Schedule 5 - Key Personnel.docx
DOCX document 39 KB Posted
- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a Schedule 5 - Key Personnel form submitted as part of a Request for Bid (RFB No. S-0627 DCTS-17) issued by the Wisconsin Department of Health Services for Preadmission Screening and Resident Review (PASRR) Level II Screens. The RFB seeks to contract with vendors to conduct federally required PASRR Level II screens for prospective and current nursing home residents in Wisconsin who have a serious mental illness or an intellectual/developmental disability. The form requires bidding companies to identify and list all Key Personnel who will perform PASRR Level II screening services, along with their qualifications, educational degrees, relevant professional certifications and licensures, specific PASRR responsibilities, and years of relevant experience. Each Key Personnel listing must be supported by detailed resumes and copies of educational degrees and professional certifications.
Key Personnel requirements are categorized by disability type: for persons with serious mental illness, vendors must provide a qualified mental health professional and either a board-certified psychiatrist or a physician completing a psychiatric residency program under a board-certified psychiatrist's supervision; for persons with intellectual/developmental disability, vendors must provide a Qualified Intellectual Disability Professional. The form requires vendors to specify the approximate percentage of full-time equivalent (FTE) work expected for each Key Personnel member. The Wisconsin Department of Health Services retains sole discretion in determining acceptable Key Personnel qualifications, and failure of Key Personnel to meet RFB requirements constitutes grounds for vendor bid disqualification.
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Text version
Preadmission Screening and Resident Review (PASRR) Level II Screens
Schedule 5 - Key Personnel
Instructions: List on this form Key Personnel, their qualifications, and responsibilities. For each person listed, attach copies of detailed resumes and photocopies of educational degree, and relevant profession certification and licensure. DHS shall be the sole judge of acceptable Key Personnel listings. Key Personnel not meeting the requirements of this RFB will be grounds for Vendor bid disqualification.
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.
Bidding Company Name:
| Name |
| Educational Degree(s) |
| License/Certification, if any, and date of expiration |
| PASRR Responsibilities |
| Approximate % of FTE expected to work |
| # of Years of Experience with Persons with SMI or ID/DD |
| # of Years of Experience with PASRR |
Example:
Sigmund Freud
| M.D. |
| Board Certified Psychiatrist, exp. 1939 |
| Quality assurance monitoring and perform evaluations, as time permits. |
| 10% |
| 0 |
| 39 |
RFB No. S-0627 DCTS-17 Schedule 5 Page 2 of 2
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