Iowa CMPQII Supplemental Application Forms.docx

Iowa Civil Money Penalty Quality Improvement Initiative Supplemental Application Packet

MEDIOMC26022

Application Packet Contents and Instructions

1. Fully complete and submit forms to the Issuing Officer listed in the RFP by the due date in the RFP’s Procurement Timetable. Submit forms in the order below.

· Tab 1: Primary Applicant Detail & Certification Form

· Tab 2: Subcontractor Disclosure Form (if applicable)

· Tab 3: Additional Certifications

· Tab 4: Certification and Disclosure Regarding Lobbying

· Tab 5: Release of Information Form

· Tab 6: Minority Impact Statement

Application Packet – Tab 1 Primary Applicant Detail & Certification Form

Primary Contact Information (person responsible for project implementation and who can address issues re: this Application)

Name:

Address:

Phone:

Fax:

E-mail:

Primary Applicant Detail

Business Legal Name (“Applicant”):

“Doing Business As” names, assumed names, or other operating names:

Parent Corporation Name and Address of Headquarters, if any:

Form of Business Entity (i.e., corp., partnership, LLC, etc.):

State of Incorporation/organization:

Primary Address:

County:

Phone:

Local Address (if any):

Addresses of Major Offices and other facilities that may contribute to performance under this RFP/Contract:

Number of Employees:

Number of Years in Business:

Primary Focus of Business:

Federal Tax ID:

Are you a certified nursing home?

□Yes □No If yes, please complete the following information:

Name of Management Company:

National Provider Identifier (NPI):

Medicare CCN:

Medicaid Provider Number:

Applicant’s Accounting Firm:

If Applicant is currently registered to do business in Iowa, provide the Date of Registration:

Do you plan on using subcontractors if awarded this Contract? (If “YES,” submit a Subcontractor Disclosure Form for each proposed subcontractor.)

□Yes □No

Request for Confidential Treatment (See Formatting Requirements for Application Submission Chart)

Exceptions to RFP/Contract Language (See Formatting Requirements for Application Submission Chart)

Application Packet – Tab 1

PRIMARY APPLICANT CERTIFICATIONS

1. APPLICATION CERTIFICATIONS. By signing below, Applicant certifies that:

1.1 Applicant specifically stipulates that the Application is predicated upon the acceptance of all terms and conditions stated in the RFP and the Sample Contract without change except as otherwise expressly stated in the Primary Applicant Detail & Certification Form. Objections or responses shall not materially alter the RFP. All changes to the proposed contract language, including deletions, additions, and substitutions of language, must be addressed in the Application. The Applicant accepts and shall comply with all Contract Terms and Conditions contained in the Sample Contract without change except as set forth in the Contract.

1.2 Applicant has reviewed the Additional Certifications, which are incorporated herein by reference, and by signing below represents that Applicant agrees to be bound by the obligations included therein;

1.3 Applicant has received amendments to this RFP issued by the Agency; and,

1.4 The person signing this Application certifies that he/she is the person in the Applicant’s organization responsible for, or authorized to make decisions regarding the prices quoted and, Applicant guarantees the availability of the services offered and that all terms, including price, will remain firm until a contract has been executed for the services contemplated by this RFP or one year from the issuance of this RFP, whichever is earlier.

2. SERVICE AND REGISTRATION CERTIFICATIONS. By signing below, Applicant certifies that:

2.1 Applicant certifies that the Applicant organization has sufficient personnel resources available to provide all services proposed by the Application, and such resources will be available on the date the RFP states services are to begin. Applicant guarantees personnel proposed to provide services will be the personnel providing the services unless prior approval is received from the Agency to substitute staff;

2.2 Applicant certifies that if the Applicant is awarded the contract and plans to utilize subcontractors at any point to perform any obligations under the contract, the Applicant will (1) notify the Agency in writing prior to use of the subcontractor, and (2) apply all restrictions, obligations, and responsibilities of the resulting contract between the Agency and contractor to the subcontractors through a subcontract. The contractor will remain responsible for all Deliverables provided under this contract;

2.3 Applicant either is currently registered to do business in Iowa or agrees to register if Applicant is awarded a Contract pursuant to this RFP; and,

2.4 Applicant certifies it is either 1) registered or will become registered with the Iowa Department of Revenue to collect and remit Iowa sales and use taxes as required by Iowa Code chapter 423; or 2) not a “retailer” of a “retailer maintaining a place of business in this state” as those terms are defined in Iowa Code subsections 423.1(47) & (48). The Applicant also acknowledges that the Agency may declare the application void if the above certification is false. Applicants may register with the Department of Revenue online at: https://revenue.iowa.gov/permits-licensing/business-permit-registration

3. EXECUTION.

By signing below, I certify that I have the authority to bind the Applicant to the specific terms, conditions and technical specifications required in the Agency’s Request for Proposals (RFP) and offered in the Applicant’s Application. I understand that by submitting this Application, the Applicant agrees to provide services described herein which meet or exceed the specifications of the Agency’s RFP unless noted in the Application and at the prices quoted by the Applicant. The Applicant has not participated, and will not participate, in any action contrary to the anti-competitive obligations outlined in the Additional Certifications. I certify that the contents of the Application are true and accurate, and that the Applicant has not made any knowingly false statements in the Application.

Signature:

Printed Name/Title:

Date:

Application Packet – Tab 2 Subcontractor Disclosure Form (If a section does not apply, label it “not applicable”.)

Fully complete a form for each proposed subcontractor. If a section does not apply, label it “not applicable.” If the Applicant does not intend to use subcontractor(s), this form does not need to be returned.

Primary Applicant (“Primary Applicant”):

Subcontractor Contact Information (individual who can address issues re: this Application)

Name:

Address:

Tel:

Fax:

E-mail:

Subcontractor Detail

Subcontractor Legal Name (“Subcontractor”):

“Doing Business As” names, assumed names, or other operating names:

Form of Business Entity (i.e., corp., partnership, LLC, etc.)

State of Incorporation/organization:

Primary Address:

Tel:

Fax:

Local Address (if any):

Addresses of Major Offices and other facilities that may contribute to performance under this RFP/Contract:

Number of Employees:

Number of Years in Business:

Primary Focus of Business:

Federal Tax ID:

Subcontractor’s Accounting Firm:

If Subcontractor is currently registered to do business in Iowa, provide the Date of Registration:

Percentage of Total Work to be performed by this Subcontractor pursuant to this RFP/Contract.

General Scope of Work to be performed by this Subcontractor

Detail the Subcontractor’s qualifications for performing this scope of work

By signing below, Subcontractor agrees to the following:

1. Subcontractor has reviewed the RFP and Application, and Subcontractor agrees to perform the work indicated in this Application if the Primary Applicant is granted an award in this procurement;

2. Subcontractor has reviewed the Additional Certifications and by signing below confirms that the Certifications are true and accurate and Subcontractor will comply with all such Certifications;

3. Subcontractor recognizes and agrees that if the Primary Applicant enters a contract with the Agency because of this RFP, all restrictions, obligations, and responsibilities of the contractor under the contract shall also apply to the subcontractor; and,

4. Subcontractor agrees that it will register to do business in Iowa before performing any services pursuant to this contract, if required to do so by Iowa law.

The person signing this Subcontractor Disclosure Form certifies that he/she is the person in the Subcontractor’s organization responsible for or authorized to make decisions regarding the prices quoted and the Subcontractor has not participated and will not participate in any action contrary to the anti-competitive obligations outlined in the Additional Certifications.

I hereby certify that the contents of the Subcontractor Disclosure Form are true and accurate and that the Subcontractor has not made any knowingly false statements in the Form.

Signature for Subcontractor:

Printed Name/Title:

Date:

Application Packet – Tab 3

ADDITIONAL CERTIFICATIONS

CERTIFICATION OF INDEPENDENCE AND NO CONFLICT OF INTEREST

By submission of an Application, the Applicant certifies (and in the case of a joint Application, each party thereto certifies) that:

1. The Application has been developed independently, without consultation, communication or agreement with any employee or consultant of the Agency who has worked on the development of this RFP, or with any person serving as a member of the evaluation committee;

2. The Application has been developed independently, without consultation, communication or agreement with any other Applicant or parties for the purpose of restricting competition;

3. Unless otherwise required by law, the information in the Application has not been knowingly disclosed by the Applicant and will not knowingly be disclosed prior to the award of the contract, directly or indirectly, to any other Applicant;

4. No attempt has been made or will be made by the Applicant to induce any other Applicant to submit or not to submit an Application for the purpose of restricting competition;

5. No relationship exists or will exist during the contract period between the Applicant and the Agency that interferes with fair competition or is a conflict of interest.

6. The Applicant and any of the Applicant’s proposed subcontractors have no other contractual relationships which would create an actual or perceived conflict of interest.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION -- LOWER TIER COVERED TRANSACTIONS

By signing and submitting this Application, the Applicant is providing the certification set out below:

1. The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the Applicant knowingly rendered an erroneous certification, in addition to other remedies available to the federal government the Agency or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

2. The Applicant shall provide immediate written notice to the person to whom this Application is submitted if at any time the Applicant learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances.

3. The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principle, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549. You may contact the person to which this Application is submitted for assistance in obtaining a copy of those regulations.

4. The Applicant agrees by submitting this Application that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Agency or agency with which this transaction originated.

5. The Applicant further agrees by submitting this Application that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.

6. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines the eligibility of its principals. A participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Non-procurement Programs.

7. Nothing contained in the foregoing shall be construed to require the establishment of a system of records to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

8. Except for transactions authorized under paragraph 4 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, the Agency or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND/OR VOLUNTARY EXCLUSION-LOWER TIER COVERED TRANSACTIONS

1. The Applicant certifies, by submission of this Application, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.

2. Where the Applicant is unable to certify any of the statements in this certification, such Applicant shall attach an explanation to this Application.

CERTIFICATION OF COMPLIANCE WITH PRO-CHILDREN ACT OF 1994

The Applicant must comply with Public Law 103-227, Part C Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act). This Act requires that smoking is not permitted in any portion of any indoor facility owned or leased or contracted by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by federal programs either directly or through State or local governments. Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such federal funds. The law does not apply to children’s services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities (other than clinics) where WIC coupons are redeemed.

The Applicant further agrees that the above language will be included in any sub-awards that contain provisions for children’s services and that all sub-grantees shall certify compliance accordingly. Failure to comply with the provisions of this law may result in the imposition of a civil monetary penalty of up to $1000 per day.

CERTIFICATION REGARDING DRUG FREE WORKPLACE

1. Requirements for Contractors Who are Not Individuals. If the Applicant is not an individual, by signing below Applicant agrees to provide a drug-free workplace by:

a. publishing a statement notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is prohibited in the person’s workplace and specifying the actions that will be taken against employees for violations of such prohibition;

b. establishing a drug-free awareness program to inform employees about:

(1) the dangers of drug abuse in the workplace;

(2) the person’s policy of maintaining a drug- free workplace;

(3) any available drug counseling, rehabilitation, and employee assistance programs; and

(4) the penalties that may be imposed upon employees for drug abuse violations;

c. making it a requirement that each employee to be engaged in the performance of such contract be given a copy of the statement required by subparagraph (a);

d. notifying the employee in the statement required by subparagraph (a), that as a condition of employment on such contract, the employee will:

(1) abide by the terms of the statement; and

(2) notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than 5 days after such conviction;

e. notifying the contracting agency within 10 days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction;

f. imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by, any employee who is so convicted, as required by 41 U.S.C. § 703; and

g. making a good faith effort to maintain a drug-free workplace through implementation of subparagraphs (a), (b), (c), (d), (e), and (f).

2. Requirement for Individuals. If the Applicant is an individual, by signing below the Applicant agrees to not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance in the performance of the contract.

3. Notification Requirement. The Applicant shall, within 30 days after receiving notice from an employee of a conviction pursuant to 41 U.S.C. § 701(a)(1)(D)(ii) or 41 U.S.C. § 702(a)(1)(D)(ii):

a. take appropriate personnel action against such an employee up to and including termination; or

b. require such employee to satisfactorily participate in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency.

NON-DISCRIMINATION

The Applicant does not discriminate in its employment practices regarding race, color, religion, age (except as provided by law), sex, marital status, political affiliation, national origin, or handicap.

Signature for Subcontractor:

Printed Name/Title:

Date:

Application Packet – Tab 4 Certification and Disclosure Regarding Lobbying

Instructions:

Title 45 of the Code of Federal Regulations, Part 93 requires the Applicant to include a certification form, and a disclosure form, if required, as part of the Applicant’s proposal. Award of the federally funded contract from this RFP is a Covered Federal action.

1. The Applicant shall file with the Agency this certification form, as set forth in Appendix A of 45 CFR Part 93, certifying the Applicant, including any subcontractor(s) at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) have not made, and will not make, any payment prohibited under 45 CFR § 93.100.

1. The Applicant shall file with the Agency a disclosure form, set forth in Appendix B of 45 CFR Part 93, in the event the Applicant or subcontractor(s) at any tier (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) has made or has agreed to make any payment using non-appropriated funds, including profits from any covered Federal action, which would be prohibited under 45 CFR § 93.100 if paid for with appropriated funds. All disclosure forms shall be forwarded from tier to tier until received by the Applicant and shall be treated as a material representation of fact upon which all receiving tiers shall rely.

Certification for Contracts, Grants, Loans, and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that:

(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, ‘‘Disclosure Form to Report Lobbying,’’ in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance The undersigned states, to the best of his or her knowledge and belief, that:

If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ‘‘Disclosure Form to Report Lobbying,’’ in accordance with its instructions.

Submission of this statement is a pre-requisite for making or entering this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 for each such failure.

I certify that the contents of this certification are true and accurate and that the Applicant has not made any knowingly false statements in the Bid Proposal. I am checking the appropriate box below regarding disclosures required in Title 45 of the Code of Federal Regulations, Part 93.

The Applicant is NOT including a disclosure form as referenced in this form’s instructions because the Applicant is NOT required by law to do so.

The Applicant IS filing a disclosure form with the Agency as referenced in this form’s instructions because the Applicant IS required by law to do so. If the Applicant is filing a disclosure form, place the form immediately behind this Attachment E in the Proposal.

Signature:

Printed Name/Title:

Date:

Application Packet Tab 5 Release of Information

_________________________________ (name of Applicant) hereby authorizes any person or entity, public or private, having any information concerning the Applicant’s background, including but not limited to its performance history regarding its prior rendering of services like those detailed in this RFP, to release such information to the Agency.

The Applicant acknowledges that it may not agree with the information and opinions given by such a person or entity in response to a reference request. The Applicant acknowledges that the information and opinions given by such a person or entity may hurt its chances to receive contract awards from the Agency or may otherwise hurt its reputation or operations. The Applicant is willing to take that risk. The Applicant agrees to release all persons, entities, the Agency, and the State of Iowa from any liability whatsoever that may be incurred in releasing this information or using this information.

Printed Name of Applicant Organization

Signature of Authorized Representative Date

Printed Name

Application Packet – Tab 6 Minority Impact Statement

Pursuant to 2008 Iowa Acts, HF 2393, Iowa Code Section 8.11, all grant applications submitted to the State of Iowa which are due beginning January 1, 2009, shall include a Minority Impact Statement. This is the state’s mechanism to require grant Applicants to consider the potential impact of the grant project’s proposed programs or policies on minority groups.

Please choose the statement(s) that pertains to this grant application. Complete all the information requested for the chosen statement(s).

|_| The proposed grant project programs or policies could have a disproportionate or unique positive impact on minority people.

Describe the positive impact expected from this project.

Indicate which group is impacted:

___Women ___ Persons with a disability ___ Blacks ___ Latinos ___ Asians ___ Pacific Islanders ___ American Indians ___ Alaskan Native Americans ___ Other

|_| The proposed grant initiative programs or policies could have a disproportionate or unique negative impact on minority people.

Describe the negative impact expected from this project.

Present the rationale for the existence of the proposed program or policy.

Provide evidence of consultation from representatives of the minority groups impacted.

Indicate which group is impacted:

___Women ___ Persons with a disability ___ Blacks ___ Latinos ___ Asians ___ Pacific Islanders ___ American Indians ___ Alaskan Native Americans ___ Other

|_| The proposed grant project programs or policies are not expected to have a disproportionate or unique impact on minority people.

Present the rationale for determining no impact.

I hereby certify that the information on this form is complete and accurate, to the best of my knowledge:

Name: ________________________ Title: ___________________________

Definitions

“Minority Persons,” as defined in Iowa Code Section 8.11, mean individuals who are women, persons with a disability, Blacks, Latinos, Asians or Pacific Islanders, American Indians, and Alaskan Native Americans.

“Disability,” as defined in Iowa Code Section 15.102, subsection 5, paragraph “b,” subparagraph (1):

b. As used in this subsection:

(1) "Disability" means, with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of the individual, a record of physical or mental impairment that substantially limits one or more of the major life activities of the individual, or being regarded as an individual with a physical or mental impairment that substantially limits one or more of the major life activities of the individual.

"Disability" does not include any of the following:

(a) Homosexuality or bisexuality.

(b) Transvestitism, transsexualism, pedophilia, exhibitionism, voyeurism, gender identity disorders not resulting from physical impairments or other sexual behavior disorders.

(c) Compulsive gambling, kleptomania, or pyromania.

(d) Psychoactive substance abuse disorders resulting from current illegal use of drugs.

“State Agency,” as defined in Iowa Code Section 8.11, means a department, board, bureau, commission, or other Agency or authority of the State of Iowa.

image1.png image2.svg