Attachment E-Dietician Short Form Revised.docx

COMMONWEALTH OF KENTUCKY

REQUEST FOR PROPOSAL-SHORT FORM APPLICATION

RFP 729 2100000074 – DIETICIAN – GLASGOW STATE NURSING FACILITY

FAP 110-10-00 GENERAL CONDITIONS AND INSTRUCTIONS FOR SOLICITATIONS AND CONTRACTS Instructions: Please fill out all spaces below with your information. Check all requirements that you meet. The links above (blue) will take you to the original RFP document and General Conditions and Instructions for Solicitations and Contracts.

APPLICATION MUST BE SIGNED IN INK.

ALL QUALIFIED APPLICANTS WILL BE REQUIRED TO PROVIDE A NOTARIZED AFFIDAVIT, AND OTHER SUPPORTING DOCUMENTATION AS REQUIRED

Overview The purpose of this Request for Proposal (RFP) is to provide Glasgow State Nursing Facility (GSNF) with the services of a part-time licensed Dietician to provide for necessary clinical and dietary needs of the patients.

Glasgow State Nursing Facility (GSNF), operated under the Department for Behavioral Health, Developmental and Intellectual Disabilities (DBHDID), within the Cabinet for Health and Family Services (CHFS), is a one hundred (100) bed licensed Nursing Facility located in Glasgow, Kentucky.

GSNF is required by the Centers for Medicare and Medicaid Services (CMS), CHFS Office of Inspector General (OIG), and various clinical and professional organizations to provide clinical dietary services to their patients. Service hours are based on the needs of the Facility, and the availability of State and/or Federal funds. There is no guarantee of number of hours or caseloads.

Contractor Qualifications You must meet the following minimum mandatory requirements and provide documentation to qualify to be considered for the award:

1. Provide Proof of Liability, Malpractice and Workers Compensation Insurance, and certificates of professional (medical) and contractual liability insurance at a minimum of $1,000,000 per incident and $3,000,000 per year.

2. Complete, sign, and submit the written statement certifying acknowledgement that the Department for Behavioral Health, Developmental and Intellectual Disabilities shall not be liable for any employee insurance associated with the contract awarded from this Solicitation, including, but not limited to medical malpractice. (Attachment B)

3. Complete, sign, and submit the written statement certifying that the contractor and any dietician provided for services is not currently and will not be an excluded Medicare/Medicaid provider. (Attachment C)

4. Complete, sign, and submit the written statement certifying that all individuals providing services under this contract if awarded shall possess at least the minimum credentials for that skill level. (Attachment D)

5. Submit documentation of certification and membership with the American Dietetic Association for all licensed dieticians to perform services.

6. Submit a Transmittal letter on the company/agency or individual letterhead, signed by an agent authorized to bind the company/agency or individual. The Transmittal letter shall include the following:

7. An authorized representative MUST complete and sign the Solicitation form and include the following:

a. “Vendor” box and “Payment” box should be completed.

b. Vendor shall indicate ownership type.

c. Vendor shall provide “FEIN” if applicable.

d. Vendor shall provide date the form is completed and signed.

e. Signed face of the most recent Addenda, if applicable.

8. Submit a signed and notarized Required Affidavit for Bidders or Offerors form – Required. Available at the following link: http://finance.ky.gov/services/forms/Pages/default.aspx

Signed and Notarized Required Affidavit for Bidders, Offerors and Contractors Claiming Resident Bidder Status – if applicable. Available at the following link: http://finance.ky.gov/services/forms/Pages/default.aspx *Offerors not claiming Resident Bidder Status need not submit this affidavit.

Signed and Notarized Required Affidavit for Bidders, Offerors and Contractors Claiming Qualified Bidder Status – if applicable. Available at the following link: http://finance.ky.gov/services/forms/Pages/default.aspx *Offerors not claiming Qualified Bidder Status need not submit this affidavit.

Please also provide the following information below as a part of your Technical Proposal attachments:

1. Provide a brief written overview and mission of the company/agency, or individual. Describe the company/agency, or individual’s background, credentials, and knowledge base as it relates to providing dietary services. Provide the name, mailing address, e-mail address, and telephone number of the individual who is to be the principal contact person with the facility. If the offeror is other than an individual, include the name and telephone number of the company representative who is to be the principle contact with the facility.

2. Provide a brief written description of past work history with similar criteria as this Solicitation. Description should include quality and depth of the company/agency or individual’s expertise and its prior capability to provide similar services. Discuss the company/agency or individuals past performance with contractual activities.

3. Provide evidence of prior contract experience with a state acute psychiatric hospital or nursing facility. The bidder with the most years of experience providing contracted services to a state owned or operated residential facility for the care and treatment of individuals with behavioral, intellectual, or developmental disabilities shall receive the maximum score (maximum used for scoring purposes is ten (10) years or more.)

4. Provide a resume for all individuals who will provide dietary services that have a direct relationship to the qualifications listed in this Solicitation, including length of service. Sample resumes shall be acceptable. Resumes shall include name, address, education, qualifications, and previous work experience (to include beginning and end dates). Special emphasis should be placed on work with individuals with behavioral health, developmental and/or intellectual disabilities.

5. Provide a brief written narrative of how the Bidder shall have a licensed dietician(s) available to provide services as needed, and as detailed in Section 2, Required Services of the RFP document.

6. Provide a written statement to indicate the number of licensed dieticians available to provide these services, and the maximum number of hours per week, month, year in which services can be provided.

7. Provide a written statement that gives details on staff turnover in the past three years and the commitment to continuity.

8. Provide a written summary outlining the plans for filling dietary needs for the patients at Glasgow State Nursing Facility.

9. Provide three (3) references from past work history for the offeror (company/agency). Provide verifiable references in providing onsite comprehensive medical care to individuals with behavioral health, developmental and/or intellectual disabilities (preferably in state facilities). References shall be provided on company letterhead and include: name of organization, type of business, type of clientele served, address, phone number, contact person, fax number, e-mail address, length of time service was provided (begin – end dates).

Proposal Submission

All proposal submissions and attachments must be sent via Secure File Transfer on https://ftp.ky.gov.

Complete instructions for submission are attached to the header of the RFP.

Proposals shall be submitted in three (3) parts:

1. The Technical Proposal (Short Form and all Completed and Signed or Written Attachments),

2. the Cost Proposal, and

3. the Proprietary Information (if applicable).

Please LABEL all files accordingly.

ELECTRONIC MAIL OR FACSIMILE PROPOSALS SHALL NOT BE CONSIDERED.

**INDIVIDUAL VENDOR*** (If company or agency, leave this section blank and complete section below)

Address: ________________________________________________________________________________ City: ______________________________________________ State: ________ Zip: ___________ KY Vendor ID Number (if known): _________________________________________________________________

***COMPANY/AGENCY VENDOR*** (If individual, leave blank unless you are a registered business/LLC) Company Name: _________________________________________________________________________ Contact Email: _____________________________________ Phone Number: _____________________________ Address: ________________________________________________________________________________ City: ______________________________________________ State: ________ Zip: ___________ KY Vendor ID Number (if known): _________________________________________________________________

Please provide the required minimum three (3) references below:

This form is for the purpose of determining eligibility to perform contractor services. This does not constitute a guarantee of a contract award.

SIGNATURE Date

By signing the short-form application, the bidder acknowledges all terms and requirements of the originating RFP.

PROGRAM DETAILS

Services Required

1. The Contractor shall be responsible for the following:

a. Provide a part-time recognized and licensed Dietician to provide for the necessary clinical and dietary needs of the patients. The dietician shall be licensed by the State of Kentucky Board of Licensure and Certification for Dieticians and Nutritionists. The dietician should have experience working with individuals with developmental and/or intellectual disabilities.

b. Be responsible for the salary, benefits, withholding of state/federal taxes, etc. of the individual.

c. Complete work on campus unless authorized by the Medical Director and/or Facility Director.

2. Dietician must:

a. Possess a bachelor’s degree or higher granted by a regionally accredited college or university in the United States (or equivalent foreign degree) with completion of academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose;

b. Be licensed as a dietitian by the State of Kentucky Board of Licensure and Certification for Dieticians and Nutritionists

3. Dietician shall be responsible for the following:

a. Assist the Director of Nursing and the Food Service Manager in the operations of the Clinical Dietary Services;

b. Plan, implement, and consult with the Dietary Department;

c. Provide patient charting and nutritional assessments;

d. Provide clinical dietary services as necessary for facility patients;

e. Consult with medical and clinical staff as needed;

f. Complete in-service training;

g. Participate in treatment planning;

h. Participate in resident assessment protocols and documentation; and

i. Work within the hours set forth by the facility to meet facility needs. The facility anticipates Dietician to work between twelve to fifteen hours per week, or around 700-800 hours for a one year term of the contract. Dietician will complete work on campus unless authorized by Facility Director. This schedule would be set between the days of Monday through Friday between the hours of 7:00 AM to 3:00 PM Central Standard Time (CST).

B. Meet Health Information Portability and Accountability Act (HIPAA) and Centers for Medicare and Medicaid Services, and/or standards, throughout the contract term.

C. Insurance

Have and maintain malpractice liability insurance in the amount of no less than $1,000,000 (policy limit) and comprehensive general insurance in the amount of no less than $1,000,000 per individual claim, and $3,000,000 in the aggregate (policy limit). In the event that any insurance coverage lapses or is modified in any way, the contractor shall notify the facility in writing within five (5) business days.

D. Mandatory Requirements for Facility Contracted Staff:

No individual providing services under this contract shall start to work without the required credentials stated below.

For each applicant recommended for consideration to provide services through this contract, the contractor shall provide individual’s (1) application to include required license/certification, as appropriate, and (2) evidence of the following credentials:

1. Record Checks: A current and satisfactory criminal and nurse aide abuse registry check in accordance with KRS 216.793, KRS 27A.300, KRS 17.151 and 902 KAR 20:410, Section 5(5). Current is within the last thirty (30) days. Satisfactory is with no convictions or outstanding charges which would constitute a felony conviction under 902 KAR 20:410, Section 5(5).

A criminal record check shall be completed through the Kentucky State Police Information Center or the Administrative Office of the Courts. The Commonwealth of Kentucky’s Justice and Public Safety Cabinet approves both. If an individual providing services under the contract has resided or worked in a state(s) other than Kentucky, a satisfactory records check shall be required of those states as well.

A check of the Kentucky Nurse Aide Registry shall also be completed. If the contract is with an individual, the contractor shall be responsible for the records, criminal, and abuse checks. This information shall be maintained by the Facility Human Resources Department and be on file prior to work assignment.

All individuals providing services under this contract shall be subject to a fingerprint-supported state and FBI check under the Kentucky Applicant Registry and Employment Screening (KARES) Program. To enroll in KARES, please go to http://chfs.ky.gov/os/oig/kares/.

2. Purified Protein Derivative (PPD/TB skin) Test: Evidence of a current PPD (TB skin) test or Blood Assay for Mycobacterium tuberculosis (BAMT). If a current PPD test or BAMT is not available, the contractor shall provide this service at no charge to the individual.

3. Drug Testing: Pursuant to 908 KAR 3:190 evidence that individuals recommended to provide services through this contract have successfully completed a ten (10) panel, plus Oxycodone drug test (“Pre-appointment testing”) within the last thirty (30) days. Pursuant to 908 KAR 3:190, section 10, paragraph (1) “… the department shall, at a minimum, test for”:

Costs associated with conducting pre-employment drug testing of prospective test-designated individuals shall be borne by the contract agency.

Pursuant to 908 KAR 3:190, the DBHDID may require random or reasonable suspicion drug testing of individuals providing direct care services under this contract.

4. OIG LEIE Record Check: In accordance with the Social Security Act sections 1128 and 1156, the Federal Office of Inspector General maintains a List of Excluded Individuals and Entities (LEIE) which shall be reviewed prior to allowing contract agencies or personnel to work within GSNF. Any contract agency or contract personnel included in such list shall be prohibited from operation in connection with this contractual agreement. The website address for the LEIE is http://exclusions.oig.hhs.gov.

No individual providing services under this contract shall start to work without the required credentials stated above. This information shall be sent to a designee at the facility level and be approved prior to work assignment.

Candidates presented by the contractor for the services defined in this contract shall be screened by the contractor and the facility and deemed qualified and suitable by the Facility Director or designee in accordance with the provisions of this contract. The contractor shall coordinate interviews between the candidates and the Facility. The contractor shall be responsible for all cost relating to interviews and relocation. The Facility Director shall have the right of refusal of any applicant for any reason.

E. Orientation

Individuals selected to provide services shall attend required facility orientation training prior to working in patient treatment areas. The cost incurred shall be the responsibility of the contractor and not that of the facility.

F. Facility Policies and Procedures

The contractor shall ensure that individual(s) providing services under this contract abide by DBHDID Facility Policies and Procedures. Facility Policies and Procedures are on file in the Facility Human Resources Department with changes posted to facility bulletin boards, as appropriate.

G. Outside Employment

During the first thirty (30) days of signing a contract, the contractor shall provide the facility director, or designee, with a list of the individuals providing services under the contract who have outside employment, indicating the individual’s name and place of employment. Subsequently, the contractor shall provide the facility director, or designee, with an updated list of individuals with outside employment on a quarterly basis.

H. Non-Compete Clauses against Commonwealth Prohibited

Contractor acknowledges that the Commonwealth considers these contracts temporary in nature and desires to use state employees to staff the various facilities to the extent possible. Contractor acknowledges and agrees that any non-compete agreement it may have with a staff person offered to provide services under this Contract will not prohibit that person from accepting a job offer from the Commonwealth after any expiration or termination of the contract, and to the extent such any non-compete contract may say otherwise, it will be void and unenforceable as against the Commonwealth and any person offered state employment.

Pricing and Payment Requirements Invoices for payment shall be submitted to Glasgow State Nursing Facility, 207 State Ave., Glasgow, KY 42141 or electronically to GSNF.Fiscal@ky.gov. Invoices must be submitted no later than thirty (30) days after completion of the service. Invoices shall include: vendor’s name and address, PON2 number, a unique invoice number, dates of service, amount due for the current billing cycle, and number of hours worked multiplied by the hourly rate. The hourly rate shall be all-inclusive. Travel is not a reimbursable expense under this contract.

Payment shall be conditioned upon receipt of appropriate, accurate, and acceptable invoices submitted in a timely manner.

The Contractor shall submit monthly invoices which shall contain two parts:

Invoices that do not contain the requirements above will be rejected and sent back to the Contractor for re-invoicing.

CHFS/Agency Responsibilities Assist Contractor in acquiring information and providing services relevant to the dietary needs of patients/residents.

Monitoring Requirements – Federal and State

The Department for Behavioral, Developmental, and Intellectual Disabilities may monitor the contract through detailed written reports, evaluations and special reports related to dietary services submitted by the contractor.