Nutrition Services

Attachment 1

By signing below, the Organization agrees:

To certify that your organization has supplied the Aging Commission of the Mid South with the reasonable, usual and customary charges that your organization would charge other organizations/persons regardless of whether the organization/person is participating or enrolled in services authorized through the Aging Commission of the Mid South.

To certify that your organization shall notify the Aging Commission of the Mid South of any changes to the usual and customary charges and that your organization’s usual and customary charges will be provided on request.

The Organization’s Usual and Customary Rates

Frozen/Shelf Stable Meal $_________ per meal

Hot Home Delivered Meal $_________ per meal

Congregate Meal $_________ per meal

Nutritional Counseling $_________ per hour

Nutritional Education $_________ per hour

Rates Charged to the Aging Commission of the Mid South

Frozen/Shelf Stable Meal $_________ per meal

Hot Home Delivered Meal $_________ per meal

Congregate Meal $_________ per meal

Nutritional Counseling $_________ per hour

Nutritional Education $_________ per hour

________________________________

Name of Applicant Organization

________________________________ ______________________

Name and Title of Authorized Signature Date

REQUEST FOR APPLICATION OF PROPOSAL APPLICATION (RFPA)

TO DELIVER

NUTRITION SERVICES

Applicant Organization Name:
Mailing Address:
Office Address:
Contact:
Name & Title
E-Mail Address:
Telephone:       .	Fax:
Emergency Contact (Name & #):
Date of Application:

COVER LETTER

Cover Letter – At a minimum, this letter must include the following:

• A statement that the accompanying application is in response to this RFPA.

• A statement that the applicant is willing, if selected, to execute a contract with the Area Agency on Aging and Disability (AAAD).

• A statement identifying the individual(s) authorized to finalize a contract with the AAAD on behalf of the Applicant.

ORGANIZATIONAL STRUCTURE AND INFORMATION

Please provide a W-9

Please identify the organizational structure of the applicant’s governing body.

Individual (sole proprietorship)

Partnership

Non-Profit Corporation

For-Profit Corporation

State University

Other (explain)

Please indicate the status of your agency (check all that apply):

minority owned/operated small business none of the above

women owned/operated faith-based organization

History/Organizational Capacity

History: (Provide a brief history of the organization and its service delivery system for proposed Nutrition Services.)

Governing Body: (Describe structure and responsibilities. Provide a list of the present membership of the Board of Directors or other governing body of the applicant. The list must include each member’s name, address, sex, race and whether he or she is a person with a disability. Also include the method used for selecting and replacing board members.)

Organizational Chart: (For overall agency and single organization unit responsible for delivering proposed service(s).)

Experience: (Describe within two pages organizational experience in working with older persons and/or adults with disabilities. Include the number of years in business.)

Mission & Values: Briefly describe the approach and plans for service implementation, including:

Mission Statement

Values and/or guiding principles

Personnel:

Identify the key personnel who will be involved with the program. Please make available upon request a resume for each of the key personnel.

Identify the supervisory structure related to proposed service delivery.

Describe the qualifications and required competencies for people who will serve as direct service workers. Include job descriptions.

Include the proposed training approaches and curriculum to be used to keep staff current in-service delivery and best practices in services and supports.

Financial Capacity: Provide Copies of the Following:

Most recently completed audited financial statements of submitting organization. The audited financial statement is preferable; however, if an organization does not have this information, IRS tax reporting forms / tax return is appropriate for the submitting organization.

A copy of the organization’s business status must be attached (i.e., 501(c), Business License, etc.)

A copy of a valid certificate of insurance indicating liability insurance in an amount sufficient to cover any potential liability arising as a result of a contract pursuant to this RFPA must be attached

A copy of the verification of Workers Compensation Insurance.

Copies of current signed site agreements or sight agreement template to be used for each location [congregate, satellite, and kitchen(s)].

If an audited financial statement is available, do not complete numbers 6 and 7.

A current written bank reference, in the form of a standard business letter, indicates that the applicant's business relationship with the financial institution is in positive standing.

Two current written positive credit references in the form of standard business letters from vendors with which the applicant has done business, or documentation of a positive credit rating determined by an accredited credit bureau within the last 6 months.

Organizational Conduct: (Answer each question):

Has the organization and/or any of the organization’s employees, agents, independent contractors been convicted of, pled guilty to, or pled no contest to any contracted crime involving a public contract?       (If the answer is yes, attach an explanation)

Has the organization and/or any of the organization’s employees, agents, independent contractors been convicted of, pled guilty to, or pled no contest to a felony?       (If the answer is yes, attach an explanation)

Has the organization and/or any of the organization’s employees, agents, independent contractors been civilly liable in an action that involved fraud, misrepresentation, material omission, misappropriation, moral turpitude, theft, or conversion?       (If the answer is yes, attach an explanation)

Has the organization and/or any of the organization’s employees, agents, independent contractors been relieved of responsibility by a court, employer, or client for actions involving fraud, misrepresentation, material omission, misappropriation, moral turpitude, theft, or conversion?       (If the answer is yes, attach an explanation)

Is your organization currently under Federal or State debarment?      

ASSURANCES & CERTIFICATIONS

By signing this application, the Applicant agrees:

• To certify that, under penalty of perjury, your provider organization has completed this Provider Application independent of any outside influence which may result in your receiving privileged information about this RFPA.

• To certify that this RFPA factually represents your administrative capabilities and proposed services, and that if your organization is approved, you agree to abide by the terms and conditions of the Provider Contract.

• To certify that if your organization is approved, you agree to contract with the AAAD for services at your usual and customary charges not to exceed the maximum charges outlined in Section V of this provider application.

• To certify that your organization is following the specific Service Description and Standards required by the State for each proposed service activity.

• To certify that your organization has written policies regarding the following:

• Personnel Policies including employee health/sick leave policy, safety and sanitation, fiscal management, food service management, and food recalls.	• Affirmative Action Policy
• Non-discrimination in Hiring Policy	• Confidentiality Policy
• Non-discrimination in Service Delivery Policy	• Civil Rights Compliance Policy (Title VI and VII)
• ADA Compliance Policy	• Certification Regarding Lobbying
• Drug Free Workplace Policy

• To certify that your organization has secured all required licenses, certifications, permits and accreditation (as required by the State and/or Federal governments). Attach copies including a copy of the most recent compliance report from the Department of Health or other regulatory entity.

IV. SERVICE DELIVERY

1. Describe and specify the availability of funds to support the cost of providing services to ensure service delivery continues throughout the contracted period and continuation of services occurs until reimbursement of services is made.

2. Describe your agency’s plan regarding weather-related emergencies. Include the following information:

• Conditions under which the agency will be closed.

• Describe weather related emergency plans to ensure elderly clients receive services they need during emergency situations. Submit name of contact persons.

• Plan for receiving emergency calls for assistance.

3. Describe and include procedures for internal monitoring and assessment. Detail how internal monitoring reports will be submitted to the AAAD when completed. The Internal monitoring should be attached to this RFP and include:

• Service to be monitored and evaluated

• Name of the person or position responsible for monitoring and evaluating each service.

• Procedures for corrective action or follow-up

• A copy of the internal monitoring tool (s) to be used.

4. Ensure compliance with Background Records Checks on employees having contact with consumers.

5. Explain the organization’s policy process for conducting Customer Satisfaction Surveys and attach the results of your most recent Customer Satisfaction Survey Report showing the percentage of satisfied customers for the period.

6. Describe how information on program income and donations will be provided to program participants and other interested parties. Include a description of procedures and mechanisms for collection, use and management of program income and donations. All donations must be accounted for and submitted to the AAAD as designated.

7. Congregate sites: Describe the accessibility features of the facility for people with disabilities. Each Service/Program Venue and collaborating agencies and/or sites shall meet accessibility requirements as prescribed by the Older Americans Act, state and local government. Narrative description and, if necessary, applicable attachments must demonstrate compliance.

8. Provide documentation demonstrating compliance with local health department and safety codes (sanitation and fire) for each Service/Program venue as applicable. Submit annual health and fire inspections for your facility.

9. Congregate Sites: Include fire safety policies and procedures for each Service/Program Venue. Fire safety procedures should include fire drills, safety inspections, maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. If not indicated in policies and procedures, validate that fire safety information is posted in the facility.

10. Describe the complete food preparation, operation and delivery system for each type of meal being proposed.

11. How are frozen meals stored packed and delivered?

12. How does the agency ensure that frozen meals comply with the published menus?

13. Types of containers used for packaging (attach descriptions)

14. Freezing Times:

a. Cooked potentially hazardous foods shall be cooled:

• Within 2 hours from 135 degrees to 70 degrees F and within a total of 6 hours from 135 degrees to 41 degrees f or less

b. Potentially hazardous food shall be cooled:

• Within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna.

15. Identify the equipment used to rapidly freeze the food and length of time that frozen meals will be stored before delivery.

16. Provide a detailed description of why frozen meals are being proposed for utilization.

a. Administrative Reason

b. Cost Effectiveness – will meals that are delivered in bulk have a lower unit cost vs. hot meals delivered daily?

c. Percentage of Frozen meals to be provided.

17. How will your agency plan to ensure that participants have meals in emergency situations?

18. If Shelf Stable Meals are utilized, how and when will they be distributed to clients?

19. Please provide 3 Shelf Stable Meal Menus as well as the Nutrient Analysis for each of the menus.

20. Indicate the type(s) of therapeutic meals (diabetic, pureed, low sodium, etc.) you can prepare.

21. Submit the name of the RD / ICE that the program will utilize and submit a copy of the Licenses and Certification, which includes the Licensed/Certification numbers.

22. Describe how your agency will continue to provide services if unusual circumstances arise such as several van drivers resign at one time or become ill, or your agency is unable to employ and train new people in a timely manner to provide services.

23. Describe how your agency will utilize NSIP funds to purchase United States agricultural commodities and other foods of United States Origin. NSIP payments may be applied toward meal purchases provided each such meal contains United States commodities or food equivalent in value to the cash payment per meal disbursed.

24. Describe how your agency will assess the following outcomes as it relates to congregate meals:

• 100% of Congregate Meal Participants will receive nutrition screening and nutrition education.

• Congregate Meal Clients identified with a Nutritional Risk will receive appropriate follow-up.

• Nutrition education will be provided at the nutrition site monthly.

• 100% of meal plans will meet the most recent Dietary Guidelines and Dietary Reference Intakes.

• Nutrition sites maintain current inspections required of their facility.

• Provide meals to senior centers according to their regular serving schedules.

• Meal temperatures of foods will be taken and recorded daily in the kitchen and again at the nutrition site upon arrival and before being served. These temperatures are to be kept on file in the respective nutrition site for monitoring purposes

25. Describe how your agency will assess the following outcomes as it relates to home delivered meals:

• 100% of Home Delivered Meal Temperatures will remain at the appropriate levels upon delivery.

• 75% of Home Delivered Meal clients will report on a satisfaction survey that the Home Delivered Meal they receive allows them to have at least one nutritionally based meal per day.

• Meals will be provided to homebound participants in case of an emergency.

• 100% of meals will be delivered within two (2) hours from the end of preparation to the destination.

V. PROPOSE SERVICE UNIT REIMBURSEMENT RATE

In order to be approved as a Service Provider, the applicant must provide a unit rate for each service proposed.

For each of the categories on which you are bidding (congregate, home delivered, frozen, and emergency), provide the following information:

	Congregate	Home Delivered	Frozen	Emergency
Food Cost:
Labor Cost:
Equipment Cost:
Utility Cost:
All Other Cost:
Delivery Cost (if applicable):
Total Cost per meal:

AUTHORIZATION FOR SUBMISSION

On this the	________________________________	day of	_________________________	, 20__,
{Name of Applicant Organization)	Is submitting this application to become an approved provider
Executive Director / CEO / President Applicant Organization		Date
Chairman, Governing Body		Date