Schedule 3 - Qualifications and Requirements Matrix.docx

Preadmission Screening and Resident Review (PASRR) Level II Screens

Schedule 3–Qualifications and Requirements Matrix

Bidding Company Name

Instructions: Respond to each requirement by checking Yes or No. The only acceptable responses are Yes or No, applied by checking the applicable box. In order to be considered responsive, the Vendor must select Yes to all of the bid requirements. Selecting Yes means the requirement can and will be met with the Vendor’s current standard offering and/or using workarounds, features currently in development, or professional services to meet the need at no additional cost to the State.

Selecting No means the requirement absolutely cannot be met with the Vendor’s current standard offering and no possible developments or professional services available to the Vendor will achieve compliance. Cells without a Yes or No responses selected will be interpreted as No.

If it is determined that all Vendors submitting a bid cannot meet a particular requirement, the State reserves the right to waive that requirement and continue with the solicitation process.

Section A – Mandatory Vendor Qualifications

Also refer to RFB section 6.4 Vendor References and complete and submit Vendor Reference Form (DOA-3478) |_| Yes |_| No

Also complete and submit Schedule 6 – Evaluation and Notice of Appeal Rights-John Doe and Schedule 7 – Evaluation and Notice of Appeal Rights-Jane Doe.

|_| Yes |_| No

Requirement Select Yes/No

Section B – Mandatory Specifications

Also complete and Submit Schedule 4 – Work Plan, Organization, and Staffing.

|_| Yes |_| No

Key Personnel for the Level II process for persons with a serious mental illness includes:

a) A qualified mental health professional, as defined in Appendix A – PASRR-Related Definitions.

b) A Board-certified psychiatrist, a physician who has satisfactorily completed the Board’s specialized training requirements in psychiatry, or a physician who is participating in a psychiatric residency program and whose work is reviewed and countersigned by a Board certified psychiatrist.

Key Personnel for the Level II process for persons with an intellectual/developmental disability includes a Qualified Intellectual Disability Professional, as defined in Appendix A – PASRR-Related Definitions.

Also complete and submit Schedule 5 – Key Personnel and submit resumes and photocopies of educational degrees, and relevant profession certifications and licensures.

|_| Yes |_| No

· Licensed physician, licensed physician assistant or licensed nurse practitioner (to perform a history and physical if necessary as required by the Federal PASRR regulations);

· Licensed psychologist (to perform a psychometric evaluation if necessary); and

· Sign language and foreign language interpreter if the person receiving the PASRR Level II screen uses sign language or a foreign language as his/her primary communication.

Also describe in Schedule 4. For professionals not listed in Schedule 5, include copies of contract(s) or other written agreements supporting these services.

|_| Yes |_| No

Authorized Signature

Date

Above name printed or typewritten

RFB No. S-0627 DCTS-17 Schedule 3 – Qualifications and Requirements Page 1 of 3