REQUEST FOR PROPOSALS FOR

Transcription

1 REQUEST FOR PROPOSALS FOR Targeted In Home Services Provider Liaison (Foster Care Worker) Child Substitute Care Services Madison County Foster Home Recruitment Issued by THE MADISON COUNTY COMMISSIONERS on behalf of: THE MADISON COUNTY DEPARTMENT OF JOB AND FAMILY SERVICES 200 MIDWAY STREET LONDON, OHIO (January, 2009) Providers Conference: February 4, 2009, 2:00pm Location: Madison County Department of Job and Family Services 200 Midway Street London, Ohio Due Date for Proposal submission: February 24, 2009, 2:00pm To: Madison County Commissioners 1 N. Main St. London, OH

2 TABLE OF CONTENTS 1.0 Purpose of the Request for Proposal MCDJFS Targetd RFP Objectives Scope of Service Population Service and Budget Components... 8 A. Service Components... 8 B. Budget and Cost Components Requirements and Specifications Proposal Information RFP Timetable MCDJFS Contact Person Provider's Conference Code of Conduct Provider Disclosures Addenda to RFP Availability of Funds Preparation of Proposal Cost of Developing Proposal Acceptance and Rejection of Proposals Proposal Evaluation Proposal Selection Protest Procedure Non-Discrimination in the Performance of Services Campaign Contribution Declaration

3 6.2 Terrorist Declaration Foster Care site Operation and Safety Requirements Attachment A Attachment B Attachment C Attachment D Attachment E Sample Budget form Campaign Contribution Declaration Terrorist Declaration Review Committee Rating Sheet RFP Submission Checklist 3

4 REQUEST FOR PROPOSAL (RFP) 1.0 Purpose of the Request for Proposal Madison County Department of Job and Family Services (MCDJFS) is currently seeking proposals for one (1) partnership managed care contract with a non-profit, licensed/ certified child care agency, for the provision of: (1) Targeted in home services, (2) a Provider Liaison (Foster Care Worker) related to child placement, (3) Child substitute care services, and (4) Madison County foster home recruitment. 1.1 MCDJFS Targeted RFP Objectives Madison County Department of Job and Family Services ( MCDJFS) is a Public Children Services Agency (PCSA), which provides comprehensive protective services to families and children. The issuance of the RFP is directed at the establishment of a contractual relationship with a qualified child serving agency, which will partner with the Department, to provide services associated with the arrangement for out of home care and the provision of out of home care and treatment services to children and their families, through direct provision and through arrangement with other qualified out of home care providers. MCDJFS does NOT currently have staff resources assigned to foster home recruitment, certification, training, and/or any staff positions assigned to arranging placement services for children entering out of home care. MCDJFS does NOT maintain a network of foster family homes, group homes, shelter care homes, or residential treatment facilities. The purpose of the RFP is to secure such services through a contractual arrangement with a SINGLE qualified agency provider who will provide a continuum of services. Further, this SINGLE provider will be available to work with the agency on a day to day basis, and when needed, on a 24/7 basis to arrange, manage, and provide out of home care services to abused, neglected, and/or dependent children and their families, as well as certain status offenders and delinquent youth as determined by the Madison County Juvenile Court. It is the intent of 4

5 MCDJFS, that all children considered by them to be in need of placement, will receive services under the contract issued pursuant to this RFP. Additionally, MCDJFS is seeking to supplement the in-home and wraparound services currently available in the community in order to prevent the placement of children in out of home care and to ensure that children returning to their own homes are successfully reunited and do not subsequently re-enter placement. MCDJFS has engaged its community partners in a planning process in connection with the out of home care and treatment services available to Madison County families. As a result of this process, the Department is seeking to make the following enhancements to services: Prevent the unnecessary placement of children in out of home care. Development of placement resources, which are within Madison County. Enhance behavioral health care services to children AND their families particularly as it relates to alcohol and other drug (AOD) related services. Improve the utilization of behavioral health care resources and ensure that services to children and their families are accessible, and where feasible, are provided by a single provider. MCDJFS will be working with the community mental health and recovery board, in an effort to ensure that the services which are provided, coordinated and effective, in meeting the needs of the family. MCDJFS expects that ALL children in need of placement as identified by MCDJFS will receive services under the contract issued pursuant to this RFP. The Provider must agree to a NO REJECT, NO EJECT policy for the contract. A NO REJECT, NO EJECT policy is defined by a principle of unconditional care and commitment to finding alternative ways and service providers to meet the unique needs of children and families. Children and families may NOT be rejected or ejected from the services network. 1.2 Scope of Service Madison County has been engaged in a participatory planning effort to improve the local capacity over the past year. As part of that effort, Madison County seeks ONE (1) Provider who will reinforce the value of serving youth within their community in a well coordinated 5

6 system of care which is seamless for the youth/family, culturally competent, standardized in terms of multi-disciplinary assessment, outcome driven, cost effective and collaborative in building upon partnerships with providers and funders in sustaining quality services. The ONE (1) service Provider is expected to increase stability for youth in placement, maintain sibling placements, reduce the length of time a youth spends in care, limit the number of foster care disruptions to less than two (2), and enhance reunification and permanency options and outcomes for children. Service elements may also include respite and crisis support to kinship, adoption and family placements. Foster home recruitment efforts for agencies will focus on attracting a diverse pool of families to work with children with varying needs, and will focus on local recruitment of homes to expand capacity within and closely surrounding Madison County. MCDJFS will be the only referral source related to the rendered services pursuant to this RFP. The Provider is expected to work collaboratively with MCDJFS and designated community providers (i.e., mental health) to ensure service continuity as a result of change that may arise out of the new contract, pursuant to this RFP. In addition, this Provider will offer a range of services to specialized populations including, but not limited to, youth with co-existing mental illness and mental retardation, sexual offending disorders, chronic medical conditions and conduct/delinquent behavior disorders. Youth will be discharged with improved ability to function in school, community and family living arrangements within birth, kin and adoptive environments. In a small percentage of cases, youth will be discharged to independent living settings or adult mental health or MRDD systems of care. 6

7 1.3 Population The following data is provided for planning purposes only. MCDJFS does not guarantee that the current service level will increase, decrease or remain the same. The numbers of youth in MCDJFS custody who require foster care placements vary from month to month. It is anticipated that MCDJFS will purchase services for approximately 40 youth in out of home paid placement during the year. In 2007, MCDJFS served a monthly average of 23 youth at out of home paid placement. It is anticipated this trend will continue. In 2007, an average of 13 youth were placed at therapeutic foster care, an average of 13 youth were placed at family foster care, an average of 12 youth were placed at specialized foster care, and an average of 10 youth were placed in residential treatment. An average of 30% of these children was ages 0-5, 23% of these children were ages 6-11, and 47% of these children were ages 12+. Typically, Madison County children have a history of abuse, neglect, unruliness, and/or dependency. MCDJFS also provides service to children who may have been determined by the Madison County Juvenile Court to be unruly (status offenders) and delinquent. These children require out-of-home-care placements and will have a range of custody statuses from Exparte, Temporary Custody (TC), Planned Permanent Living Arrangements (PPLA), to Permanent Commitments (PC). The primary outcomes for these children are safety, permanency, and well-being. The Provider will incorporate these outcomes into their treatment plans and program curriculums. Many of the children suffer from emotional, psychological, behavior and learning problems. Some national estimates indicate approximately 90% of children in placement have an identifiable mental health or behavioral health issue. For those youth who are in PPLA custody status or older youth in permanent custody, the prevalence of conduct disorder, post traumatic stress disorder, and mild mental retardation is especially high. Many of these children are also at greater risk of being placed out of Madison County because local services have not 7

8 been able to effectively engage families, locate alternate permanent placement options, address specific treatment needs or keep the children safe in a least restrictive environment (kinship home or family). These children are at greater risk of being involved in the child welfare system for a longer period of time and therefore at greater risk for unstable placements and poor overall educational, social, health, and poverty outcomes long-term. Programs incorporating evidence-based logic and treatment models, and successful histories of effectively working with children who have complex post traumatic stress disorders, conduct disorders, sexual behavior disorders and other mental health and attachment difficulties are currently needed to improve local services and long term outcomes for high-risk MCDJFS children. 2.0 Service and Budget Components Provider should clearly state its competitive advantage and its ability to meet the terms, conditions, and requirements as defined in the RFP in responding to this section. Providers must describe in detail all information set forth in subsection A; Service Components and subsection B; Budget and Cost Components. A. Service Components Describe in detail, the activities that will be provided for each service component. Be sure to identify those activities that will be provided directly by the Provider s own employees and separately identify activities for which the Provider will be subcontracted. For subcontracted services, the proposal must clearly identify the organization with whom the Provider plans to subcontract. Services will be individualized and capitalize on the strengths of the youth and the family. The following service components shall be available: 1. Targeted In Home Services- Identify and describe any intensive In Home services activities that will be available to children and their families who may have been identified by MCDJFS as needing 8

9 placement, but who the Provider believes can be safely and successfully serviced in their own homes. Describe the model. Identify any evidence based research which supports the successful utilization of the service for the families to be served. Describe how the service will be arranged and provided, the level of intensity, duration, and qualifications of the staff to be used. 2. Provider Liaison (Foster Care Worker) related to Child Placement, In Home Service and Child Substitute Care Services- Describe how services will be made available to MCDJFS to ensure that all children in need of placement will receive appropriate care and services on a timely basis. Describe how your staff will be assigned, what arrangements will be made to assure that placement services are accessible on a day to day, 24/7 basis. Provide a description of the qualifications for the person(s) to be assigned to these tasks, with particular emphasis on their abilities to assist MCDJFS staff in assessing risk and developing alternative service plans that might reduce the need for purchased out of home care. 3. Out of Home Care Services, Maintenance, and Case Management and Related Services- Be sure to include all levels of care to be made available, describe each level and how it will be provided. Identify separately, those placement resources that will be provided directly and those resources for which the Provider may be subcontracting. Describe how the placement process will accommodate the child and families needs as it relates to access to the placement of sibling sets, behavioral health care services, visitation, school attendance, and access to any needed special services. Describe how the proposed program will reduce and limit the number of disruptions in foster care to less than two (2). 9

10 Describe how services and supports will be in place to match children and families, maintain and preserve stability of placements, and promote positive relationships between foster families and the child s biological family, both during and following placement. 4. Development of Madison County Placement Resources- Describe how you propose to develop and/or secure additional placement resources within Madison County. Describe your recruitment, training, and retention effort. Address how you will be providing the local staff resources that may be necessary and any incentives or inducements that will be utilized. Specifically describe training for specialized populations as identified in Section 2.0, A. #6. Identify the specific groups or segments of the community, which will be targeted as possible resources for the recruitment of Foster Homes and Treatment Foster Homes. Identify any assistance that MCDJFS will be called upon to assist in this effort. Describe how recruited families will be trained and properly certified and what incentives will be used to support their successful continuation in the program. Identify any activities that will be undertaken to develop access to existing Madison County foster family homes, which are certified by other agencies. 5. Behavioral Health Care Services- Describe the behavioral health care services that will be available in connection with this proposal. Distinguish between the services which will be provided directly by your agency and services which will be arranged or subcontracted from other providers. Include all services irrespective of the funding streams, which are anticipated to be used. 10

11 Describe, in detail, how you will assure that family members of children in out of home placement will receive service, and how those services will be coordinated with the behavioral health services that the child/children may be receiving. Describe how behavioral health services will be provided and coordinated to families and children in placement outside of Madison County. Describe how the mix of services is appropriate to the types of children and families likely to be served. Pay particular attention to addressing how the treatment needs of children and families in need of alcohol and other drug related services will be addressed. Describe any process or procedures that will be in place to assess behavioral health care services utilization and effectiveness; both for services you directly provide and with others you may be contracting or arranging service. 6. Explain your specific capacity to accept placement for and work with each of the following child populations: Mild mental health, Moderate mental health, Severe mental health, Borderline mental retardation, Mild mental retardation, Moderate mental retardation, Chronic medical conditions that require ongoing monitoring, Substance abuse, Attachment disorders, Sex offenders, Delinquent youth, Youth with a history of trauma, Youth who have experienced sexual or physical abuse, Youth who have endured death of a caregiver, 11

12 Youth over age sixteen (16) in need of independent living, Youth with a history of fire-setting, Youth who have had chronic exposure to violence, and Any other specific populations you serve. B. Budget and Cost Components For each of the service components listed in sub section A, provide a budget narrative which describes how the activities within each component will be funded and the basis upon which MCDJFS will be charged for year one of the contract period- July 1, 2009 through June 30, Describe the method to be used in invoicing and reporting services that have been provided. Describe how any start up costs will be handled. Provide up to three (3) suggested methods of providing incentives/disincentives to your organization for meeting objectives set out from this RFP. Provide a categorical budget that itemizes the anticipated cost for each component for which MCDJFS will be billed. A sample/blank budget form is enclosed for your use (Attachment A). 3.0 Requirements and Specifications Also to be included in proposal with RFP responses of Service and Budget Components: Provide the headquarter and service addresses of organization, include phone #, and sign original proposal and submit two additional copies with original. Provide job descriptions for all positions in the program budget which will be newly created in response to the RFP. Provide any historical outcome data that would meet the goals of this RFP. Provider must indicate whether you are a Medicaid certified facility. 12

13 Provide a copy of your most recent annual report, and/or financial report, and/or the most recent independent audit report. Provide a brief history of organization. Include mission statement and philosophy of service, what population you currently serve and what provider resources and experiences will support this program. All placements shall be in IV-E allowable settings. Provider must submit all completed and signed Declarations as listed: A. Attachment B - Declaration of Campaign Contributions per Section 6.1 B. Attachment C Declaration of Material Assistance/Non Assistance to a Terrorist, per Section 6.2. Provide information promoting your program s value to MCDJFS consumers. The Provider must be appropriately licensed and accredited for the services that it proposes to provide directly, and maintain such licensure from ODJFS or Ohio Department of Mental Health (ODMH) or other licensing or accrediting agencies. Identify any actions taken by ODJFS, ODMH or any other licensing/accrediting body against your organization or any subsidiaries or business partners over the past two (2) years including, but not limited to Corrective Action Plans, temporary licenses or revocations. Also, provide the outcome of any such actions. Provider must demonstrate an established capacity to provide the services proposed and to work cooperatively with other out of home care providers in the placement and management of services provided to MCDJFS children and their families. Provider s subcontractors must be approved by MCDJFS and will be held to the same contract standards as the Provider. Provider must agree to be responsible for making direct payments to all subcontractors. Provider agrees that they are deemed as an independent contractor and either the Provider nor its agents, subcontractors, or employees shall be deemed to be agents or employees of the county. Provider agrees to procure and maintain for the duration of any contract the following insurance: insurance against claims for injuries to persons or damages to property 13

14 which may arise from or in connection with Provider s products or services as described in the contract; auto liability; professional liability (errors and omissions) and umbrella/excess insurance. Further, Provider agrees to procure and maintain for the duration of any contract; Workers Compensation insurance at the statutory limits required by Ohio Revised Code. The cost of all insurance shall be borne by Provider. Insurance shall be purchased from a company licensed to provide insurance in Ohio. Purchase and maintenance of the proper insurance for the duration of the Contract is a material element of the Contract. If any work or services contemplated by this Contract is subcontracted, Provider will ensure that any and all subcontractors comply with all insurance requirements contained herein. 4.0 Proposal Information Each submission must have one (1) signed original proposal and two (2) duplicate copies of the entire written proposal. It must be received by the Madison County Commissioners at 1 N. Main St., London, OH 43140, no later than 2:00 p.m. EST on Tuesday, February 24, Proposals must be labeled MCDJFS RFP. Proposals received after this date and time will not be considered. If Provider is not submitting the proposals in person, Provider should use certified or registered mail, UPS, or Federal Express with return receipt requested. No , telegraphic, facsimile, or telephone proposals will be accepted. MCDJFS anticipates services will begin July 1, 2009 through June 30, 2011, and that the term of the contract may be renewed for two (2) additional one (1) year periods. For renewal years, any increases in Unit Rates will be at the sole discretion of MCDJFS, subject to funding availability and contract performance. MCDJFS does not guarantee that the Unit Rate will be increased from one contract term to the next. Nothing in the RFP shall be construed to be a guarantee of any Unit Rate increase. The estimated amount of funds paid annually for services under the contract pursuant to this RFP will be about $ 750,000.00, excluding payments to Medicaid; however 14

15 MCDJFS is open to proposals that exceed this amount if your proposal is exceptional, non-traditional, and meets the needs and desired outcomes. Provider must certify the proposal and pricing will remain in effect for 180 days after the proposal submission date. 4.1 RFP Timetable ACTION ITEM DELIVERY DATE RFP Issued Providers Conference Deadline for Receiving Final RFP Questions Deadline for Issuing Final RFP Answers Deadline for Proposals Due to Madison County Mon., January 5, 2009 Wed., Feb. 4, 2009, 2:00pm Tue., Feb 10, 2009, 4:00pm Fri., Feb. 13, 2009, 4:00pm Tue., Feb. 24, 2009, 2:00pm Commissioners Office Proposal Review Completed March 23, 2009 Anticipated Start Date July 1, MCDJFS Contact Person MCDJFS Contact Person regarding questions about the RFP is: Steve Kaifas, Fiscal Officer Madison County Department of Job and Family Services 200 Midway St. London, Ohio Fax: (740)

16 A. Prior to the Provider s Conference, questions may be faxed and/or ed regarding the RFP or proposal process to the MCDJFS Contact Person. The questions and answers will be distributed at the Provider s Conference and they will be posted on the county website: RFP path on front page, to Providers who are unable to attend the Provider s Conference. B. After the Provider s Conference, questions may be faxed or ed regarding the RFP or the RFP Process to the MCDJFS Contact Person. C. The answers to these questions will be posted on the county website, following the path in section A. D. The answers issued in response to such Provider questions become part of the RFP. E. No questions will be accepted after February 10, 2009 by 4:00pm. The final responses will be posted on the county web site, on February 13, 2009 by the close of business. 4.3 Provider s Conference The Provider s Conference will take place at Madison County Department of Job and Family Services, 200 Midway St., London, Ohio 43140, Wednesday, February 4, 2009, 2:00 p.m. 4.4 Code of Conduct The integrity of the RFP process is very important to MCDJFS in the administration of our business affairs, in our responsibility to the residents of Madison County, and to the providers who participate in the process in good faith. MCDJFS employees must conduct themselves, at all times, in a manner that discourages conflict of interest, maintains fairness, avoids favoritism, bias, and the appearance of impropriety. MCDJFS shall not solicit or accept gratuities, favors, or anything of monetary value ($25.00 or more) from contractors or potential contractors, vendors, or providers. 16

17 4.5 Provider Disclosures Provider must disclose any pending or threatened court actions and claims brought by or against the Provider, its parent company or its subsidiaries. This information will not necessarily be cause for rejection of the proposal; however, withholding the information may be cause for rejection of the proposal. If awarded the contract, Provider ensures that they are not debarred or suspended or is otherwise ineligible for participation in federal assistance programs under Executive Order 12549, including 7 CFR Part 3017, 29 CFR Part 97, and 45 CFR Part 76, and Provider will ensure they are in conformance with ORC Section 9.24, and will not be awarded a contract if there is a finding for recovery issued by the State Auditor of Ohio. 4.6 Addenda to RFP MCDJFS may modify this RFP no later than February 13, 2009 by issuance of one or more addenda to all parties. In the event modifications, clarifications, or additions to the RFP become necessary, all Providers will be notified and the addenda will be posted on the county website, Availability of Funds This program is conditioned upon the availability of federal, state, or local funds which are appropriated or allocated for payment of the proposed services. If, during any stage of this RFP process, funds are not allocated and available for the proposed services, the RFP process will be canceled. MCDJFS will notify Provider at the earliest possible time if this occurs. MCDJFS is under no obligation to compensate Provider for any expenses incurred as a result of the RFP process. 17

18 5.0 Preparation of Proposal Proposals must provide a straightforward, concise delineation of qualifications, capabilities, and experience to satisfy the requirements of the RFP. Emphasis should be concentrated on conformance to the RFP instructions, responsiveness to the RFP requirements, completeness, and clarity of content. The proposal must include all costs relating to the services offered. 5.1 Cost of Developing Proposal The cost of developing proposals is entirely the responsibility of the Provider and shall not be chargeable to MCDJFS under any circumstances. All materials submitted in response to the RFP will become the property of MCDJFS and may be returned only at MCDJFS option and at Provider s expense. 5.2 Acceptance and Rejection of Proposals MCDJFS reserves the right to: A. award ONE(1) contract for one or more of the proposed services, B. award ONE(1) contract for the entire list of proposed services, C. reject any proposal, or any part thereof, and D. waive any informality in the proposals, in the best interest of Madison County and MCDJFS. The recommendation of MCDJFS staff and the decision by the MCDJFS Director shall be final. Waiver of an immaterial defect in the proposal shall in no way modify the RFP documents or excuse the Provider from full compliance with its specifications if Provider is awarded a contract. 5.3 Proposal Evaluation The proposal evaluation shall be consistent with the Code of Federal regulations (CFR), specifically 45 CFR 92.36, Procurement section. MCDJFS will review each proposal with respect to price, applicant s service and budget components, and RFP criteria 18

19 conformance. Proposals will be rated utilizing a Review Committee Rating Sheet which appears as Attachment D. The evaluation of proposals submitted in response to this RFP may result in the issuance of ONE(1) contract. The contract shall incorporate the terms, conditions and requirements of the RFP, the Provider s proposal, and any other mutually agreed upon terms. The contents of this RFP and the commitments set forth in the selected proposals shall be considered contractual obligations, if a contract ensues. Failure to accept these obligations may result in cancellation of the award. All legally required terms and conditions shall be incorporated into final contract agreements with the selected Providers. This RFP and all attachments are intended to supplement and compliment each other and shall where permissible be so interpreted. However, if any provision of this RFP or the attachments conflict, this RFP takes precedence. The RFP, the evaluation of responses, and the award of any resultant contract shall be made in conformance with current federal, state, and local laws and procedures. 5.4 Proposal Selection Proposal selection does not guarantee a contract for services will be awarded. The selection process is as follows: 1. Based upon the results of the evaluation, MCDJFS will select ONE (1) Provider for the services who it determines to be the responsible firm whose proposal is most advantageous to the program, with price and other factors considered. 2. MCDJFS will work with the selected Provider to finalize details of the agreement. 19

20 3. If MCDJFS and Provider are able to successfully finalize an agreement, the BOCC and MCDJFS may award and execute a contract with the Provider. 4. If MCDJFS and successful bidder are unable to come to terms regarding an agreement, in a timely manner as determined by MCDJFS, MCDJFS will terminate the agreement discussions with Provider. In such event, MCDJFS reserves the right to select another Provider from the RFP process, cancel the RFP or reissue the RFP as deemed necessary. 5.5 Protest Procedure Two types of protests can be submitted: 1. Any potential or actual responder objecting to the matters relating to the process of soliciting the RFP must submit a protest in the form of a written statement and contain the information from below. The protest must be submitted no later than 4:00pm on the closing date for receipt of proposals. 2. Any potential or actual responder objecting to the award of a contract resulting from this RFP must submit their protest in the form of a written statement and contain the information from below. The protest must be submitted no later than 4:00pm of the tenth (10) calendar day after the issuance of the Letter of Intent to Award the contract. Information required in protest statement: A. Name of organization/individual, address, and phone number of protester. B. Detailed statement(s) of factual grounds for protest. C. Any other information the protestor believes to be essential to the determination of the questions at the issue in the written protest. A timely protest shall be considered by MCDJFS, if it is received within the submittal guidelines. Upon review of the facts provided in the written request for a review, the 20

21 Director may at his or her discretion, schedule a formal review meeting. Should the review meeting be scheduled, it will be held within five (5) working days of receipt of the request for a review. The Director will render a written decision within fifteen (15) working days from receipt of request. All protests must be submitted at the following location: Director, Madison County Department of Job and Family Services, 200 Midway St., London, OH Non-Discrimination in the Performance of Services Provider agrees to comply with the non-discrimination requirements of Title VI of the Civil Rights Act of 1964, 42 USC Section 2000d, and any regulations promulgated there under. Provider further agrees that it shall not exclude from participation in, deny the benefits of, or otherwise subject to discrimination any MCDJFS consumer in its performance of this Contract on the basis of race, color, religion, sex, national origin, ancestry, disability, Vietnam-era veteran status, age, political belief, or place of birth. Provider further agrees to comply with OAC 5101: and OAC 5101: , as applicable, which require that contractors and sub-grantees receiving federal funds must assure that persons with limited English proficiency (LEP) can meaningfully access services. To the extent Provider provides assistance to LEP consumers through the use of an oral or written translator or interpretation services, in compliance with this requirement, consumers shall not be required to pay for such assistance. 6.1 Campaign Contribution Declaration As part of the submitted proposal, Provider will include the applicable notarized Affidavit in Compliance with ORC (Campaign Contribution Declaration Amended Substitute House Bill 694 ( HB 694 )), Attachment B. HB694 limits solicitations of and political contributions by owners and certain family members of owners of businesses seeking or awarded public contracts. 21

22 All individuals or entities interested in contracting with MCDJFS are required by HB 694 to complete the applicable affidavit certifying compliance with contribution limits set forth by the Bill. All current and potential vendors should closely review HB 694 or risk loss of their opportunity to obtain or retain MCDJFS contracts. Please seek guidance from your legal counsel if you have questions pertaining to HB 694 as we are unable to provide individual legal advice. 6.2 Terrorist Declaration In accordance with ORC (A)(2)(b), Provider agrees to complete the Declaration Regarding Material Assistance/No Assistance to a Terrorist Organization, Attachment C. Any material assistance to a terrorist organization or organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List is a felony of the fifth degree. 6.3 Foster Care Site Operation and Safety Requirements Provider agrees to comply with the provisions of OAC 5101:2-7 et seq. relating to the operation, safety and maintenance of foster homes. 22

23 Attachment A MCDJFS CONTRACT BUDGET * For Period: July 1, 2009 to June 30, 2010 Agency Name of Program Total Expenses by Program Services Program Mgmt. Indirect Other Direct Services Expense A. Staff Salaries B. Employee Payroll Taxes & Benefits C. Professional & Contracted Services D. Consumable Supplies (i.e., office, cleaning) E. Occupancy Costs (i.e. maintenance/repairs, phone, utilities) F. Travel/ mileage reimbursement costs G. Insurance Costs (i.e. liability, property, etc.) H. Supplies/Equipment I. Staff Training J. Incentives K. Miscellaneous SUB TOTAL TOTAL PROGRAM EXPENSES This budget is for sample purposes; providers may add or delete categories to suit their needs. 23

24 Attachment B AFFIDAVIT IN COMPLIANCE WITH SECTION OF THE OHIO REVISED CODE STATE OF OHIO COUNTY OF MADISON SS: Personally appeared before me the undersigned, as an individual or as a representative of for a contract for (Name of Entity) (Type of Service) to be let by Madison County, who being duly cautioned and sworn, makes the following statement with respect to prohibited activities constituting a conflict of interest or other violations under Ohio Revised Code Section , and further states that the undersigned has the authority to make the following representation on behalf of himself or herself or of the business entity: 1. That none of the following has individually made after April 4, 2007, and that, if awarded a contract for the purchase of goods or services with a cost aggregating more than $ 10,000 in a calendar year, none of the following individually will make, beginning on the date of the contract is awarded and extending until one year following the conclusion of the contract, as an individual, one or more campaign contributions totaling in excess of $ 1,000.00, to any member of the Madison County Board of Commissioners or their individual campaign committees: a. Myself (if applicable); b. any partner or owner or shareholder of the partnership (if applicable); c. any owner of more than 20% of the corporation or business trust (if applicable); d. each spouse of any person identified in (a) through (c) of this section; e. each child seven years of age to seventeen years of age of any person identified in divisions (a) through (c) of this section (only applicable to contributions made on or after January 1, 2007). 2. That none of the following have collectively made after April 4, 2007, and that, if awarded a contract for the purchase of goods or services with a cost aggregating more than $ 10,000 in a calendar year, none of the following collectively will make, beginning on the date the contract is awarded and extending until one year following the conclusion of the contract, one or more campaign contributions totaling in excess of $ 2,000.00, to any member of the Madison County Board of Commissioners or their individual campaign committees: a. myself If applicable); b. any partner or owner or shareholder of the partnership (if applicable); c. any owner of more than 20% of the corporation or business trust (if applicable); d. each spouse of any person identified in (a) through (c) of this section; e. each child seven years of age to seventeen years of age of any person identified in divisions (a) through (c) of this section; f. any political action committee affiliated with any person identified in divisions (a) through (c) of this section. Signature Title: Sworn to before me and subscribed in my presence this day of, 20. Notary Public My Commission Expires: 24

25 Attachment C Ohio Department of Public Safety DIVISION OF HOMELAND SECURITY GOVERNMENT BUSINESS AND FUNDING CONTRACTS In Accordance with section of the Ohio Revised Code DECLARATION REGARDING MATERIAL ASSISTANCE/NO ASSISTANCE TO A TERRORIST ORGANIZATION This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland Security Division website for a reference copy of the Terrorist Exclusion List). Any answer of yes to any question, or the failure to answer no to any question on this declaration, shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disclose the provision of material assistance to such an organization or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. For the purposes of this declaration, material support or resources means currency, payment instruments, other financial securities, funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well as communications, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials. COMPLETE THIS SECTION ONLY IF YOU ARE AN INDEPENDENT CONTRACTOR LAST NAME FIRST NAME MI HOME ADDRESS CITY STATE ZIP COUNTY HOME PHONE WORK PHONE COMPLETE THIS SECTION ONLY IF YOU ARE A COMPANY, BUSINESS, OR ORGANIZATION LAST NAME FIRST NAME MI BUSINESS/ORGANIZATION NAME PHONE BUSINESS ADDRESS CITY STATE ZIP COUNTY Page 1 25

26 DECLARATION In accordance with section (A)(2)(b) of the Ohio Revised Code For each question, indicate either circle yes or no in the space provided. Responses must be truthful to the best of your knowledge. 1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 2. Have you used any position of prominence you have with any country to persuade others to support an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 3. Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 5. Have you committed an act that you know, or reasonably should have known, affords material support or resources to an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act of terrorism? Yes No In the event of a denial of a government contract or government funding due to a positive indication that material assistance has been provided to a terrorist organization, or an organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List, a review of the denial may be requested. The request must be sent to the Ohio Department of Public Safety s Division of Homeland Security. The request forms and instructions for filing can be found on the Ohio Homeland Security Division website. CERTIFICATION I hereby certify that the answers I have made to all of the questions on this declaration are true to the best of my knowledge. I understand that if this declaration is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this declaration. I understand that failure to disclose the provision of material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List, or knowingly making false statements regarding material assistance to such an organization is a fifth degree felony. I understand that any answer of yes to any question, or the failure to answer no to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided by myself or my organization. If I am signing this on behalf of a company, business, or organization, I hereby acknowledge that I have the authority to make this certification on behalf of the company, business, or organization referenced on page 1 of this declaration. X Applicant Date Page 2 26

27 Attachment D REVIEW COMMITTEE RATING SHEET BIDDER NAME: Proposal Component Requirements (75%) Service Component (1): Described in detail- Targeted In Home Services Service Component (2): Described in detail- Provider Liaison(Foster Care Worker) related to child placement. Rating scale: Reviewers comments: Score I MA G E Service Component (3): Described in detail- Out of Home Care Services Service Component (4): Described in detail- Development of Madison County Placement Resources Service Component (5): Described in detail- Behavioral Health Care Services Budget Component: Provided budget narrative for each service component Budget Component: Described method for invoicing and reporting services for service components. Budget Component: Described how start up costs will be handled. Budget Component: Described up to 3 methods of providing incentives for meeting objectives for provider Budget Component: Provided a itemized budget for anticipated costs for components (Attachment A) Requirements/Specifications: Provided appropriate documentation and certifications per Section 3.0. Proposal Component Score (75%) Reviewer score of proposal meeting MCDJFS needs. Score will range from 1-10 ( 1= low score & 10= high score) (25%) Reviewer s name: Score: Score: Date: I= Inadequate, MA= Minimally Acceptable, G= Good, E= Excellent 27

28 Attachment E MADISON COUNTY DEPARTMENT OF JOB & FAMILY SERVICES RFP SUBMISSION CHECKLIST The following items are to be included in your proposal in order for it to be deemed qualified. Please indicate that the items are included by checking the corresponding column. Action Required Is a response to each Service Component included? RFP Section 2.0 A Included Is a response to each Budget Cost Component included? Is a Budget completed? (Attachment A) Did you provide all information regarding the Requirements and Specifications section. 2.0 B 2.0 B 3.0 Did you sign the original proposal and submit two copies with the original? 4.0 Did you include the Campaign Contribution Declaration? (Attachment B) 6.1 Did you include the Terrorist Declaration? (Attachment C)