Attachment B - Response Form~2.docx

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

REQUEST FOR RESPONSES FOR CLINICAL AND SAFETY RISK ASSESSMENT SITES, STAFFING, AND RELATED SERVICES

RFR DOCUMENT #: 24PMOPRTCLNCLSFTYRSSTE

COMMBUYS ID #: BD-24-1039-EHS01-ASHWA-96819

ATTACHMENT B

RESPONSE FORM

ISSUED: March 1, 2024 SUBMITTED BY (Bidder Name): [ ]

BIDDER ORGANIZATION

Organization Legal Name: [ ] Trade name(s) and any other name(s) under which the Organization does, or has done, business: [ ] Principal Address:

City: [ ] State: [ ] Zip: [ ] Telephone: ( ) - FAX: ( ) - URL: [ ]

FEIN: [ ]

MMARS Vendor Customer (VC) Code (if known): [ ] Type of legal entity (e.g. corporation, limited partnership, nonprofit corporation, etc.): [ ] State where the entity is organized (including any parent organization): [ ]

CONTACT PERSON

Include the following information for the individual who should be contacted for purposes of discussing any aspect of this completed response form submitted by the Respondent:

First Name: [ ] Last Name: [ ] Title: [ ] Telephone: ( ) - FAX: ( ) - E-mail: [ ] Contact Person Address (if different):

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

BUSINESS RESPONSE

Provide the information requested below and attach the required documents.

A. COVER LETTER

Attach a Cover Letter (one page maximum) that:

· Certifies that the information contained in your organization’s Response to this RFR is true and complete;

· Certifies the Bidder has the capability and willingness to perform all responsibilities set forth in Attachment A, Model Contract (“Attachment A”);

· Certifies the Respondent is a business entity registered with the Massachusetts Secretary of State to do business in the Commonwealth;

· Certifies that the Respondent has experience with direct service provision in areas relevant to the scope of the contract;

· States that the Respondent accepts the terms of the RFR and of the Model Contract provided in Attachment A, without substantive change;

· States that the Response will remain in effect until a contract resulting from the RFR is executed; and

· Is signed by an authorized Contractor signatory.

☐ Cover Letter uploaded to COMMBUYS or attached.

B. ORGANIZATION

1. Attach a listing of the Board of Directors of your organization and your parent organization, if any.

☐ Listing uploaded to COMMBUYS or attached.

2. Attach an organizational chart, including names, titles, and reporting relationships of key organization officers, subsidiary relationships, and subcontractors.

☐ Organizational chart uploaded to COMMBUYS or attached.

C. SUBCONTRACTS

1. Identify proposed subcontractors (if any):

(maximum 250 characters)

(maximum 250 characters)

(maximum 250 characters)

Attach additional pages, if more than 3 subcontractors

2. Acknowledge that all subcontracts and other financial and programmatic agreements or arrangements will be in writing and will contain terms consistent with all terms and conditions of the RFR and Model Contract.

☐ Check to acknowledge. or ☐ Not applicable/No subcontracts.

3. Acknowledge that the Bidder shall not be relieved of any legal obligations under any contract resulting from the RFR as a result of any subcontract and that it shall be fully responsible for the subcontractors’ performance.

☐ Check to acknowledge. or ☐ Not applicable/No subcontracts

D. FINANCIAL CONDITION

Your organization must demonstrate to the satisfaction of EOHHS that it is in sound financial condition and that any significant financial problems are being addressed with appropriate corrective measures. EOHHS may disqualify a Bidder if the Bidder fails to submit the documents required by this section, or if the documents indicate to EOHHS, in its reasonable discretion, that the Bidder’s financial condition is unsatisfactory.

1. Indicate your current total annual organizational budget.

1. Attach a statement (two page maximum) that includes the following certifications and disclosures:

a. Certification that your organization is in stable financial condition and has not been in any bankruptcy or insolvency proceedings (whether voluntary or involuntary) within the last three calendar years or undergone the appointment of a receiver, trustee, or assignee for the benefit of creditors.

b. Disclosure of any bankruptcy or insolvency proceedings (whether voluntary or involuntary) or receivership appointments within the last three calendar years.

c. Certification that your organization has complied with all laws of the Commonwealth relating to taxes, reporting of employees and contractors, and is in good standing with respect to all returns due and taxes payable. Corporations with principal offices in Massachusetts may satisfy this requirement may be satisfied 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/faqs-dor-certificate-of-good-standing-or-corporate-tax-lien-waiver.

d. Disclosure of any financial audit of the organization that is ongoing or concluded in the last three years and a copy of the auditor’s report. Disclosure shall also include any financial audit information for the organization’s parent organization and material subcontractors, if any. (Audit report not subject to 1 page maximum)

e. Disclosure of any circumstances materially and adversely affecting your organization’s financial condition that are not reported in the financial statements or disclosures submitted to the Commonwealth.

f. Disclosure if, in the last three years, any vendors or subcontractors have cancelled contracts with your organization or implemented sanctions based on performance.

g. Disclosure of any current corrective action plans or sanctions imposed against the Bidder.

h. Disclosure of any civil litigation, criminal investigation, indictment, prosecution, or other proceeding that has been brought against your organization in the last three years.

☐ Statement of Financial Condition uploaded to COMMBUYS or attached.

E. CONTRACTUAL RELATIONSHIPS

Attach a list of current grants, contracts, and other funding sources including contractual relationships with the Commonwealth of Massachusetts, if any, and those completed within the previous two-year period. The listing must include:

1. The contract/funder name/description;

1. The contract/funding term, if applicable; and

1. The total budget.

☐ Contract listing uploaded to COMMBUYS or attached.

F. CONFLICT OF INTEREST

Neither the Bidder, nor any subcontractor shall have any interest that will conflict with the performance of services required under any contract resulting from the RFR, or that may be otherwise anti-competitive, as determined by EOHHS, for the duration of the Contract. If EOHHS determines that a Bidder possesses a conflicting interest, EOHHS reserves the right to propose or consider any proposal of the Bidder of any measures that would eliminate or mitigate such conflicting interest to EOHHS’s satisfaction.

To demonstrate freedom from conflicting interests, the Bidder certifies that:

Bidder shall disclose any other information that may be relevant to its financial, legal, contractual, or any other business interest as it relates to the RFR and the Contract in an attached conflict of interest statement if additional detail is needed to demonstrate freedom from conflicting interest.

G. REQUIRED FORMS AND ACKNOWLEDGEMENTS

a. Submit the Commonwealth-required forms below. These forms may be downloaded from the “File Attachments” section of this solicitation on the COMMBUYS website:

Contractor Authorized Signatory Listing Form (CASL)

b. Bidders agree to abide by the terms of the Commonwealth Terms and Conditions for Human and Social Services Contracts, the Standard Contract Form, and Standard Contract Form Instructions by clicking the checkboxes below. These documents may be downloaded from the “File Attachments” section of this solicitation on the COMMBUYS website:

EOHHS is prohibited from amending these documents or agreeing to any change in the language. Any Bidder’s suggestion or requirement altering these documents will be disregarded.

c. The following documents are included among the required forms posted on COMMBUYS for review purposes only. The selected Bidders will complete these documents as part of the contract execution process.

· Authorization for Electronic Funds Transfer Form (New Contractors only)

· W-9 Form (Massachusetts Substitute W-9 Format - Request for Taxpayer Identification Number and Certification)

PROGRAMMATIC RESPONSE

Provide your response as directed below in a separate attachment. You may not exceed the page limit for each attachment, if specified.

Your response must demonstrate your ability to assume all programmatic requirements in Section 2 of Attachment A. If you are unable to provide the information required in a specific submission requirement, expressly identify which information is not being submitted and why. Submit the most comparable information you have available and explain, in accordance with this section, how you will have the capability to perform all Contract responsibilities.

A. INTRODUCTION (1 page maximum) Provide a brief overview of your organization and your proposed Subcontractors, including:

a. Formation date, goals and mission;

b. Brief discussion of current services offered, and areas served; and

c. Main funding sources.

B. RELEVANT HISTORY AND EXPERIENCE (2 page maximum) Discuss your organization’s history and experience providing services similar to those described in Section 2 of Attachment A, including but not limited to:

a. Experience collaborating with EOHHS, EOHLC (formerly DHCD), ORI, the Department of Public Health (DPH), and EA shelter providers;

b. Experience with clinical staff (nursing or advanced practice clinicians) providing basic clinical assessments and/or support to families with medical vulnerabilities, including (but not limited to) high risk pregnancy, newborn care, medical devices and/or multiple chronic conditions;

c. Experience providing services to homeless families and pregnant individuals, and/or immigrant and newly arrived individuals and families;

d. Ability to ensure cultural, linguistic, and socio-economic sensitivity and respect;

e. Experience in collecting and reporting on client encounter data; and

f. Discussion of how the organization’s experience, contractual relationships and staff expertise relate to the key activities required under the RFR and Attachment A

C. PROPOSED APPROACH AND IMPLEMENTATION PLAN (5 page maximum) Discuss your proposed approach for implementing and operating CSRA Sites. Your response must:

a. Identify the proposed CSRA Site(s) by name, street address, and anticipated number of Family Spaces. Include in your response any relevant information regarding the layout of and facilities available at the CSRA Site.

b. Indicate whether the proposed CSRA Sites are Full Service or Limited CSRA Sites, and whether the Bidder anticipates that they will be managed and funded by EOHHS, EOHLC, the Contractor, or another entity.

c. Include a Program Plan as described in Attachment A that:

i. Describes the service delivery model and services available at each proposed CSRA Site, consistent with Section 2 of Attachment A.

ii. Describes any additional services or capabilities related to those described in Attachment A that the Bidder would be able to provide under the Contract.

d. Identify any anticipated challenges related to operationalizing CSRA Sites and proposed solutions and resolutions.

D. STAFFING AND KEY PERSONNEL (3 page maximum) The Bidder shall describe a staffing plan consistent with Attachment A, Section 2.4, including:

a. A list of the Key Personnel as described in Attachment A and other staffing that will be assigned to the Contract, including an estimated number of hours (FTEs) for each individual.

b. A description of the expertise or experience possessed by staff, volunteers or board members that uniquely enhance the organization’s capacity to deliver the proposed service, and specifically identify current bilingual/bicultural staffing capacity.

c. A description of any material subcontractors identified in Business Response Section C that the Bidder will use or seek to engage to satisfy the responsibilities set forth in Attachment A. The Bidder shall indicate whether it has a current contract or other commitment (such as letter of support or memorandum of understanding) with such material subcontractor for the work the Bidder describes in its response. Please also identify any local organizations you anticipate partnering with in delivering services set forth in Attachment A.

d. An organization chart identifying where key personnel are in the Bidder’s organization and identifying any and all material subcontractors the Bidder will use to satisfy the responsibilities required under the Contract and who will oversee them. The Bidder shall include function and names, where available.

☐ Response to Programmatic Sections A-D is uploaded to COMMBUYS or attached.

COST RESPONSE

Attach a completed Budget in the form and format posted on COMMBUYS, Attachment C, consistent with Section 4 of Attachment A. The budget must also include a narrative response explaining the proposed line items of the budget.

☐ Budget and narrative attached.

Attachment B – Response Form Clinical and Safety Risk Assessment Site Staffing and Related Services RFR Page 2 of 37