factors in determining daily staffing.

· If applicable, describe how staff will work as an integrated team.

In addition:

For Site Only, Blended Capacity and Mobile Only: Describe how the multidisciplinary nature of the proposed team(s). Also, describe how the staff positions are aligned with the clinical expectations for the Service as addressed in Subsections 1.2; 5.1, 5.2, 5.5, 6.5 and 6.12.

For Blended Capacity address staffing for both site based and mobile respite. Also address the role of Human Rights Officer in your response.

For Blended and Peer Respite: Attach a sample staffing schedule for one month’s time at the Peer Respite and Blended Capacity Program. Assume the same number of individuals/beds as proposed in your response. Identify the time allotted for supervision, consultation, training, and internal communication.

For Peer Respite:

1. The Peer Respite Services Director and staff who provide direct services must be Persons with Lived Experience. Describe how you propose to meet this staffing requirement.

2. The Peer Respite Services Director and direct care staff must have completed a recognized peer certification program and been awarded a certificate by the program. Describe how you propose to meet this staffing requirement. If applicable, identify any other certifications you propose to require of staff and which staff will be required to have these certifications.

3. Address how the role of Human Rights Officer will be filled

C. Staff Deployment

Subsections 5.9, 6.12.1, 6.12.2, 6.12.3, 7.10 Sections 4, 5, 6 and 7

Describe your plan for staff deployment and how it will ensure that services are appropriately and adequately staffed.

In addition for Site Only, Blended Capacity and Mobile Only:

Indicate how your proposed staff deployment will ensure that Peers are incorporated into the service model with clearly defined roles and with sufficient support, supervision and consultations. Specify what the defined roles may be.

Also indicate how Clinical staff will be available for consultation.

D. Training and Supervision

Subsections 6.12 and 7.10

1. Describe the frequency and approaches that you intend to use for supervision.

2. Describe your intended approach for training. Describe how you will ensure that staff members are trained timely and appropriately on the service and operation procedures and protocols.

E. Organizational Chart

Attach an organizational chart for your staffing structure, showing supervision responsibility.

CATEGORY III. SERVICE MODEL AND SERVICE DELIVERY

Questions/Requests For Information

A. Service Model

Sections 4, 5 and 6 and 7; Subsections 1.2, 1.3 and 1.4.

In addition for Peer Respite: Indicate if you plan to use the IPS Model or a similar service delivery model. If not using IPS, identify what model you are using and submit as an attachment a description of the model (basic tenets, who developed it, where it is currently being utilized, service components, required training, etc.). In addition, as part of the attachment, submit published descriptions of the model and supporting literature. Also describe why you picked this model and how it is similar to IPS and consistent with the goals and purpose of Peer Respite.

B. Service Delivery

Section 4

Describe how your will address the following:

C. Referrals and Enrollment

For: Site Only Blended Capacity and Mobile Only

Subsections 6.2, 6.3 and 6.4

C.

Service Access

For: Peer Respite

Subsections 7.5-7.7

Describe how you will meet the requirements of the RFR concerning hours of operation and length of stay at the Peer Respite Program.

D. Assessments

For: Site Only, Blended Capacity and Mobile Only

Subsection 6.5

Describe your proposed assessment protocol which addresses the following:

D. Entering the Peer Respite Program

For Peer Respite

Subsections 7.7

E. Community Service Plans (CSP)

For Site Only, Blended Capacity and Mobile Only

Subsection 6.6

Describe your Community Service Plan protocols which addresses the following:

E. Goal Planning

For Peer Respite

Subsection 7.7

· Describe your proposed protocols for developing and updating Personal Goal Statements.

· Describe how the protocols will ensure the following:

· that planning is strength-based and person-centered;

· Personal Goal statements are completed in a timely fashion;

· Individuals are supported to develop goals for their stay through a process that is Culturally and Linguistically competent.

F. Records

Subsection 6.10, 7.11

Describe your protocol for how records of Persons Served will be developed, maintained and retained. Specify if records will be manual, electronic or a combination.

G. Discharge Planning

Subsection 6.7

Describe your Discharge Planning protocols which addresses the following:

G. Completion or Termination of Services

For Peer Respite

Subsection 7.8

Attach a draft of the protocol you will use to implement the provisions of Subsection 7.8, Completion or Termination of Services. The protocol must address the actions steps that will be followed when a decision is made to end an individual stay at the Peer Respite Program for safety reasons.

H. Medication

Subsections 5.1, 5.4, 6.5 and 6.12

Attach your medication policies and procedures

Describe your staffing plan for medication administration and training; indicate licensure and/or Medication Administration Program (MAP) certification for staff as is applicable. I an Applicant proposes to meet the staffing requirements for medication administration by MAP certified staff, then it must identify its proposed DPH-registered site in its staff responses.

CATEGORY IV. SCENARIOS

Questions/Requests For Information

Provide brief responses to the following 7 scenarios as to how you will provide services to the individuals:

50 year old woman who has been struggling with substance misuse and symptoms of a PTSD and a schizoaffective illness for many years. She has had periods of not using substances, is not in agreement with her treating psychiatrist’s recommended medications and does not always take medications as prescribed. She has had to move from her apartments several times to avoid eviction due her not letting the landlord, her mother or community based service providers into her apartment to make necessary repairs. There have been constant complaints from the neighbors as well. She is the lease holder of the unit and it is unclear if she will be able to successfully maintain community tenure without additional support. She has been frequently hospitalized due to concerns about her safety and inability to care for herself including medical follow-up. Recently, she was hospitalized on an acute unit for two months and the community hospital has assessed her as not needing longer term continuing care and is now ready for discharge.

Client enrolled in Adult Community Clinical Services- Integrated Team is using crack and letting people suspected of drug dealing into her apartment putting herself at risk of eviction. She recently had a medical event due to the drug use which resulted in a medical hospital admission and is now ready for discharge but the hospital feels a period of increased behavioral health support is necessary to reduce SUD relapse related risks.

Long-term DMH Client has successfully lived independently for many years in a subsidized apartment. She receives Case Management services only. She receives her outpatient medication and therapy from a local behavioral health center and is consistent with her appointments. Yesterday she presented at the local Emergency Room with confusion and paranoia but did not meet hospital level of care. Client informs Case Manager she is not comfortable returning to her apartment at this time and refuses to leave the Emergency Room.

25 year old male recently authorized for DMH adult services with diagnoses of PTSD, bi-polar, and polysubstance abuse is about to be released from jail following a six month incarceration for assault and battery with dangerous weapon (knife). The charge appears related to Client seeking money to support cocaine use. Client is without benefits and housing. The brief history that has been obtained indicates some work history, several temporary housing situations, brief periods of engagement with outpatient treatment since he was nineteen and estrangement from family. There is mention in the history of an incident of inappropriate sexual conduct with a minor but no formal charges.

21 year old male recently authorized for DMH adult services and will now be dually served by DMH and the Department of Developmental Services (DDS). He is diagnosed with PTSD, ADHD, a learning disorder, and mild mental retardation. He has a severe trauma history as a child, exhibits problematic sexual behaviors with male peers, and makes accusations about inappropriate behavior of staff. He has been served in a variety of settings including residential facilities and foster care placements with little change in behavior. He has difficulty understanding the outcome and consequences of inappropriate behaviors. He has difficulty in educational settings as his comprehension and memory are poor. Typical behavioral interventions have little positive effect due to his limited capacity to understand. He needs intensive supervision where he is living (especially near bathrooms) and two to one supervision in the community.

Young female Client whose DMH application adult services was recently approved and who is hospitalized in an acute psychiatric unit under a 7&8 and approved for the DMH Continuing Care (Section 3) waitlist. She is currently homeless, has a history of multiple hospitalizations related to an inadequate connection to outpatient services and acute symptomatology, and has an inability to care for herself. The DMH Site Office is working closely with the hospital as her symptoms have improved and diversion from continuing care is clinically indicated.

Middle aged male who is diagnosed with Bipolar Disorder and had been incarcerated at a local jail for charges of assault and battery and larceny. He was unexpectedly released from jail and had no re-entry services. He was admitted to an acute psychiatric unit and has no stable community living arrangement to transition to and he is now ready for discharge.

CATEGORY V. SITE-BASED LOCATION(S) AND MOBILE RESPITE DMH SITE OFFICE(S)

COMPLETE A SEPARATE CATEGORY V RESPONSE FOR EACH PROPOSED LOCATION FOR SITE-BASED RESPITE OR DMH SITE OFFICE FOR MOBILE RESPITE FOR THE SERVICE MODELS THAT YOU ARE SEEKING TO BE QUALIFIED FOR PURPOSE OF THE MASTER SERVICE AGREEMENT

Questions/Requests For Information

A. Physical Site

For Site Only, Blended Capacity and Peer Respite

Subsections 6.11, 6.13 and 7.9; Sections 4, 6 and 7

· If you have an actual or planned location, provide the address, ADA compliance status, and a detailed description of the space.

· Verify that the physical site is properly zoned for the intended use. Describe the ways in which the physical site can be considered safe and of a size and design that is consistent with the RFR requirements.

· Describe how individuals will access the physical location including a description of available public transportation, if any. Indicate if the location is leased or owned. Describe why this location was selected.

· Describe how the physical site meet the requirements set forth in Subsection 6.11 or if applicable, Subsection 7.9.

· Describe your plan for meals.

A. DMH Site Offices

For Mobile Only and Blended Capacity ( for this model services are provided by DMH Area where the vendors physical sites are located and thus the provider should address questions 2 and 3 by DMH Area)

Subsections 1.2, 1.3 and 1.4; 6.13 and 4.12. Sections 4, 5 and 6

Subsection 6.13

CATEGORY VI. QUALITY MANAGEMENT, REPORTING REQUIREMENTS

Questions/Requests For Information

A. Quality Management (QM)

Subsection 8.4

B. Reporting Requirements

Subsections 6.15, 6.16 and 7.13

CATEGORY VII. CONTRACT FORMS

Questions/Requests For Information

A. Contract Forms

Contract Forms. The following forms must be submitted with the Proposal, as Attachments, unless otherwise indicated.

___ An executed Massachusetts Form W-9 (1 original)* ___ A Contractor Authorized Signatory Listing (1 original). Note: both pages are required, with the second page notarized) ___ An Executed Standard Contract Form that indicates the Commonwealth Terms and Conditions For Human and Social Services are applicable ___ Authorization for Electronic Funds Payment (1 original)*

*Note: If An Applicant has already submitted to DMH or another Commonwealth agency Form W-9, and/or Authorization for Electronic Funds Payment, as listed above, and such are on record with the Office of the Comptroller, it does not need to submit another. If any of these forms are not included in a response, DMH will verify that they are on record with the Office of the Comptroller.

The following Form is optional but strongly recommended is for providers that expect to or do provide at least $150,000 worth of Services under their MA and/or would like their participation in the SDP considered in the selection of providers for Purchase Agreements.

___ SDP Plan Form for POS