buckeyehills.orgbuckeyehills.org/.../uploads/BHRC-2018-19-Title-III-E-bi… · Web viewODA shall...

1

Buckeye Hills Regional Council

Request for Proposal: PY 2018-19 Title III-E National Family Caregiver Support Program (NFCSP) Overview and Forms

BUCKEYE HILLS REGIONAL COUNCILAPPLICATION OVERVIEW

PY 2018-19 TITLE III-E NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM (NFCSP)

TABLE OF CONTENTS

BACKGROUND..........................................................................................................................................................3

DEFINITIONS..............................................................................................................................................................3

INVITATION FOR PROPOSALS.............................................................................................................................4

AVAILABLE FUNDING.............................................................................................................................................4

APPLICATION PROCESS TIME LINE...................................................................................................................5

REQUEST FOR PROPOSAL ANNOUNCEMENT ..............................................................................................5APPLICATION MATERIALS....................................................................................................................................5

RULES..........................................................................................................................................................................6

APPLICATION DEADLINE REQUIREMENTS ....................................................................................................6APPLICATION QUESTIONS...................................................................................................................................7

APPLICATION REVIEW PROCESS.......................................................................................................................7

EVALUATION CRITERIA ........................................................................................................................................7NOTIFICATION OF AWARDS.................................................................................................................................8

AWARD APPEAL PROCESS .................................................................................................................................8SUMMARY OF FUNDED SERVICES......................................................................................................................9

CONTRACTING.........................................................................................................................................................10

MONITORING.............................................................................................................................................................10

NEW PROVIDER ORIENTATION ..........................................................................................................................10

REQUEST FOR PROPOSAL REQUIREMENT EXHIBITS AND FORMS……………………………….11-44

2

BUCKEYE HILLS REGIONAL COUNCIL (BHRC)PY 2018-19 Title III-E NFCGSP Funds

BACKGROUND:

The National Family Caregiver Support Program, which recognizes the vital role performed by informal caregivers, is authorized by Title III-E of the Older Americans Act Reauthorization of 2000 (the Act). Its intent is to directly benefit informal caregivers with services consistent with the Act’s mandates through a statewide, easily identifiable program that supports the efforts of caregivers. Goal for the Program: to provide support, services and education and outreach to the thousands of persons who provide assistance to vulnerable persons, either related or not, who may need to either rely on formal caregivers or seek entry into an institutional versus community living arrangement. These services aid the caregiver to better understand his/her role, consequences, when and how to access assistance, how to utilize services/information to be able to decrease stress, better care for their loved one, understand the needs of caregivers, access services for themselves and their loved one, etc.

Unlike many other programs funded and managed by ODA through the AAAs, the caregiver rather than the care recipient is the target of the program. Therefore, for the purposes of the National Family Caregiver Support Act, AAAs should design programs and individual services that meet the identified needs of caregivers – the target clients of the program. As noted below, though, it will be the care recipient that actually must meet certain eligibility requirements in order for the caregiver to receive respite and supplemental services.

The BHRC Caregiver Advocacy Program promotes self-direction by the caregiver. The Caregiver Advocate performs an in-home assessment to identify the needs of the Caregiver based on the needs of the care recipient. The Caregiver Advocate then uses the assessment to determine the amount of respite support to be allotted to the Caregiver. The Caregiver Advocate works with the Caregiver to establish personal goals for the respite services. The Caregiver chooses a respite provider from the list of providers who have contracted with BHRC to provide Title III E respite services. Once the Caregiver Advocate authorizes the services to the provider, the Caregiver then works directly with the provider to schedule respite as needed, in an effort to reach the Caregiver’s personal respite goals. Successful Title III E bidders will be included on the contracted provider list provided to Caregivers during the in-home assessment.

DEFINITIONS: Family caregiver, an adult family member, or other individual, who is an informal provider of in-home and community care to an older individual.

3

Respite care, services that enable caregivers to be temporarily relieved from their caregiving responsibilities which shall/may include in-home, institutional and emergency respite.

is “unable to perform at least two activities of daily living without substantial human assistance, including verbal reminding, physical cueing, or supervision; or due to a cognitive or other mental impairment, requires substantial supervision because the individual behaves in a manner that poses a serious health or safety hazard to the individual or to another individual”

INVITATION FOR PROPOSALS:

BHRC is soliciting proposals from service providers which provide support and services to caregivers of individuals who are 60+ in Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry and Washington Counties.

BHRC is soliciting applications from agencies which, at the time of application, providePersonal Care Respite, Homemaker Respite, Overnight Respite or Adult Day Respite. Successful applicants will be awarded funds for the 24 month period from January 1, 2018 through December 31, 2019.

AVAILABLE FUNDINGThe table below displays funding amounts available by county. Title III-E NFCGSP funding for Program Years (PY) 2018-19 is provided through the Ohio Department of Aging. The total available funding per program year is estimated to be approximately $43,023.00. The State of Ohio Budget for PY 2018-19 has not been finalized. Therefore, funding amounts may be different when awards are granted. Awards may be reduced at any time if federal or state funding is reduced, even during the contract period.

4

TOTAL COUNTY ALLOCATION

ATHENS $8,254.35

HOCKING $5,072.05

MEIGS $4,581.00

MONROE $3,002.16

MORGAN $3,046.74

NOBLE $2,839.72

PERRY $5,264.59

WASHINGTON $10,962.40

TOTAL ALLOCATION $43,023.00

It is the policy of the BHRC that available funds shall be allocated to each county in the PSA by formula. Each county will have only those funds allocated by formula available to it. The allocation formula reflects 2010 census data for those elements for which 2010 census data is available. In the event that a service gap is identified after reviewing all proposals received, BHRC reserves the right to allocate funds in a manner that ensures service delivery.

APPLICATION PROCESS TIME LINE

PY 2018-19 Title III-E NFCGSP Request for Proposal Announcement Week of July 10, 2017

PY 2018-19 Title III-E NFCGSP application and instructions made available to prospective bidders July 17, 2017

Proposal Application Due Date September 1, 2017

BHRC Staff review of submitted proposals September 1-24, 2017

BHRC recommendations presented to Buckeye Hills Regional Advisory Council September 29, 2017

BHRC recommendations presented to Buckeye Hills Executive Committee November 3, 2017

PY 2018-19 Title III-E NFCGSP Contracts mailed to successful bidders for signature November 6-10, 2017

PY 2018-19 Title III-E NFCGSP Contracts due back to BHRC December 1, 2017

First day of PY 2018-19 Title III-E NFCGSP January 1, 2018

Last day of PY 2018-19 Title III-E NFCGSP December 31, 2019

REQUEST FOR PROPOSAL ANNOUNCEMENT: Week of July 10, 2017

Posted on BHRC website www.buckeyehills.org/aging Posted in legal notice section in newspapers throughout the eight-county service area.

APPLICATION MATERIALS

5

http://www.buckeyehills.org/aging

All instructions and materials needed to apply for PY 2018-19 Title III-E NFCGSP funding are available to download from the BHRC website www.buckeyehills.org/aging; no hard copy applications will be available.

Required forms are in Microsoft Word and Excel. Applicants must use these forms and formats to apply for services; other forms and formats will not be accepted for review. All responses must be typed in a legible font style and size. Hand written or typed responses are not accepted.

The instructions and application documents are intended to assist applicants in applying for funding under this Request for Proposals (RFP) announcement. Nothing in the instructions or application documents is intended to impose any paper work beyond those specifically required under the regulations of the Ohio Department of Aging (ODA) and the BHRC competitive bidding process.

RULES

Rules are available at - h ttp://aging.ohio.gov/information/rules/current.aspx

All applicants are encouraged to read all instructions and application materials before making a decision to apply for the Title III-E NFCGSP funding. The BHRC is not liable for any costs incurred or associated with the preparation of any applicant’s application.

APPLICATION DEADLINE REQUIREMENTS

The deadline to submit the completed application to the BHRC is September 1, 2017 by 4:00 p.m. One (1) complete original and one (1) complete copy application in hard copy must be received by BHRC by 4:00 p.m. on September, 1, 2017.

Proposal Packet submission: 1. Proposal packets can be mailed to Buckeye Hills Regional Council, 1400 Pike

Street, Marietta, OH 45750. If mailed, bidder is required to use certified return receipt.

2. Proposal packets can be hand delivered to 1400 Pike Street, Marietta, OH 45750. If hand delivered, bidder will be given a receipt at time of delivery.

Faxed or emailed proposal applications will be rejected.

formats. BHRC will reject the following applications:

1. The application is not received by the required stated due date and time.2. The application is missing any required document listed on the document checklist.

6

3. The application is missing any required signature.4. The application is emailed or faxed.5. The application contains altered application forms and/or formats.6. The application responses are hand written and/or not in a legible font style or size.

It is not the responsibility of the BHRC, upon receipt of the proposal application, to notify applicants if they have not met any of the above listed application deadline requirements for completeness and/or compliance with required formats, even if the proposal is submitted before the application deadline.

APPLICATION QUESTIONS

Questions about the application process may be emailed to Cathy Ash, Program Manager at [email protected]. All questions and responses will be posted on the BHRC website at www.buckeyehills.org/aging.

APPLICATION REVIEW PROCESS

1. All applications accepted for review are evaluated by a team of BHRC staff who make funding recommendations to Regional Advisory Council on Aging.

2. The Regional Advisory Council on Aging makes funding recommendations to the BHRC Executive Committee who reviews the recommendations.

3. The BHRC Executive Committee will make the final funding decision.

EVALUATION CRITERIA

Each proposal accepted for review will be evaluated and scored using the following criteria:Criteria ScoreAgency policies and procedures reflect experience in:

1. Collaboration with other agencies (5)2. Service quality (5) 3. Consumer satisfaction (5)4. Employee training and development (5)

25

Applicant demonstrates adherence to Ohio Administrative Code (OAC) Rule, Ohio Department of Aging (ODA) and BHRC Policies and Procedures as outlined in the RFP. 25

Applicant demonstrates cost effectiveness, based on an itemization of the costs that comprise the total bid price for the service.

25

Applicant describes effective staffing level management to ensure that all services are delivered at the scheduled time and in accordance with OAC Rules, ODA and

25

7

BHRC policies and procedures.

TOTAL 100

Each proposed service will be evaluated and scored separately. All services will be ranked by score within each county. The scoring system is used to compare and rank proposed services among provider agencies within each county. Funding is not determined by scores and rankings alone.

BHRC reserves the right to select one or more lower ranked services in order to achieve a continuum of services for targeted populations.

BHRC reserves the right to award applicants less funds than requested if federal or state funding is not sufficient to fully fund all applicants that merit awards.

BHRC reserves the right to reject any proposals received in response to this Request for Proposals; to request additional materials from any or all applicants; and to conditionally select proposals for funding.

NOTIFICATION OF AWARDS

Successful bidders will be notified of award by receipt of contract for provision PY 2018-19 National Family Caregiver Support Program Services.

AWARD APPEAL PROCESS

An applicant may appeal its award. The specified process for an appeal is as follows:

1. The complainant agency requesting an appeal must submit a certified latter to BHRC within thirty (30) days from the final decision of adverse action, which outlines the request for an appeal and supported reasons for a hearing.

2. Upon receipt of the request, BHRC will inform the complainant agency through a certified letter of the date, time, and location of the hearing to be held.

3. All receipts of such requests by complainant agencies shall be time/date stamped by BHRC.

4. BHRC will hold the hearing within forty-five days after the receipt of the request of the complainant agency.

5. The BHRC Executive Committee, on the specified hearing date, will hear both parties present their case.

8

6. The Executive Committee may terminate the hearing procedures at any point if BHRC or the complainant agency:

a. Negotiate a written agreement that resolves the issue(s) prompting the hearing; orb. The complainant agency, in a written statement, withdraws their appeal.

7. Upon completion of the hearing, the Executive Committee will make a decision and forward it to BHRC Executive Director. BHRC Executive Director will inform the complainant agency of the decision by a certified letter.

8. An agency may request a hearing by the Ohio Department of Aging in the event of an “adverse action”, which means an BHRC’s action concerning a particular provider to not award a provider agreement to that provider. ODA shall only honor a request for an appeal hearing before ODA if the provider has fully complied with the written process for appealing an adverse action by BHRC that committed the adverse action and that BHRC has rendered its final decision on the appeal. To request a hearing before ODA, the provider shall submit a written request to ODA’s director via certified mail no later than fifteen (15) business days after the date BHRC renders its final decision. ODA shall hold a hearing and render its final decision on the appeal no later than thirty (30) business days after the date of the hearing. Rule 173-3-09.

SUMMARY OF FUNDED SERVICES

Services funded under this Request for Proposal are summarized below. These rules govern the use of these funds. All contracted providers must comply with these rules and will be monitored for compliance by the BHRC Quality Improvement Department. Printed hard copy of Rules, Service Specifications and Conditions of Participation will NOT be furnished to bidders. Rules are available at - h ttp://aging.ohio.gov/information/rules/current.aspx

Personal Care Respite: A service comprised of tasks that help a consumer achieve optimal functioning with Activities of Daily Living (eating, dressing, bathing, toileting, transferring in and out of bed/chair, and walking) and Instrumental Activities of DailyLiving (preparing meals, shopping for personal items, medication management, managing money, using the telephone, doing heavy housework, doing light housework, and the ability to use available transportation without assistance). Rule 173-3-06.5(A)(1) And Rule 173-3-01 (B) (1) and B (10)

Homemaker Respite: A service that provides routine tasks to help a consumer to achieve and maintain a clean, safe, and healthy environment. Rule 173-3-06.4 (A) (1)

Adult Day Respite: A non-residential, community-based service provided through an individualized care plan to encourage optimal capacity for self-care or maximizes functional abilities by meeting the needs of a consumer who has functional or cognitive impairments. Rule 173-3-06.1

9

Overnight Respite: Provision of 24-hour, overnight care and supervision on a temporary basis.

SERVICE UNIT DEFINITIONS

Service Unit Definition Service SpecificationsAdult Day Respite 4 to 8 Hour Day Rule 173-3-06.1Overnight Respite 24 hour N/A

Homemaker Respite One Full Hour Rule 173-3-06.4Personal Care Respite One Full Hour Rule 173-3-06.5

The contracting method for Title III-E Service funds is Purchase of Service. A provider is reimbursed for only the units of service delivered based upon the contracted unit cost. The unit cost of service encompasses all elements associated with the production of the unit of service.

Rule 173-3-04 (C) The provider will be reimbursed for the number of units of service provided to the Caregiver and invoiced to the BHRC. Partial units will not be reimbursed. There is no guarantee for the provision of service as this program is consumer-directed meaning the Caregiver chooses the service provider.

MONITORING

Each Area Agency on Aging (BHRC) is responsible to the Ohio Department of Aging (ODA) for ensuring that all state and federal funds received from ODA are used in the manner that complies with state and federal laws. Rule 173-3-04 (A). The BHRC monitors all contracted providers for compliance with service specifications and conditions of participation. This includes an annual on-site visit to review service records and verify units of service reported for reimbursement.

NEW PROVIDER ORIENTATION

Title III-E Service funded providers will be required to participate in Provider Orientation sessions at BHRC offices. These sessions will include an overview of contracting, billing, reporting, and monitoring.

10

REQUEST FOR PROPOSAL REQUIREMENT APPLICATION FORMS AND INSTRUCTIONS

TITLE III-E NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM PY 2018-19

REQUEST FOR PROPOSAL REQUIREMENT EXHIBITS AND FORMS

Introduction 11

Document Checklist Form 14

Agency Authorization to Submit Certification Form 16

Terms and Conditions Form 20

General Assurance Form 21

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered Transactions

26

Status of Pending Litigation 27

Agency Overview Questions 28

Organizational Chart Instructions 28

Adherence to OAC Rules, ODA, BHRC Policies and Procedures 29

New Applicant Questions 32

Service Application Questions

Adult Day Respite Questions 33

Overnight Respite Service Questions 35

Homemaker Respite Service Questions 37

Personal Care Respite Service Questions 40

Appendix A - Demographic Categories and Definitions 42

11

Appendix B – IRS Form W-9 44

12

INTRODUCTION

Title III of the Older Americans Act provides for formula grants to Agencies on Aging, under approved State plans, to stimulate the development or enhancement of comprehensive and coordinated community-based systems resulting in a continuum of services to older persons with special emphasis on older individuals with the greatest economic or social need, with particular attention to low-income minority individuals. A responsive community-based system of services shall include collaboration in planning, resource allocation and delivery of a comprehensive array of services and opportunities for all older Americans in the community.

The intent is to use Title III funds as a catalyst in bringing together public and private resources in the community to assure the provision of a full range of efficient, well-coordinated and accessible services for older persons.

The Older Americans Act Section 306 (B) (i) specifies that outreach efforts shall be targeted to identify individuals eligible for assistance under this Act, with special emphasis on:

(I) Older individuals residing in rural areas; (II) Older individuals with greatest economic need (with particular attention to low-

income minority individuals and older individuals residing in rural areas); (III) Older individuals with greatest social need (with particular attention to low-income

minority individuals and older individuals residing in rural areas);(IV) Older individuals with severe disabilities; (V) Older individuals with limited English proficiency; (VI) Older individuals with Alzheimer’s disease and related disorders with neurological

and organic brain dysfunction (and the caretakers of such individuals); and(VII) Older individuals at risk for institutional placement;

PROPOSAL PACKAGE CONTENTS

This section of the proposal package contains the following forms:

Optional completion check forms

1. Agency Authorization to Submit Certification Form

2. Terms and Conditions Form

3. General Assurance Form

4. Agency Overview Questions

5. Conditions of Participation Questions

6. Service Application Questions

7. IRS W-9 Form

13

8. New Applicant Questions

To respond to the questions in this application, click inside the gray text box and begin

typing.

The following documents are available on the BHRC website:

1. Title III-E National Family Caregiver Support Program Overview

2. Title III-E National Family Caregiver Support Program Application Forms and

Instructions

3. Title III-E National Family Caregiver Support Program Proposal Workbook (Excel format)

Bidders are required to submit the following documentation in their proposal package:

1. Organizational chart

2. Proof of registration with the Secretary of State as a non-profit organization or as a for-

profit business

3. Status of Pending Litigation

4. Evidence of at least one million dollars of commercial liability insurance coverage

including evidence of insurance coverage for consumer loss due to theft or property

damage

5. Copy of the written procedure describing the step-by-step instructions a consumer may

follow to file a claim

6. Organization Mission Statement

7. Current Annual Report

8. Most Recent Audit or Financial Statement

NOTE: Ohio Department of Aging Rules are not included in this proposal package. You will

find them on the Ohio Department of Aging website:

http://aging.ohio.gov/information/rules/current.aspx

14

http://aging.ohio.gov/information/rules/current.aspx

DOCUMENT CHECKLIST FORM

Please use this checklist to organize all application documents for the final submission.

Agency Name (Type):

This application packet includes all materials needed to apply for Title III-E National Family Caregiver Support Program funding. The deadline to submit the completed application to Buckeye Hills Regional Council is September 1, 2017 by 4:00 p.m. One (1) complete original and one (1) complete copy application in hard copy must be received by the BHRC by 4:00 p.m. on September 1, 2017.

Proposal Packet submission:

1. Proposal packets can be mailed to Buckeye Hills Regional Council, 1400 Pike Street, Marietta, OH 45750. If mailed, bidder is required to use certified return receipt.

2. Proposal packets can be hand delivered to 1400 Pike Street, Marietta, OH 45750. If hand delivered, bidder will be given a receipt at time of delivery.

Faxed or emailed proposal applications will be rejected.

Document CHECKLIST Application Document

Order

You Provide

Form in This

Document

Forms in Excel

Workbook

Your Checklist

Document Checklist 1 This Form

Contact Sheet Form 2 ×Agency Authorization to Submit Certification Form

3 ×Terms and Conditions Form 4 ×General Assurance Form 5 ×Agency Overview Questions 6 ×Conditions of Participation Questions 7 ×Organizational Chart 8 ×Service Application Questions 9 ×

15

Contract Service Pages and Budget Narratives for Each Service ×

Proof of registration with the secretary of state as a non-profit organization or as a for-profit business

10 ×

Evidence of at least one million dollars of commercial liability insurance coverage

11 ×

Status of Pending Litigations 12 ×A copy of the written procedure describing the step-by-step instructions a consumer may follow to file a claim

13 ×

IRS W-9 Form 14 ×

Agency Authorization to Submit Certification Form

16

AGENCY: We, the undersigned certify that all information (including funding levels) is true to

the best of our knowledge.

General Assurance of Compliance with Conditions of Participation and Service Specifications

The Applicant Service Provider Agency hereby assures and certifies that it will comply with the

ODA and BHRC Conditions of Participation, procedures, Service Specifications, guidelines and

requirements, as they relate to the application, acceptance and use of Title III-E National Family

Caregiver Support Program funds for the Applicant's proposed aging services program. Also the

Applicant Agency assures and certifies that:

1. It recognizes that although quality assurance practices and procedures are mandated and

monitored by the ODA and BHRC, it is the provider agency that must retain ultimate responsibility

for the quality assurance function. It further recognizes that the overall responsibility for ensuring

quality rests within the provider's organization.

2. It shall comply with the Ohio Administrative Code, and ODA/BHRC Rule which focus on

agency operations and client care.

3. It shall comply with Rules for the following services: Personal Care Respite, Homemaker

Respite and Adult Day Respite and Overnight Respite. The applicant acknowledges responsibility

as to compliance and awareness that failure on its part to comply may constitute sufficient basis for

(1) a finding by BH-AAA8 of lack of administrative capability, and (2) imposition by BHRC of

appropriate sanctions.

The Applicant Agency also recognizes and agrees that Title III-E National Family Caregiver

Support Program Service funds will be extended in reliance on the representation and agreements

made in this Assurance and that the ODA and BHRC will have the right to enforce this Assurance

17

through lawful means. This Assurance is binding on the recipient, its successors, transferees, and

assignees, and the person or persons whose signatures appear below as authorized to sign this

Assurance on behalf of the applicant agency.

The Assurance obligates the provider agency for the period of their service contract to proceed in

good faith and in cooperative effort to bring those services subject to quality assurance which are

contracted for into compliance with all applicable quality assurance standards and requirements.

NAME OF APPLICANT AGENCY (TYPE)

.....................................................................................................

SIGNATORY NAME (TYPE) TITLE OF SIGNATORY (TYPE)

..........................................................................................................

..........................................................................................................

SIGNATURE OF AUTHORIZED OFFICIAL......................................................................................

................................................................................................DATE

Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier

Covered Transactions

This certification is required by the regulations implementing Executive Order 12549,

18

Debarment and Suspension, 29 CFP Part 98, Section 98.510, Participants’ responsibilities.

The regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160-

19211).

(1) The prospective recipient of Federal assistance funds certifies, by submission of this

proposal, that neither it nor its principles are 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 prospective recipient of Federal assistance funds is unable to certify to any of

the statements in this certification, such prospective participation shall attach an explanation to this

proposal.


..........................................................................................................


..........................................................................................................

..........................................................................................................

SIGNATURE OF AUTHORIZED OFFICIAL......................................................................................

DATE

This application was approved and authorized for submission to the BHRC by

(NAME OF GOVERNING BOARD) during a meeting held: (DATE OF MEETING)

19

Should this agency receive the grant(s) applied for, we will fulfill the intent of the application.

We further understand that additional documentation will be required after grants are awarded and

agree to comply with BHRC requirements regarding it.

President, Governing Board:

(PLEASE TYPE NAME)

Signature of President

Director of Agency:

(PLEASE TYPE NAME)

Signature of Director:

________________________

20

Terms and Conditions Form

The undersigned understands and agrees that:

1) Funds awarded as a result of this proposed request shall be expended for the purposes set forth herein and in accordance with all applicable laws, regulations, policies and procedures of BHRC and the Ohio Department of Aging.

2) The Applicant's employment practices, the provision of services, and the purchasing or subcontracting of goods and services shall be non-discriminatory in accord with all applicable laws and regulations. The Applicant further assures that no portion of its program(s) for which Area Agency funding is sought will in any way discriminate against, deny benefits to, deny employment to, or exclude from participation any persons on the grounds of race, color, national origin, religion, age, sex, handicap, or political affiliation or belief. Effort shall be made by Applicant to make programs and facilities accessible to eligible qualified handicapped and disabled persons.

3) The Applicant assures that it complies with all federal wage and hour laws, and all workers’ compensation laws.

4) Any proposed changes in the proposal as approved shall be submitted in writing by the applicant and upon written notification of approval by BHRC shall be deemed incorporated into and become part of this Agreement.

Funds awarded by BHRC may be terminated at any time for violation of any terms, conditions and/or requirements of this agreement.

SIGNATURE OF PERSON AUTHORIZED TO SIGN DATE

PROPOSAL FOR APPLICANT AGENCY

TYPED NAME & TITLE OF AUTHORIZED SIGNATORY

TYPED ADDRESS OF AUTHORIZED SIGNATORY

21

General Assurance of Compliance with Conditions of Participation and Service Specifications

The Applicant Service Provider Agency hereby assures and certifies that it will comply with the ODA and BHRC Conditions of Participation, procedures, Service Specifications, guidelines and requirements, as they relate to the application, acceptance and use of Title III-E National Family Caregiver Support Program funds for the Applicant's proposed aging services program. Also the Applicant Agency assures and certifies that:

1. It recognizes that although quality assurance practices and procedures are mandated and monitored by the ODA and BHRC, it is the provider agency that must retain ultimate responsibility for the quality assurance function. It further recognizes that the overall responsibility for ensuring quality rests within the provider's organization.

2. It shall comply with the Ohio Administrative Code, and ODA/BHRC Rule which focus on agency operations and client care.

3. It shall comply with Rules for the following services: Personal Care Respite, Homemaker Respite and Adult Day Respite and Overnight Respite. The applicant acknowledges responsibility as to compliance and awareness that failure on its part to comply may constitute sufficient basis for (1) a finding by BHRC of lack of administrative capability, and (2) imposition by BHRC of appropriate sanctions.

The Applicant Agency also recognizes and agrees that Title III-E National Family Caregiver Support Program Service funds will be extended in reliance on the representation and agreements made in this Assurance and that the ODA and BHRC will have the right to enforce this Assurance through lawful means. This Assurance is binding on the recipient, its successors, transferees, and assignees, and the person or persons whose signatures appear below as authorized to sign this Assurance on behalf of the applicant agency.

The Assurance obligates the provider agency for the period of their service contract to proceed in good faith and in cooperative effort to bring those services subject to quality assurance which are contracted for into compliance with all applicable quality assurance standards and requirements.



SIGNATURE OF AUTHORIZED OFFICIAL DATE

23

Certification RegardingDebarment, Suspension, Ineligibility and Voluntary ExclusionLower Tier Covered Transactions

This certification is required by the regulations implementing Executive Order 12549,Debarment and Suspension, 29 CFP Part 98, Section 98.510, Participants’ responsibilities.The regulations were published as Part VII of the May 26, 1988 Federal Register (pages 19160- 19211).

(1) The prospective recipient of Federal assistance funds certifies, by submission of this proposal, that neither it nor its principles are 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 prospective recipient of Federal assistance funds is unable to certify to any of the statements in this certification, such prospective participation shall attach an explanation to this proposal.



SIGNATURE OF AUTHORIZED OFFICIAL DATE

26

STATUS OF PENDING LITIGATION

All Bidders must provide a written statement from their legal counsel, which provides a description of any pending litigation, or a statement that there is no pending litigation.

Page 27

Agency Overview Questions

In the space provided below please answer the listed questions.

Please do not attach agency brochures, newspaper clippings or other materials. All questions must be answered as instructed. Points will be deducted for unanswered questions.

Agency Description

Provide a detailed description of your agency’s experience in providing the proposed service(s).

Describe your agency’s policy and procedure for correcting poor employee performance.

Describe your agency’s policy and procedure for handling consumer complaints.

Provide an example of your agency’s employee development plan.

Provide your agency’s procedure in dealing with the accusation of theft involving medication.

Organizational Chart Instructions

Please submit an organizational chart with your application for funding. The organizational chart submitted must identify all staff involved in the delivery of Title III-E National Family Caregiver Support Program services. The staff names, titles, full or part time status, and lines of authority.

Page 28

Adherence to OAC Rules, ODA/BHRC Policies and Procedures

Answers to these questions must reflect current practices for your agency.

Points will be deducted for unanswered questions or failure to answer questions as instructed.

Organizational Structure Yes No

Does your agency have a mission statement defining the purpose of business or service agency, policies and directives, bylaws, or articles of incorporation?

Do you have a written table of organization that clearly identifies managers, supervisors, staff and lines of authority?

Do you operate in compliance with all applicable federal, state, and local laws, and have a written statement supporting compliance with : non-discrimination laws, federal wage and hour laws, and workers compensation laws in the recruitment and employment of individuals; non-discrimination laws in the provision of services?

Do you have a written affirmative action plan that is used by the organization when posting open positions and making hiring decisions?

Personnel Yes No

Do you have written job descriptions including qualifications for each position involved in the delivery of services?

Do you provide performance appraisals or a development plan for all employed, contract workers, and volunteers involved in providing services?

Do you have a signed and dated document indicating completion of employee orientation including: employee position description and expectations, personnel policies, reporting procedures and policies, an organizational table, and a code of ethics?

Page 29

Rules, Policies and Procedures Yes No

Do you have a system to document services delivered, billed, and reimbursed that complies with the rules, policies and procedures referenced in this application document?

Can you provide evidence detailing financial responsibility in the coverage of consumer loss due to theft, property damage, or personal injury, as well as written procedures which identify the steps a consumer must take to file a liability claim?

Do you have written procedures regarding business operations and provisions of service?

Do you have a written procedure for reporting and documenting all consumer incidents including significant changes that affect service delivery or imminent health or safety risks?

Do you maintain a file for each consumer that includes: name, address, telephone number, DOB, gender, emergency contact person or caregiver information, functional abilities and limitations relevant to authorized services, demographic data as requested by BHRC, and the service provider’s contact information?

Do you maintain documentation of each consumer contact and each service delivered?

Do you obtain written approval from the consumer to release any consumer information?

Do you retain all consumer records for at least six years or until an audit is completed?

Do you have a written procedure for follow-up and investigation of consumer complaints and grievances?

Do you provide the opportunity for consumers to make voluntary contributions for services?

Page 30

Compliance Yes No

Does your organization deliver services in compliance with OAC Rule, ODA and BHRC policies and procedures?

Do you maintain documentation demonstrating that all requirements have been met when delivered either directly or by sub-contract?

Are you willing to allow access to ODA, BHRC, and other representatives with a need to access the provider’s facility, policies, procedures, records, and other documents related to the provision of OAA funded supportive services?

Do you demonstrate compliance with Rule 173-9-1 regarding background investigations of direct service workers?

Comments

Please provide a brief written explanation regarding each question for which a “NO” response was given:

Page 31

New Applicant Questions

Give a brief history of your organization. Include the year your organization was started and share significant milestones that shaped the organization.

List the services your agency provides for older persons and how long your agency has been providing these services.

What proportion of the total consumers served by your agency is age 60 and over?

How many have family caregivers?

How long have you been working with persons 60+ and their caregivers?

Do you do cost sharing or charge a fee? If so, include your policies with the application

Page 32

SERVICE APPLICATION QUESTIONS

Adult Day Respite Questions The following questions are required for those agencies applying for Adult Day Respite

Please do not attach agency brochures, newspaper clippings or other materials. All questions must be answered as instructed. Points will be deducted for unanswered questions or failure to answer questions as instructed.

Purpose of Adult Day Respite Yes No N/A

Is the Adult Day Program provided by your agency designed to meet the needs of participants with Alzheimer’s or related dementia?

Is the Adult Day Program designed to provide respite for the participant’s Caregiver?

Is the Adult Day Program staff trained to understand the unique needs of participants with Alzheimer’s or other related dementia?

In the space below briefly describe how your agency conducts outreach in your service area:

Adult Day Participant Service Management Yes NO N/A

Does an RN perform an initial health assessment which identifies the Participant’s physical, cognitive and psychosocial needs in the Adult Day Program?

Is a care plan created that addresses the consumer and Caregiver needs?

Does the agency convene interdisciplinary care conferences for each consumer at least every six months at which time care plans are reviewed and revised according to changes in the consumer’s status?

Page 33

Does the agency maintain documentation of physician’s authorization prior to administering medications, nursing services, nutrition counseling, or therapeutic services?

Are daily and monthly planned activities posted in full view of participants and caregivers?

Are participant activities planned and supervised by an Activity Coordinator?

Staff Qualifications and Training for Adult Day Services Yes No N/A

Does your agency ensure that an RN or LPN (under RN supervision) will be on-site a minimum of eight hours per month while participants are in attendance.

Does your agency provide task based instruction to all direct care staff prior to working with participants?

Can your agency ensure that the staff to consumer ratio will be at least one staff person to every six participants?

Does your agency require eight hours of in-service continuing education for Adult Day staff for each twelve month period, excluding agency and program-specific orientation?

List all staff members that will participate in the delivery of the proposed services. Include job titles and credentials:

Facility Requirements Yes NO N/A

Does your facility have a separate, identifiable space available for ADS where at least sixty square feet is available per participant and at least one accessible, working toilet per each ten participants?

Are all medications and toxic substances kept locked and

Page 34

stored away from participants?

Does your agency have a documented and posted fire and emergency safety plan?

Does your agency engage in and document periodic inspections and routine maintenance of fire extinguishers, smoke alarms, and quarterly evacuation drills?

Does your agency provide noon meals and snacks planned by a licensed dietician?

Does your agency provide or arrange for transportation to the Adult Day Program as specified in ODA Policy 308.00 (d)(7)?

Overnight Respite QuestionsThe following questions are required for those agencies applying for Overnight Respite


Purpose of Overnight Respite Yes No N/A

Is the Overnight Respite Program provided by your agency designed to meet the needs of participants with Alzheimer’s or related dementia?

Is the Overnight Respite Program designed to provide respite for the participant’s Caregiver?

Is the Overnight Respite Program staff trained to understand the unique needs of participants with Alzheimer’s or other related dementia?

Page 35

Overnight Respite Participant Service Management Yes NO N/A

Does an RN perform an initial health assessment which identifies the Participant’s physical, cognitive and psychosocial needs in the Overnight Respite Program?

Is a care plan created that addresses the consumer and Caregiver needs?

Does the agency convene interdisciplinary care conferences for each consumer at least every six months at which time care plans are reviewed and revised according to changes in the consumer’s status?

Does the agency maintain documentation of physician’s authorization prior to administering medications, nursing services, nutrition counseling, or therapeutic services?

Are daily and monthly planned activities posted in full view of participants and caregivers?

Are participant activities planned and supervised by an Activity Coordinator?

Staff Qualifications and Training for Overnight Respite Services

Yes No N/A

Does your agency ensure that an RN or LPN (under RN supervision) will be on-site while participants are in attendance?

Does your agency provide task based instruction to all direct care staff prior to working with participants?

Can your agency ensure that the staff to consumer ratio will be at least one staff person to every six participants?

Does your agency require eight hours of in-service continuing education for Overnight Respite staff for each twelve month period, excluding agency and program-specific orientation?

Page 36

List all staff members that will participate in the delivery of the proposed services. Include job titles and credentials:

Facility Requirements Yes NO N/A

Does your facility have a separate, identifiable space available for Overnight Respite?

Are all medications and toxic substances kept locked and stored away from participants?

Does your agency have a documented and posted fire and emergency safety plan?

Does your agency engage in and document periodic inspections and routine maintenance of fire extinguishers, smoke alarms, and quarterly evacuation drills?

Does your agency provide meals and snacks planned by a licensed dietician?

Does your agency provide or arrange for transportation to the Overnight Respite Program?

Homemaker Respite Service QuestionsThe following questions are required for those agencies applying for Homemaker Respite Service.


Purpose of Homemaker Respite Service Yes No N/A

Is the Homemaker Respite Service provided by your agency designed to achieve and maintain a clean, safe, and healthy environment?

Page 37

Is the Homemaker Respite Service designed to provide routine meal-related tasks: planning a meal, preparing a meal and planning a grocery purchase?

Is the Homemaker Respite Service designed to provide routine transportation tasks: Performing an errand outside of the presence of the consumer - e.g. picking up a prescription, grocery shopping assistance, or transportation assistance, but not a transportation service under rule 173-3-06.6 of the Administrative Code?

In the space below briefly describe what activities are routinely performed by your agency’s in home service:

Delivery of Homemaker Respite Service Yes No N/A

Does your agency have the capacity to deliver services five days a week?

Does your agency have a back up service delivery plan that will ensure participants receive services despite changes in staffing levels?

Does your agency maintain a participant record of each service visit?

Does the service record document specific tasks performed, in home staff signatures, arrival and departure times, and the participant’s or caregiver’s signature upon completion of service delivery?

Homemaker Respite Service Staff Qualifications and Training

Yes No N/A

Does your agency require eight hours of in-service continuing education for In Home staff for each twelve month period, excluding agency and program-specific orientation?

Please describe the qualifications of In Home staff providing services.

Page 38

Homemaker Respite Service Staff Supervision Yes No N/A

Prior to service initiation, does the supervisor complete and document a participant home visit to define the expected activities of the In Home staff and prepare a written care plan?

Does the supervisory staff evaluate In Home staff’s compliance with the care plan?

Does the supervisory staff evaluate participant satisfaction with service?

Does the supervisory staff evaluate changes in Participant status that may affect the care plan and confer with the BHRC Caregiver Advocate about such changes?

Does this supervision include an in home visit with the In Home staff to observe care provided?

Please describe the qualifications of supervisory staff:

Describe your agency’s back up plan for supervisory coverage in the event that a supervisor resigns:

Provide a copy of your tracking documentation form that ensures timeliness of visits.

Page 39

Personal Care Respite QuestionsThe following questions are required for those agencies applying for Personal Care Respite Service.


Purpose of Personal Care Respite Service Yes No N/A

Is the Personal Care Respite Service provided by your agency designed to achieve optimal functioning with ADLs and IADLs?

Is the Personal Care Service designed to provide routine tasks that are components of homemaker service under rule 173-3-06.4 of the Administrative code?

Is the Personal Care Service Program designed to provide respite services?

In the space below briefly describe what activities are routinely performed by your agency in home service:

Delivery of Personal Care Respite Service Yes No N/A

Does your agency have the capacity to deliver services five days a week?

Does your agency have a back up service delivery plan that will ensure participants receive services despite changes in staffing levels?

Does your agency maintain a participant record of each service visit?

Does the service record document specific tasks performed, in home staff signatures, arrival and departure times, and the participant’s or caregiver’s signature upon completion of service delivery?

Page 40

Personal Care Respite Staff Qualifications and Training Yes No N/A

Does your agency require that a Personal Care Attendant (PCA) is listed on the Ohio Department of Health’s nurse aide registry?

Does your agency require that a PCA has successfully completed a State Tested Nursing Assistant (STNA) program?

Please describe the qualifications of In Home staff providing services.

Personal Care Respite Staff Supervision Yes No N/A

Prior to service initiation, does the supervisor complete and document a participant home visit to define the expected activities of the PCA and prepare a written care plan?

Does the supervisory staff evaluate PCA compliance with the care plan?

Does the supervisory staff evaluate participant satisfaction with service?

Does the supervisory staff notify the BHRC Caregiver Advocate of changes in Participant status?

Does this supervision include an in home visit with the PCA to observe care provided?

Please describe the qualifications of supervisory staff:

Describe your agency’s back up plan for supervisory coverage in the event that a supervisor resigns:

Page 41

Provide a copy of your tracking documentation form that ensures timeliness of visits.

Page 42

APPENDIX ADemographic Categories and Definitions for

Title III-E Contracts

BHRC requires that providers target services to priority populations within a defined geographic area of service and record demographic data in order to track progress toward goals.

o Minority Status:

American Indian or Alaskan Native Asian Hispanic or Latino Black or African American Native Hawaiian or Other Pacific Islander

o In Poverty – Those whose income is at 100% of, or below, the official poverty guideline.

o Disabled – A person with mental or physical impairment, or a combination of mental or physical impairments, that result in substantial functional limitations in 1 or more of the following areas of major life activity: (A) self-care, (B) receptive and expressive language, (C) learning, (D) mobility, (E) self-direction, (F) capacity for independent living, (G) economic self-sufficiency, (H) cognitive functioning, and (I) emotional adjustment.

o Rural – A person living in any area that is not urban. Urban areas comprise (1) urbanized areas (a central place and its adjacent densely settled territories with a combined minimum population of 50,000) and (2) an incorporated place or a census designated place with 20,000 or more inhabitants.

o Living Alone – A person living in a one-person household, where the householder lives by his or herself in an owned or rented place of residence in a non-institutional setting.

o Frail – A person who is unable to perform at least two activities of daily living (bathing, dressing, toilet use, eating, walking, and transfer - for example, from bed to chair) without substantial human assistance, including verbal reminding, physical cueing, or supervision. In this context, ‘Frail’ has the same meaning as ‘At Risk of Institutionalization’.

o Limited English Proficiency – A person whose primary language is not English. Note: There is a “disconnect” between this terminology and SAMS, which has been identified as a needed enhancement; however it cannot be changed at this time. In SAMS, you have to enter the data in answer to the question “Understands English”. Although the person may understand English, if it is not their primary language you should enter ‘No’, in order to capture the information we are targeting, which is “Limited English Proficiency”.

Page 43

Definitions Family caregiver, an adult family member, or another individual, who is an informal provider of in-home and community care to an older individual.

Grandchild, an individual who is not more than 18 years of age cared for by grandparent, step grandparent, relative by blood or marriage, person with legal relationship or is raising the child informally.

Information, to caregivers about available services

Assistance, to caregivers to facilitate accessing

Counseling, individual counseling, the organization of support groups, and caregiver training to caregivers to assist the caregivers in making decisions and solving problems relating to their caregiving roles.

Respite care, services that enable caregivers to be temporarily relieved from their caregiving responsibilities which shall/may include in-home, institutional and emergency respite.

Supplemental services, services provided on a limited basis, that complement the care provided by caregivers. (Example of service fitting this definition is legal services; this is a good section for flexibility or services that can’t be provided by other sources)

Frail or functionally impaired older person (OAA definition): a person who is “unable to perform at least two activities of daily living without substantial human assistance, including verbal reminding, physical cueing, or supervision; or due to a cognitive or other mental impairment, requires substantial supervision because the individual behaves in a manner that poses a serious health or safety hazard to the individual or to another individual”

Page 44

buckeyehills.orgbuckeyehills.org/.../uploads/BHRC-2018-19-Title-III-E-bi… · Web viewODA shall...

Documents

Transcript of buckeyehills.orgbuckeyehills.org/.../uploads/BHRC-2018-19-Title-III-E-bi… · Web viewODA shall...