Request for Proposal: PY 2018-19 Older Americans Act (OAA...

Bid Packet

Serving Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry and Washington Counties in Southeast Ohio

1400 Pike Street | Marietta, OH 45750 | 1.800.331.2644 | 740.373.6400 | fax: 740.373.1594

buckeyehills.org

Buckeye Hills Regional Council

Request for Proposal: PY 2018-19 Older Americans Act (OAA)Title III-B Supportive Services and Title III-C Nutrition Services

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BUCKEYE HILLS REGIONAL COUNCILAPPLICATION OVERVIEW

PY 2018-19 OLDER AMERICANS ACTTITLE III-B/BLOCK GRANT FUNDED SUPPORTIVE SERVICE FUNDS

And TITLE III-C/BLOCK GRANT FUNDED NUTRITION SERVICES

TABLE OF CONTENTS

GENERAL INFORMATION............................................................................................................................3

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

APPLICATION PROCESS TIME LINE...........................................................................................................7

APPLICATION

MATERIALS...........................................................................................................................7

APPLICATION DEADLINE REQUIREMENTS ..............................................................................................8

APPLICATION REVIEW PROCESS..............................................................................................................8

PROPOSAL EVALUATION CRITERIA .........................................................................................................9

NOTIFICATION OF

AWARDS......................................................................................................................13

AWARD APPEAL PROCESS ......................................................................................................................13

SUMMARY OF FUNDED SERVICES AND

RULES.....................................................................................14

SERVICE UNIT DEFINITIONS……………………………………………………………………………………..15

CONTRACTING...........................................................................................................................................16

MATCHING FUNDS, COST SHARING AND DONATIONS ........................................................................16

REPORTING ...............................................................................................................................................17

DATA QUALITY AND MONITORING...........................................................................................................17

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NEW PROVIDER ORIENTATION ...............................................................................................................18

REQUEST FOR PROPOSAL REQUIREMENT EXHIBITS AND FORMS………....……..…...………...19-40

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GENERAL INFORMATION

Buckeye Hills Regional Council (BHRC) is soliciting proposals from agencies which, at the time of application, provide Personal Care Service, Homemaker Service, Adult Day Service, Transportation, Congregate Meals, Home Delivered Meals and Legal Assistance to individuals who are 60+ in Athens, Hocking, Meigs, Monroe, Morgan, Noble, Perry and Washington Counties.

Older Americans Act (OAA) Title III Funds will be awarded through a competitive bid process. Successful applicants will be awarded funds for the 24-month period from January 1, 2018 through December 31, 2019.

In order for an applicant’s submission to be considered, a representative from that organization or agency MUST attend the Mandatory Bidder’s Conference on Tuesday, July 11, 2017 from 10:00 am to 12:00 pm at Buckeye Hills Regional Council, 1400 Pike Street, Marietta, Ohio. Attendees must remain for the entire meeting. Please RSVP to [email protected] with names of your attendees no later than Monday, July 7, 2017.

No individualized instruction or clarification will be given after the conclusion of the Mandatory Bidders Conference. All questions and responses will be posted to the BHRC website www.buckeyehills.org on a rolling basis as they are received during the period of June 16 through July 21, 2017. Submit questions in writing to [email protected].

BHRC has determined to fund the following Older Americans Act services:OAA Title III-B: Transportation OAA Title III-C: Congregate Meals

Personal Care Home-Delivered MealsHomemakerAdult Day ServiceLegal Services

If applicant is applying for more than one sub-part (Title III-B, Title III-C1, Title III-C2) of OAA funding, the applicant needs to provide only ONE set of:

Certification Regarding Debarment Certification for Contracts and Grants Section 504 Assurances Title VI Civil Rights Claims Agreement Fiscal and Record Keeping Agreement Declaration regarding Assistance to Terrorist Organizations Standard Affirmation and Disclosure Form for Grants Organizational Information Organizational Chart Articles of Incorporation/Certificate of Continuing Existence Certification of Organizational Documentation

mailto:[email protected]

http://www.buckeyehills.org/

mailto:[email protected]

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Providers selected under Older Americans Act Title III will be required to provide a Monthly Invoice with the type and number of clients receiving contract services and units of service provided, and any applicable attachments, preferably delivered via electronic communications (email submissions) during the contracted years.

BHRC retains the right to contact the applicant to request clarification of any and all information provided in the application packet.

AVAILABLE FUNDING

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. 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 targeted service delivery.

Older Americans Act Title III-B/Block Grant Supportive Service Program funding for Program Year (PY) 2018-19 is provided through the Ohio Department of Aging. The total available funding is estimated to be approximately $363,975.92. 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.

Title III-B/Block Grant Supportive Service Program funding for Program Year (PY) 2018-19COUNTY TITLE III-B

TRANSPORTATION

SCSBG

TRANSPORTATION

TITLE III-B

IN-HOME

SERVICES

SCSBG

IN-HOME

SERVICES

Total

COUNTY

LEGAL

ASSISTANCE

All Counties combined

Athens $24,515.96 $4,115.21 $13,790.23 $10,059.40 $52,480.80 Athens

Hocking $21,232.80 $3,361.42 $11,943.45 $8,216.80 $44,754.47 Hocking

Meigs $20,726.19 $3,245.10 $11,658.48 $7,932.48 $43,562.26 Meigs

Monroe $19,097.30 $2,871.12 $10,742.23 $7,018.30 $39,728.96 Monroe

Morgan $19,143.30 $2,881.68 $10,768.11 $7,044.11 $39,837.20 Morgan

Noble $18,929.72 $2,832.65 $10,647.97 $6,924.25 $39,334.58 Noble

Perry $21,431.44 $3,407.03 $12,055.19 $8,328.29 $45,221.94 Perry

Washington $27,309.84 $4,756.67 $15,361.79 $11,627.42 $59,055.71 Washington

TOTALS $172,386.56 $27,470.88 $96,967.44 $67,151.04 $363,975.92 $22,000.00

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Title III-C Nutrition Program funding for Program Year (PY) 2018-19 is provided through the Ohio Department of Aging. The total available funding is estimated to be approximately $540,634.08. 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.

Title III-C Nutrition Program funding for Program Year (PY) 2018-19

COUNTY TITLE III C-1 CONGREGATE

TITLE III C-2 HOME

DELIVERED

SCSBGHOME

DELIVERED

TOTAL TITLE III-C/SCSBG

COUNTY ALLOCATION

Athens $38,878.29 $53,720.49 $8,687.67 $101,286.45Hocking $23,889.54 $33,009.63 $7,096.33 $63,995.50Meigs $21,576.70 $29,813.84 $6,850.78 $58,241.32Monroe $14,140.27 $19,538.47 $6,061.26 $39,740.00Morgan $14,350.25 $19,828.61 $6,083.55 $40,262.41Noble $13,375.20 $18,481.32 $5,980.03 $37,836.55Perry $24,796.41 $34,262.71 $7,192.61 $66,251.73Washington $51,633.34 $71,344.93 $10,041.86 $133,020.13TOTAL $202,640.00 $280,000.00 $57,994.08 $540,634.08

The mission of the BHRC is to serve those individuals who are in the greatest need as identified in the Older Americans Act.

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;

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The current allocation formula reflects a mix of 2000 and 2010 census data. BHRC Demographic Data is available on the BHRC website for use in planning and targeting strategy.

Data Sources:60+ Minority 2010 Census60+ Poverty 2010 Census75+ 2010 CensusLives Alone 2000 Census, AoA Special Tabulation on Aging; P5; Age by Sex Living Alone65+ Disability 2000 Census, Summary File (SF 3)

WEIGHT 5% 26% 27% 27% 15%

60+

MINORITY60+

POVERTY 75+ LIVES ALONE

65+ DISABILITY

ATHENS 367 1075 2877 2235 4678HOCKING 167 720 1770 1190 3271MEIGS 110 555 1629 1270 3340MONROE 37 455 1228 780 1191MORGAN 167 355 1184 815 1704NOBLE 320 300 1091 665 1420PERRY 91 635 1969 1480 3720WASHINGTON 390 1020 4871 3140 7530TOTAL 1649* 5115* 16619* 11575* 26854*

*Denotes the total number of people in each category.

Proposals for home-delivered meals and congregate meals must include preparing and serving of the menus specifically developed and approved by BHRC Registered Dietician. Providers must also cooperate with BHRC to provide Nutrition Education for home delivered meal consumers.

If received by the United States Department of Agriculture (USDA), BHRC will provide a partial reimbursement for raw foods cost through the Nutrition Services Incentive Program (NSIP) for qualifying meals.

BHRC retains the right to contact the applicant to request clarification of any and all information provided in this packet.

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APPLICATION PROCESS TIME LINE

PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services Request for Proposal Announcement in Legal Notice Section of papers

Week of June 5, 2017

PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services application and instructions made available to prospective bidders on website

June 16, 2017

Mandatory Bidders Conference July 11, 2017

Questions and answers regarding the PY 2018-19 RFP process will be posted to the www.buckeyehills.org website as they are received.

OngoingJune 15 –July 21, 2017

Proposal Application Due Date August 1, 2017

BHRC Staff review of submitted proposals August 1 – August 31, 2017

BHRC Staff contract recommendations presented to Regional Advisory Council September 29, 2017

Regional Advisory Council recommendations presented to Buckeye Hills Executive Committee November 3, 2017

PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services Contracts mailed to successful bidders for signature

Week of November 6, 2017

PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services Contracts due back to BHRC November 30, 2017

First day of PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services January 1, 2018

Last day of PY 2018-19 Title III-B Supportive Service and Title III-C Nutrition Services December 31, 2019

APPLICATION MATERIALS

All instructions and materials needed to apply for PY 2018-19 Title III-B/Block Grant Supportive Service and Title III-C/Block Grant Supportive Service funding are available to download from the BHRC website www.buckeyehills.org ; 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 responses are not accepted.



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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.

APPLICATION DEADLINE REQUIREMENTS

One (1) complete original and one (1) complete copy application in hard copy must be received by BHRC at 1400 Pike Street, Marietta, Ohio 45750 by 4:00 p.m. on August 1, 2017. Faxed or emailed proposal applications will be rejected. If mailed, bidder is required to use certified return receipt. If hand delivered, bidder will be given a receipt at time of delivery.

Applications will be reviewed for completeness and compliance with required formats and must meet the Minimum Criteria.

It is not the responsibility of 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 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.

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TOTAL SCORE /

OLDER AMERICANS ACT TITLE IIIPROPOSAL EVALUATION CRITERIA BY SERVICE

Applicant Agency:

County of Service: _______________________________________________________

Service: ________________________________________

Section I – Minimum Criteria

All six (6) criteria in this section must be met in order for the application to receive further consideration. Points will not be given for responses in this section.

The applicant has submitted a complete project proposal with all required exhibits AND authorized signatures.

Applicant has not been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from receiving federal funding.

Responses are typed clearly.

The application is hand delivered or received via postal service by due date.

The applicant has used BHRC application forms.

The applicant meets the submission deadline.

Section II – Addressing Social and Economic Need (50 points maximum)

Number of Projected Clients who are:

60 + MINORITY

10 points Percentage of minority elderly to be served is ator above 90% of 60 + minority in the county

5 points Percentage of 60 + minority to be served is 50% of minority elderly in the county

0 points No 60 + minority will be served

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LOW INCOME (60 + in POVERTY) (based on current HEAP income guidelines)

10 points Percentage of low-income elderly to be served is ator above 90% of low-income elderly in the county

5 points Percentage of low-income elderly to be served is 50% of low-income elderly in the county

0 points No low-income elderly will be served

75 +

10 points Percentage of 75+ elderly to be served is ator above 90% of 75+ elderly in the county

5 points Percentage of 75+ elderly to be served is 50% of 75+ elderly in the county

0 points No 75+ elderly will be served

LIVES ALONE

10 points Percentage of lives alone elderly to be served is ator above 90% of lives alone elderly in the county

5 points Percentage of lives alone elderly to be served is 50% of lives alone elderly in the county

0 points No lives alone elderly will be served

65+ DISABILITY

10 points Percentage of 65 + with disability elderly to be served is ator above 90% of 65 + with disability elderly in the county

5 points Percentage of 65 + with disability elderly to be served is 50% of 65 + with disability elderly in the county

0 points No 65 + with disability elderly will be served

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Section III – Provider Ability to Cover Geographic Area (20 points max)

20 points Service extends to 100% of townships in the county

15 points Service extends to 50-99% of townships in the county

10 points Service extends to 25-49% of townships in the county

5 points Service extends to less than 5% of townships in the county

Section IV – Program Design (30 points maximum)

10 points The service descriptions adhere to service rules and clearlyexplain how each service will be delivered by a sufficient number of qualified staff.

10 points Applicant has internal system of Quality Assurance to monitorcompliance with the service rules.

Provider explains how it shall offer person direction for Nutrition Program 173-4-04 with consideration to quality, cost and other factors.

-5 points Provider does not meet the level of Person Direction

5 points Provider meets the level of Person Direction

10 points Provider exceeds the level of Person Direction

Section V – Current Provider Performance (25 points maximum)

SERVICE UNITS:

15 points 91% or higher of FY2017 planned units delivered.

10 points 50%-90% of FY2017 planned units delivered.

0 points 49% or less of FY2017 planned units delivered.

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MONITORING/EVALUATIONS:

10 points Most recent BHRC OAA unit audit results were within allowable parameters.

5 points Most recent BHRC OAA unit audit results required correction of findings.

0 points Most recent BHRC OAA unit audit results required additional technical assistance and monitoring.

Section VII – Performance Issues (maximum LOSS of 30 points) (Applicant can LOSE 0-30 points in this section)

-5 points Agency earned less than 95% of program funds duringmost recent contract period.

-10 points Agency maintained contract relationship with program/fiscal finding requiring plan of correction and/or returnof funds to BHRC

-15 points Applicant has had contracts with BHRC terminated, or has filed for bankruptcy in last five years.

Section VII – New Applicants (15 points maximum)

15 points Applicant is already certified by BHRC as a current PASSPORT provider, in good standing, of service for which they are applying, OR

Applicant is a Medicare, Medicaid or JCAHO accredited homehealth agency in good standing, OR

Applicant provides the service under a funding source otherthan BHRC, Medicare, or Medicaid.

MAXIMUM POINTS AVAILABLE – CURRENT PROVIDER : 145MAXIMUM POINTS AVAILABLE – NEW PROVIDER: 160

RANKING IS BASED ON PERCENTAGE (Points Received divided by Points Available)

TOTAL SCORE: _________PERCENT: __________

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NOTIFICATION OF AWARDS

Successful bidders will be notified of award by receipt of a 2-year contract for provision of 2018-19 Title III Supportive Services or Nutrition 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 letter to the 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, the 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.

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 AAA’s action concerning a particular provider to no 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.

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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.

For the most current rules refer to the Ohio Department of Aging website http://aging.ohio.gov/information/rules/current.aspxhttp://aging.ohio.gov/information/rules/current.aspx#provideragreementshttp://aging.ohio.gov/information/rules/current.aspx#nutrition

All applicants are encouraged to read all instructions and application materials before making a decision to apply for the Title III-B Supportive Service and Title III-C Nutrition Services funding. The BHRC is not liable for any costs incurred or associated with the preparation of any applicant’s application. Personal Care Service: A service comprised of tasks that help a consumer achieve optimal functioning with Activities of Daily Living (eating, dressing, bathing, toileting, grooming, transferring in and out of bed/chair, and walking) and Instrumental Activities of Daily Living (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)

Homemaker Service: 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 Service: A non-residential, community-based service including recreational and education programming to support a consumer’s health and independence goals; at least one meal, but no more than two meals per day and sometimes, health status monitoring, skilled therapy services and transportation to and from the ADS center. Rule 173-3-06.1

Transportation service: A service that transports a consumer from one place to another through the use of a provider's vehicle and driver. Examples of places to which the service may transport a consumer are a medical office, congregate nutrition program site, grocery store, senior center, or government office. Rule 173-3-06.6. BHRC requests providers to itemize transportations rates for in-county or out-of-county medical.

Congregate Nutrition program: A program that consists of administrative functions; meal production; the provision of nutritious, safe, and appealing meals for eligible consumers in a group setting; and the provision of the nutrition-related services described in Rules 173-4-01 to 173-4-09 of the Administrative Code. The purpose of a congregate nutrition program is to promote health, to reduce risk of malnutrition, to improve nutritional status, to reduce social isolation, and to link older adults to community services. Please note the addition of Nutrition Rule 173-4-04 Procuring for Person direction

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

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

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

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Home-delivered Nutrition program: A program that consists of administrative functions; meal production; the delivery of nutritious and safe meals to eligible consumers in a home setting; and the provision of the nutrition-related services described in Rules 173-4-01 to 173-4-09 of the Administrative Code. The purpose of a home-delivered nutrition program is to sustain or improve a consumer’s health through safe and nutritious meals served in a home setting. Please note the addition of Nutrition Rule 173-4-04 Procuring for Person direction

Nutrition Education Service: A service that promotes better health by providing accurate and culturally-sensitive information and instruction to consumers or family caregivers on nutrition, physical activity, food safety or disease prevention, whether provided in a group or individual setting as described in Rule 173-4-08.

Nutrition Screening Service: A health screening that indicates a person’s level of nutritional risk as described in Rule 173-4-09.

Legal Assistance: This service is the provision of legal advice, counseling, and representation by an attorney or other person acting under the supervision of an attorney. Providers must adhere to ODA rules in effect.

SERVICE UNIT DEFINITIONS

Service Service Code

Unit Definition Service Specifications

Adult Day Care 05 4 to 8 Hour Day Rule 173-3-06.1Homemaker 02 One Hour Rule 173-3-06.4

Personal Care 01 One Hour Rule 173-3-06.5Transportation 10 One-way trip Rule 173-3-06.6

Congregate Nutrition Program 07 One meal prepared and served Rule 173-4-05.1

Home-delivered Nutrition Program 04 One meal prepared and delivered Rule 173-4-05.2

Nutrition Education Service 12 One nutrition education session per

consumerRule 173-4-08

Nutrition Health Screening

Service35

One annual nutrition screen per customer

Rule 173-4-09

Legal Assistance 11 One hour

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CONTRACTING

The contracting method for Title III-B 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 173-3-05 (C) The provider must provide 100% of contracted units to achieve 100% reimbursement of contracted funds. If the provider does not deliver all service units during the contract period, unused funds will be forfeited as Title III service funds do not carry over from one state fiscal year to another.On a monthly basis, providers can earn the lesser of units served multiplied by the unit rate, or 1/12th of the contract. Monthly Invoices will be submitted to BHRC detailing units of service delivered.

The BHRC staff monitors the utilization of all contracted funds monthly. If any contracted provider has not utilized at least 75% of contracted funds for service delivery as of September 30 of the program year, the award may be reduced and the BHRC will reallocate funds within the program year without a new Request for Proposals (RFP).

MATCHING FUNDS, COST SHARING AND DONATIONS

Matching Funds

Title III of the Older Americans Act funds has a match requirement of 15%; match may be cash or in-kind.

Older American’s Act funds are intended to fund ONLY 85% of the total services delivered. All awards for these programs require the recipient to provide the remaining 15% in Match Funding

This calculation is to be used to determine Required Match Funding for all services.

Cost Sharing

The current cost sharing policy (Rule 173-3-07) is available for review on the ODA website.1. Cost share will be in effect for the following services funded by Title III-B and Senior Community

Services Block Grant for PY 2018-19: Adult Day Service, Homemaker, and Personal Care. 2. The sliding fee scale has been determined by ODA. The current cost sharing policy and poverty

guidelines (Rule 173-3-07) are available for review on the ODA website. 3. Funds from the cost share contributions will be used to enhance the program and provide

additional units of service in the county the contribution have been received.

Voluntary Contributions

Providers are encouraged to solicit and accept voluntary contributions (program income) for all Title III services.

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REPORTING

Social Assistance Management System (SAMS) Database

Each funded provider agency shall be required to report all service delivery in the SAMS database according to the Ohio Department of Aging Reporting Requirements. BHRC will provide successful applicants with a subscription and license to access the Social Assistance Management System (SAMS). Access and licenses to SAMS is limited to the contract period. The BHRC will provide training for the database application. Each funded provider agency is encouraged to have two staff members who are trained and have access to the SAMS system.

Consumers must be registered by the Provider in the SAMS system, and units of service must be entered into the consumer’s record on a monthly basis. A Monthly Invoice and print out of the SAMS Monthly Agency Summary Report (in a format designated by BHRC must be submitted by the 10th day of the month following the provision of the service.

The SAMS application is hosted remotely by Harmony Information Systems, Inc. The application is accessible over the internet, without the need to install the application locally.Servers, network administration, updates, installations, maintenance, and disaster recovery are all handled by Harmony and are included in the Harmony Information Systems, Inc. subscription service. The BHRC systems administrator arranges access to the site through user ID’s and passwords. When users log in to the domain, they are presented with the applications that the domain owner is licensed. Access to specific database information is controlled by the administrator of the application, just as if it were installed locally. The application is HIPPA compliant.

If a provider chooses to use a software program other than SAMS, a request for waiver narrative must be submitted to BHRC in the proposal package stating the reason the waiver is being requested, the name of the software and an example of a monthly service delivery report for approval by the fiscal manager. The provider must offer proof that the software is compatible with SAMS and must work with Harmony/Synergy to ensure that the export/import process into SAMS is seamless.

DATA QUALITY AND MONITORING

In order to meet the Older Americans Act requirement for annual performance reporting, Area Agencies on Aging (AAA) shall collect information as necessary, and quarterly, submit information to the Ohio Department of Aging. Mandatory information includes participant characteristics and service profile by funding source on selected services funded in whole or in part by Older Americans Act, Senior Community Services Block Grant, or Alzheimer’s Respite dollars as prescribed by the Ohio Department of Aging (ODA).

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Providers of OAA funded services are the front line for ensuring data accuracy since they gather and enter consumer information. To help providers self-monitor data for their organization, instructions have been posted on the Provider Information section of the Area Agency on Aging 8 website.

SAMS data will be reviewed for accuracy and completeness as a part of the provider’s annual review. The following data elements are mandated and will be reviewed during annual monitoring:

a. NAPISa. Genderb. Birth datec. In Povertyd. Lives Alonee. Ruralf. ADL/IADLg. Ethnicity & Ethnic Raceh. Disabled

Deficiencies in NAPIS data input will be noted during the annual review.

Monthly service delivery must match the monthly request for funds to receive reimbursement. Service delivery in SAMS cannot be altered after the provider has submitted a request for funds; irregularities or discrepancies discovered after the fact will be noted during the annual review.

The Quarterly Report submitted to the AAA by the provider must match the monthly requests included in the quarter that is being reported. Discrepancies discovered will be noted during the annual monitoring.

NEW PROVIDER ORIENTATION

New Title III funded providers will be required to participate in Provider Orientation sessions at the BHRC office. These sessions will include an overview of contracting, reporting, monitoring and basic skills in using the SAMS database application. Schedule to be determined.

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REQUEST FOR PROPOSAL REQUIREMENT EXHIBITS AND FORMS

EXHIBITS

Introduction Agency Authorization to Submit Certification Terms and Conditions General Assurance Status of Pending Litigation Declaration Regarding Material Assistance/Non-Assistance to a Terrorist Organization Certification for Contracts, Grants, Loans and Cooperative Agreements Assurances of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended Assurance of Compliance under Title VI of the Civil Rights Act of 1964 Organizational Narrative Certification of Organizational Documentation Organizational Chart Articles of Incorporation and Certificate of Continuing Existence Social Services Information (submit one for each service) Nutrition Services Home-Delivered Meals Nutrition Services Congregate Meals Minority Agency Certification Proof of Insurance Policy and Procedure for Filing Insurance Claims Grievance Policy Emergency Plan Proof of Registration with the Secretary of State as a Non-Profit or For-Profit Business Current Annual Report Most Recent Audit or Financial Statement IRS W-9 Form 2018-19 Title III Proposal Workbook

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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;

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

To respond to the questions in this application, click inside the text box (where applicable) and begin typing.

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

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AGENCY AUTHORIZATION TO SUBMIT CERTIFICATION FORM

AGENCY: ____________________________________________We, the undersigned certify that all

information (including funding levels) is true to the best of our knowledge.

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

_ Click here to enter text. (NAME OF GOVERNING BOARD) during a meeting held: __ Click here to enter text. (DATE OF MEETING)

Should this agency receive the funding applied for, we will fulfill the intent of the application.

We further understand that additional documentation will be required after funds are awarded and agree to

comply with BHRC requirements regarding it.

President, Governing Board: Click here to enter text.

Signature of President

Director of Agency: Click here to enter text.

Signature of Director:

Date: ________________________

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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 the 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 BHRC 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 the BHRC shall be deemed incorporated into and become part of this Agreement.

Funds awarded by the 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

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TYPED ADDRESS OF AUTHORIZED SIGNATORY

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GENERAL ASSURANCE FORM

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 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 ODA/ BHRC Conditions of Participation, which focus on agency operations and client care. Conditions of Participation are found in the Appendix.

3. It shall comply with Service Specifications for the following services: Congregate Meal Service, Home Delivered Meal Service, Nutrition Education and Nutrition Education, Nutrition Health Screening Program, Personal Care Service, Homemaker Service, Transportation Service and Legal Assistance. 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 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.

NAME OF APPLICANT AGENCY (TYPE)

SIGNATORY NAME (TYPE) TITLE OF SIGNATORY (TYPE)

SIGNATURE OF AUTHORIZED OFFICIAL DATE

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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.

Please attach signed form here

DECLARATION REGARDING MATERIAL ASSISTANCE/ NON-ASSISTANCE TO A TERRORIST ORGANIZATION

This is a PDF document. Please obtain this form by clicking on the link below.

http://www.publicsafety.ohio.gov/links/hls0038.pdf

Please attach signed form here.

http://www.publicsafety.ohio.gov/links/hls0038.pdf

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CERTIFICATION FOR CONTRACTS, GRANTS, LOANSAND COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief that:

1. No federal appropriated funds have been or will be paid, by or on behalf of the undersigned to any person for influencing or attempting to influence an officer or employee of this agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement.

2. If any funds other than federally-appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit the form, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

3. The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

STATEMENT FOR LOAN GUARANTEES AND LOAN INSURANCE

The undersigned states, to the best of his or her knowledge and belief, that if any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress in connection with this commitment providing for the United States to ensure or guarantee a loan, the undersigned shall complete and submit the form, “Disclosure Form to Report Lobbying”, in accordance with its instructions.

Submission of this statement is a pre-requisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.

Signature, Agency Director Date

Signature, Chair of Board of Directors Date

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DEPARTMENT OF HEALTH AND HUMAN SERVICES ASSURANCES OFCOMPLIANCE WITH SECTION 504 OF THE REHABILITATION ACT OF 1973,

AS AMENDED

The undersigned (hereinafter called the “recipient”) HEREBY AGREES THAT it will comply with Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by the applicable HHS regulation (45 C.F.R. Part 84), and all guidelines and interpretations issued pursuant thereto.

Pursuant to §84.5(a) of the regulation [45 C.F.R.84.5(a)], the recipient gives this Assurance in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts (except procurement contracts and contracts of insurance or guaranty), property, discounts, or other federal financial assistance extended by the Department of Health and Human Services after the date of this Assurance, including payments or other assistance made after such date on applications for federal financial assistance that were approved before such date. The recipient recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this Assurance and that the United States will have the right to enforce this Assurance through lawful means. This Assurance is binding on the recipients, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this Assurance on behalf of the recipients.

This Assurance obligates the recipient for the period during which federal financial assistance is extended to it by BHRC through the Department of Health and Human Services or, where the assistance is in the form of real or personal property, for the period provided for in §84.5(b) of the regulation [45 C.F.R.84.5(b)].

The recipient [check (a) or (b)]:

a. employs fewer than fifteen persons;b. employs fifteen or more persons and, pursuant to §84.7(a) of the regulation [45

C.F.R.84.7(a)], has designated the following person(s) to coordinate its efforts to comply with the Health and Human Services regulations:

Name of Designee: Click here to enter text.

Name of Recipient: Click here to enter text.

Address: Click here to enter text.

IRS Employer Identification Number: Click here to enter text.

I certify that the above information is complete and correct to the best of my knowledge.

Title: Click here to enter text.Signature of Authorized Official

Date:

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ASSURANCE OF COMPLIANCE WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES REGULATION UNDER

TITLE VI OF THE CIVIL RIGHTS ACT OF 1964

Organization Name: Click here to enter text.

hereinafter called the “sub-grantee”, HEREBY AGREES THAT it will comply with Title VI of the Civil Rights Act of 1964 (P.L.88-352) and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 80) issued pursuant to that title, to the end that, in accordance with Title VI of that Act and Regulation, no person in the United States shall, on the ground of race, color, or national origin, be denied the benefits of or be otherwise subjected to discrimination under any program or activity for which the Sub-grantee receives federal financial assistance from BHRC, a recipient of federal financial assistance from the Department (hereinafter called the “Grantor:); and HEREBY GIVES ASSURANCE THAT is will immediately take any measures necessary to effective this agreement.

If any real property or structure thereon is provided or improved with the aid of federal financial assistance extended to the Sub-grantee by the Department this assurance shall obligate the Sub-grantee, or in the case of any transfer of such property, and transferee, for the period during which the real property structure is used for a purpose for which the federal financial assistance is extended or for another purpose involving the provision of similar services of benefits. If any personal property is so provided, this assurance shall obligate the Sub-grantee for the period during which it retains ownership or possession of the property. In all other cases, this assurance shall obligate the Subgrantee for the period during which the federal financial assistance is extended to it by the Grantee.

THIS ASSURANCE is given in consideration of and for the purpose of obtaining any and all federal grants, loans, contracts, property, discounts or other federal financial assistance extended after the date hereof to the Sub-grantee by the Grantor, including installment payments after such date on account of applications for federal financial assistance which were approved before such date. The sub-grantee recognizes and agrees that such federal financial assistance will be extended in reliance on the representations and agreements made in this assurance, and that the Grantor or the United States or both shall have the right to seek judicial enforcement of this assurance. This assurance is binding on the Sub-grantee, its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Subgrantee.

Applicant Name: Click here to enter text.

Mailing Address: Click here to enter text.

Title of Authorized Official: Click here to enter text.

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Signature of Authorized Official: Date:

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ORGANIZATIONAL NARRATIVE

ORGANIZATION NAME: Click here to enter text.

Administrative Description

1. Describe the type of organization applying to serve as the legally-responsible sponsor of this grant.

Click here to enter text.

2. Describe the relationship between the sponsor and the applicant program, if applicable.


3. Describe the applicant’s service area.


4. List all services or programs currently offered by your agency/organization regardless of whether they are funded by BHRC.


Agency Capacity for Delivering the Proposed Services

5. Describe the organization’s experience in administering public funds.


6. Given the limits of federal funding, how has your organization obtained local financial and community support for your services?


7. Does your agency currently meet requirements for United Way, Community Block Grant or Title XX funds? If no, explain.


Do you receive any of these funds?


What services do they fund?


Explain if these funds have been lost and why.


8. If local cash is provided in full or in part by local levy funds, provide the following information:

a) yearly amount of levy revenues by dollar and millage amount; Click here to enter text.

b) time span covered by the levy; Click here to enter text.

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c) next expiration date-month and year; d) plans for renewal, if any.


9. Does your organization have experience in GAP (General Accounting Procedures) for fiscal management? Explain.


If no, what accounting method do you utilize?


10. Describe specific efforts to be made by the applicant to increase usage of your agency services by:

a) geographically-isolated elders;


b) minority elders;


c) low-income elders; and


d) elders with limited English-speaking ability.


11. Describe efforts to provide outreach and communicate aging services information to older adults who are lesbian, gay, bisexual or transgender (LGBT).


12. Describe your organization’s program management capacity.


Does your organization currently provide the services you have applied for with any other funds?


13. Describe your organization’s method or plan to monitor the proposed services or obtain client satisfaction feedback.


What has your agency done in the last year to address the issue? Please provide results of your surveys.


14.Describe any future plans for expansion or anticipated change in service delivery.


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CERTIFICATION OF ORGANIZATIONAL DOCUMENTATION

The applicant organization hereby verifies that the following documentation is on file for review by the BHRC, in accordance with the Ohio Department of Aging Conditions of Participation (check all that apply):

Corporate By-laws

Workers’ Compensation Certificate

Bond Certificate and list of individuals who are bonded by the agency

Medicare/Medicaid Provider Agreement Letters, if applicable

If the agency is for-profit, a copy of the latest tax return - 1120 If the agency is non-profit, a copy of the latest tax return - 990

Personnel Policy and Procedure Manual

Affirmative Action/Equal Opportunity Plan

Program/Operational Policy and Procedure Manual

Job Descriptions for positions related to service delivery

Documented training(s) for positions related to service delivery

Signature, Executive Director Date

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ORGANIZATIONAL CHART

Please attach a copy of your Agency Organizational Chart as it relates to your application.

ARTICLES OF INCORPORATION AND CERTIFICATE OF CONTINUING EXISTENCE

Please attach a copy of your Articles of Incorporation AND a copy of your Certificate of Continuing Existence.

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SOCIAL SERVICES INFORMATION


SERVICE: Click here to enter text.

(Add a separate page for each service applying for.)

Answer each question completely. Explain the service as if describing it for the first time.

1. Describe how the applicant will deliver this service, including:

a) activities to be performed; Click here to enter text.

b) schedule/frequency of each client receiving services; Click here to enter text.

c) criteria for receiving services/methods of prioritizing;


d) waiting list size/average length of wait; Click here to enter text.

e) townships served/not served; Click here to enter text.

f) areas to which service will be expanded. Click here to enter text.

g) if providing transportation services will you be providing in county one way trips? Where do you transport consumers to?Click here to enter text.

h) If providing transportation services will you be providing out-of-county medical transportation? What areas out of your county will you travel to for out-of-county transportation?Click here to enter text.

Remember to include Route Maps if applying for transportation service.

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2. List other agencies or organizations that provide this general service in your service area.


3. All services are defined by Ohio Administrative Code rule. Describe how the rule definition is currently being met or NOT MET.


If not met, describe what you will do in 2018-2019 to better this standard.


4. Explain the need for this service in your area, and how you will make seniors aware of its availability.


5. Describe your method (and most recent results) for evaluating consumer satisfaction with the proposed service.


6. Describe your agency’s internal quality assurance system for this system (beyond customer satisfaction surveys). Speak to supervisor oversight, required/optional training, documentation/forms utilized, etc.


7. Describe how you will encourage clients to provide project income to expand this service.


8. Describe any plans for expansion of this service.


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NUTRITION SERVICES – HOME-DELIVERED MEALS

Successful applicants for nutrition programs must have an approved Food Service License from the county in which they will provide service, and provide a copy to BHRC. Copies of the Food Service License must be included with the bid packet.

In addition, successful nutrition applicants must provide proof that an adequate number of employees have obtained ServSafe Certification to ensure there is a ServSafe-certified employee in the kitchen at all times. Copies of ServSafe certificates must be included with the bid packet.


1. Describe your agency’s meal transportation system, including: a description of all hot and cold packaging, transport containers and vehicles used.


2. Describe how you test and record end temperatures of a home-delivered meal, including: personnel that will be responsible, how personnel will be trained, and frequency of testing.


3. If you plan to distribute frozen home-delivered meals, please describe in detail your process for meal provision (i.e., purchasing from an approved vendor, self-producing, etc.).


If self-producing, describe steps by which that process is completed, including all equipment utilized.


4. Describe how you meet all the requirements, including qualifications of internal personnel responsible for food service monitoring/inspection, and include copies of all monitoring/inspection tools that are used for documentation.


5. Describe in detail how your individualized delivery system will be organized and function. Please include any circumstances that do not allow you to individualize for certain clients and/or delivery patterns.


6. Provide current waiting list size and average length of wait time. Is waiting list in SAMS?


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7. If you are a current provider of home-delivered meals, please attach your 2017 completed documentation of community referrals for consumers with nutritional high-risk. If you are not a current provider, please explain the process by which you will track referrals to community-based organizations (i.e., JFS, food banks, soup kitchens, etc.) for individuals who are at high nutrition risk.


8. Describe specific geographic areas served and not served (i.e., township, city, county). Individually list townships served with the county, and areas to which services will be expanded. (Remember to include Map of Home-Delivered Meal Routes.)Click here to enter text.

9. List other agencies or organizations that provide this service in your service area.


10. This service is defined by Ohio Administrative Code rule. Describe how the rule is currently being met or NOT being met. If not being met, describe what you will do in 2017-2018 to meet the standard.


11. Per ODA Rule 173-4-08 Nutrition providers are required to provide nutrition education. The service must include a method for participants to evaluate the education received. Please describe your method for providing this service.


12. Describe your methods and most current results (other than surveys) for evaluating consumer satisfaction with the proposed service.


13. Describe how you will encourage consumers to provide project income to expand this service.


14. Describe any anticipated plans for expansion or service delivery change(s).


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NUTRITION SERVICES INFORMATION-CONGREGATE MEALS

Successful applicants for nutrition programs must have an approved Food Service License from the county in which they will provide service, and provide a copy to BHRC. Copies of the Food Service License must be included with the bid packet.

In addition, successful nutrition applicants must provide proof that an adequate number of employees have obtained ServSafe Certification to ensure there is a ServSafe-certified employee in the kitchen at all times. Copies of ServSafe certificates must be included with the bid packet.


1. If satellite congregate meal sites are part of your service delivery, describe your agency’s meal transportation system, including: a description of all hot and cold packaging, transport containers and vehicles to be used.


2. Describe how you will test and record end temperatures of congregate meal site foods, including: personnel that will be responsible, and how personnel will be trained to perform this function.


3. Describe how you will meet all the requirements, including qualifications of internal personnel responsible for food service monitoring/inspection. Include copies of all monitoring/inspection tools that will be used for documentation.


4. Describe in detail how your individualized delivery system will be organized and function. This includes methods used at both the main congregate site and satellite sites.


5. Do you maintain a waiting list for congregate meal participation? If yes, how many are currently on the list and what is the average length of wait? Is the waiting list documented in SAMS?


6. Describe specific geographic areas not served by a congregate meal site. Are any other meal services available to those areas?


7. List other agencies or organizations that provide this service in your service area.

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8. This service is defined by Ohio Administrative Code rule. Describe how the rule is currently being met or NOT being met. If not met, describe what you will do in 2017-2018 to better meet this standard.

Click here to enter text.9. Describe how you will encourage clients to provide project income to expand this service.


10. Describe your reservation system.


11. Per ODA Rule 173-4-08 Nutrition providers are required to provide nutrition education. The service must include a method for participants to evaluate the education received. Please describe your method for providing this service.


12. List the physical address, site manager name, phone number, fax number, e-mail address and meal service time for all congregate sites.


13. Describe any anticipated plans for expansion or change in service delivery.


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MINORITY AGENCY CERTIFICATION(complete ONLY if applicable)

(This information is required by ODA and does not affect the status of the proposal)

Name of Agency/Organization: Click here to enter text.

Mailing Address: Click here to enter text.

City, State, Zip: Click here to enter text.

The above-identified Agency or Organization certifies that it is a minority organization based upon meeting the following criteria (check one):

☐ 1. Private Profit-Making Agency/Organization

☐ a. An organization whose sole ownership, or 50.1%, of whose stock is held by minorities.

☐ b. A partnership with at least 50% of the interest in the partnership controlled by a minority individual.

The ownership is as follows: Click here to enter text.

☐ 2. Non-Profit Agency/Organization (public or private)

☐a. The make-up of the board of directors/policy-making body is at least 50.1% Minority, AND

☐b. The total staff is at least 50% minority.

Signature of President or Chairman of the Board/Owner/Partner Date

Name and Title of Signatory: Click here to enter text.

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PROOF OF INSURANCE

Please enclose a copy of the page of your Insurance Policy which shows commercial liability coverage in the minimum amount of $1,000,000 (one million) per occurrence.

Please DO NOT submit your entire insurance policy.

POLICY/PROCEDURE FOR FILING INSURANCE CLAIMS

Please include your written policy and/or instructions which you provide to consumers that explains to them how they can file an insurance claim.

GRIEVANCE POLICY

Please attach a copy of your organization’s Grievance Policy. Include all forms utilized in this process.

EMERGENCY PLAN

Please attach a copy of your organization’s Emergency Plan.

PROOF OF REGISTRATION WITH THE SECRETARY OF STATE AS A NON-PROFIT ORGANIZATION OR AS A FOR-PROFIT BUSINESS

Please attach a copy of proof of registration with the secretary of state as a non-profit organization or as a for-profit business

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CURRENT ANNUAL REPORT

Please attach a copy of your organization’s Current Annual Report.

MOST RECENT AUDIT OR FINANCIAL STATEMENT

Please attach a copy of your organization’s most recent Audit or Financial Statement.

IRS W-9 FORM

Please complete and attach the IRS W-9 form with your organization’s information.

https://www.irs.gov/pub/irs-pdf/fw9.pdf

2018-19 Title III PROPOSAL WORKBOOK

Please find the 2018-19 Title III Proposal Workbook at www.buckeyehills.org


https://www.irs.gov/pub/irs-pdf/fw9.pdf

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