Attachment A Application.docx

ATTACHMENT A:

TEMPORARY MEDICAL STAFFING SERVICES APPLICATION

Each Bidder must complete the following application in accordance with all submission instructions and submit the completed application, along with any attachments, as part of its response to the RFR. Please see Section 6.1.B. of the RFR.

SECTION 1: BACKGROUND INFORMATION

A. Bidder Organization or Individual:

Bidder Name (including DBA, if applicable):

Principal Address:

Local (Greater Boston) Address (if applicable, and if different from principal address):

E-mail address of Bidder’s contact for this Application:

Telephone number of Bidder’s contact:

Contact Person to receive requests for services under this Contract:

E-mail Address of Contact Person:

Phone Number of Contact Person:

Contract Manager for Standard Contract Form (if different from Contact Person):

E-mail Address of Contract Manager:

Phone Number of Contract Manager:

B. Temporary Medical Staffing Services for which Bidder seeks to be considered:

Each Bidder must check the category or categories of Temporary Medical Staffing Services described in Section 4 of the RFR for which it seeks to be considered.

☐ Section 4.1.1: Nursing Staff, Category 1 ☐ Section 4.1.2: Direct Care Workers, Category 2 ☐ Section 4.1.3: Clinicians, Category 3

INSTRUCTIONS FOR SECTIONS 2-5

Each Bidder must satisfy all submission requirements listed below in accordance with the corresponding submission instructions. Please clearly label all attachments with the section number of this Bidder Application to which the attachments apply. Unless otherwise noted, each Bidder must check the box to the left of each submission requirement to indicate its compliance with the requirement.

SECTION 2: RESPONDENT INFORMATION

B. Bidder’s Organizational Chart/Key Personnel:

1. Provide the Bidder’s organizational chart, showing Bidder’s staff who are expected to manage the Contract. The organizational chart should include the names, titles, and reporting relationships of all key organization officers, as well as any subsidiary relationships and subcontractors. If this requirement is not applicable because Bidder is an individual or sole proprietor, please indicate as much in the response. indicating their respective areas of expertise and qualifications; and

2. The résumés of staff designated as key personnel who are likely to be responsible for fulfilling the requirements of the Contract and any Statements of Work requested thereunder.

Submit as attachments

C. Entity Requirements

1. A copy of the Bidder’s Dept. of Labor Standards certificate of licensure. (Section 3.1.1.)

2. Statement of number of years in business. (Section 3.1.2.)

3. Statement of number of years experience in each category of services for which Bidder is applying. (Section 3.1.3.)

1. Submit as attachment 2.&3. Submit as a brief statement.

D. Financial Condition:

1. Bidders’ Dunn and Bradstreet number; or if not available or provided, a Certification of Good Standing from the Mass. Department of Revenue and a statement of gross income for the last three financial periods, and a list of any outstanding contingencies and liabilities, such as lawsuits or other claims or charges against the Bidder.

2. A copy of the Bidder’s audited financial statement for the Bidder’s last fiscal year; or in the absence of such an audited statement, an unaudited financial statement for the Bidder’s last fiscal year, with a letter from the Bidder’s Chief Financial Officer certifying to the solvency of the Bidder.

3. A statement confirming the Bidder has not been in bankruptcy under the U.S. Bankruptcy Code and/or state or federal receivership within the 7 calendar years preceding this response.

4. A statement confirming their financial business model will be able to support and fund their daily business as a Qualified Vendor under any contract awarded from this RFR, and that the Bidder has at least four months of adequate reserves.

5. A statement confirming Bidder is in good standing and compliance with the filing requirements of its state of incorporation and the Commonwealth of Massachusetts.

6. A certificate from the taxing authority of the state in which the Bidder has its principal office, attesting that the Bidder is not in default of any obligation under its tax laws. Corporations with principal offices in Massachusetts may satisfy this requirement by submitting a “Certificate of Good Standing” issued by the Massachusetts Department of Revenue (DOR). For instructions on obtaining the DOR certificate, visit: https://www.mass.gov/info-details/dor-certificate-of-good-standing-andor-corporate-tax-lien-waiver-faqs.

7. A statement confirming Bidder is not subject to a federal or state debarment order or aware of an investigation that could result in a debarment.

Submit as attachments

E. Liability Coverage

1. A copy of Bidders statement of insurance sufficient to meet the requirements of RFR Section 3.3.

Submit as an attachment

F. Conflict of Interest: To demonstrate freedom from conflicting interests, the Bidder shall submit the following:

1. A statement of any and all of the financial, legal, contractual, and other business interests of the Bidder and any material subcontractor, its affiliates, partners, parent(s), subsidiaries, and related organizations, if any, that may impact its performance under the Contract. In cases where such relationships or interests exist or appear to exist, describe how a potential or actual conflict of interest will be avoided or remedied;

2. Any other information requested by EOVS that, in EOVS’s judgment, is relevant to the Bidder’s financial, legal, contractual, or other business interests.

If EOVS determines that a Bidder possesses a conflicting interest, EOVS reserves the right to propose or consider the Bidder’s proposal of any measures to eliminate or mitigate such conflicting interest to EOVS’ satisfaction.

Submit as attachments:

1. Statement not to exceed one page

2. Additional documents, only if requested by EOVS.

SECTION 3: PROGRAMATIC RESPONSE

1. Category 1: Describe Bidder’s experience providing temporary nursing staff (RNs, LPNs, CNAs) to hospitals or congregate facilities.

2. Category 2: Describe Bidder’s experience providing Direct Care workers for temporary assignment at care facilities or other patient care environments. Include the types of positions and entities the Bidder has helped with in the past.

3. Category 3: Describe Bidder’s experience providing medical doctors (MD or OSD) for temporary assignments.

Submit as an attachment a narrative of not more than one page for each of the RFR categories for which the Bidder seeks to be considered.

B. Examples of Experience and References: Examples of projects demonstrating the Bidder’s qualifications and expertise to perform the work described in Section 4 of the RFR. Include as project references individuals who have direct knowledge of the services the Bidder provided for the reference organization. EOVS staff may be included as a reference.

(Note: EOVS reserves the right to contact any of the references Bidder includes in its response.)

Submit no more than three specific examples in total using the table below

1.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

2.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

3.

Name of Project:

Contracting Entity:

Project Reference Contact Information (Name, address, e-mail, phone):

C. Largest Customers: List up to five customers in the following categories, consistent with the requirements in RFR Section 3.5:

1. Three largest customers in Massachusetts;

2. Largest government customer and/or

3. Largest customer in other states.

Bidders may indicate additional out-of-state customers to reach the five-customer limit, if the Bidder so wishes.

For each entity listed include a brief one-two-sentence description of the scope of services provided, and duration of service relationship/contract.

Submit as an attachment.

(one page or less)

SECTION 4: ADDITIONAL RESPONDENT QUALIFICATIONS

Category 1 -Nursing Staff: Narrative Description The Bidder shall provide a narrative description for contract implementation as set forth below. The Bidder should not simply recite or restate requirements. The Bidder shall include:

1. A description of the steps or processes Bidder would use to identify temporary nursing staff upon EOVS request;

2. A description of Bidder’s pre-screening and interviewing processes; and

3. A description of Bidder’s processes to verify licensure, educational background, and background checks.

Submit as attachment

Category 2 – Direct Care Workers: Narrative Description The Bidder shall provide a narrative description for contract implementation for Category 2 services, as set forth below. The Bidder should not simply recite or restate requirements. The Bidder shall include:

1. A description of the steps or processes Bidder would use to identify temporary direct care workers upon EOVS request;

2. A description of Bidder’s pre-screening and interviewing processes; and

3. A description of Bidder’s processes to verify licensure and educational background (as applicable), and background checks.

Category 3 – Medical Doctors: Narrative Description The Bidder shall provide a narrative description for contract implementation for Category 3 services, as set forth below. The Bidder should not simply recite or restate requirements. The Bidder shall include:

1. A description of the steps or processes Bidder would use to identify medical doctors (MD or OSD) for temporary assignment to EOVS facilities upon EOVS request;

2. A description of Bidder’s pre-screening and interviewing processes; and

3. A description of Bidder’s processes to verify licensure and educational background (as applicable), and background checks.

SECTION 5: COST RESPONSE (Respond only for applicable Category(ies))

Category 1 – Nursing Staff: Cost Response

1. Bidder shall provide their rate card for Category 1 nursing staff services consistent with the Maximum Rates set forth in Exhibit 1 of the RFR.

2. Rate Card must include: (i) job title; (ii) hourly rate; (iii) overtime rate; (iv) holiday rate; (v) conversion schedule; and (v) direct placement fee.

3. Rate Card may include additional rates for (i) Travel add-on; (ii) COVID-19 rate add-on; and any additional terms as may be applicable to services offered.

4. Rate Card must specify for the hourly rate, the gross amount paid to the temporary worker (pay rate) and the amount retained by Contractor (Contractor mark-up).

Submit as attachment

Category 2 – Direct Care Worker: Cost Response

1. Bidder shall provide their proposed rate card for Category 2 services consistent with the Maximum Rates set forth in Exhibit 1 of the RFR.

2. Rate Card must include: (i) job title; (ii) hourly rate; (iii) overtime rate; (iv) holiday rate; (v) conversion schedule; and (v) direct placement fee.

3. Rate Card may include additional rates for (i) Travel add-on; (ii) COVID-19 rate add-on; and any additional terms as may be applicable to services offered.

4. Rate Card must specify for the hourly rate, the gross amount paid to the temporary worker (pay rate) and the amount retained by Contractor (Contractor mark-up).

Submit as an attachment

Category 3 – Clinicians: Cost Response Bidder shall provide their rate card for Category 3 medical doctors (MD or OSD). The rate card must describe the types of physicians and specialties the Bidder can provide and the anticipated rates and any related additional fees and costs.

Contractor will be required to disclose the amount paid to the temporary worker (pay rate) and the amount retained by Contractor (Contractor mark-up).

Submit as an attachment

RFR for Master Agreement for Temporary Medical Staffing Services Attachment A – Bidder Application