RFP Short Form - WSH Dentistry Services (C2303).xml

HYPERLINK "https://finance.ky.gov/services/policies/Documents/FAP%20110-10-00.pdf" \h FAP 110-10-00 GENERAL CONDITIONS AND INSTRUCTIONS FOR SOLICITATIONS AND CONTRACTS 361315 146050 Instructions: Please fill out all spaces below with your information. Check all requirements that you meet. The links above (blue) w ill take you to the original RFP document and General C onditions and Instruction s 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 0 0 Instructions: Please fill out all spaces below with your information. Check all requirements that you meet. The links above (blue) w ill take you to the original RFP document and General C onditions and Instruction s 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 is to provide a part-time Dentist, and a part-time Dental Hygienist for the patients/residents at Western State Hospital (WSH) and Western State Nursing Facility (WSNF) (collectively referred to as Western State Hospital (WSH). These services are flexibly designed to meet the individual needs of the facility patients/residents. There is no guarantee of a specific number of cases or service hours. Service hours are based on the needs of the Facility, and the availability of state and/or federal funds. Western State Hospital is a 160 bed acute care psychiatric facility, with a 144 bed Skilled Nursing Facility (Western State Nursing Facility) located in Hopkinsville, Kentucky. Western State Hospital is regulated by The Joint Commission, Centers for Medicare and Medicaid Services (CMS), the Cabinet for Health and Family Services Office of the Inspector General, as well as various clinical and professional organizations to provide routine and emergency medical procedures and/or services. Estimated Schedule Estimated hours per week: Dentist – 5 hours Dental Hygienist – 5 hours The estimated five (5) hours per week shall be concurrent in one (1) day per week for a minimum of fifty (50) weeks per fiscal year. The state fiscal year starts on July 1st and ends on June 30 th of the following year. WSH will provide as much advanced notice of staffing need and scheduled appointments as possible. It is realized by both parties that emergency situations do occur. Mandatory Requirements Vendor must meet the following requirements to qualify to receive a contract to participate. 1. Submit p roof of Liability, Malpractice and Workers Compensation Insurance, and certificates or professional (medical) and contractual liability insurance at a minimum of $1,000,000 per incident and $3,000,000 per year. 2. Submit documentation of current licensure to practice as a Dentist/Dental Hygienist in the Commonwealth of Kentucky in accordance with current Kentucky Revised Statutes (KRS) requirements. Offerors who do not have a license to practice in the Commonwealth of Kentucky must submit a copy of their current Dental and/or Dental Hygienst License. Any Out-of-State candidate that does not currently possess licensure to practice in the Commonwealth of Kentucky must obtain a liscense to practice in the state within thirty (30) days of contract award. 3. Submit a 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. 4. Submit a statement certifying that the contractor or individual that will provide services is not currently an excluded Medicare/Medicaid provider, and from the Office of Inspector General, List of Excluded Individuals/Entities (LEIE). 5. Submit a statement certifying that all individuals providing services under this contract for any given skil l level shall possess at least the minimum credentials for that skill level. Please Note: Failure to provide any of the required documentation will render the bid non-responsive. Proposal Submission Submit the following form, all applicable affidavits, copy of medical license, Check, Curriculum Vitae (CV) , and signed Solicitation via Secure File Transfer on https://ftp.ky.gov . Complete Instructions for submission are attached to the header of the Solicitation. If you have questions about submissions please contact : Travis Mazurek Cabinet for Health & Family Services Office of Administrative Services Division of Procurement Services and Grants Travis.Mazurek@ky.gov CONTACT INFORMATION: Company/Agency Name ( I f Applicable): ____________ _____________________________ Last Name: ______________________________ _____ _____ First Name: _________________________ ________ Contact Email: ________________________ ________ _____ Phone Number: _____________________________ Address: _______________________________________ _________________________________________ City: ________________________________ ______________ State: ________ Zip: ___________ SPECIALITY: _________________________________________________ ____________________________________ Please list ALL States you hold License in: _____________________________________ Has your license ever been revoked, restricted or suspended for any reason, if yes, please explain. ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ Professional Reference #1: Name: ________________________________________________________________ _ Phone Number: __________________________________________________________ Email Address: ___________________________________________________________ Professional Reference #2: Name: ________________________________________________________________ _ Phone Number: __________________________________________________________ Email Address: ___________________________________________________________ Professional Reference #3: Name: ________________________________________________________________ _ Phone Number: __________________________________________________________ Email Address: ___________________________________________________________ Please provide a brief overview and mission of the company/agency. Describe the company/agency’s background and credentials: ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ Provide a brief description of past Work with similar criteria as this Solicitation . Description should include quality and depth of the company/agency’s expertise and its prior capability to provide similar services, and number of years providing these services. Discuss the company/agency’s past performance with contractual activities. Discuss the company/agency’s past performance working with individuals with behavioral health, developmental and intellectual disabilities, and who are medically fragile. ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ ________________________________________________________________________ _________________________ This form is for the purpose of determining eligibility to perform contractor services. This does not constitute a guarantee of a contract award. 640080 184150 SIGNATURE Date By signing the short-form application, the bidder acknowledges all terms and req uirements of the originating RFP . 0 0 SIGNATURE Date By signing the short-form application, the bidder acknowledges all terms and req uirements of the originating RFP . PROGRAM DETAILS Services Required 1. The Contractor shall: a. Assign only those individuals that are licensed or certified in their respective skill levels. All individuals must be adequately trained, shall meet appropriate licensure requirements, and be in good standing to practice in the Commonwealth of Kentucky. b. Provide an individual to perform the functions of a part-time Dentist. c. Provide an individual to perform the functions of a part-time Dental Hygienist. d. Be responsible for the salary, benefits, withholding of state/federal taxes, etc. of those individuals. e. Be responsible for the billing of Medicaid, Medicare, and other third party payors in accordance with the facility’s practice. f Utilize the equipment available in the dental lab housed in Western State Hospital needed to perform required dental services for the patients/residents of Western State Hospital and Western State Nursing Facility. g. Individuals served shall have their basic rights of self-determination and participation in treatment decision making safeguarded and respected. Treatments provided shall be least restrictive and any form of medical or dental restraint shall be used only under the auspices of a human rights committee and in conjunction with behavior support specialists of Western State Hospital and/or Western State Nursing Facility. 2. The Dentist shall: a) Have and maintain a license to practice dentistry and be in good standing with the Kentucky Board of Dentistry. b) Provide supervision of dental auxiliary staff, as needed. c) Provide appropriate referrals to other sources, as needed. If the referral to a specialist requires transportation of the WSH/WSNF patient, the facility will be responsible for the transport and cost. d) Provide direct comprehensive general dentistry services to the patients/residents of WSH to include, but not limited to, the following: 1) oral exams; 2) cleanings; 3) fillings; 4) fluoride treatments; 5) sealants; 6) extractions, and 7) any other indicated dental treatment services. e) Maintain documentation of appropriate medical records and progress notes on patients examined, including maintaining a personal provider note pad, leaving original of all provider notes with the facility for scanning into MediTech records, and maintaining a provider copy for individual provider records. f) Consult with facility physician(s) regarding advisability of treatment, if necessary upon review of the patient’s chart and medical history. g) Order and provide follow-up medication in concurrence with the facility’s primary care physician. h) Participate in and preparation of interventional hemostasis products (IHP’s), if necessary. i ). Assist in monitoring dental supplies and equipment. j). Provide information to facility staff relating to ordering dental supplies and equipment. 3. The Dental Hygienist shall: a) Have and maintain certification to practice as a dental hygienist and be in good standing with the Kentucky Board of Dentistry. b) Assess the dental condition and needs of the patients. c) Provide patient screening procedures that include, but not limited to, the following: 1) medical history reviews; 2) dental charting; 3) perio -charting, and 4) patient vital signs. d) Deliver direct care to patients which may include, but not limited to the following: 1) established dental hygienist procedures; and 2) routine treatment procedures such as cleaning, polishing, x-rays, application of sealants, and fluorides. e) Provide chair side assistance to the dentist in the performance of special tests, procedures, and complex treatments. f) Maintain documentation of appropriate medical records and progress notes on patients examined, including maintaining a personal provider note pad, leaving original of all provider notes with the facility for scanning into MediTech records, and maintaining a provider copy for individual provider records. g) Assist with, or institute emergency measures for sudden adverse developments during treatment of patients. Note: Available dental equipment includes basic dental office equipment such as, a steam sterilizer, a dental chair, a cavitron , and an x-ray processor. Additional equipment may be acquired by the hospital and is subject to prior approval and availability of funds. Western State Hospital has an available Dental Lab for the contractor to utilize to perform required services. B. Meet HIPAA and maintain The Joint Commission, Centers for Medicare and Medicaid Services, and various other licensing requirements and/or standards, throughout the contract term. C. Mandatory Requirements for Facility Contracted Staff No individual providing services under this contract shall start to work without the required credentials stated below. This information shall be sent to a designee at the facility level and be approved prior to work assignment 1. 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. 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) working days. 2. Submit documentation of current licensure to practice as a Dentist/Dental Hygienist in the Commonwealth of Kentucky in accordance with current Kentucky Revised Statutes (KRS) requirements. Offerors who do not have a license to practice in the Commonwealth of Kentucky must submit a copy of their current Dental and/or Dental Hygienist License. Any Out-of-State candidate that does not currently possess licensure to practice in the Commonwealth of Kentucky must obtain a license to practice in the state within thirty (30) days of contract award. 3. 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 State Justice Cabinet approves both. If an individual providing services under the contract has resided or worked in a state other than Kentucky a satisfactory records check shall be required of those states as well. All individuals providing services under this contract may be subject to a fingerprint-supported state and FBI check under the KARES Kentucky Applicant Registry and Employment Screening Program (KARES). 4. 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. 5. Cardiac Pulmonary Resuscitation certification (CPR): Evidence of CPR certification, if required of the position. 6. 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 30 days. Pursuant to 908 KAR 3:190, section 10, paragraph (1) “… the department shall, at a minimum, test for”: (a) Marijuana; (b) Cocaine; (c) Opiates; (d) Amphetamines; (e) Phencyclidine; (f) Morphine; (g) MDMA (Ecstasy); (h) Methadone; ( i ) Benziodiazepines ; (j) Barbiturates, and (k) Oxycodone. 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. 7. 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 WSH or WSNF. 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. D . 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. E . 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 found on the facility Intranet. Changes to Facility Policies and Procedures are sent to all staff by email. F . 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 The Contractor shall: The basis of payment will be an hourly rate per position based on the cost proposal form submitted with this RFP. Hourly rate is all-inclusive. Travel costs or training costs will not be reimbursed. Provide a monthly invoice for services rendered to the Facility Business Office. Invoices shall be submitted monthly following the services provided on the PSC Invoice Form. Supporting information will be reviewed by the Facility Business Office staff. The billing information received from the contractor will be reconciled to copies of the time records that have been approved by the appropriate department staff. Follow-up will be performed on discrepancies. Contract information will be referenced to any clarification. The Facility Business Office should be contacted for any questions, concerns, or problems with billing issues. Contractor shall submit monthly invoices. Services are to be billed as follows: Invoices for payment shall be submitted to electronically to wshbusinessoffice@ky.gov . Invoices must be submitted no later than thirty (30) days after completion of the service. Payment shall be conditioned upon receipt of appropriate, accurate, and acceptable invoices submitted in a timely manner. The Contractor shall submit monthly invoices in accordance with Section 10.00-Invoices for fees. Invoices shall contain two parts: 1. Legislative Research Commission’s Government Contract Review Committee Invoice Form; and 2. Supporting documentation. Invoices that do not contain the requirements above will be rejected and sent back to the Contractor for re-invoicing. CHFS/Agency Responsibilities The Facility may: 1. Assist the contractor in acquiring information and providing services relevant to treatment of patients/ residents. 2. Provide appropriate clinical staff to authorize treatments. 3. Provide the contractor as much advance notice of staffing needs and appointment as possible. It is realized by both parties that emergency situations do occur. 4. Review invoices for accuracy, provide monitoring of contract performance and completion of contractual requirements. 5. Provide monitoring of contract performance and ensure completion of contractual requirements. PAGE \* MERGEFORMAT 8 COMMONWEALTH OF KENTUCKY REQUEST FOR PROPOSAL-SHORT FORM APPLICATION RFP 729 21 0000 0 189 – Western State Hospital Dentistry Services 2019-05-30T00:00:00Z Microsoft® Word 2016 2020-02-13T00:00:00Z Mize, Richard (Finance Administration) Mazurek, Travis (CHFS OAS DPGO) 5 2020-03-17T15:14:00Z 2021-03-15T18:35:00Z 2021-04-08T18:45:00Z Normal 4 9 3493 19911 Microsoft Office Word 0 165 46 false Title 1 Commonwealth of Kentucky false 23358 false false 16.0000