competitive model rfp without instructions

Federally Qualified Health Center

Incubator Program Community Grants

Texas Primary Care Office Website: http://www.dshs.state.tx.us/chpr/

RFP #: CSH/FQHC- 0150.1

Published April 25, 2005

Letters of Interest Due May 6, 2005(Requested but not required)

Applications Due 2:00 p.m., May 27, 2005

1100 W. 49th Street Austin, Texas 78756-3199

Eduardo J. Sanchez, M.D., M.P.H.

Commissioner

FQHC Incubator Program RFP FY 2006

TABLE OF CONTENTS

INFORMATION............................................................................................................... 5

I. INTRODUCTION................................................................................................... 5 A. Eligible Applicants................................................................................... 6 B. Project and Budget Periods............................................................... 10 C. Use of Funds ........................................................................................... 13 D. Schedule of Events................................................................................ 13

II. PROGRAM INFORMATION ............................................................................... 14 A. General Purpose and Program Goals.................................................. 14 B. Background............................................................................................ 16 C. Legal Authority ...................................................................................... 18 D. Project Development ............................................................................. 18 E. Program Requirements ......................................................................... 19 F. DSHS Contact ........................................................................................ 19 G. DSHS Applicant Conference................................................................. 20

III. APPLICATION DEADLINE AND SUBMISSION ................................................ 20 A. Application Deadline ............................................................................. 20 B. Submission ............................................................................................ 20

IV. APPLICATION REVIEW, SELECTION & NEGOTIATION................................. 21 A. Screening Process ................................................................................ 21 B. Evaluation Process................................................................................ 22 C. Evaluation Criteria ................................................................................. 22 D. Selection and Negotiation..................................................................... 25

V. DSHS ADMINISTRATIVE INFORMATION......................................................... 26 A. Incurring Costs and Rejection of Applications................................... 26 B. Right to Amend or Withdraw RFP........................................................ 26 C. Authority to Bind DSHS ........................................................................ 26 D. Contracts with Sub-contractors ........................................................... 26 E. Historically Underutilized Business (HUB) Participation................... 27 F. Contract Information ............................................................................. 35 G. Contract Award Protest Policy ............................................................. 36

CONTENT AND PREPARATION ................................................................................. 36

VI. APPLICATION CONTENT.................................................................................. 36 A. Instructions for Preparation ................................................................. 36 B. Confidential Information ....................................................................... 36 C. Table of Contents .................................................................................. 37 USE THE APPLICATION’S FORM B AS THE GUIDE FOR ORGANIZATION

AND ARRANGING THE TABLE OF CONTENTS.................................. 37 VII. BLANK FORMS AND INSTRUCTIONS ............................................................. 37

FORM A: FACE PAGE – Application for Financial Assistance- RFP# CHS/FQHC-0150.1.................................................................................. 39

FORM A: FACE PAGE Instructions.................................................................. 40 FORM B: APPLICATION CHECKLIST .............................................................. 41


FORM B-1: HUB CHECK LIST........................................................................... 43 FORM C: CONTACT PERSON INFORMATION ................................................ 44 FORM D: ADMINISTRATIVE INFORMATION ................................................... 45 FORM E: SITE INFORMATION.......................................................................... 47 FORM F: FUNDING INFORMATION.................................................................. 48 FORM F a PROJECT ABSTRACT..................................................................... 49 FORM G: APPLICANT BACKGROUND............................................................ 50 FORM H: ASSESSMENT NARRATIVE ............................................................. 51 FORM H: ASSESSMENT NARRATIVE Guidelines .......................................... 52 FORM I: FQHC COLLABORATION NARRATIVE............................................. 53 FORM J: FQHC FUNDING FEASIBILITY NARRATIVE .................................... 54 FORM J a FUNDING FEASIBILITY CHECKLIST .............................................. 55 FORM J b: SERVICES PROVIDED FY 05 & PROPOSED FY 06 ..................... 58 FORM J c: STAFF PROFILE.............................................................................. 59 FORM J d: HEALTH CENTER AFFILIATION CHECKLIST .............................. 60 Form J e: CURRENT PATIENT POPULATION AND REVENUE INFO ............ 63 FORM K: SUSTAINABILITY NARRATIVE ........................................................ 65 FORM K a: SUSTAINABILITY: EXPENDITURE AND PROJECT BUDGET

REPORT.................................................................................................. 67 FORM L: PERFORMANCE MEASURES........................................................... 69 FORM M: DELIVERABLES AND PAYMENT SCHEDULE Instructions .......... 87 FORM N: DSHS GRANT/CONTRACT APPLICANTS HUB ATTACHMENTS ..90 Form N-1 HUB Subcontracting Plan................................................................ 93 Form N-2: HUB Subcontracting Plan (HSP) .................................................. 100 Prime Contractor Progress Assessment Report.......................................... 100 Form N-3: Self Performance........................................................................... 101 HUB Subcontracting Plan (HSP) .................................................................... 101 FORM O: NONPROFIT BOARD OF DIRECTORS AND EXECUTIVE

DIRECTOR ASSURANCES FORM ...................................................... 102 FORM P: CURRENT BOARD OF DIRECTORS CHARACTERISTICS*.......... 103 APPENDIX A DSHS ASSURANCES AND CERTIFICATIONS ....................... 104 APPENDIX B STANDARDS FOR EVIDENCE OF........................................... 109 COMPLETED DELIVERABLE.......................................................................... 109 APPENDIX C CONTACT AND REFERENCE INFORMATION........................ 120 APPENDIX D BPHC POLICY INFORMATION NOTICE 98-23........................ 121 APPENDIX E 200 POOREST COUNTIES........................................................ 146


INFORMATION

I. INTRODUCTION

The Texas Department of State Health Services (DSHS) Texas Primary Care Office (TPCO) announces the expected availability of fiscal years (FY) 2006-2007 General Revenue to provide funds to support the development of Federally Qualified Health Centers (FQHCs) through four components described in A. Eligible Applicants:

1. Planning Grants 2. Development Grants 3. Transitional Operating Support (TOS) Grants 4. Capital Improvement Grants

Eligible applicants may submit a single proposal requesting funding for one component listed above, or a single proposal for one of the combinations listed below : Planning and Development Grants Development and Transitional Operating Support (TOS) Grants TOS and Capital Improvement Grants

Current FQHC Incubator grantees may be eligible to apply for this funding. However, there are changes in the total amount of funds that can be requested by a current or previous FQHC Incubator grantee. An organization designated as a FQHC in fiscal years 2004 or 2005 is eligible to apply for FQHC Incubator Program funds only if the organization is eligible for the federal application, New Access Point (NAP), Expanded Medical Capacity (EMC), or Services Expansion-Oral Health and/or Mental Health and Substance Abuse for which it intends to apply. TPCO will use the most recent federal guidance (FY 2005 Policy Information Notices) as a reference for applicant eligibility. Organizations that will be designated as a FQHC on or before December 1, 2005 are eligible to apply for FQHC Incubator Program grants. Although not required, DSHS is requesting that interested applicants send an e-mail indicating their interest in applying for FQHC Incubator Funds. This letter of interest needs not include potential program designs or the amount of funding sought. The Letter of Interest will not factor into the evaluation process, but will be used to ensure a timely review and evaluation process. Please e-mail Letter of Interest by May 6, 2005:

[email protected]

mailto:[email protected]


This Request for Proposal (RFP) contains the requirements that all applicants must meet to be considered for funding. Failure to comply with these requirements will result in disqualification of the applicant without further consideration. Each applicant is solely responsible for the preparation and submission of an application in accordance with instructions contained in this RFP. Before completing the application, refer to any relevant program standards provided in SECTION II. PROGRAM INFORMATION. Other sections within the RFP may contain additional instructions pertaining to unique program requirements set forth in legislation or regulations. Definitions for grant contract terms used in this document are located at: http://www.tdh.state.tx.us./grants/faq.htm#Definitions. PLEASE READ THIS RFP COMPLETELY BEFORE PREPARING YOUR APPLICATION.

A. Eligible Applicants

Eligible applicants include public and private non- profit entities, but more specific eligibility criteria applicable for each FQHC Incubator Component are detailed below. If applicant is currently debarred, suspended, or otherwise excluded or ineligible for participation in Federal or State assistance programs, applicant is ineligible to apply for funds under this RFP. Grant funds will not be awarded to fund organizations that cannot or choose not to meet the requirements of Federally Qualified Health Centers (FQHC) as outlined in Public Health Service Act, Section 330, Public Law 104-299, codified as 42 U.S.C. 254b et seq., or the Bureau of Primary Health Care’s Program Information Notice 98-23 (hereinafter referred to as “PIN 98-23”- see APPENDIX D for a copy of PIN 98-23) and any other policy or statutes relating to FQHCs as determined by DSHS. DSHS may fund an organization while the organization is in the process of complying with the above statutes and policies as long as the organization provides verifiable evidence of its intent and progress in complying with the required statutes and policies. DSHS will make the final determination of an organization’s ability and intent to comply with the required statutes and requirements. The FQHC Incubator Program is comprised of four components:

1. Planning Grants 2. Development Grants 3. TOS Grants 4. Capital Improvement Grants

The eligibility criteria become more restrictive with each component. With the exception of organizations applying only for Planning Grants, all or part of the applicant’s target area or population must be designated as a Medically Underserved Area or Population (MUA/P). As grantees move from one


component to the next, the organizations should increasingly resemble a FQHC. All applicants must meet the eligibility criteria outlined in each component described below.

All applicant organizations must fall into one of three organizational categories:

• a currently-designated FQHC or Federally Qualified Health Center Look-Alike

(FQHC-LA); • an Internal Revenue Service (I.R.S)-designated non-profit 501(c)(3)

organization, including but not limited to, hospitals and community organizations; or,

• a public entity such as a county, city, or local public health department; hospital; or health district; and local governments.

Additionally, all non-profit organization applicants must provide a copy of a currently valid I.R.S. Tax Exempt Certificate. The I.R.S. Exempt Certificate should be placed in the FORM J section, “FQHC Funding Feasibility Narrative” after completed forms J a through J e. A copy of this document must be provided, whether or not it may already be on file with DSHS.

Under each component (Planning, Development, TOS and Capital Improvements) applicants should identify the eligibility criteria for the appropriate organizational category. Organizational categories are separated by the word “OR”. Under some components, an organization may have to meet several criteria.

Planning Grants-Eligible Applicants:

• Current FQHCs or FQHC-LAs; OR

• An I.R.S-designated non-profit 501 (c)(3) organization, including but not limited to hospitals, community organizations; OR

• Public entities (county, city, or local public health departments; hospital or health districts; and local governments).

Planning Grant requests must include a letter from DSHS indicating that the area is designated or a designation request is pending at the federal Shortage Designation Branch. Applicants for Planning Grant money only may document its MUA/P through a pending request with the TPCO. If not already designated, interested Planning Grant applicants should contact the DSHS/TPCO to request a designation (see APPENDIX C).

Development Grants-Eligible Applicants:

In addition to meeting one of the organizational categories requirements


stated below, applicants for Development Grants should submit a board approved resolution stating that the organization intends to meet the requirements found in PIN 98-23 and will submit a federal application for certification as a FQHC-LA and a Section 330 Grant application in fiscal years 2006 or 2007.

• Current FQHCs or FQHC-LAs

OR • Current non-profit organizations that meet A or B:

A) An I.R.S.-designated non-profit 501(c)(3) organization that has met the requirements found in Bureau of Primary Health Care (BPHC) PIN 98-23; or

B) An I.R.S.-designated non-profit organization that is not currently compliant with PIN 98-23. The applicant must submit a board approved resolution stating that the applicant intends to meet the requirements by September 1, 2005 by doing one of the following:

1.) Change applicant board composition and by-laws to meet the federal BPHC governance requirements found in PIN 98-23; or

2.) Create a separate, independent 501(c) (3) organization and submit an application for tax-exempt status to the I.R.S. by September 1, 2005. This new spin-off organization must meet the governance requirements as found in PIN 98-23 and have a signed Memorandum Of Understanding (MOU) indicating that this second organization will be the federal FQHC applicant. (Applicants may identify and include potential or prospective clinic users as governing board members if the clinic is not currently operational.)

OR • A public entity (county, city, or local public health department, hospital or health

district; and local government) that meets A or B: A) Has a “co-applicant” board that meets the governance requirements

described in BPHC PINs 98-23, 97-27, 98-24 and 99-09, and an affiliation agreement between the co- applicant board and the government entity that comply with the requirements listed on the Health Center Affiliation Checklist (FORM J d, “Health Center Affiliation Checklist”); or

B) By September 1, 2005, has established an advisory board comprised of 51% users of the clinic services (or potential, prospective clinic users if the clinic is not currently operational) with the authority outlined in PIN 98-23 that will transition to the “co-applicant board” 30 days before application for certification as a FQHC-LA is submitted to the BPHC. Also by September 1, 2005 an affiliation agreement between the co-applicant board and the government entity that meets the Health Center Affiliation Checklist requirements (FORM J d) must be prepared, approved by both boards and submitted.


Transitional Operating Support Grants-Eligible Applicants:

All applicants must have a clinic facility that is already operational or ready to begin operations by November 30, 2005.

In addition to meeting one of the organization categories requirements stated below, all applicants for a TOS Grant must submit a board approved resolution stating that: a) the organization meets all of the requirements found in PIN 98-23, and b) the organization will submit a federal application for FQHC-LA certification on or before February 1, 2006 and a federal grant application (NAP, EMC, or Service Expansion) in FY 2006 for which it is eligible.

TPCO will not release TOS funds until the grant contractor has met the Mission and Strategy and Governance requirements found in PIN 98-23.

Organizations that will be designated as a FQHC on or before December 1, 2005 are eligible to apply for FQHC Incubator Program grants.

• Current FQHC or FQHC-LAs;

OR • An I.R.S. designated non-profit 501(c)(3) organization that meets the Mission and

Strategy and Governance requirements of PIN 98-23; OR

• A public entity (county, city, or local public health department, hospital or health district; or local government) that has a co-applicant board meeting the governance requirements described in PINs 98-23, 97-27,98-24 and 99-09 with affiliation agreements between the co-applicant board and the government entity that meet the requirements found in Health Center Affiliation Checklist FORM J d.

Capital Improvement Grant-Eligible Applicants:

In addition to meeting one of the requirements stated below, all applicants for a Capital Improvement Grant must submit a board approved resolution stating that: a) the organization meets all of the requirements found in PIN 98-23, and b) will submit a federal application for FQHC-LA certification on or before February 1, 2006 and a federal grant application (NAP, EMC, or Service Expansion) for which it is eligible in FY 2006. With the exception of existing FQHC’s, no organization may receive more than $100,000 in Incubator Capital Improvement Grant funds during FY 2004, 2005, and 2006 combined.

• Current FQHCs or FQHC-LAs;

OR • I.R.S.-designated non-profit organizations meeting the Mission and Strategy and

Governance requirements of PIN 98-23; OR


• A public entity (county, city, or local public health department; hospital or health district; and local government) that has a co-applicant board meeting the Mission and Strategy and Governance requirements described in PINs 98-23, 97-27, 98-24 and 99-09 with an affiliation agreement between the co-applicant board and the government entity complies with the requirements listed on the Health Center Affiliation Checklist FORM J d.

Planning Grant & Development Grant - Eligible Applicants:

Refer to Section I A. Development Grant - Eligible Applicant requirements.

Development Grant & Transitional Operating Support – Eligible Applicants:

Refer to Section I A. Transitional Operating Support – Eligible Applicant requirements.

Transitional Operating Support & Capital Improvement Grant – Eligible Applicants:

Refer to Section I A. Transitional Operating Support – Eligible Applicant requirements.

B. Project and Budget Periods

It is expected that the contract will begin on or about September 1, 2005, and will be made for a six-month budget period within a six-month project period. A second competitive Request for Proposal will be issued for March through August 2006 budget period. Approximately $4.85 million is expected to be available during FY 2006. However, this may be reduced pending the adoption and certification of the Fiscal Years 2006-2007 General Appropriations Act. This RFP is contingent upon the continued availability of funding. DSHS reserves the right to alter, amend or withdraw this RFP at any time prior to the execution of a contract if funds become unavailable through lack of appropriations, budget cuts, transfer of funds between programs or agencies, amendment of the appropriations act, health and human services agency consolidations, or any other disruption of current appropriations. If a contract has been fully executed and these circumstances arise, the provisions of the Termination Article in the contract General Provisions shall apply.

Continued funding in future years is contingent upon the availability of funds and the satisfactory performance of the contractor during the prior budget period. Funding may vary and is subject to change each budget period. If applicant organization has been awarded FQHC Incubator Program grant awards


in FY 04 and/or FY 05 as either an applicant organization or as a spin-off organization, use Table 1 to determine the total amount that can be requested in this application.

If applicant’s individual component awards for FY 04 and FY 05 are equal to or are greater than the amount in Column A, the applicant may apply for up to the amount listed in Column B. If applicant has been awarded less than the amount in Column A, applicant may apply for the remaining amount in Column A, or the amount in Column B, whichever is greater.

TABLE 1

Column A Column B Planning $ 5,000.00 -0- Development $ 50,000.00 $15,000.00 TOS $250,000.00 $125,000 Capital Improvement $100,000.00 -0- Capital Improvement for existing FQHCs for new site not previously funded through FQHC Incubator Program.

$100,000.00

$100,000.00

If applicant organization has not been awarded FQHC Incubator Program grant awards in FY 04 and/or FY 05 use Table 2 to determine total amount that can be requested in this application.

TABLE 2 If applicant has not been awarded grants for FY 04 and/or

FY 05, the applicant may apply for the following maximum awards.

Planning $ 5,000.00 Development $ 50,000.00 TOS

$250,000.00 Capital Improvement $100,000.00

The specific dollar amount awarded to each applicant depends upon the merit and scope of the proposed project and the ability to secure an FQHC-LA certification or new or additional FQHC grant funding.

FQHCs should include in the application specific information about the use of internal cash resources to develop a new satellite, expand medical capacity, or develop oral health, mental health and substance abuse services. This may be done through the narrative and the budget. FQHCs are expected to demonstrate a significant amount of funds from other resources to leverage the FQHC Incubator


Program request.

It is the intention of the TPCO to make awards in the following order: 1) To applicants that specifically develop or locate primary health care services in counties that are considered eligible under the nation’s 200 poorest counties.

Although no specific Program Information Notices (PINs) have been released by the Bureau of Primary Health Care/HRSA regarding the placement of community health centers in the nation’s 200 poorest counties that do not have a FQHC, the DSHS will give priority consideration to applicants that propose to locate primary health care services in an eligible county. Although Federal guidance/criteria for the nation’s poorest counties have not been released as of April 22, 2005. Thirty-one of the 200 poorest counties appear to be in Texas. The DSHS has developed a listing of potential Texas counties for reference. See Appendix E.

2) To FQHCs for satellites, Expanded Medical Capacity, and/or service expansion proposals; 3) To non-profit organizations that will be designated as a FQHC on or before December 1 2005; 4) To non-profit organizations that have received FQHC Incubator Program awards in FY 2005 or are FQHC-LAs; 5) To non-profit organizations or public entity applicants that currently provide at least 32 hours of primary health care services: and,

a. Have or will incorporate necessary changes to their existing organizations to comply with the program expectations found in PIN 98- 23 (such as by-laws, adding oral health, mental health and substance abuse services, hiring CEO, CFO, CMO, etc.); and, b. Will seek certification as a FQHC-LA in FY 2006 and NAP, if

appropriate; and,

6) To non-profit organizations that do not currently operate a clinic or have not met Mission and Strategy and Governance expectations found in Policy Information Notice (PIN) 98-23.

The contract will include a deliverables-based budget instead of the usual categorical budget. A deliverables budget pays a predetermined amount to the contractor once an acceptable “deliverable” is provided to DSHS. In the case of the FQHC Incubator Program, contractors will be paid based on their accomplishment of Performance Standards outlined in APPENDIX B Standards for Evidence of Completed Deliverables. Federal guidelines were used to develop the Standards for Evidence of Completed Deliverables and


may be referred to when evaluating deliverables for determining acceptability and payment. When developing a budget, the applicant will identify Performance Measures (Deliverables) that must be completed to become a FQHC-LA and seek Section 330 grant support. For example, out of the numerous Performance Measures outlined in the Performance Measures, for a development grant, the applicant can request to be paid a certain amount once it has developed and implemented a Board of Directors that meets the governance requirements of PIN 98-23, or has submitted a draft FQHC-LA application. The applicant determines how much funding to request for specific deliverables, and the amount is finalized during contract negotiations with TPCO. The request should be reasonable and based on market value. With a deliverables based budget, a contractor cannot be paid until the deliverables are accomplished and accepted by DSHS.

The DSHS reserves the right to alter, amend or withdraw this RFP at any time prior to the execution of the contract if funds become unavailable through the lack of appropriations, budget cuts, transfer of funds between programs or agencies, amendment of the appropriation act, health and human services agency consolidations, or any other disruption of current appropriations. If a contract has been fully executed and these circumstances arise, the provisions of the Termination Article in the contract General Provisions shall apply.

C. Use of Funds

Funds are awarded for a specifically defined purpose and shall not be used for any other project. Funds may be used to support the sustainable development or expansion of a FQHC and FQHC-LAs.

Funds cannot be used to replace local or state funds.

Funds will not be used to support an organization that: • does not intend to meet the requirements of PIN 98-23 or other

federal guidance found in such PINs as 97-27,98-24 or 99-09; • is not eligible for the federal application as determined by the

most recent PIN for that service expansion (NAP, EMC or Service Expansion); and/or

• does not intend to apply for certification as an FQHC-LA, or FQHC service expansion grants.

D. Schedule of Events

1. Post to the Electronic State Business Daily (ESBD) 04/25/05 2. Issuance of RFP 04/25/05

3. Letters of Interest submitted (requested, but not required) 05/06/05 4. Applicant Conference 05/10/05 5. Deadline for Submitting Questions 05/12/05 6. Final Posting of Answers to Questions 05/17/05 7. Deadline for Submission of Applications 05/27/05


8. Post Awards on Electronic State Business Daily (ESBD) 06/27/05 9. Mail Contract (s) to Awarded Applicants for Signature 08/01/05 10. Expected Contract Begin Date 09/01/05

II. PROGRAM INFORMATION

A. General Purpose and Program Goals

The purpose of the Incubator Program is to prepare clinics to apply for and receive new or additional support as a FQHC and to secure FQHC-LA certification. This is a seed funding initiative and grant funds are not intended to be the sole source of funding for an organization pursuing designation as a FQHC or certification as a FQHC-LA or service expansion. DSHS will supervise each grantee to ensure that appropriate strategic steps are undertaken to promote grantees’ long-term sustainability. Component 1: Planning Grants are designed to support specific technical assistance activities that are key to successful FQHC applications. For example, clinics must develop a realistic analysis, understanding, and commitment to FQHC funding and demonstrate that it is a viable option for them. Planning grants will support organizational feasibility studies; analysis of need and asset mapping; financial impact analysis including patient payer mix; basic training on FQHC requirements; development of a work plan for submitting an application to the BPHC; development of basic collaborations necessary to support more intensive development efforts; preparation of 501(c)(3) applications, and other necessary planning activities. Refer to APPENDIX B, “Standards for Evidence of Completed Deliverables-Feasibility Study”. Organizations with well-developed internal capacities (i.e. existing FQHCs, hospitals, local health departments, etc.) will be expected to leverage additional resources in the planning process. Component 2: Development Grants provide support for development of the complex organizational and collaborative capacities required of FQHCs as well as development of a FQHC-LA and Section 330 federal grant proposal. One of the most effective methods to demonstrate organizational and collaborative capacity for organizations that are not FQHCs is to become a FQHC-LA clinic. Applicants are required to use these funds to support development of a FQHC-LA application as well as the more in-depth proposal for full Section 330 funding/FQHC designation if appropriate to the organization. Applicants who have not completed Planning Grant criteria should consider applying for a Planning Grant. Development Grants will support grant writers, technical assistance on grant proposals or any individual component of the proposal; staffing to develop collaborative and organizational capacities; training for staff or board members; technical assistance on developing and implementing policies and procedures; and other activities necessary to develop a FQHC. Refer to APPENDIX B


“Standards for Evidence of Completed Deliverables-Governance, Health Care Plan, Service Delivery Plan, etc.” Organizations with well-developed internal capacities (i.e. existing FQHCs, hospitals, local health departments, etc.) will be expected to leverage additional resources in the development process. Component 3: Transitional Operating Support is the most significant source of grant support. The purpose of Transitional Operating Support is to operationalize community-based clinics to meet FQHC requirements. This applies to both current FQHCs,FQHC-LAs and non-FQHCs. Sites that are operational and demonstrating their ability to comply with health center expectations through FQHC-LA status are more likely to leverage federal funds than those organizations proposing brand new clinics and services. Transitional Operating Support will fund salaries, medical supplies, contractual medical services, physician and management recruitment and retention efforts, technical support for information systems, and other activities necessary to operate a sustainable clinic that meets the requirements of FQHC-LA’s. The TPCO will not release TOS until the grant contractor has met the Mission and Strategy and Governance requirements found in PIN 98-23. The TPCO expects that clinics receiving TOS will sustain at least the same level of operations after TOS ends regardless of whether the clinic receives new or expanded federal FQHC grant funding. For organizations that are not currently FQHCs, the FQHC-LA certification is one method to sustain operations since it provides enhanced reimbursement from Medicaid and Medicare that is based on the actual cost of providing services. FQHCs may use TOS to support a satellite clinic or expanded services at a current location. Since satellite clinics within a clinic’s current scope of service are excluded from applying as a NAP clinic, the FQHC could use TOS for a new satellite clinic and apply for a change of scope with the BPHC and then apply for EMC from the BPHC. The federal FQHC grant is for expanded services. Therefore, all applicants should plan strategically and use TOS to establish the minimum services necessary. For non-FQHCs, the minimum level would be those services required for a FQHC-LA certification (PIN 2003-21). For existing FQHCs, the minimum level would be what the FQHC could sustain after the Incubator Program ends if additional federal funds are not secured. These funds will not support services that are currently being supported by a FQHC or any other type of funding. Supplantation of funds, or the replacement of local dollars with state funds is strictly prohibited.


Refer to APPENDIX B “Standards for Evidence of Completed Deliverables-Governance, Health Care Plan, Service Delivery Plan, etc.” Organizations with well-developed internal capacities (i.e. existing FQHCs, hospitals, local health departments, etc.) will be expected to leverage additional resources in operating the clinic. Component 4: Capital Improvement Grants are designed to provide sufficient physical infrastructure for clinics to apply for FQHC-LA status as well as new or expanded FQHC funding. This component is intended to support those clinics that need capital support to become operational. Capital Improvement Grants may be used to purchase equipment and/or make alterations and renovations to an existing facility. Examples of eligible capital expenditures include medical equipment, management information systems including hardware and software, altering the office configuration of an existing facility, and converting existing space for use as a medical facility, and/or leasing a facility. These funds may not be used to construct new buildings or to add space on to an existing facility (i.e. add a new wing to an existing building). With the exception of existing FQHCs, no organization may receive more than $100,000 in Incubator Capital Improvement Grant funding during FY 2004, 2005, 2006 combined. Organizations with well-developed internal capacities (i.e. existing FQHCs, hospitals, local health departments, etc.) will be expected to leverage additional resources in operating the clinic.

B. Background Federally Qualified Health Centers. FQHCs are public or not-for-profit, consumer-directed health care corporations which provide high quality, cost-effective and comprehensive primary and preventive care to medically underserved and uninsured people. This nationwide network of safety-net providers is primarily comprised of health centers which are supported by federal grants under the US Public Health Service Act (PHSA): Community Health Centers, Migrant Health Centers, Health Care for the Homeless Programs, Public Housing Primary Care Programs and Urban Indian and Tribal Health Centers. These providers must meet rigorous federal standards related to quality of care and services as well as cost, and are qualified to receive enhanced reimbursement under Medicaid and Medicare law.

Federally Qualified Health Center Look-Alikes. FQHC-LAs meet the same basic qualifications as regular FQHCs: they are public or not-for-profit, furnish services to anyone regardless of ability to pay, and have consumer boards made up of a majority of patients (at least 51% must be consumers of center services). However, these centers are not official FQHCs because there are insufficient funds for them to receive Public Health Service grants.


Because they "look like" FQHCs, they receive the same enhanced reimbursement and access to 340(b) discount drug pricing program as FQHCs.

Community Health Centers. Originally known as neighborhood health centers in the mid-1960s, community health centers provide comprehensive primary medical care services with a culturally sensitive, family-oriented focus to anyone needing care regardless of ability to pay. These centers tailor their services to meet the specific needs of the community and its special populations that include the homeless, migrant and seasonal farm workers, people infected with HIV/ AIDS, the elderly and people who abuse alcohol and other drugs. In addition, users of health center services make up a majority of centers' governing boards. The Community Health Center Program is a federal grant program funded under Section 330 of the PHSA to provide for primary and preventive health care services in medically-underserved areas throughout the U.S. and its territories.

Migrant Health Centers. The Migrant Health Act was passed in 1962 to provide a broad array of medical and support services to migrant and seasonal farm workers and their families (authorized under Section 329 of the PHSA). Migrant health centers are linked or integrated with hospital services and other health and social services existing within the services area. They use lay outreach workers (“promotoras”, or migrant farm workers trained as health educators), bilingual/ bicultural health personnel and culturally appropriate protocols.

Health Care for the Homeless (HCH) programs. Established under the Stewart B. McKinney Homeless Assistance Act of 1987 and authorized under Section 340 of the PHSA, HCH programs are intended to improve access for homeless people to primary health care and substance abuse treatment services.

Public Housing Primary Care (PHPC) programs. The PHPC program was established under the Disadvantaged Minority Health Improvement Act of 1990, which amended the PHSA to add Section 340A. The PHPC program was developed to improve the health of residents of public housing by providing accessible and comprehensive preventive and primary health care services. Recipients of PHPC federal funds include resident management corporations, community health centers and Health Care for the Homeless Programs.

The President’s Initiative. President Bush has implemented a five-year plan to support new FQHCs or expand existing FQHCs. A key component of the President’s Initiative is to double the number of people served by community health centers by making awards to 1200 applicants over a five-year period through New Access Point, Service Expansion, and Expanded Medical Capacity grants. Since 2002, including awards announced on April 11, 2005, HHS has funded more than 700 new or expanded health centers


and increased the number of patients served annually to 13.2 million (estimate for Calendar Year 2004). The Texas FQHC Incubator Program. This program is designed to support local efforts and collaborations to develop FQHCs including but not limited to FQHC-LAs and work through the development and application process. One of the barriers has been a lack of expertise on how to develop FQHCs. This program will support increasing local expertise on FQHCs development as well as securing more technical assistance resources for local communities. Another barrier has been an absence of in-depth collaboration from all of the interested human service sectors including mental health, dental health, transportation, and other primary care providers. The Incubator Program supports the involvement of these groups in the planning process and the investigation of best practice models to address each of these issues. The Incubator Program seeks to increase New Access Point funding as well as funding for Service Expansion and Expanded Medical Capacity. The strategy of the Incubator Program is to increase local capacity in a sustainable manner. Therefore, the Incubator Program requires securing FQHC Look-Alike certification in the process of pursuing full FQHC funding as a method of long-term sustainability. For existing FQHCs, any services added under the Incubator Program should be sustainable regardless of whether additional federal funds are secured. FQHC-LA’s receive many benefits that will increase sustainability. FQHC-LAs are compensated by Medicaid and Medicare based on the actual expense of delivering care instead of the standard allowable costs. FQHC-LAs receive access to 340(b) drug pricing discounts and may receive National Health Service Corps scholars and loan repayment providers, and other federal programs. FQHC-LAs do not receive coverage under the Federal Tort Claims Act, which means they must purchase medical malpractice insurance.

C. Legal Authority This program is authorized by Health & Safety Code, §31.017.

D. Project Development Applicants are encouraged to participate in local and regional planning activities, including collaboration with existing or potential FQHCs. For general information on local planning activities, contact your local health department or DSHS Regional Health Department. For specific planning activities related to FQHCs, contact the Texas Association of Community Health Centers (TACHC) and the TPCO DSHS. Communities are also strongly encouraged to involve other human service


providers in the FQHC development process especially mental health, dental, transportation, hospitals, and private providers.

E. Program Requirements For those entities receiving TOS and/or Capital Improvement Grants, contractors must conduct project activities in accordance with the new DSHS Standards for Public Health Clinic Services, as well as program-related standards and/or requirements. A copy of the new Texas Department of State Health Services Standards for Public Health Clinic Services is posted on DSHS website at http://www.dshs.state.tx.us/qamonitoring. Contractors are required to conduct project activities in accordance with various federal and state laws prohibiting discrimination. Guidance for adhering to non-discrimination requisites can be found on the following website:http://www.hhs.state.tx.us/aboutHHS/CivilRights.shtml#learn. All fees and income generated as a result of an awarded contract shall be used to enhance the sustainability of the services to the target population.

F. DSHS Contact For questions concerning this RFP, contact Bill Walk. All communications concerning this RFP shall be addressed in writing, by fax, or by e-mail to:

Bill Walk Client Services Contracting Unit (CSCU) Room T-502 Texas Department of State Health Services 1100 West 49th Street Austin, Texas 78756-3199 FAX (512) 458-7351

Email: [email protected] Upon issuance of this RFP, other employees and representatives of DSHS will not answer questions or discuss the contents of the RFP with any potential applicants or their representatives. Failure to observe this restriction may result in disqualification of any subsequent proposal. This restriction does not preclude discussions between affected parties for the purpose of conducting business unrelated to this RFP. Written inquiries or questions about this RFP must be received no later than 5:00 p.m. CDT on May 12, 2005. Questions submitted after this date and time will not be answered. Questions will not be answered verbally. Questions shall be submitted by e-mail or faxed to the address or telephone number above.


All questions and answers will be posted on the Electronic State Business Daily (ESBD) at http://esbd.tbpc.state.tx.us/1380/sagency.cfm. Postings may be made as questions are answered; however, all questions will be answered and posted no later than 5:00 p.m. CDT on May 17, 2005. Below are steps to navigate the ESBD web site to view all documents posted related to this RFP including questions and answers. 1. On the ESBD page, under the Browse heading:

For the Agency Field, click Name then select Department of State Health Services from the pull down menu. For the Search Type Field, select Search Bid/Procurement Opportunities from the pull down menu. In the Agency Requisition Number field, type CSH/FQHC 0150.1 Leave the NIGP Class – Item Number field blank. For the Order Results By field, select your preference from the pull down menu. Click the FIND button.

2. All documents that are posted for this RFP will be displayed with a description of each document.

3. Click on the appropriate document or bid package to see the file. Client Services Contracting Unit (CSCU) is the point of contact with regard to all procurement and contractual matters relating to the services described herein. CSCU is the only office authorized to clarify, modify, amend, alter, or withdraw the project requirements, terms, and conditions of this RFP and any contract awarded as a result of this RFP.

G. DSHS Applicant Conference The TPCO FQHC Incubator Program Applicant Conference will be held on Tuesday May 10, 2005 in M-739, Moreton Building, 1100 West 49th Street, Austin, from 10:30 a.m. to 1:30 p.m.

III. APPLICATION DEADLINE AND SUBMISSION

A. Application Deadline

The original application and six (6) copies must be received on or before 2:00 p.m. CDT May 27, 2005.

B. Submission The original application and six (6) copies must be submitted to:

Bill Walk Client Service Contracting Unit (CSCU) Room T- 502 Texas Department of State Health Services

http://esbd.tbpc.state.tx.us/1380/sagency.cfm


1100 West 49th Street Austin, Texas 78756-3199 Ref: RFP # CSH/FQHC -0150.1

If an application is sent by overnight mail or hand-delivered to the DSHS address above, the applicant should request a receipt at the time of delivery to verify that the application was received on or before the application due date and time. If an application is mailed, it is considered as meeting the deadline if it is received on or before the due date and time. DSHS will not accept applications by facsimile or e-mail. Applicants sending applications by the United States Postal Service or commercial delivery services must ensure that the carrier will be able to guarantee delivery of the application by the closing date and time. If an application is received after closing due to 1) carrier error, when the carrier accepted the package with a guarantee for delivery by the closing date and time, or 2) significant weather delays or natural disasters, DSHS will, upon receipt of proper documentation showing that the application would have been timely received except for the carrier error, significant weather delay or natural disaster, consider the application as having been received by the deadline. Applications that do not meet the above criteria will not be eligible for competition.

IV. APPLICATION REVIEW, SELECTION & NEGOTIATION

Applications will be reviewed according to the criteria below. To maximize fairness for all applications during review, DSHS staff may only confirm receipt of an application and are not permitted to discuss the application or its review during the review process. All applications remain with DSHS and are not returned to the applicant. A. Screening Process

Applications are initially screened for eligibility and completeness. The preliminary screening requirements include:

1. Application received on or before the application due date and time. 2. The original application bears an original signature of the authorized

official of the applicant organization on the Face Page. 3. The correct number of copies received along with the original

application.

APPLICATIONS THAT DO NOT MEET THESE REQUIREMENTS WILL NOT BE CONSIDERED FOR REVIEW.


B. Evaluation Process Prior to the receipt of applications, TPCO will establish a review process. Applications will be reviewed by a combination of DSHS staff and external reviewers. Each application will be scored based upon the following Evaluation Criteria. The TPCO will have the final decision on awards.

C. Evaluation Criteria

Each application section may be reviewed as a single unit without complete review of the entire application. Therefore, applicants are encouraged to respond to each section request with complete and accurate information. Having placed requested information in another section and not repeating it if requested may lead to a lower score. The application sections as required in the Application Instructions will be weighted as follows: APPLICANT BACKGROUND Form G (Maximum 10 points) a. Applicant states its legal name and any affiliations; its overall purpose

or mission statement; and a brief history of its accomplishments. b. Applicant describes its organizational structure, such as board of

directors, officers, committees and management staff. c. Applicant describes its organizational involvement in primary care,

dental, and/or mental health, cultural competency, and efforts to respond to community primary care needs.

d. Applicant describes its work thus far on developing a FQHC including any training from TPCO or the TACHC.

e. If applicant is preparing a spin-off I.R.S. designated non-profit organization, applicant provides a description of the originating organization and completes the information requested above for the new spin-off organization.

ASSESSMENT NARRATIVE Form H (Maximum 10 Points) a. Applicant provides a brief synopsis of the community as a whole,

including general descriptions of geographic boundaries (urban or rural, physical environment) and basic demographics (i.e. poverty, ethnicity, languages spoken).

b. Applicant describes the target population, including geographic service area by county, census tracts, and zip codes as well as the characteristics of target population (including demographic and socioeconomic data specific to the target population).

c. Applicant describes gaps in resources and potential barriers to developing a FQHC or FQHC-LA. Applicant that has not received FQHC Incubator Program

grants in FY 04 or 05 provides a discussion of organizational and


community barriers toward development of a FQHC, including issues related to meeting FQHC governance requirements, providing required services, and becoming operational; or Applicant that has received FQHC Incubator Program grants

in FY 04 and/or FY 05 provide a discussion of remaining barriers to submitting a competitive Section 330 grant application and/or FQHC-LA application.

d. Applicant includes MUA or MUP documentation.

FQHC COLLABORATIVE NARRATIVE Form I (Maximum 10 points) a. Applicant provides a description of collaborative efforts. (If applicant

is preparing a spin-off I.R.S. 501(c)(3) designated non-profit organization, that has not been fully developed yet, the originating organization’s collaborative efforts should be described.)

b. Applicant demonstrates current collaborative efforts for this project, including partnerships to increase access to health care specific to this project.

c. MOUs, support letters, or documented efforts to collaborate with: o existing FQHCs or FQHC-LAs; o rural health clinics; o hospitals; and, o clinical services not directly provided by applicant

d. Applicant describes other sliding fee scale clinics in area and efforts to collaborate.

e. Applicant describes MOUs for enabling services. f. Applicant describes coordination with TPCO and/or TACHC regarding

this project. FQHC FUNDING FEASIBLITIY NARRATIVE Form J (a - e) (Maximum 20 points) a. Applicant describes the feasibility of securing new or expanded FQHC

funding for applicant. b. If applicant is preparing a spin-off I.R.S-designated non-profit

organization, applicant describes the originating organization’s ability to support the creation of an organization with staff, funding, etc., that will become a FQHC or FQHC-LAs.

c. Applicant demonstrates commitment to develop a safety net clinic in the targeted community and its ability to overcome barriers as identified in Assessment Narrative (FORM H).

d. Applicant demonstrates how the target area will support additional services.

e. Applicant describes: o ability to comply with all of the program expectations

(requirements) for FQHC –LA; o impact of becoming a FQHC-LA; or o impact (for existing FQHCs) of new or additional FQHC

funding.


f. Applicant describes previous governing board training on the program expectations/requirements for FQHC-LA.

• FORM J a Funding Feasibility Checklist: Applicant demonstrates through the checklist the ability to develop a FQHC-LA. If a specific item is checked “NO”, applicant should include it in the performance measures (FORM L). Applicant should demonstrate consistency between those activities necessary to becoming a FQHC-LA and the performance measures and deliverables and payment schedule.

• FORM J b Services Provided In FY 04 & Proposed FY 05: Applicant demonstrates ability through employed staff or contractual services to provide FQHC-LA required services.

• FORM J c Staff Profile: Applicant demonstrates that staffing is consistent with performance measures to be completed and with implementation of FQHC required services. Applicant demonstrates it is not dependent on FQHC Incubator funds to support full staffing.

• FORM J d Health Center Affiliation Checklist: Applicant demonstrates knowledge of BPHC affiliation requirements, completes form appropriately and attaches copies of MOUs and/or contracts.

• FORM J e Current Patient Population and Revenue Information: This section is to be completed only by applicants for Development, TOS, and Capital Improvement Grants.

• Applicant provides copy of valid I.R.S. tax-exempt certificate.

SUSTAINABILITY NARRATIVE Form K (15 Points) & Form K a (5 Points) a. Applicant describes a sustainability plan for FY 06 including how

operations will continue if new or additional federal FQHC funds are not secured.

b. Applicant describes other resources that will be leveraged to make the clinic sustainable. If applicant is not applying for TOS or Capital Improvement Grants, applicant describes how sustainability will be included in development plans.

c. If applicant has received FQHC Incubator Programs funds in FY 04 and/or FY 05, applicant identifies:

o how local fundraising has contributed to clinic operations; and, o how payer mix (Medicaid, self pay, etc.) has impacted

sustainability projections. d. All applicants submit board approved minutes and the

accompanying financial statements with balance sheets from October 2004 through March 2005.

e. Applicant provides Expenditure and Project Budget Report.

PERFORMANCE MEASURES (and Action Steps) Form L (Maximum 20 points) a. Applicant describes performance measures that are specific,

measurable, time-phased, and feasible.


b. Applicant describes performance measures that have quantified outcomes and outputs, the number of outputs to be performed, and the efficiency with which they will be performed.

c. Applicant describes performance measures that include detailed action steps, evidence of completion/deliverable, completion date, and payment.

d. Applicant defines performance measures that are required in order to develop the organization for federal funding and to meet its contract (open for services, apply for FQHC-LA, etc).

DELIVERABLES and PAYMENT SCHEDULE Form M (Maximum 10 points) a. Applicant provides a reasonable set of deliverables and payment

schedule. b. Applicant defines deliverables that are sufficiently specific to

performance measures and action steps. Applicant provides information consistent with Feasibility and Sustainability Narratives.

D. Selection and Negotiation Once award decisions are made, DSHS staff is responsible for negotiating contracts to obtain the needed deliverables within the framework of the goals of the FQHC Incubator Program and available funds. As funds are limited, it is expected that the applicants selected for contract awards may be asked to revise the deliverables, as well as the goals and objectives, of their proposals in order to achieve the FQHC Incubator Program goals within available funding limits. This process is commonly referred to as contract negotiation. Applicant shall submit written revisions reflecting negotiated changes. Once the contract negotiation process is complete, the Texas Primary Care Office initiates the development of a contract. Organizations receiving FQHC Incubator Program grant awards should be prepared to conduct contract negotiations beginning the week of June 27, 2005. A posting to the Electronic State Business Daily (ESBD) board will be made of each applicant whose proposal is selected for a contract. This posting does not constitute a fully executed contract. Providers who commence work without a contract signed by both parties are at risk of being unable to invoice DSHS for those services and expenses. If an organization does not meet the deliverables and timelines specified in the contract, DSHS will withdraw, decline to release, and/or suspend payments to an organization. If the BPHC or any other federal agency changes any of the policies related to FQHCs or FQHC-LAs, DSHS may amend any existing contract based on those changes.


Awarded applicants must encumber all expenses and meet all deliverables by February 28, 2006.

V. DSHS ADMINISTRATIVE INFORMATION

A. Incurring Costs and Rejection of Applications Any costs incurred in the preparation of this application shall be borne by the applicant and are not allowable costs. DSHS reserves the right to reject any or all applications and is not liable for any costs incurred by the applicant in the development, submission, or review of this application.

B. Right to Amend or Withdraw RFP DSHS reserves the right to alter, amend, or modify any provisions of this RFP or to withdraw this RFP at any time prior to the execution of a contract if it is in the best interest of DSHS and the State of Texas. The decision of DSHS is administratively final. Amendment or withdrawal of the RFP will be posted to the ESBD.

C. Authority to Bind DSHS For the purposes of this RFP, the Commissioner of Health, Chief Operating

Officer, Executive Deputy Commissioner, Chief Financial Officer or designee(s), are the only individuals who may legally commit DSHS to the expenditure of public funds. No costs chargeable to the proposed contract will be reimbursed before the contract is fully executed by the Enterprise Contract and Procurement Services Division. DSHS will not reimburse expenses incurred by the contractor prior to the effective date of the contract.

D. Contracts with Sub-contractors The selected applicant may enter into procurement contracts with vendors. The selected applicant is responsible for the performance of any subcontractor. If the applicant enters into procurement contracts with vendors, the documents shall be in writing and shall comply with the requirements specified in the Contracts with Subcontractors articles in the FQHC General Provisions for DSHS Grant Contracts. The contract general provisions are available online at http://www.DSHS.state.tx.us/grants/form_doc.htm. If an applicant plans to enter into a contract in which a vendor will receive a substantial portion of the scope of the project, i.e., $25,000 or 25% of the applicant’s funding request, whichever is greater, the applicant shall submit justification to DSHS and receive prior written approval from DSHS before entering into the contract.


E. Historically Underutilized Business (HUB) Participation

Note to All Respondents: Texas law provides that a proposal filed in response to this RFP that does not contain a historically underutilized business subcontracting plan is non-responsive, in accordance with Texas Government Code § 2161.252.

Introduction

This section sets forth requirements that every proposal must meet in order to comply with state laws and administrative rules regarding HUBs. Respondents should read this article carefully before preparing a proposal. The Department of State Health Services (DSHS) is committed to promoting full and equal business opportunities for all businesses in State contracting in accordance with the goals specified in the State of Texas Disparity Study. DSHS has adopted the Texas Building and Procurement Commission’s (TBPC) HUB rules and encourages the use of HUBs through race, ethnic, and gender-neutral means. Pursuant to Texas Administrative Code Title 25, Chapter 1, Subchapter N, and pursuant to §§2161.181-182, Texas Government Code, DSHS is required to make a good faith effort to increase HUB participation in contracts for construction, service (including professional and consulting services), and commodity contracts. DSHS may accomplish the goal of increased HUB participation by contracting directly with HUBs or indirectly through subcontracting opportunities.

In accordance with Texas Government Code, Chapter 2161, Subchapter F, each state agency that considers entering into a contract with an expected value of $100,000 or more shall, before the agency solicits bids, proposals, offers, or other applicable expressions of interest, determine whether subcontracting opportunities are probable under the contract.

(A) State agencies shall use the following steps to determine if subcontracting opportunities are probable under the contract:

i. Use the HUB participation goals in Texas Administrative Code Title 1, Chapter 111, Subchapter B, (relating to Annual Procurement Utilization Goals); and

ii. Research the Centralized Master Bidders List, the HUB Directory, the Internet, and other directories, identified by the Commission, for HUBs that may be available to perform the contract work.

(B) In addition, determination of subcontracting opportunities may include, but is not limited to, the following:

i. contacting other state and local agencies and institutions of higher education to obtain information regarding similar contracting and

http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=1&sch=N&rl=Y

http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=1&sch=N&rl=Y

http://info.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=5&ch=111&rl=13



subcontracting opportunities; and ii. reviewing the history of similar agency purchasing transactions.

The statewide HUB participation goals, set by the Texas Building and Procurement Commission (TBPC), as a result of the State of Texas Disparity Study, are classified under the following categories:

(1) Heavy construction other than building contracts 11.9%; (2) Building construction 26.1%; (3) Special trade construction contracts 57.2%; (4) Professional services contracts 20%; (5) All other services contracts 33%; and (6) Commodities contracts 12.6%.

DSHS and its contractors shall make a good faith effort to meet or exceed

the HUB participation goals listed above for each fiscal year by maximizing the inclusion of certified HUBs in the procurement process. The goods and/or services requested under this RFP are classified under “Other Services Contract” and the HUB participation goal is 33.0%.

HUB Subcontracting Plan (HSP) Procedures

The following procedures are in accordance with the TBPC HUB rules. If there are any discrepancies between the TBPC HUB rules and this RFP, the rules shall take priority.

DSHS has determined that subcontracting opportunities are probable under this RFP. Therefore, DSHS requires the submission of a HUB Subcontracting Plan (HSP), at the same time as the RFP response, as a part of each proposal. The HSP, if accepted by DSHS, will become a provision of any contract awarded as a result of this RFP. Proposals that do not include a HSP, or proposals that contain a HSP that DSHS determines was not developed in good faith, shall be rejected as a material failure to comply with the specifications set forth in this RFP (as related to the Texas Administrative Code, Title 1, Part 5, Chapter 111, Subchapter B, Rule 111.14, (a) (2)(B).

To search for potential HUB vendors who may perform subcontracting opportunities, respondents shall refer to the TBPC Centralized Master Bidders List (CMBL) <http://www.tbpc.state.tx.us/cmbl/cmblhub.html> and/or TBPC HUB Directory <http://www.tbpc.state.tx.us/cmbl/hubonly.html>. Class and item codes for potential subcontracting opportunities under this RFP, include, but are not limited to:

920-00 Data Processing, Computer, Programming, and Software Services 924-16 Course Development Services, Instructional/Training




948-00 Health Related Services

961-90 Writing Services, All Kinds (Including Resumes, Calligrapher/Engrosser Services)

In order for DSHS to determine that a good faith effort was made, each Respondent shall send notices to three (3) or more HUBs for each area that the Respondent plans to subcontract. Respondents are not limited to the list of subcontracting opportunities identified above, and may identify additional areas of subcontracting.

Upon request, DSHS will provide Respondents with a list of HUB vendors from the TBPC CMBL or other related listings that may perform the subcontracting opportunities. The listing of potential subcontractors is for informational purposes only. DSHS does not endorse, recommend nor attest to the capabilities of any company or individual listed. This listing of certified HUBs is subject to change, therefore Respondents are encouraged to use the TBPC website to find the most current listing of certified HUBs. A complete and more updated list of all TBPC certified HUBs may be electronically accessed through the Internet at http://www.tbpc.state.tx.us. DSHS may provide additional information concerning HUB certified vendors at the vendor conference, if applicable.

As part of the HSP, DSHS requires each Respondent to state in writing whether the Respondent itself is a Texas certified HUB. This information is collected for the purpose of reporting DSHS’s HUB utilization. However, being certified as a HUB does not exempt any Respondent from complying with the required HSP.

If the Respondent Intends to Subcontract Portions of the “Other Services” Contract

Because DSHS has determined that subcontracting opportunities are probable, a Respondent who intends to subcontract any part of the work must include a HSP with its response. For each area identified, the Respondent should provide documentation of the notices sent to three or more HUBs in each of the areas the Respondent plans to subcontract. DSHS’s review of a Respondent’s HSP will include evidence of good faith effort in developing a HSP for “Other Services” Contracts, which includes, but is not limited to the following procedures:

(A) Divide the contract work into reasonable lots or portions to the extent

consistent with prudent industry practices. The Respondent should identify each area of the contract work the Respondent plans to subcontract.

(B) Notify HUBs of the subcontracting opportunities that the Respondent intends to subcontract. The preferable method of notification shall be in writing. The notice shall, in all instances, include 1) the scope of the work;

http://www.gsc.state.tx.us/


2) specifications; and 3) identify a contact person. The notice shall be provided to potential HUB subcontractors prior to submission of the

Respondent's response.

(i) The Respondent shall provide potential HUB subcontractors reasonable time to respond to the Respondent's notice. "Reasonable time to respond" in this context is no less than five working days from receipt of notice, unless circumstances require a different time period, which is determined by the DSHS and documented in the contract file.

(ii) The Respondent shall use the commission's Centralized Master Bidders List, the HUB Directory, Internet resources, and/or other directories as identified by the commission or DSHS when searching for HUB subcontractors. Respondents rely on the services of minority, women, and community organizations, contractor groups, local, state, and federal business assistance offices, and other organizations that provide assistance in identifying qualified applicants for the HUB program who

are able to provide all or select elements of the HUB subcontracting plan. (iii) The Respondent shall provide the notice described in this section to three or more HUBs per each subcontracting opportunity that provide the type of work required for each subcontracting opportunity identified in the contract specifications or any other subcontracting opportunity the Respondent cannot complete with their own equipment, supplies,

materials, and/or employees. The Respondent must document the HUBs contacted on the HSP forms provided, which is part of this RFP.

(C) Provide written justification of the selection process if a non-HUB subcontractor

is selected.

(D) Provide notice to minority or women trade organizations or development centers to assist in identifying HUBs by disseminating subcontracting opportunities to their membership/participants. Examples of minority or women trade organization websites are, but not limited to:

i. Texas Women’s Chamber of Commerce www.womenschambertexas.com;

ii. Texas Asian Chamber of Commerce www.txasianchamber.org;

iii. Texas Association of Mexican American Chamber of Commerce http://www.tamacc.org/chambers/index.html;

iv. Texas Association of African American Chamber of Commerce http://www.taaacc.org; and

v. Minority/Women Business Links http://www.tbpc.state.tx.us/hub/minoritywomenbuslinks.htm

(E) The Respondent must notify HUBs of the subcontracting opportunities that the respondent intends to subcontract. The preferable method of notification shall be in writing. The notice shall, in all instances, include the scope of the work,

http://www.womenschambertexas.com/

http://www.txasianchamber.org/

http://www.tamacc.org/chambers/index.html

http://www.taaacc.org/

http://www.tbpc.state.tx.us/hub/minoritywomenbuslinks.htm


information regarding the location to review plans and specifications, information about bonding and insurance requirements, and identify a contact person. The notice shall be provided to potential HUB subcontractors prior to submission of the respondent's response.

In making a determination if a good faith effort has been made in the development of the required HUB subcontracting plan, DSHS may require the Respondent to submit supporting documentation explaining how the Respondent has made a good faith effort. When requested, the documentation shall include at least the following:

(A) how the Respondent divided the contract work into reasonable lots or

portions consistent with prudent industry practices identifying each area the Respondent plans to subcontract.

(B) how the Respondent's notices contain adequate information about bonding, insurance, the availability of plans, the specifications, scope of work, required qualifications and other requirements of the contract allowing reasonable time for HUBs to participate effectively;

(C) how the Respondent negotiated in good faith with qualified HUBs, not rejecting qualified HUBs who were also the best value responsive bidder;

(D) how the Respondent provided notice to minority or women trade organizations or development centers to assist in identifying HUBs by disseminating subcontracting opportunities to their membership and/or participants; and

(E) Evidence that, for each area the Respondent plans to subcontract, the Respondent provided the notice described above to three or more HUBs that perform the type of work. Evidence of notice should include official

written documentation, (i.e. phone logs, fax transmittals confirmations, e- mail correspondence confirmation, certified mail receipts, etc) to demonstrate compliance with the notice required in this subsection.

A Respondent's participation in a Mentor Protégé Program under the Texas Government Code §2161.065, and the submission of a protégé as a subcontractor in the HSP constitutes a good faith effort for the particular area to be subcontracted with the protégé. When submitted, state agencies may accept a Mentor Protégé Agreement that has been entered into by the Respondent (mentor) and a certified HUB (protégé). The DSHS shall consider the following in determining the Respondent's good faith effort:

(A) if the Respondent has entered into a fully executed Mentor Protégé Agreement that has been

registered with the commission prior to submitting the plan, and (B) if the Respondent's HUB subcontracting plan identifies the areas of

subcontracting that will be performed by the protégé.

In developing the HSP, Respondents are encouraged to identify, as part of the HSP, multiple subcontractors who are able to perform the work in each area that the Respondent is planning to subcontract. Selecting additional subcontractors for each area may assist the awarded contractor in making


changes to its original HSP, when needed, and will allow DSHS to approve any necessary changes expeditiously.

The HSP shall also include the following:

(I) certification that respondent has made a good faith effort to meet the requirements of this section; (ii) identification of the subcontractors that will be used during the course of the contract; (iii) the expected percentage of work to be subcontracted; and

(iv) the approximate dollar value of that percentage of work.

A Respondent’s participation in a Mentor Protégé Program under the Texas Government Code §2161.065, and the submission of a protégé as a subcontractor in the Respondent’s HSP constitutes a good faith effort for the particular area(s) to be subcontracted with the protégé. When applicable, the Respondent must attach a copy of its Mentor Protégé Agreement that has been approved by a sponsoring state agency and identify each protégé on the prescribed HSP form.

If the Respondent Does Not Intend to Subcontract

If the Respondent is able to fulfill any of the potential subcontracting opportunities

identified with their own equipment, supplies, materials and/or employees, the Respondent shall complete and submit the Self Performance HUB Subcontracting Plan (HSP) with their response. An explanation shall be provided documenting how the Respondent intends to fulfill each subcontracting opportunity. The Respondent shall provide supporting documentation to substantiate the statement. The Respondent agrees to provide the following if requested by DSHS:

(A) agree to produce evidence of existing staffing to meet contract objectives’ (B) agree to supply monthly payroll records showing company staff fully

engaged in the contract; (C) agree to periodic on site reviews of company headquarters or work site

where services are to be performed; and (D) agree to produce documentation proving employment of qualified personnel

holding the necessary licenses and certificates required to perform the work.

Evaluation of the HSP

The HUB subcontracting plan shall be reviewed and evaluated prior to contract award and, if accepted, shall become a provision of DSHS's contract. Revisions necessary to clarify and enhance information submitted in the original HUB subcontracting plan may be made in an effort to determine good faith effort. DSHS shall review the documentation submitted by the Respondent to determine if a good faith effort has been made in accordance with this section. If DSHS determines that a submitted HUB subcontracting plan was not developed in good faith, DSHS shall treat the lack of good faith as a material failure to comply with


advertised specifications, and the RFP shall be rejected. The reasons for rejection shall be recorded in the procurement file.

Changes to the HSP After a Contract Has Commenced

If the Respondent is selected and decides to subcontract any part of the contract after the award, as a provision of the contract, the Contractor must comply with provisions of this section relating to developing and submitting a subcontracting plan before any modifications or performance in the awarded contract involving subcontracting can be authorized by DSHS. If the selected Contractor subcontracts any of the work without prior authorization and without complying with this section, the Contractor would be deemed to have breached the contract and be subject to any remedial actions provided by Texas Government Code, Chapter 2161, state law and this section. DSHS may report nonperformance relative to its contracts to the commission in accordance with Chapter 113, Subchapter F of the TAC Code (relating to the Vendor Performance and Debarment Program).

If at any time during the term of the contract, a Contractor desires to make changes to the approved subcontracting plan, proposed changes must be received for prior review and approval by DSHS before changes will be effective under the contract. The DSHS shall approve changes by amending the contract or by another form of written DSHS approval. The reasons for amendments or other written approval shall be recorded in the procurement file.

If DSHS expands the original scope of work through a change order or contract amendment, including a contract renewal that expands the scope of work, the DSHS shall determine if the additional scope of work contains additional probable subcontracting opportunities not identified in the initial solicitation. If the DSHS determines additional probable subcontracting opportunities exist, the DSHS will require the Contractor to submit a HSP/revised HSP for the additional probable subcontracting opportunities.

The HSP/revised HSP shall comply with the provisions of this section relating to development and submission of a subcontracting plan before any modifications or performance in the awarded contract involving the additional scope of work can be authorized by the DSHS. If the Contractor subcontracts any of the additional subcontracting opportunities identified by the DSHS without prior authorization and without complying with this section, the Contractor would be deemed to have breached the contract and be subject to any remedial actions provided by Texas Government Code, Chapter 2161, state law and this section. DSHS may report nonperformance relative to its contracts to the commission in accordance with Chapter 113, Subchapter F of the TAC Code (relating to the Vendor Performance and Debarment Program.)


Reporting and Compliance with the HSP

After a contract between DSHS and the awarded prime vendor has been executed, DSHS may coordinate a post award meeting with the awarded vendor to discuss the HSP reporting requirements.

The contractor/vendor shall maintain business records documenting its compliance with the HUB subcontracting plan and shall submit a HUB Subcontracting Plan – Prime Contractor Progress Assessment Report to the DSHS monthly and in the format required by the Texas Building and Procurement Commission and DSHS. The compliance report submission shall be required as a condition for payment. During the term of the contract, the DSHS shall monitor the HUB subcontracting plan monthly to determine if the value of the subcontracts to HUBs meets or exceeds the HUB subcontracting provisions specified in the contract.

DSHS staff will monitor the Contractor for compliance from the date of award to the completion of the contract. The Contractor shall report HUB subcontracting information to DSHS on a monthly basis (5th day of each month), or as requested. Accordingly, DSHS shall audit and require a Contractor to whom a contract has been awarded to report to the DSHS the identity and the amount paid to its subcontractors in accordance with State Agency reporting requirements, provided that payment was made to a historically underutilized business in the month to be reported.

DSHS shall maintain documentation of the Contractor’s efforts in DSHS’s contract compliance file. The Contractor shall provide the HSP Prime Contractor Progress Assessment Report to report the Contractor’s identification of its subcontractors and the amount paid to certified HUB subcontractors, in accordance with their original HSP. Include a copy of the Texas Building and Procurement Commission’s (TBPC) HUB Certificate. (This form is for reporting purposes only after award of the contract. Do not submit this document with the HSP.)

If the Contractor is meeting or exceeding the provisions, DSHS shall maintain documentation of the contractor's/vendor's efforts in the contract file. If the contractor/vendor fails to meet the HUB subcontracting provisions specified in the contract, DSHS contracting division shall notify the Contractor of any deficiencies. The DSHS shall give the Contractor an opportunity to submit documentation and explain to the DSHS why the failure to fulfill the HUB subcontracting plan should not be attributed to a lack of good faith effort by the Contractor.

In determining whether the Contractor made the required good faith effort, DSHS may not consider the success or failure of the Contractor to subcontract with HUBs in any specific quantity. DSHS’s determination is restricted to considering factors indicating good faith including, but not limited to, the following:


(a) Whether the Contractor gave timely notice to its subcontractors regarding the time and place of the subcontracted work.

(b) Whether the Contractor facilitated access to the work-site, provided electrical power and other necessary utilities.

(c) Whether documentation or information was provided that included potential changes in the scope of contract work.

If a determination is made that the Contractor failed to implement the HSP in good faith, DSHS, in addition to any other available remedies, may report nonperformance to the Texas Building and Procurement Commission in accordance with 1 Texas Administrative Code, Chapter 113, Subchapter F (relating to “Vendor Performance and Debarment Program”). In addition, if the contractor/vendor failed to implement the subcontracting plan in good faith, the agency may revoke the contract for breach of contract and make a claim against the contractor/vendor.

If the Contractor is a HUB, they must perform at least 25% of the total value of the contract with its own or leased employees, as defined by the United States Internal Revenue Service, in order for DSHS to receive 100% HUB credit for the entire contract. The HUB Contractor may subcontract up to 75% of the contract with HUB or non-HUB subcontractors. If a HUB Contractor’s HSP identifies that it is planning to perform less than 25% of the total value of contract with its employees, the HUB Contractor must report, to DSHS, the value of the contract that was actually performed by the Contractor and its HUB subcontractors. The Contractor must rectify any deficiencies of the HSP prior to the next reporting period. In accordance with Texas Administrative Code 111.26 (relating to HUB Coordinator responsibilities) DSHS’s HUB Coordinator and Contract Administrators will facilitate institutional compliance with this section. All questions concerning HUBs and the DSHS HUB program should be directed to the HUB Program Coordinator at 512-458-7394 / 800-243-7487 or by email at: [email protected].

F. Contract Information

The final funding amount and the terms of the contract shall be determined through negotiations between DSHS Staff and the applicant(s). DSHS reserves the right to adjust the funding allocation during the term of the contract, pursuant to the terms of the contract. Any exceptions to the requirements in the RFP shall be specifically noted and satisfactorily explained by the applicant in the application before consideration by DSHS. DSHS reserves the right to deny requests for exceptions.



G. Contract Award Protest Policy DSHS has established a policy for a protest regarding an award. It states that a bidder, offerer, or applicant who has an allegation that DSHS has failed to follow applicable statutes and rules in the procurement process, may file a protest. Information on the filing process, requirements, resolution, and appeal may be reviewed at http://www.DSHS.state.tx.us/grants/law_reg.htm.

CONTENT AND PREPARATION

VI. APPLICATION CONTENT

A. Instructions for Preparation The application should be developed and submitted in accordance with the instructions outlined in this section. The application should meet the following stylistic requirements:

• All pages clearly and consecutively numbered; • Original and 6 copies unbound, but secured with binder clips or

rubber bands; • Typed (computer or typewriter); • Single spaced; • 12-point font on 8 1/2 “ x 11” paper with 1” margins; • Blank forms provided in SECTION VII. BLANK FORMS AND

INSTRUCTIONS shall be used (electronic reproduction of the forms is acceptable; however, all forms shall be identical to the original form(s) provided; and

• Signed in ink by an authorized official (copies must be signed but need not bear an original signature).

Specific instructions for each required section are provided. Instructions for completing forms are found on each form.

B. Confidential Information The applicant shall clearly designate any portion(s) of this application that contains confidential information and state the reasons the information should be designated as such. Marking the entire application as confidential will neither be accepted nor honored. If any information is marked as confidential in the application, DSHS will determine whether the requested information may be excepted from disclosure under the Public Information Act, Texas Government Code, Chapter 552. If it constitutes an exception, and if a request is made by any other entity for the information marked as confidential, the information may be excepted from disclosure and shall be forwarded to the Texas Attorney General along with a request for a ruling on its confidentiality. Applicants are advised to consult with their legal counsel regarding disclosure issues and to take the appropriate precautions to safeguard trade secrets or any other confidential information. Following the

http://www.tdh.state.tx.us/grants/law_reg.htm


award of any contract, applications to this RFP are subject to release as public information unless any application or specific parts of any application can be shown to be exempt from the Public Information Act, Chapter 552, Texas Government Code.

C. Table of Contents USE THE APPLICATION’S FORM B AS THE GUIDE FOR

ORGANIZATION AND ARRANGING THE TABLE OF CONTENTS. VII. BLANK FORMS AND INSTRUCTIONS

To use the check box, place the pointer over the box and double click the left mouse button. In the Check Box Form Field Options, change the Default Value to Checked by clicking the circle in front of it. Unlocked Forms To have the computer do the addition:

1. Completely fill out the column or row you are going to sum. If you are summing all of the totals, update the sum all of the columns and all of the rows before updating the sum of the totals.

2. Word will not update the totals automatically. Select the form field for the sum in one of the following ways: • Use the tab key to move from field to field or place the cursor

immediately in front of the “0” or previous total with gray shading. • Drag the cursor over the “0” or previous total with gray shading so that

only number is selected. Note: If the entire table cell is selected (black), the formula will not work and you risk deleting the form field.

Tip: The first time you use the forms, the totals are all “0” with gray shading. Before updating a total, zoom in until you can easily see the “0” and the gray shading.

3. Press the F9 key (usually at the top of the keyboard). 4. Check the results. If it looks wrong, check the numbers you put in the

row or column. Caution: Never delete the form field for the total (the “0,” or previous total, with gray shading). The formulas will not work after the form field for the total is deleted. Selecting the field and typing over it will delete the field. The Backspace key will delete the field. The Delete key will delete the field. Tip: You must update the totals for the columns and rows each time you change a number in that column or row. Locked Forms Fill in the form by entering information in the form fields. You can use the TAB and SHIFT+TAB or the arrow keys to move between fields.


To have the computer do the addition:

1. Use the tab key to move from field to field. Completely fill out the column or row you are going to sum.

2. Word will not update the totals automatically. On the Tools menu, click Options, and then click the Print tab.

3. Under “Printing” options, click the Update fields check box. Print the document or the changed page and the new sum will be calculated.

4. Check the results. If it looks wrong, check the numbers you put in the row or column.

Tip: You must update the totals for the columns and rows each time you change a number in that column or row.

Department of State Health Services

FORM A: FACE PAGE – Application for Financial Assistance- RFP# CHS/FQHC-0150.1

This form requests basic information about the applicant and project, including the signature of the authorized representative. The face page is the cover page of the application and shall be completed in its entirety.

APPLICANT INFORMATION 1) LEGAL NAME: 2) MAILING Address Information (include mailing address, street, city, county, state and zip code): Check if address change

3) PAYEE Mailing Address (if different from above): Check if address change

4) Federal Tax ID No. (9 digit), State of Texas Comptroller Vendor ID No. (14 digit) or Social Security Number (9 digit) : *The vendor acknowledges, understands and agrees that the vendor's choice to use a social security number as the vendor identification number for the contract, may result in the social security number being made public via state open records requests.

5) TYPE OF ENTITY (check all that apply): City Nonprofit Organization* Individual County For Profit Organization* FQHC Other Political Subdivision HUB Certified State Controlled Institution of Higher Learning State Agency Community-Based Organization Hospital Indian Tribe Minority Organization Private Other (specify):

*If incorporated, provide 10-digit charter number assigned by Secretary of State: 6) PROPOSED BUDGET PERIOD: Start Date: End Date: 7) COUNTIES SERVED BY PROJECT:

8) AMOUNT OF FUNDING REQUESTED: 10) PROJECT CONTACT PERSON 9) PROJECTED EXPENDITURES

Name: Phone: Fax: E-mail:

11) FINANCIAL OFFICER

Does applicant’s projected state or federal expenditures exceed $500,000 for applicant’s current fiscal year (excluding amount requested in line 8 above)? ** Yes No **Projected expenditures should include funding for all activities including “pass through” federal funds from all state agencies and non project-related DSHS funds.

Name: Phone: Fax: E-mail:

The facts affirmed by me in this application are truthful and I warrant that the applicant is in compliance with the assurances and certifications contained in APPENDIX A: DSHS Assurances and Certifications. I understand that the truthfulness of the facts affirmed herein and the continuing compliance with these requirements is conditions precedent to the award of a contract. This document has been duly authorized by the governing body of the applicant and I (the person signing below) am authorized to represent the applicant. 12) AUTHORIZED REPRESENTATIVE Check if change 13) SIGNATURE OF AUTHORIZED REPRESENTATIVE

14) DATE

Name: Title: Phone: Fax: E-mail:



FORM A: FACE PAGE Instructions This form provides basic information about the applicant and the proposed project with the Department of State Health Services (DSHS), including the signature of the authorized representative. It is the cover page of the application and required to be completed. Signature affirms that the facts contained in the applicant’s response are truthful and that the applicant is in compliance with the assurances and certifications contained in APPENDIX A: DSHS Assurances and Certifications and acknowledges that continued compliance is a condition for the award of a contract. Please follow the instructions below to complete the face page form and return with the applicant’s response. 1) LEGAL NAME - Enter the legal name of the applicant.

2) MAILING ADDRESS INFORMATION - Enter the applicant’s complete street and mailing address, city, county, state, and zip code.

3) PAYEE MAILING ADDRESS - Enter the PAYEE’s name and mailing address if PAYEE is different from the applicant. The PAYEE is the corporation, entity or vendor who will be receiving payments.

4) FEDERAL TAX ID/STATE OF TEXAS COMPROLLER VENDOR ID/SOCIAL SECURITY NUMBER - Enter the Federal Tax Identification Number (9-digit) or the Vendor Identification Number assigned by the Texas State Comptroller (14-digit). *The vendor acknowledges, understands and agrees that the vendor's choice to use a social security number as the vendor identification number for the contract, may result in the social security number being made public via state open records requests.

5) TYPE OF ENTITY - The type of entity is defined by the Secretary of State and/or the Texas State Comptroller. Check all appropriate boxes that apply.

HUB is defined as a corporation, sole proprietorship, or joint venture formed for the purpose of making a profit in which at least 51% of all classes of the shares of stock or other equitable securities are owned by one or more persons who have been historically underutilized (economically disadvantaged) because of their identification as members of certain groups: Black American, Hispanic American, Asian Pacific American, Native American, and Women. The HUB must be certified by the Texas Building and Procurement Commission or another entity.

MINORITY ORGANIZATION is defined as an organization in which the Board of Directors is made up of 50% racial or

ethnic minority members. If a Non-profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the Secretary of

State. 6) PROPOSED BUDGET PERIOD - Enter the budget period for this application. Budget period is defined in the RFP. 7) COUNTIES SERVED BY PROJECT - Enter the proposed counties served by the project. 8) AMOUNT OF FUNDING REQUESTED - Enter the amount of funding requested from DSHS for proposed project

activities. This amount must match column (1) row J from FORM I: BUDGET SUMMARY. 9) PROJECTED EXPENDITURES - If applicant’s projected state or federal expenditures exceed $500,000 for applicant’s

current fiscal year, applicant shall arrange for a financial compliance audit (Single Audit). *Note: As stated in the Preface of this RFP, the UGMS are being revised. This process is expected to be complete before 05/01/2004. A change that is proposed will raise the single audit threshold from $300,000 to $500,000.

10) PROJECT CONTACT PERSON - Enter the name, phone, fax, and e-mail address of the person responsible for the

proposed project. 11) FINANCIAL OFFICER - Enter the name, phone, fax, and e-mail address of the person responsible for the financial

aspects of the proposed project. 12) AUTHORIZED REPRESENTATIVE - Enter the name, title, phone, fax, and e-mail address of the person authorized to

represent the applicant. Check the “Check if change” box if the authorized representative is different from previous submission to DSHS.

13) SIGNATURE OF AUTHORIZED REPRESENATIVE - The person authorized to represent the applicant signs in this blank. 14) DATE - Enter the date the person authorized to represent the applicant signed this form.


FORM B: APPLICATION CHECKLIST

Legal Name of Applicant: This form is provided to ensure that the application is complete, proper signatures are included, and the required assurances, certifications and attachments have been submitted.

FORM DESCRIPTION Included Not Applicable

A Face Page completed, and proper signatures and date included

B Application and HUB Checklist completed and included

C Contact Person Information completed and included

D

Administrative Information completed and included (with supplemental documentation attached if required)

E Site Information completed and included

F Funding Information and Project Abstract completed and included

G Applicant Background completed and included

H Assessment Narrative completed and included (MUA/MUP documentation)

I

FQHC Collaborative Narrative completed and included (MOUs/Contracts/Support letters)

J FQHC Feasibility Narrative completed and included

J a Funding Feasibility Checklist and attachments completed and included

J b Services Provided in FY 05 and Proposed in FY 06 completed and included

J c Staff Profile completed and included

J d Health Center Affiliation Checklist completed and included (Affiliation Agreements)

J e Current Patient Population and Revenue Information completed and included (Not required if applying for Planning Grant funds.)

Copy of Board Approved Resolution to meet FQHC-LA requirements. Refer to A. Eligible Applicant criteria for the specific resolution requirements for each component. (Not required if applying for Planning Grant funds.)

A copy of a currently valid IRS Tax Exempt Certification

K Sustainability Narrative completed and included

K a Expenditure and Project Budget Report completed and included. (Not required if applying for Planning Grant funds.)

Board Minutes and Financial Statements for October 2004 through March 2005 required for all Development, TOS, or Capital Improvement requests. (Not required if applying for Planning Grant funds.) Copy of most recent annual audit.


Renovations and Equipment Cost Estimates

L Performance Measures completed and included

M Deliverables and Payment Schedule completed and included

N DSHS Grant/Contract Applicants HUB Attachments

O Nonprofit Board of Directors and Executive Director Assurance Form

P Board of Directors Characteristics. This characteristics form should be completed for the spin-off organization if one is proposed and is waiting on I.R.S. non-profit designation

Q If a spin-off organization is proposed, an acknowledgement letter from the IRS stating that an IRS Tax Exemption Application has been received from that entity must be submitted.


FORM B-1: HUB CHECK LIST Summary Of Attachments Required From All Respondents

HSP CHECKLIST ATTACHMENTS

FORM “X” FORM “X”

1. Respondent intends to subcontract.

Attachments required from the Respondent for the HUB Subcontracting Plan (HSP).

2. Respondent intends to subcontract under a Mentor Protégé relationship.

Attachment and Mentor Protégé (MP) Agreement is required from the Respondent for the HUB Subcontracting Plan (HSP). MP identifies the areas of subcontracting that will be performed by the protégé.

3. Respondent does not intend to subcontract.

Attachments required from the Respondent for the HUB Subcontracting Plan (HSP) if the RFP states that subcontracting opportunities are probable, but the Respondent intends to perform such opportunities with its own employees, equipment and resources.

ATTACHMENT “X” SUMMARY OF ATTACHMENTS REQUIRED FROM THE RESPONDENT AFTER THE CONTRACT HAS BEEN AWARDED. THIS FORM IS FOR REPORTING PURPOSES ONLY. DO NOT SUBMIT THESE DOCUMENTS WITH THE HSP.

Post Award Reporting Checklist Attachments Form “X”

A. Subcontracting – Forms required from Contractor for compliance with the HUB Subcontracting Plan (HSP) after the contract award.

FORM C: CONTACT PERSON INFORMATION

Legal Name of Applicant: This form provides information about the appropriate contacts in the applicant’s organization in addition to those on FORM A: FACE PAGE. If any of the following information changes during the term of the contract, send written notification immediately to the Client Services Contracting Unit and TPCO.

Contact: Mailing Address (incl. street, city, county, state, & zip): Title: Phone: Fax: E-mail: Contact: Mailing Address (incl. street, city, county, state, & zip): Title: Phone: Fax: E-mail: Contact: Mailing Address (incl. street, city, county, state, & zip): Title: Phone: Fax: E-mail: Contact: Mailing Address (incl. street, city, county, state, & zip): Title: Phone: Fax: E-mail: Contact: Mailing Address (incl. street, city, county, state, & zip): Title: Phone: Fax: E-mail:


FORM D: ADMINISTRATIVE INFORMATION

This form provides information regarding identification and contract history of the applicant, executive management, project management, governing board members, and/or principal officers. Respond to each request for information or provide the required supplemental document behind this form. If responses require multiple pages, identify the supporting pages/documentation with the applicable request.

Legal Name of Applicant: Identifying Information 1. The applicant shall attach the following information: If a Governmental Entity

• Names (last, first, middle) and addresses for the officials who are authorized to enter into a contract on behalf of the applicant.

If a Nonprofit or For profit Corporation

• Full names (last, first, middle), addresses, telephone numbers, titles and occupation of members of the Board of Directors or any other principal officers. Indicate the office held by each member (e.g. chairperson, president, vice-president, treasurer, etc.).

• Full names (last, first, middle), and addresses for each partner, officer, and director as well as the full names and addresses for each person who owns five percent (5%) or more of the stock if applicant is a for-profit corporation.

2. Is applicant a private, nonprofit organization? YES NO If YES, applicant shall include evidence of its nonprofit status with the application. Any one of the following is

acceptable evidence. Check the appropriate box for the attached evidence or complete the “Previously Filed” section, whichever is applicable.

(a) A reference to the organization’s listing in the Internal Revenue Service’s (IRS’) most recent list of

tax-exempt organizations described in section 501(c)(3) of the IRS Code. (b) A copy of a currently valid IRS Tax exemption certificate.

(c) A statement from a State taxing body, State Attorney General, or other appropriate State official certifying that the applicant organization has a nonprofit status and that none of the net

earnings accrue to any private shareholders or individuals. (d) A certified copy of the organization’s certificate of incorporation or similar document if it clearly establishes the nonprofit status of the organization. (e) Any of the above proof for a State or national parent organization, and a statement signed by The parent organization that the applicant organization is a local nonprofit affiliate. If an applicant has evidence of current nonprofit status on file with a program of DSHS, indicate name of program

and date of filing.

Previously Filed with: (DSHS Program) On (Date)



FORM D: ADMINISTRATIVE INFORMATION continued Conflict of Interest and Contract History The applicant shall disclose any existing or potential conflict of interest relative to the performance of the requirements of this RFP. Examples of potential conflicts may include an existing business or personal relationship between the applicant, its principal, or any affiliate or subcontractor, with DSHS, the participating agencies, or any other entity or person involved in any way in any project that is the subject of this RFP. Similarly, any personal or business relationship between the applicant, the principals, or any affiliate or subcontractor, with any employee of DSHS, a participating agency, or their respective suppliers, must be disclosed. Any such relationship that might be perceived, or represented as a conflict, shall be disclosed. Failure to disclose any such relationship may be cause for contract termination or disqualification of the proposal. If, following a review of this information, it is determined by DSHS that a conflict of interest exists the applicant may be disqualified from further consideration for the award of a contract. 1. Does anyone in the applicant organization have an existing or potential conflict of interest relative to the

performance of the requirements of this RFP? YES NO If YES, detail any such relationship(s) that might be perceived or represented as a conflict. (Attach no more than

one additional page.) 2. Has any member of applicant’s executive management, project management, governing board or principal

officers been employed by the State of Texas 24 months prior to the application due date? YES NO If YES, indicate his/her name, social security number, job title, agency employed by, separation date, and reason

for separation. 3. Has applicant had a contract with DSHS within the past 24 months? YES NO If YES, indicate the contract number(s):

Contract Number(s)

If NO, applicant shall be able to demonstrate fiscal solvency. Submit a copy of the organization’s most recently

audited balance sheet, statement of income and expenses and accompanying financial footnotes. If audited documentation is not available, provide explanation and submit a complete copy of the most recent Federal Income Tax Return (i.e. Form 990) as filed with the Internal Revenue Service. DSHS will evaluate the documents that are submitted and may, at its sole discretion, reject the proposal on the grounds of the applicant’s financial capability.

4. Is applicant or any member of applicant’s executive management, project management, board members or

principal officers: • delinquent on any state, federal or other debt;

• affiliated with an organization which is delinquent on any state, federal or other debt; or • in default on an agreed repayment schedule with any funding organization?

YES NO

If YES, please explain. (Attach no more than one additional page.)

FORM E: SITE INFORMATION

Legal Name of Applicant: This form provides information about the applicant organization for the Texas Primary Care Office. If any of the following information changes during the term of the contract, please send written notification to the Texas Primary Care Office. ADD ADDITIONAL SHEETS IF NECESSARY. Clinic Name (if applicable): Mailing Address of Clinic (if applicable): DSHS Primary Health Care Grantee: Rural Health Clinic: Critical Access Hospital: County: Physical Clinic Address (if applicable): Counties Served: MD or DO Provider FTE: Mid-level FTE: Mental health/dental FTE: County: Second Clinic Physical Address: Counties Served: MD or DO Provider FTE: Mid-level FTE: Mental health/dental FTE: County: Third Clinic Physical Address: Counties Served: MD or DO Provider FTE: Mid-level FTE: Mental health/dental FTE: County: Fourth Clinic Physical Address: Counties Served: MD or DO Provider FTE: Mid-level FTE: Mental health/dental FTE:


FORM F: FUNDING INFORMATION

Legal Name of Applicant: This form provides information about the applicant organization for the Texas Primary Care Office.

AMOUNT REQUESTED IN THIS APPLICATION

Planning $ Development $ TOS $ Capital Improvements $ TOTAL $

FY 04/05 INCUBATOR GRANT AWARDS

FY 04 FY 05 Planning $ $ Development $ $ TOS $ $ Capital Improvements $ $ TOTAL $ $

FY 06 INCUBATOR GRANT AWARDS

CYCLE 1 CYCLE 2 Planning $ Development $ TOS $ Capital Improvements $ TOTAL $

Notes:


FORM F a PROJECT ABSTRACT

Legal Name of Applicant: Applicant shall provide a brief one-page project abstract. No additional pages are permitted. The Project Abstract is not included in the Evaluation Criteria.

A. Describe applicant’s current services including but not limited to service area, target population, number of providers, FTEs, delivery location(s), clinical services, and total number of users and encounters, etc.

B. Describe how applicant will use the FQHC Incubator Program requested funds to increase access and services and/or to meet the FQHC program expectations (PIN 98-23, etc.).

C. Describe briefly what the applicant organization will provide in an overview narrative for the BPHC’s FQHC-LA application, or if a FQHC, an application for additional 330 funding. Information should be similar to information requested under A above.


FORM G: APPLICANT BACKGROUND Legal Name of Applicant: Applicant shall provide a narrative description including: the legal name of the applicant; any affiliations; its overall purpose or mission statement; and a brief history of its accomplishments. Describe the organizational structure, such as board of directors, officers, committees, and management staff. Describe organizational involvement in primary care, dental, and/or mental health, cultural competency, efforts to respond to community primary care needs, and work thus far on developing a FQHC including any training from the TPCO or the TACHC. If applicant is preparing a spin-off I.R.S. designated, non-profit organization, briefly describe the originating organization and then complete the information requested above for the new spin-off organization. A maximum of 1 additional page may be attached if needed.


FORM H: ASSESSMENT NARRATIVE

Legal Name of Applicant: Multiple data sources and assessments exist for most communities. Applicant is encouraged to utilize these resources when completing this form. Address each of the assessment activities (see ASSESSMENT NARRATIVE Guidelines) associated with the services proposed in this application. A maximum of 1 additional page may be attached if needed.


FORM H: ASSESSMENT NARRATIVE Guidelines

Multiple data sources and assessments exist for most communities. Applicant is encouraged to utilize these resources when completing this form. Specifically address each of the assessment activities listed below associated with the services proposed in this application. The required assessment items include: 1. Provide brief synopsis of the community as a whole describing in general: a. Geographic boundaries (urban or rural, physical environment); and b. Basic demographics (i.e. poverty, ethnicity, languages spoken). 2. Describe target population including: a. Geographic service area by county, census tracts, and zip codes; and

b. Characteristics of target population (including demographic and socioeconomic data specific to the target population).

3. Describe gaps in resources and potential barriers to developing an FQHC or FQHC-LA.

o Applicant has not received FQHC Incubator Program grants in FY 04 or FY 05, provide a discussion of organizational and community barriers toward development of a FQHC including issues related to meeting FQHC governance requirements, providing required services and becoming operational.

o If applicant has received FQHC Incubator Program grants in FY 04 and FY 05, provide a discussion of remaining barriers to submitting a competitive Section 330 Grant application and/or FQHC-LA application.

4. Documentation of MUA/MUP.


FORM I: FQHC COLLABORATION NARRATIVE Legal Name of Applicant: Describe applicant’s collaborative efforts. If applicant is preparing a spin-off I.R.S. 501(c)(3) designated non-profit organization, but it has not been fully developed yet, the originating organization’s collaborative efforts should be described.

1. Describe current collaborative efforts for this project, including partnerships to increase access to health care specific to this project; 2. Describe and include Memoranda of Understanding (MOUs), support letters or, document efforts to collaborate with:

o existing area FQHCs or FQHC-LA; o rural health clinics; o hospitals; and, o clinical services not provided directly by the applicant, specifically, oral health, mental health and substance

abuse services required for FQHC-LA applications. The Services Provided Form can be used as a checklist for MOU inclusion.

3. Describe other sliding fee scale clinics in area and efforts to collaborate; 4. Describe only MOUs for enabling services. 5. Describe coordination with TPCO and/or TACHC regarding this project.

Attach signed Memoranda of Understanding (MOUs) to document collaboration specific to this project. (MOUs will not count toward page limits.) A maximum of 1 additional page may be attached if needed.


FORM J: FQHC FUNDING FEASIBILITY NARRATIVE Legal Name of Applicant: Describe feasibility of securing new or expanded FQHC funding for applicant*;

• document eligibility criteria for components for which you are applying (Section I., A, “Eligible Applicants”) • provide evidence regarding applicant’s commitment to develop a safety net clinic in the targeted community and its ability to overcome

barriers as identified in Assessment Narrative (Form H); • write a justification as to how the target area will support additional services; • describe:

o applicant’s ability to comply with all of the program expectations (requirements) for FQHC-LA; o the impact of becoming a FQHC-LA; or o the impact (for existing FQHCs) of new or additional FQHC funding; and,

• describe any previous governing board training on the program expectations/requirements of applying for FQHC-LA. *If applicant is preparing a spin-off I.R.S designated non-profit organization, briefly describe the originating organization’s ability to support (staff, funds, etc.) the creation of an organization that will have the ability to become an FQHC-LA or FQHC. A maximum of 1 additional page may be attached if needed. Compete the following Forms J a through J e; include appropriate resolution(s) described in Section A. Eligible Applicants and a copy of I.R.S Tax Exempt Certificate.


FORM J a FUNDING FEASIBILITY CHECKLIST

Legal Name of Applicant:________________________________________________________________________ All applicants should complete this checklist by marking the appropriate column with an X. If there is a XXX in the third column, and the applicant has checked X “YES” the document should be attached to the application. If applicant is preparing a spin-off I.R.S. 501(c)(3) designated non-profit organization, the checklist should be completed for the spin-off organization that will have the ability to become an FQHC-LA and/or FQHC.Assessment Item YES,

Currently In Place

NO REQUIRED ATTACHMENT

Mission Statement Board approved written mission statement. XXX Needs Assessment A written, site-specific Needs Assessment. Needs Assessment was reviewed and approved by the Board. Planning Board approved short-term (1 year) strategic plan. XXX Board approved annual operating/business plan. XXX Annual Health Care Plan A health care plan that addresses the identified highest priority needs and health disparities in the community/needs assessment. Quality Improvement/ Management Plan Board approved a Quality Improvement/Management Plan. Systems to monitor performance and improvement in the following: Patient Satisfaction Access Quality of clinical care Quality of workforce/environment Cost Health Status Board Structure Board approved by-laws XXX Board approved minutes for the months of Oct 2004 through March 2005 XXX Organization Current board approved organizational chart. XXX Management Which of the following positions are included in the senior management team: Chief Executive Officer (CEO) NAME: Chief Medical Officer (CMO) NAME: Chief Financial Officer (CFO) NAME: Is the CFO full-time? Is the Chief Medical Officer full-time? Risk Management Is there a Safety Committee and/or Safety Officer? NAME: Facility List the facility operating hours Is the building lease in compliance with Federal regulations, i.e. ADA?


Fees and Billing Is there a fee schedule? The fee schedule covers the cost of the following: All types of visits Procedures Lab tests Other ancillary services Does Center have Medicaid and Medicare provider numbers? Are Medicare and Medicaid billed electronically? Sliding Fee Scale Discount (SFSD) Program

Copy of SFSD program including discount scale based on current FPGs? XXX Are there signs in your lobby and at the exit/cashier’s desk (in all languages appropriate to the patient mix). Attach copy(ies) of notice(s) (in all languages appropriate to target population) announcing the availability of discounts for eligible low-income persons? XXX Is access provided for services without regard to the patient’s ability to pay? Financial Management Is there a monthly cash budget for the Center? Are monthly financial statements prepared for review by the Finance Committee and Board? Do the statements include a comparative balance sheet and an income statement showing variances from budget? A report on encounter activity compared to budget by payer type? A comparative report on the status of receivables? Management Information Systems Does the center operate its own Management Information System (MIS) or collaborate with another organization on MIS? Required Services - Primary, Preventive, Dental, Mental Health, Substance Abuse, Emergency, Pharmacy Are the following Primary Care Services provided directly (P), by formal referral (F), by informal referral (I), or not provided (N): Perinatal ___, Pediatric ___, Adolescent ___, Adult ___, Geriatric ___? Are the following Dental Services provided directly (P), by formal referral (F), by informal referral (I), or not provided (N): Perinatal ___, Pediatric ___, Adolescent ___, Adult ___, Geriatric ___? Are the following Substance Abuse Services provided directly (P), by formal referral (F), by informal referral (I), or not provided (N): Perinatal ___, Pediatric ___, Adolescent ___, Adult ___, Geriatric ___? Are the following Mental Health Services provided directly (P), by formal referral (F), by informal referral (I), or not provided (N): Perinatal ___, Pediatric ___, Adolescent ___, Adult ___, Geriatric ___? Have arrangements been made with a Pharmacy so that all patients are able to fill written prescriptions? Is there a system in place to assist patients who have transportation needs? Inpatient Continuity of Care Do center physicians admit and follow hospitalized patients? Specialty Referrals Through formal and informal arrangements has the center been able to access specialty care for the underserved?


After-Hours Coverage Does the health care center have a system for after-hour clinical consultation/care made available and communicated to the patients? Are the answering service and/or provider multilingual in order to communicate effectively with special populations? Consumer Bill of Rights Has board adopted Patient Bill of Rights and Responsibilities, in all languages appropriate to the target population? XXX Is the Bill of Rights in the Waiting Room?


FORM J b: SERVICES PROVIDED FY 05 & PROPOSED FY 06

Legal Name of Applicant: All applicants requesting grant support for development, transitional operating support and/or capital improvements must complete this form. Check all that apply. If applicant is preparing a spin-off I.R.S 501(c)(3) designated non-profit organization, this information should describe the spin-off organization’s ability to provide these services. SERVICE TYPE

Provided by Applicant Yes or No

By Referral/Applicant Pays

By Referral/Applicant Doesn’t Pay

General Primary Medical Care Diagnostic Laboratory Diagnostic X-Ray Urgent Medical Care 24-Hour Coverage Family Planning HIV Testing Immunizations

PRIMARY MEDICAL CARE SERVICES

Following Hospitalized Patients Gynecological Care OB/GYN

CARE Obstetrical Care Preventive Restorative Emergency

DENTAL SERVICES

Other Developmental Screening 24-Hour Crisis Other Mental Health Substance Abuse Other Substance Abuse

MENTAL HEALTH SERVICES

Pharmacy WIC Case Management Eligibility Assistance Translation Outreach Transportation Other Other

ENABLING AND OTHER SERVICES

Other


FORM J c: STAFF PROFILE

Legal Name of Applicant: All applicants must complete this form. Staff Profile will document the applicant’s capacity to provide the required services for FQHC-LA status and additional Section 330 funding programs. Indicate with a “E” or “C” for employed or contracted respectively and include salary or contract fee. If applicant is preparing a spin-off I.R.S designated non-profit organization, this information should describe the spin-off organization.

Total FTEs Annual Salary or Contract Fee

Will FQHC Incubator Support be used for position? Indicate Yes (Y) or No (N); and, Employee (E) or Contractor (C)

PERSONNEL BY CATEGORY

May 2005 Feb 2006 Administration CEO CFO COO Administrative Support Staff Medical Staff Medical Director Family Practitioners Internists OB/GYNs Pediatricians Psychiatrists Physician Assistants Nurse Practitioners Certified Nurse Midwives Nurses (RNs) Pharmacist Other Medical Personnel X-Ray Personnel Laboratory Personnel Clinical Support Staff Dental Staff Dentists Dental Hygienists Dental Assistants, Aids, Techs Mental Health Staff Mental Health Specialists Substance Abuse Specialists Case Managers Other Professional Personnel Other Staff Education Specialists Outreach Translation Transportation Eligibility Assistance Other


FORM J d: HEALTH CENTER AFFILIATION CHECKLIST Page 1 of 2

Legal Name of Applicant: Must be completed by all applicants. Checklist should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. 1. a) Does your organization have, or propose to establish any of the following arrangements with another

organization? (NOTE: You must complete a checklist for each organization with which you have any of the following arrangements. Copies of all applicable documents must be included with the application.)

YES (Please check all that apply and proceed to question #2)

NO (Go to question #2)

a) Contract for a substantial portion of the approved scope of project

b) Memorandum of Understanding (MOU)/Agreement (MOA) for a substantial portion of the approved scope of project

c) Contract with another organization or individual contract for core providers

d) Contract with another organization for staffing health center

e) Contract with another organization for the Chief Medical Officer (CMO) or Chief Financial Officer (CFO)

f) Merger with another organization

g) Parent Subsidiary Model arrangement

h) Acquisition by another organization

i) Establishment of a New Entity (e.g., Network corporation)

1. b) The arrangements presented in the affiliation agreements YES NO as defined in Question 1 do not compromise the Board’s authority.

(Examples of compromising arrangements are: overriding approval or veto authority by another entity; dual majority requirements; super-majority requirements; or hiring and selection of the CEO). Name of Affiliating Organization: Address: STAFFING 2) The center directly employs the CEO, CFO, CMO and the core staff of full-time primary care providers. YES NO

3) The center directly employs all non-provider health center staff. YES NO

FORM J d: Health Center Affiliation Checklist Page 2 of 2 GOVERNANCE: 4) The Governing Board structure is in compliance with all Section 330 requirements. YES NO


5) If applicant:

a) Was awarded FQHC Incubator Grant Development, TOS or Capital Improvements in FY 04 or FY 05; or

b) Is requesting TOS and/or Capital Imporvement Grants, complete the following information about the Governing Board indicating that it retains its full authorities, responsibilities and functions as prescribed in legislation/regulations/BPHC PIN 98-23 (see Appendix D) guidelines in regard to the following as identified below.

Page Number from attached by-laws • board composition

• executive committee function and composition

• selection of board chairperson

• selection of members

• strategic planning

• approval of the annual budget of the center

• directly employs, selects, dismisses and evaluates the Chief Executive Officer (CEO)/Executive Director

• adoption of policies and procedures for personnel and financial management

• establishes center priorities

• establishes eligibility requirements for partial payment of services

• provides for an independent audit

• evaluation of center activities

• adoption of center’s health care policies including scope and availability of services, location, hours of operation and quality of care audit procedures

• establishes and maintains collaborative relationships with other health care providers in the service area

• existence of a conflict of interest policy


Form J e: CURRENT PATIENT POPULATION AND REVENUE INFORMATION To be completed by applicants for Development, TOS and Capital Improvements.

Legal Name of Applicant:

Fiscal Year End Date: _________

Patients: Fiscal Yr Total Number of

Unduplicated Patients

Total Number of Encounters

2003 2004 2005-Projected Age Distribution: Fiscal Yr 0-16 years 17-25 years 36-49 years 50-64 years 65+ years 2003 2004 2005- Projected

Gender Distribution (%): Fiscal Yr Male Female 2003 2004 2005-Projected Family Income (%): Fiscal Yr 0-100%FPL 101-125 FPL 126-150 FPL 151-175%

FPL 176-200% FPL

201-250% FPL

251-300% FPL

301% FPL

2003 2004 2005-Projected


Patients Employed %:

Payer Information:

Fiscal Yr 2003 2004 2005 Projected

Fiscal Yr 2004 Only

Medicaid FFS

Medicaid MC

S-CHIP MedicareFFS

Medicare MC

Commercial Uninsured/SelfPay

Other (PHC, Title V, M&CH, etc.)

Total

Patient distribution %

%

%

%

%

%

%

%

%

100%

Number of patients

%

%

%

%

%

%

%

%

100%

Visit distribution by payer %

%

%

%

%

%

%

%

%

100%

Visits by payer

%

%

%

%

%

%

%

%

100%

Billable visits per patient

%

%

%

%

%

%

%

%

100%

Notes:


FORM K: SUSTAINABILITY NARRATIVE

Legal Name of Applicant: Please describe your sustainability plan for FY 06. Address how you will continue operations if new or additional federal FQHC funding is not secured. Also address other resources that will be leveraged to make the clinic sustainable. If you are not currently applying for TOS or Capital Improvement grants, please address how you will factor sustainability into your development plans. If you have received FQHC Incubator Programs funds in FY 04 and/or FY 05:

a. Clearly identify how local fundraising has contributed to clinic operations; b. Clearly state how payer mix (Medicaid, self pay, etc.) has impacted sustainability projections.

All fees and income generated as a result of an awarded contract shall be used to enhance the sustainability of the services to the target population. Complete Form K, and all applicants (except for those applying for planning component only) must submit approved board minutes and the accompanying financial statements with balance sheets from October 2004 through March 2005.


FORM K a: SUSTAINABILITY: EXPENDITURE AND PROJECT BUDGET REPORT


Fiscal Year Ends on:

All applicants requesting grant support for development, transitional operation support and/or capital improvements must complete this form. This form should be completed for the proposed a spin-off organization. Revenues FY 04 Projected FY 05 Proposed FY 06

Patient Services Income (consistent with preceding from Current Patient Population & Revenue Information)

FQHC-internal cash resources for project development

Local Funding (City/County, United Way, etc.)

State Funding (Primary Care, Title X, etc)

FQHC Incubator Funds Other Sources (fundraisers, foundation grants, etc.)

TOTAL REVENUE

Personnel (refer to Form J c: Staff Profile)

Fringe Benefits Travel & Technical Assistance Costs (Registration, Hotel, etc.)

Supplies

Office & Printing Costs Medical Supplies Dental Supplies Pharmacy Supplies Including Drugs

X-Ray Supplies Laboratory Supplies Building & Maintenance Costs Including Lease

Total Supplies

Actual FY 04 Projected FY 05 Proposed FY 06


Contractual (Please Describe With Detail That State Auditor Can Locate And Justify Expense)

Patient Care Contracts (Such As CMO, OB/GYN, Dental, etc.)

Non-Patient Contracts (Such As MIS, security, etc.)

Total Contractual

Renovations & Equipment

Description (Such As Dental Operatories, Lab Set Up, etc.

APPLICANT MUST ATTACH DETAILED RENOVATIONS AND EQUIPMENT LISTS WITH ACCURATE COSTS ESTIMATES. FAILURE TO PROVIDE ADEQUATE DETAIL MAY LEAD TO NO OR INADEQUATE GRANT AWARD.

Total Renovations & Equipment Costs


FORM L: PERFORMANCE MEASURES

Performance measures represent the most basic and necessary steps needed to apply for FQHC-LA status and other Section 330 Grant funding support (NAP, EMC, or Service Expansion grants). Each applicant* is encouraged to include other Performance Measures that may be needed to ready the organization for federal funding. If applicant is selected for funding, Performance Measures can be negotiated (deadlines, payment, etc.) and mutually agreed upon by applicant and DSHS. Performance Measures are specific, measurable, time-phased and feasible. They quantify outcomes and outputs, the number of such outputs to be performed, and the efficiency with which they will be performed. They also define the applicant’s obligations in order to meet its contract requirements. If the Performance Measure has been completed, the applicant should indicate the date of completion and be able to provide documentation to TPCO if requested. Otherwise each Performance Measure should include detailed action steps, evidence of completion/deliverable, completion date and payment. Again, each applicant is encouraged to include other Performance Measures that may be needed to develop the organization for federal funding. The Texas Primary Care Office has provided in this section a general listing of activities/accomplishments that must be completed prior to submitting a FQHC-LA, NAP, EMC or Service Expansion application to the Bureau of Primary Health Care (BPHC). Applicants should review this list carefully, and use these activities to guide and develop a comprehensive timeline for FQHC development. The development of a FQHC is not a linear process. Organizations must be working on several activities at the same time. Each deliverable with a payment requested should be reasonable and based on market value. Also, to receive a Development and TOS, or Capital Improvement Grant, it is a requirement that the grantee will submit a FQHC-LA application to the BPHC. A February 1, 2006 deadline for FQHC-LA application submittal is a requirement for TOS and Capital Improvement Grants. If applicant has not received FQHC Incubator Program grants and is applying for Planning and/or Development funds only, a federal application submission is not required. * If applicant is preparing a spin-off I.R.S. 501(c)(3) designated non-profit organization, this information should describe the spin-off organization.


Performance Measures Examples: The following examples are not intended to be complete or to be copied by the applicant. # Performance

Measures Action Steps by Applicant (include detail steps necessary to complete measure(s) such as staffing, purchases, contracts, facility, etc.)

Evidence of Completion

Completion Date

Payment

Planning Example Community

involvement

in planning process

Persons responsible: CEO and Board Chair Identify staff to support the following community involvement program Identify dates, times and places to conduct 3 community outreach programs regarding organization’s desire to apply for FQHC funding support Identify key stakeholders to attend meeting(s) Identify FQHC expertise to assist with community meetings Analyze and write report on 3 meetings Distribute community meeting findings to local stakeholder, media, etc.

Final Report reviewed by board

10/31/05 $1,000

Development Example

CompletedCollaboration Plan

Persons Responsible: CEO and Board Identify local dental providers Meet with several dental providers and discuss plans to become a FQHC and the need to provide dental services Select dental provider for dental care plan requirements Write agreement that includes a. the services that patients can access through this affiliate dental provider (comprehensive,

non-specialty dental services); b. how the outside provider will be reimbursed for all referred dental patients, insured and

uninsured c. demonstrate that all patients will have reasonable access to services, meaning no lengthy

waiting time for a new patient appointment; d. attorney review of the agreement as a legal document; e. TACHC and the TPCO review of the draft agreement for content.

Sign agreement and incorporate into dental care plan

Complete and compliant Dental Care Plan

11/30/05 $1,000


Performance Measures Examples: continued TOS Example Identify and open for business a

clinic facility that meets capacity requirements necessary for federal application (identify one additional funding source): NAP; EMC; or Service Expansion

Persons Responsible: COO and CFO, Clinic Manager Identify 4,000 sq ft clinic facility in designated MUA Negotiate and sign lease Identify and sign the building rehab contractors Persons Responsible: Personnel Director and Clinic Manager Recruit providers, primary care physician, PA (contact TPCO, TACHC for assistance and announcements) Hire providers Hire medical assistants and administration staff

Lease and CO Personnel Contracts

11/30/05 12/15/05

$12,000 $17,000

Capital Improvements Example Purchase and install Management

Information System (MIS) that will meet UDS and FSR reporting requirements

Persons Responsible: CEO, CIO Write MIS specs Develop Bid Qualifications Accept Bids/Compliance with HUB Award Contract Installation

MIS installation

12/15/05 $40,000



Legal Name of Applicant: To be completed by applicants requesting Planning Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 1: Planning Grant # Performance Measures Action Steps by Applicant (include detailed steps necessary to complete

measure(s) such as staffing, purchases, contracts, facility, etc.)

Evidence of Completion Deliverable

Completion Date

Payment

1. Feasibility Study (Refer to Standards for Evidence of Completed Deliverables Section I Feasibility Study)

Feasibility Study, Standards for Evidence of Completing Deliverables

2. Designation of the target area by TPCO population as a Medically Underserved Area or Population.

Designation letter, maps, and other source information

3. Identified organization to apply for FQHC funding and/or FQHC-LA designation.

Board minutes with approval

4 I.R.S. non-profit designation as a 501(c)(3) organization.

Application cover letter and Copy of IRS designation letter

5. Internal and external resources leveraged (i.e. in-kind, other grants, utilization of existing staff and resources).

Written plan for internal and external resource leverage including local support, grants, staffing, etc.

6. Governance requirements in BPHC PIN 98-23 are met.

Governance requirements Standards for Evidence of Completed Deliverables.



Legal Name of Applicant: To be completed by applicants requesting Planning Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 1: Planning Grant continued 7. Community and/or organizational

training regarding FQHCs and compliance requirements

Technical assistance plan requirements Standards for Evidence of Completed Deliverables.

9. Other Performance Measures

10 Other Performance Measures



Legal Name of Applicant: To be completed by applicants requesting Development Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 2: Development Grant # Performance Measures Action Steps by Applicant (include detailed steps necessary to complete

measure(s) such as staffing, purchases, contracts, facility, etc. Attach on a separate sheet of paper a complete list of all purchases with a value exceeding $1,000).


Completion Date

Payment

1. Organization meets all governance requirements as outlined in PIN 98-23

Governance Section requirements of Standards for Evidence of Completed Deliverables.

2. Completed Service Delivery Plan Service Delivery Plan requirements of Standards for Evidence of Completed Deliverables.

3. Completed Health Care Plan Health Care Plan requirements of Standards for Evidence of Completed Deliverables.

4. Completed Business & Sustainability Plan

Sustainability & Business Plans requirements of Standards for Evidence of Completed Deliverables.



Legal Name of Applicant: To be completed by applicants requesting Development Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 2: Development Grant 5. Completed Collaboration Plan Collaboration

Plan requirements of Standards for Evidence of Completed Deliverables.

6. Completed Technical Assistance Plan

Technical Assistance Plan requirements of Standards for Evidence of Completed Deliverables.

7. Draft of appropriate federal application (NAP, EMC, Service Expansion, FQHC-LA) submitted to TPCO for review 30 days prior to federal submission (or deadline), if appropriate to the organization in terms of its development and readiness.

LOI and Draft to TPCO

8. Submit appropriate federal application (NAP, EMC, Service Expansion, FQHC-LA) application to BPHC if appropriate to the organization development and readiness

Copy of final application

9. I.R.S. non-profit designation as a 501(c)(3) organization

Application cover letter and Copy of IRS designation letter



Legal Name of Applicant: To be completed by applicants requesting Development Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 2: Development Grant 10. Audit, if appropriate to the

applicant organization. Contract-

independent financial audit meeting OMB Circular A-133 or A-128

11. Other 12.



Legal Name of Applicant: To be completed by applicants requesting Transitional Operating Support (TOS) Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 3: Transitional Operating Support (TOS) # Performance Measures Action Steps by Applicant (include detailed steps necessary to complete

measure(s) such as staffing, purchases, contracts, facility, etc. Attach on a separate sheet of paper a complete list of all purchases with a value exceeding $1,000).


Completion Date

Payment

1. If not requesting Development Grant Support, submit to TPCO a completed copy of: Service Delivery Plan; Health Care Plan; Business & Sustainability Plan; Collaboration Plan; Technical Assistance Plan; & Mission statement & compliant by-laws

Plans meet all Standards for Evidence of Completed Deliverables.

9/1/05

2. Identify and open, or maintain for business a clinic facility that meets capacity requirements necessary for federal application: FQHC-LA; NAP; EMC; or Service Expansion.

Monthly report: staff productivity; encounters report (by payment type, age, gender, and ethnicity, referrals out to provider type); expense and revenue report with variance narrative and/or plan of correction; & monthly BOD minutes. Executed contracts for services or MOUs for formal referrals.

12/1/05



Legal Name of Applicant: To be completed by applicants requesting Transitional Operating Support (TOS) Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 3: Transitional Operating Support (TOS) continued 3. Submit draft of FQHC-LA

application to TPCO for review (requirement of all applicants receiving TOS support)

LOI and Draft to

1/1/06

4. Submit FQHC-LA application to BPHC February 1, 2006(requirement of all applicants receiving TOS)

Copy of final application to TPCO

2/1/06

5. Secure Health Clinic Management (a requirement for FQHC LA application): Chief Executive Officer (CEO) Chief Medical Officer (CMO) Chief Fiscal Officer (CFO)

Signed and dated employment agreements/ contracts specifying duration, responsibilities, and salary with attached evidence of credentials /experience; & job descriptions.

6. Clinical program compliant with PIN-98-23 and personnel to provide: Dental Care

7. Clinical program compliant with PIN-98-23 and personnel to provide: Preventive Services

BOD minutes reflect discussion and approval of appropriate policies and implementation procedures.



Legal Name of Applicant: To be completed by applicants requesting Transitional Operating Support (TOS) Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 3: Transitional Operating Support (TOS) continued 8. Clinical program compliant with

PIN-98-23 and personnel to provide: Perinatal Preventive Services

9. Clinical program compliant with PIN-98-23 and personnel to provide: Substance Abuse Services

10. Clinical program compliant with PIN-98-23 and personnel to provide: Mental Health Services

11. Program to offer pharmacy services to clients

Patient Assistance Procedures; executed contracts or MOUs.

12. Clinic has a Management Information System (MIS) that will meet UDS and FSR reporting requirements

Contract with FQHC knowledgeable MIS provider; BOD minutes reflect discussion and approval of MIS contract.

13. Secured Medicaid and Medicare Provider Numbers

Submit provider numbers if requested by TPCO.



Legal Name of Applicant: To be completed by applicants requesting Transitional Operating Support (TOS) Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 3: Transitional Operating Support (TOS) continued 14. Recruitment Plan for needed

personnel requirement for FQHC-LA, NAP, EMC, and Service Expansion applications. Staffing should be in place when submitting a FQHC-LA application)

BOD minutes reflect discussion and approval of Recruitment.

15. TPCO or designee site visit to conduct mock New Start Protocol with clinic staff & board of directors

Completed mock New Start Protocol.

1/06

16. For existing FQHCs, change of Scope (or date approved)

Copy of change of Scope.

17. Draft of appropriate federal application NAP, EMC, Service Expansion) including Letter of Intent (LOI) submitted to the TPCO 30 days prior to application deadline

LOI and Draft to TPCO.

18. Appropriate federal Section 330 funding application (NAP, EMC, Service Expansion) submitted by federal Section 330 funding application deadline

Copy of final application to TPCO..



Legal Name of Applicant: To be completed by applicants requesting Transitional Operating Support (TOS) Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 3: Transitional Operating Support (TOS) continued 19. Ability to leverage additional local

support including but not limited to grants, staffing, etc.

Written plan for internal and external resource leverage including local support, grants, staffing, etc.; independent financial audit demonstrates applicant revenues equal to at least 90 percent of expenditures.

20.

Audit Contract- independent financial audit meeting OMB Circular A-133 or A-128.



Legal Name of Applicant: To be completed by applicants requesting Capital Improvement Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 4: Capital Improvement 1. Met objectives found under the

Planning grant. See Standards

for Evidence of Completion Deliverables of Completed Deliverables.

9/1/05

2. Met objectives found under the Development Grant requirements including mission and governance requirements per PIN 98-23.

See Standards for Evidence of Completion Deliverables.

9/1/05

3. Meet objectives found under TOS.

See Standards for Evidence of Completion Deliverables.



Legal Name of Applicant: To be completed by applicants requesting Capital Improvement Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 4: Capital Improvement continued 4. Identify and open, or maintain a

clinic facility that meets capacity requirements necessary for federal FQHC-LA application (required of all non-FQHC applicants) or, identify one additional funding source from one of the following: FQHC-LA; NAP; EMC; & Service Expansion

Monthly report consisting of: staff productivity, encounter report (by payment type, age, gender, and ethnicity, referrals out to provider type), expense and revenue report with variance narrative and/or plan of correction, & monthly BOD minutes; appropriate Policy & Procedures; lease or rent agreements, executed contracts for services or MOUs for formal referrals.

11/30/05



Legal Name of Applicant: To be completed by applicants requesting Capital Improvement Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 4: Capital Improvement continued 5. Secure sufficient equipment and

facilities to begin operations to implement clinical program for primary care, dental, and mental health services as outlined in service delivery plan. APPLICANT MUST ATTACH DETAILED RENOVATIONS AND EQUIPMENT LISTS WITH ACCURATE COSTS ESTIMATES. FAILURE TO PROVIDE ADEQUATE DETAIL MAY LEAD TO NO GRANT AWARD.

Renovation plans; appropriate HUB forms; equipment lists and cost estimates including bids; rental or lease agreements.

12/1/05

6. Secure Health ClinicManagement: Chief Executive Officer (CEO) Chief Medical Officer (CMO) Chief Fiscal Officer (CFO)

Signed and dated employment agreements/contracts specifying duration, responsibilities, and salary with attached evidence of credentials /experience; job descriptions; BOD minutes reflect discussion and approval.

12/1/05



Legal Name of Applicant: To be completed by applicants requesting Capital Improvement Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 4: Capital Improvement continued 7. Secure all needed medical staff

(including contractual and referral arrangements) to support FQHC-LA application and that is necessary for additional federal Section 330 support application

Executed contracts for services or MOUs for formal referrals;; signed and dated employment agreements/ contracts specifying duration, responsibilities, and salary with attached evidence of credentials /experience; job descriptions; BOD minutes reflect discussion and approval.

12/1/05



Legal Name of Applicant: To be completed by applicants requesting Capital Improvement Grant Funding. If applicant has completed these performance measures, then date of completion should be indicated. Performance measures should be completed by the spin-off organization if it has been developed but lacks I.R.S. non-profit designation. Component 4: Capital Improvement continued 8. TPCO or designee site visit to

conduct mock New Start Protocol (NSP) with clinic staff and board of directors

Completed mock NSP with Board/staff follow-up.

12/05

9. For existing FQHCs, Change of Scope submitted (or date approved)

Copy of Change of Scope.

10. Draft of FQHC-LA application submitted to TPCO for review (requirement of all applicants receiving TOS & Capital Improvement Grants)

LOI and Draft to TPCO.

1/1/06

11. FQHC-LA application submitted to BPHC for review (requirement of all applicants receiving TOS & Capital Improvement Grants)

Copy of final application to TPCO.

2/1/06

12. Draft of appropriate federal Section 330 funding application (NAP, EMC, Service Expansion) including Letter of Intent (LOI) submitted to TPCO 30 days prior to application deadline

LOI and Draft to TPCO

13. Appropriate federal Section 330 funding application (NAP, EMC, Service Expansion) submitted to BPHC

Copy of final application.

14. Audit Contract for independent financial audit meeting OMB Circular A-133 or A-128;

15. Other Performance Measures 16. Other Performance Measures


FORM M: DELIVERABLES AND PAYMENT SCHEDULE Instructions

GENERAL INFORMATION: The FQHC Incubator Program does not use the typical categorical budget system. Instead, contractors will be paid upon completion of Performance Measures (Form L) (as deliverable activities) AND submission of evidence to the Texas Primary Care Office that the Performance Standard has been met. This is called a deliverables-based budget. DELIVERABLES: Payment will be based on the payment schedule submission and approval of deliverables from each Component as described in the general purpose and program goals. The deliverables and timelines on FORM M Deliverables and Payment Schedule should reflect what the contractor has detailed in the PERFORMANCE MEASURES L section. Each applicant should identify items from the PERFORMANCE MEASURES L section as deliverables for payment once the Performance Measure/Deliverable has been met. Not all Performance Measures/Deliverables require a payment from the grant. For example, if your performance measure is to hire a physician to begin operations, hiring the physician can be the Deliverable listed in the Performance Measures. Evidence of the deliverables will be submitted to the Texas Primary Care Office to demonstrate that the contractor has met the performance measure. (See Appendix B “Standards for Evidence of Completed Deliverable”). The federal guidelines were used to develop the Standards for Evidence of Completed Deliverables and will be referred to when evaluating deliverables for determining acceptability and payment. For example, when TPCO staff is evaluating an organization’s by-laws for approval and payment, the PIN 98-23 program expectations are used as a reference. When contracts for services (dental, financial, leases, etc.) are submitted by an organization, again, various PINs as well as state guidelines are used. DSHS legal department is consulted when questions arise. Proposed deliverables may be edited and standardized for final contract deliverables. During the contract negotiations, each contractor should expect to develop a set of deliverables for each month of the contract period. Those contractors receiving TOS will be expected to meet the minimum requirements necessary to submit a qualified FQHC-LA application. To receive TOS, all contractors shall have met the governance requirements in PIN 98-23, shall provide, at a minimum, monthly board minutes and financial statements that exhibit FQHC and non-profit corporate compliance, hours of operation (32 per week minimum), number of patients and encounters for primary care, oral health services, mental health and substance abuse services, and appropriate senior management and clinical staff. CONTRACT BUDGETS: Based on the information below, all contracts awarded will contain a deliverables budget. A deliverable amount will be paid to the contractor upon the submission and approval of each Deliverable that demonstrates that the Standards for Completed Deliverables and/or appropriate PIN has been met. Each deliverable with a payment request should be reasonable and have market value. CONTRACTORS WILL NOT BE PAID UNLESS THEY MEET THEIR DELIVERABLES. APPLICANTS ARE STRONGLY ENCOURAGED TO MAKE DELIVERABLES AND TIMELINES REASONABLE. Awarded applicants must encumber all expenses and meet all deliverables by February 28, 2006. Specific Instructions for FORM M: For each month, applicant should identify: deliverables that will be accomplished; component (Planning, Development, TOS, Capital Improvements) under which each deliverable would be paid; amount requested to accomplish deliverable; and, date of completion. The applicant may request deliverables from two components (for example, development and TOS) in the same month. The identified monthly deliverables should provide the applicant, and the reviewer, with a progression towards meeting the program expectations/requirements of a FQHC.


FORM M: DELIVERABLES AND PAYMENT SCHEDULE

Legal Name of Applicant: # September Deliverables Component: Planning, Development, TOS

or Cap Imp Deliverable Amount Due Date

$ $ $ $ Total $ # October Deliverables Component: Planning, Development, TOS


$ $ $ $ Total $ # November Deliverables Component: Planning, Development, TOS


$ $ $ $ Total $ # December Deliverables Component: Planning, Development, TOS


$ $ $ $ Total $



# January Deliverables Component: Planning, Development,

TOS or Cap Imp Deliverable Amount Due Date

$ $ $ $ Total $

# February Deliverables Component: Planning, Development,

TOS or Cap Imp Deliverable Amount Due Date

$ $ $ $ Total $

TOTAL FQHC INCUBATOR FUNDING September 2005-February 2006 $


90

FORM N: DSHS GRANT/CONTRACT APPLICANTS HUB ATTACHMENTS

Historically Underutilized Business (HUB)

Subcontracting Plan Information

In accordance with Texas Government Code (TGC) §2161.252 and Texas Administrative Code (TAC) Title 1, Part 5, Chapter 111, Subchapter B, Rule §111.14, each state agency (including institutions of higher education) as defined by TGC §2151.002 that considers entering into a contract with an expected value of $100,000 or more shall, before the agency solicits bids, proposals, offers, or other applicable expressions of interest, determine whether subcontracting opportunities are probable under the contract. If subcontracting opportunities are probable, each state agency’s invitation for bids or other purchase solicitation documents for construction, professional services, other services, and commodities with an expected value of $100,000 or more shall state that probability and require a HUB Subcontracting Plan (HSP). In accordance with Texas Government Code, §2161.181 and §2161.182, each state agency shall make a good faith effort to increase the contract awards for the purchase of goods or services to HUBs based on rules adopted by the Commission to implement the disparity study described by TGC §2161.002(c). The purpose of the HUB Program is to promote equal business opportunities for economically disadvantaged persons (as defined by TGC §2161) to contract with the State of Texas in accordance with the goals specified in the State of Texas Disparity Study. The HUB goals per TAC §111.13 are: 11.9% for heavy construction other than building contracts; 26.1% for all building construction, including general contractors and operative builders contracts; 57.2% for all special trade construction contracts; 20% for professional services contracts; 33% for all other services contracts; and 12.6% for commodities contracts.

IF YOUR RESPONSE TO THIS SOLICITATION DOES NOT

CONTAIN A HUB SUBCONTRACTING PLAN, YOUR RESPONSE SHALL BE REJECTED AS A MATERIAL FAILURE TO COMPLY WITH THE ADVERTISED SPECIFICATIONS.

91

INSTRUCTIONS 1. HUB Subcontracting Plan (HSP) Development and Good Faith Effort Requirements – All respondents (HUBs and non-HUBs)

submitting bids, proposals, offers, or other applicable expressions of interest must follow, but are not limited to, the following procedures when developing a HUB Subcontracting Plan (HSP): a. The respondent shall divide the contract work into reasonable lots or portions to the extent consistent with

prudent industry practices. b. The respondent shall use the Texas Building and Procurement Commission's (TBPC) Centralized Master

Bidders List (CMBL), the HUB Directory, and may use other Internet resources and directories as identified by the contracting agency to identify HUBs that perform the type of work required for each subcontracting opportunity identified in the contract specifications or any other subcontracting opportunity the respondent cannot complete with its own equipment, supplies, materials, and/or employees. Note: The contracting agency does not endorse any company or individual identified on any listings/directories included or referenced herein. A complete list of all State of Texas certified HUBs may be accessed via the Internet at http://www.tbpc.state.tx.us/cmbl/cmblhub.html or http://www.tbpc.state.tx.us/cmbl/hubonly.html.

c. The respondent shall provide notice to three (3) or more HUBs that perform the type of work required for each subcontracting opportunity identified in the contract specifications or any other subcontracting opportunity the respondent cannot complete with its own equipment, supplies, materials, and/or employees. In addition, the respondent shall provide notice of subcontracting opportunities to minority or

omen trade organizations or development centers to assist in identifying potential HUBs. w The preferable method of notification to HUBs and minority or women trade organizations or development centers shall be in writing and, as applicable, include: the scope of the work; information regarding the location to review plans and specifications; information about bonding and insurance requirements; information about required qualifications and specifications; and identify a contact person.

d. Unless circumstances require a different time period that shall be specified by the contracting agency and documented in the agency’s contract file, the respondent’s subcontracting opportunity notice(s) must be provided to the potential HUB subcontractors, and minority or women trade organizations or development centers no less than five (5) working days prior to the submission of the respondent’s bid, proposal, offer, or other applicable expression of interest to the contracting agency.

e. On forms provided by the contracting agency and prescribed by TBPC, the respondent shall document the HUBs they contacted regarding their subcontracting opportunities. The respondent should negotiate in good faith with qualified HUBs, not rejecting qualified HUBs who were the best value responsive bidder to their subcontracting opportunities.

f. The respondent shall provide written justification of the selection process if a HUB subcontractor is not selected.

g. Prior to contract award, the respondent shall provide the contracting agency with supporting documentation (phone logs, fax transmittals, electronic mail, etc.) to document their good faith effort in the development and submission of their HSP.

2. Alternatives to Good Faith Effort Requirements (Applicable to Mentor Protégé Agreements and Professional Services Contracts Only) a. A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement and a

commitment to use their Protégé (All Protégé’s must be State of Texas HUB certified) as a subcontractor

http://www.tbpc.state.tx.us/cmbl/cmblhub.html

http://www.tbpc.state.tx.us/cmbl/hubonly.html

92

to perform the subcontracting opportunity(ies) listed in its HSP (Texas Government Code, Chapter 2161.065) may constitute good faith effort without performing the procedures listed in Item 1. For additional information, please contact the HUB Coordinator for the contracting agency.

b. A respondent who submits an HSP for a professional services contract that meets or exceeds Annual

Procurement Utilization goals for Historically Underutilized Businesses (HUBs) as defined in Texas Administrative Code, § 111.13, will be determined to have met the good faith effort requirement. (Applicable to Professional Services Contracts as defined by Texas Government Code 2254.)

3. HUB Subcontracting Plan Reporting and Contract Compliance – The contracting agency will receive HUB credit for the total amount of

expenditures made directly to prime contractors who are State of Texas HUB certified. In addition, if the prime contractor is not a HUB, agencies will receive HUB credit for the total amount of expenditures the prime contractor makes to HUB subcontractors, if applicable. All prime contractors (HUBs and non-HUBs) are required to comply with the following reporting and contract compliance procedures: a. Prime contractors shall report to the contracting agency their use of HUB subcontractors to fulfill the subcontracting opportunities

identified in their HSP (See Prime Contractor Progress Assessment Report, at http://www.tbpc.state.tx.us/hubbid/forms/index.html).

b. Prime contractors shall notify the contracting agency and obtain prior approval before any changes can be made to its HSP. The proposed changes must comply with the good faith effort requirements related to developing and submitting a HSP as described in Item 1, or if applicable, Item 2 above.

c. The contracting agency will determine if the value of subcontracts to HUBs meet or exceed the HUB

subcontracting provisions specified in the prime contractor’s HSP. If the contracting agency determines that the prime contractor’s subcontracting activity does not demonstrate a good faith effort, the prime contractor may be subjected to provisions in the Vendor Performance and Debarment Program (1 TAC, Part 5, Chapter 113, Subchapter F).

4. Special Instructions/Additional Requirements, as applicable when specified by the contracting agency:

http://www.tbpc.state.tx.us/hubbid/forms/index.html

93

Form N-1 HUB Subcontracting Plan The contracting agency has determined that subcontracting opportunities are probable under this contract. Therefore, all respondents, including State of Texas certified Historically Underutilized Businesses (HUBs), are required to complete and submit this HUB Subcontracting Plan (HSP) with their response (bid, proposal, offer or other applicable expression of interest). IF YOUR RESPONSE DOES NOT CONTAIN AN HSP, IT SHALL BE REJECTED AS A MATERIAL FAILURE TO COMPLY WITH THE ADVERTISED SPECIFICATIONS.

1. Respondent and Solicitation Information

a. State Agency/University Name: _________________________________________

b. Company Name:

c. Is your company a State of Texas certified HUB? - Yes - No If Yes, provide VID/Certificate #:

d. Solicitation Number:

By signature on solicitation response, respondent certifies that its HSP and supporting documentation are true and correct and understands that if awarded any portion of the solicitation referenced above, any modifications to the HSP must be submitted to the contracting agency for prior approval. In addition, respondent understands that if the HSP is modified without the contracting agency’s prior approval, respondent will be in breach of contract and subject to any remedial actions provided by Texas Government Code, Chapter 2161. Respondent also understands that if awarded this solicitation, respondent will be required to submit monthly compliance report(s) to the contracting agency, specifying the use, including expenditures to HUB subcontractor(s), if applicable. (See Prime Contractor Progress Assessment Report, at http://www.tbpc.state.tx.us/hubbid/forms/index.html.)

2. Development of an HSP and Subcontracting Intentions

In developing the HSP, which includes dividing the contract work into reasonable lots or portions to the extent consistent with prudent industry practices, the respondent must determine what portion(s) (including goods or services) they intend to subcontract. If the respondent determines that they are able to fulfill all of the potential subcontracting opportunities identified with its own equipment, supplies, materials and/or employees, the respondent must complete the Self Performance HSP (enclosed) and provide a statement explaining how they intend to fulfill the entire contract scope of work. Space is provided to list up to six (2a-2f) subcontracting opportunities on this form. The respondent must complete Item 3 of the HSP for each subcontracting opportunity. If there are more than six subcontracting opportunities, Item 3 may be photocopied and completed for each subcontracting opportunity. I intend to subcontract the following portion(s)/scope of work:

(a) (d) (b) (e) (c) (f)

NOTE: In accordance with Texas Government Code, Chapter 2251.001, a “Subcontractor” means a person who contracts with a vendor to work or contribute toward completing work for a governmental entity. In addition, a “Vendor” means a person who supplies goods or a service to a governmental entity or another person directed by the entity.

http://www.tbpc.state.tx.us/hubbid/forms/index.html

94

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2a.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2a of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2a to your Protégé?

- Yes (If Yes, skip to Item 3e and omit Item 3b, 3c and 3d.) - No - Not Applicable

b. Professional Services Contracts Only (This item is only applicable for professional services subcontracting opportunities.) My proposed HUB Subcontracting Plan for this professional services contract (as defined by Texas Government

Code 2254) meets or exceeds Annual Procurement Utilization goals for HUBs. - Yes (If Yes, skip to Item 3e and omit Item 3c and 3d.) - No - Not Applicable

c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2a. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.

- I utilized the Centralized Master Bidders List, the HUB Directory, the Internet, and other directories identified by the contracting agency to solicit my subcontracting opportunity to HUBs that may be available to perform the contract work.

- I provided notice to three (3) or more HUBs per each subcontracting opportunity that provide the type of work required for each subcontracting opportunity.*

- I provided notice to minority or women trade organizations or development centers to assist in identifying HUBs by disseminating subcontracting opportunities to their membership/participants.*

d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2a. Include the date(s) you provided notice and indicate if you received a response(s).

Company Name Notice Date Was Response Received? - Yes - No - Yes - No - Yes - No e. In the space provided below, identify the subcontractor(s) you selected to perform the scope of work you listed in

Item 2a. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #

Expected % of Contract

Approximate Dollar Amount

Texas Certified HUB?

- Yes - No

Company Name

VID #




- Yes - No

Provide/Select justification if subcontractor(s) is not a Texas certified HUB: - Lowest Price - Best Qualified - Best Value

*Notice must be provided with reasonable time to respond, which is no less than five (5) working days, unless circumstances require a different time period, which is determined by the contracting agency and documented in the contract file.

95

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2b.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2b of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2b to your Protégé?




c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2b. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.




d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2b. Include the date(s) you provided notice and indicate if you received a response(s).


Item 2b. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #




- Yes - No

Company Name

VID #




- Yes - No



96

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2c.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2c of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2c to your Protégé?




c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2c. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.




d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2c. Include the date(s) you provided notice and indicate if you received a response(s).


Item 2c. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #




- Yes - No

Company Name

VID #




- Yes - No



97

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2d.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2d of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2d to your Protégé?




c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2d. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.




d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2d. Include the date(s) you provided notice and indicate if you received a response(s).


Item 2d. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #




- Yes - No

Company Name

VID #




- Yes - No



98

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2e.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2e of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2e to your Protégé?




c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2e. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.




d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2e. Include the date(s) you provided notice and indicate if you received a response(s).


Item 2e. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #




- Yes - No

Company Name

VID #




- Yes - No



99

3. Good Faith Effort Information and Supporting Documentation (Note: Use this attachment for the Subcontracting Opportunity you identified in Item 2f.)

a. Mentor Protégé Program A respondent’s participation as a Mentor in a State of Texas Mentor Protégé Agreement under Texas Government Code, Chapter 2161.065 and the use of their Protégé as a subcontractor to perform the scope of work they listed in Item 2f of this HSP, constitutes a good faith effort. If applicable, do you intend to subcontract the portion of work you listed in Item 2f to your Protégé?




c. Check the appropriate box to identify the good faith effort you made to solicit and notify State of Texas certified HUBs to perform the scope of work you listed in Item 2f. If applicable, all items below must be performed to demonstrate good faith effort. The contracting agency shall request additional documentation to substantiate your responses prior to contract award.




d. In the spaces provided below, list a minimum of three (3) State of Texas certified HUBs who you provided notice regarding the subcontracting opportunity you listed in Item 2f. Include the date(s) you provided notice and indicate if you received a response(s).


Item 2f. Also, list the expected percentage of work to be subcontracted; the approximate dollar value of the work to be subcontracted, and indicate if the company is a State of Texas certified HUB.

Company Name

VID #




- Yes - No

Company Name

VID #




- Yes - No



Form N-2: HUB Subcontracting Plan (HSP) Prime Contractor Progress Assessment Report

This form must be completed and submitted to the contracting agency on a monthly basis to document compliance with your HSP.

Contract/Requisition Number: Date of Award: Object Code: (mm/dd/yyyy) (Agency use only)

Contracting Agency/University Name: _____________________________

Contractor Name:

Contractor Vendor Identification Number (VID Number):

Reporting Period: Total Contract Amount Paid this Reporting Period to Contractor: $ (January, February, March…)

Document HUB Subcontractor Information, as applicable below:

Signature: Title: Date:

HUB Subcontractor Name(s)

HUB Subcontractor’s VID or HUB

Certificate Number

Total Contract $ Amount from HSP

with HUB Subcontractor

Total $ Amount Paid This Period to

HUB Subcontractor

Total Contract $ Amount Paid to

Date to HUB Subcontractor

Object Code (agency use only)

TOTALS

$

$

$

Form N-3: Self Performance HUB Subcontracting Plan (HSP)


The contracting agency has determined that subcontracting opportunities are probable under this contract. However, in developing your HSP, which includes dividing the contract work into reasonable lots or portions to the extent consistent with prudent industry practices, if you have determined that you are able to fulfill the entire contract scope of work with your own equipment, supplies, materials and/or employees, your completion of this Self Performance HUB Subcontracting Plan is required.

1. Respondent and Solicitation Information

a. State Agency/University Name: __________________________

b. Respondent Name:

c. Is respondent a TBPC certified HUB? - Yes - No

If yes, provide VID/Certificate #:

d. Solicitation Number:

2. Provide an explanation documenting how you intend to fulfill the entire contract scope of work, without subcontracting (including the provision of goods and services) any portion of the work:

3. As an authorized representative of the company identified above, I affirm that in developing the HSP

required for the solicitation referenced above, respondent is capable of fulfilling the entire contract scope of work with its own equipment, supplies, materials and/or employees. Respondent understands and agrees that, if awarded any portion of the solicitation referenced above,

• any modifications to the HSP must be submitted to the contracting agency for prior approval; • if the HSP is modified without the contracting agency’s prior approval, respondent will be in breach of the

contract and subject to any remedial actions provided by Texas Government Code, Chapter 2161; • upon request by the contracting agency, respondent shall allow the contracting agency to perform on-site

reviews of the company’s headquarters or work-site where services are to be performed and provide the contracting agency with documentation that includes, but is not limited to evidence of existing staffing to meet contract scope of work, monthly payroll records showing company staff fully engaged in the contract, and licenses and certificates of employees qualified and used to perform the contract scope of work.

Signature: Title:

Printed Name: Date:

FORM O: NONPROFIT BOARD OF DIRECTORS AND EXECUTIVE DIRECTOR ASSURANCES FORM

If the applicant is a nonprofit organization, this form must be completed (state or other governmental agencies are not required to complete this form). The purpose of the form is to inform nonprofit board members and officers of the responsibilities and administrative oversight requirements of nonprofit applicants intending to or contracting with Texas Department of State Health Services (DSHS). This form is in addition to the appropriate board resolution(s) required under A. Eligible Applicants page 5 that is/are to be placed with Forms J: FQHC Funding Feasibility.

(Name & Address of Organization) The persons signing on behalf of the above named organization certify that they are duly authorized to sign this Assurances form on behalf of the organization. The undersigned acknowledge and affirm: A. That an annual budget has been approved for each contract with DSHS. B. The Board of Directors convenes on a regularly scheduled basis (no less than quarterly) to discuss the operations of

the organization. C. Actual revenue and expenses are compared with the approved budget, variances are noted, and corrective action

taken as needed (with Board approval). D. Timely and accurate financial statements are presented by the designated financial officer on a regular basis to the

board. E. That the Board of Directors will ensure that any required financial reports and forms, whether federal or state, are

filed on a current and timely basis. F. Adequate internal controls are in place to ensure fiscal integrity, accountability, and to safeguard assets. G. The Treasurer of the Board has been fully informed of his or her responsibilities as Treasurer. H. The Board has Audit and/or Finance Committees that convene regularly and communicate effectively with the Board

Treasurer and other Board members in understanding and responding to financial developments. I. The organization follows Generally Accepted Accounting Principles when preparing financial statements, and fund

accounting practices are observed to ensure integrity among specific contracts or grants. J. If a contract is executed with the DSHS, this form will be discussed in detail at the next official Board meeting and that

notes of the discussion and a signed copy of this form will be included in the minutes of the meeting. A copy of the minutes will be kept at the organization and be available for inspection by DSHS staff.

K. If a contract is executed with the DSHS and the nonprofit organization has not received any funding from DSHS for the past 24 months, the Legal and Fiscal Responsibilities for Nonprofit Board of Directors Video and Guide will be viewed and a signed “tear-out” sheet will be completed and filed by each board member with the nonprofit organization no later than 45 days after contract execution. Newly appointed/elected board members will comply with these requirements no more than 45 days after taking office. All tear-out sheets will be available for inspection by DSHS staff.

L. The organization will administer any contract executed with the DSHS in accordance with applicable federal statutes and regulations, including federal grant requirements applicable to funding sources, Uniform Grant Management Standards issued by the Governor’s Office, applicable Office of Management and Budget Circulars, applicable Code of Federal Regulations, and provisions of the contract document.

*Chairman of the Board Signature/Date *President or Executive Director Signature/Date *If the signed original of this form has been provided to the DSHS during the calendar year and the officers signing the document have not changed, a copy of the signed form will be accepted


FORM P: CURRENT BOARD OF DIRECTORS CHARACTERISTICS* Legal Name of Applicant:

BOARD MEMBER NAME

BOARD OFFICE HELD

AREA OF EXPERTISE

INDICATE IF USER

OF HEALTH CENTER SERVICES

(Yes or No)

NON-USER: >10% OR <10% INCOME FROM HEALTH CARE

INDUSTRY

YEARS OF CONTINUOUS

BOARD SERVICE

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

*Public entities should provide information on their co-applicant or advisory board, or spin-off non-profit organization. Total Number of Board Members by Gender: ____Female _____Male Total Number of Board Members by Race/Ethnicity: ______White ______African American ______ Hispanic______ American Indian & Alaska Native _______Asian/Pacific Islander


APPENDIX A DSHS ASSURANCES AND CERTIFICATIONS

Note: Some of these Assurances and Certifications may not be applicable to your project. If you have questions, contact the Bill Walk. As the duly authorized representative of the applicant, my signature on the FACE PAGE Form certifies that the applicant:

1. Has the legal authority to apply for state/federal assistance, and the institutional, managerial and financial capability and systems (including funds sufficient to pay the non-state/federal share of project costs) to ensure proper planning, management and completion of the project described in this application;

2. Has a financial system that demonstrates accounting, budgetary and internal

controls; cash management; reporting capability; cost allowability determination; and source documentation;

3. A parent, affiliate, or subsidiary organization, if such a relationship exists, will give

DSHS, the Texas State Auditor, the Comptroller General of the United States, and if appropriate, the federal government, through any authorized representative, access to and the right to examine all records, books, papers, or documents related to the award; and will establish a proper accounting system in accordance with generally accepted accounting standards or agency directives;

4. Will supplement the project/activity with funds made available through a contract

award as a result of this RFP and will not supplant funds; 5. Will establish safeguards to prohibit employees from using their positions for a

purpose that constitutes or presents the appearance of personal or organizational conflict of interest, or personal gain;

6. Will comply, as a subgrantee, with Texas Government Code, Chapter 573, Vernon’s

1994, by ensuring that no officer, employee, or member of the applicant’s governing body or of the applicant’s contractor shall vote or confirm the employment of any person related within the second degree of affinity or the third degree of consanguinity to any member of the governing body or to any other officer or employee authorized to employ or supervise such person. This prohibition shall not prohibit the employment of a person who shall have been continuously employed for a period of two years, or such other period stipulated by local law, prior to the election or appointment of the officer, employee, or governing body member related to such person in the prohibited degree;

7. Affirms that it has not given, nor intends to give, at any time hereafter any economic

opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant or any employee or representative of same, in connection with this procurement;


8. Will honor for 90 days after the application due date the technical and business terms contained in the application;

9. Will initiate the work after receipt of a fully executed contract and will complete it

within the contract period; 10. Will not require a client to provide or pay for the services of a translator or

interpreter;

11. Will identify and document on client records the primary language/dialect of a client who has limited English proficiency and the need for translation or interpretation services;

12. Will make every effort to avoid use of any persons under the age of 18 or any family

member or friend of a client as an interpreter for essential communications with clients who have limited English proficiency. However, a family member or friend may be used as an interpreter if this is requested by the client and the use of such a person would not compromise the effectiveness of services or violates the clients confidentiality, and the client is advised that a free interpreter is available;

13. Will comply with the requirements of the Immigration Reform and Control Act of

1986, 8 USC §1324a, as amended, regarding employment verification and retention of verification forms for any individual(s) hired on or after November 6, 1986, who will perform any labor or services proposed in this application;

14. Agrees to comply with the following to the extent such provisions are applicable:

A. Title VI of the Civil Rights Act of 1964, 42 USC§§2000d, et seq.; B. Section 504 of the Rehabilitation Act of 1973, 29 USC §794(a); C. The Americans with Disabilities Act of 1990, 42 USC §§12101, et seq.; D. All

amendments to each and all requirements imposed by the regulations issued pursuant to these acts, especially 45 CFR Part 80 (relating to race, color and national origin), 45 CFR Part 84 (relating to handicap), 45 CFR Part 86 (relating to sex), and 45 CFR Part 91 (relating to age); and

E. DSHS Policy XO-0119, Non-Discrimination Policies and Procedures for DSHS Programs, which prohibits discrimination on the basis of race, color, national origin, religion, sex, sexual orientation, age, or disability;

15. Will comply with the Uniform Grant Management Act (UGCMA), Texas Government

Code, Chapter 783, as amended, and the Uniform Grant Management Standards (UGMS), as amended by revised federal circulars and incorporated in UGMS by the Governor's Budget and Planning Office, which apply as terms and conditions of any resulting contract. A copy of the UGMS manual and its references are available upon request;

16. Will remain current in its payment of franchise tax or is exempt from payment of

franchise taxes, if applicable; 17. Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child

Support, and certifies that it is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract may be terminated and payment may be withheld if this certification is inaccurate;


18. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin, or age;

19. Will comply with environmental standards prescribed pursuant to the following:

A. Institution of environmental quality control measures under the National Environmental Policy Act of 1969, 42 USC §§4321-4347, and Executive Order (EO) 11514 (35 Fed. Reg. 4247), "Protection and Enhancement of Environmental Quality;"

B. Notification of violating facilities pursuant to EO 11738 (40 CFR, Part 32), "Providing for Administration of the Clean Air Act and the Federal Water Pollution Control Act with Respect to Federal Contracts, Grants or Loans";

C. Conformity of federal actions to state clean air implementation plans under the Clean Air Act of 1955, as amended, 42 USC §§7401 et seq.; and

D. Protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, 42 USC §§300f-300j, as amended;

20. Will comply with the Pro-Children Act of 1994, 20 USC §§6081-6084, regarding the

provision of a smoke-free workplace and promoting the non-use of all tobacco products;

21. Will comply, if applicable, with National Research Service Award Act of 1971, 42

USC §§289a-1 et seq., as amended and 6601 (P.L. 93-348 – P.L. 103-43), as amended, regarding the protection of human subjects involved in research, development, and related activities supported by this award of assistance, as implemented by 45 CFR Part 46, Protection of Human Subjects;

22. Will comply, if applicable, with the Clinical Laboratory Improvement Amendments of

1988 (CLIA), 42 USC §263a, as amended, which establish federal requirements for the regulation and certification of clinical laboratories;

23. Will comply, if applicable, with the Occupational Safety and Health Administration

Regulations on Blood-borne Pathogens, 29 CFR §1919.030, which set safety standards for those workers and facilities in the private sector who may handle blood-borne pathogens, or Title 25 Texas Administrative Code, Chapter 96, which affects facilities in the public sector;

24. Will not, if a for profit organization, charge a fee for profit. A profit or fee is

considered to be an amount in excess of actual allowable, allocable, and reasonable direct and indirect costs that are incurred in conducting an assistance project;

25. Will comply with all applicable requirements of all other state/federal laws, executive

orders, regulations, and policies governing this program; 26. Defined as the primary participant in accordance with 45 CFR Part 76, and his/her

principals: A. are not presently debarred, suspended, proposed for debarment, declared

ineligible, or voluntarily excluded from covered transactions by any federal department or agency;

B. have not within a 3-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a


criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

C. are not presently indicted or otherwise criminally or civilly charged by a governmental entity (federal, state, or local) with commission of any of the offenses enumerated in paragraph (b) of this certification; and

D. has not within a 3-year period preceding this application/proposal had one or more public transactions (federal, state, or local) terminated for cause or default;

Should the applicant not be able to provide this certification (by signing the FACE PAGE Form), an explanation should be placed after this form in the application response;

The applicant agrees by submitting this proposal that he/she will include, without modification, the clause titled “Certification Regarding Debarment, Suspension, Ineligibility, and Voluntary Exclusion-Lower Tier Covered Transaction” (Appendix B to 45 CFR Part 76) in all lower tier covered transactions (i.e., transactions with subgrantees and/or contractors) and in all solicitations for lower tier covered transactions;

27. Understands that Title 31, USC §1352, entitled “Limitation on use of appropriated

funds to influence certain federal contracting and financial transactions,” generally prohibits recipients of federal grants and cooperative agreements from using federal (appropriated) funds for lobbying the executive or legislative branches of the federal government in connection with a SPECIFIC grant or cooperative agreement. Section 1352 also requires that each person who requests or receives a federal grant or cooperative agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds. These requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR Part 93): A. No federal appropriated funds have been paid 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 any 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;

B. 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 agent, 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 Standard Form-LLL, “Disclosure of Lobbying Activities,” (SF-LLL) in accordance with its instructions. SF-LLL and continuation sheet are available upon request from the Texas Department of State Health Services; and

C. The language of this certification shall be included in the award documents


for all sub-awards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly;

This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by USC §1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure; and,

28. Affirms that the statements herein are true, accurate, and complete (to the best of

his or her knowledge and belief), and agrees to comply with the DSHS terms and conditions if an award is issued as a result of this application. Willful provision of false information is a criminal offense (Title 18, USC §1001). Any person making any false, fictitious, or fraudulent statement may, in addition to other remedies available to the Government, be subject to civil penalties under the Program Fraud Civil Remedies Act of 1986 (45 CFR Part 79).


APPENDIX B STANDARDS FOR EVIDENCE OF COMPLETED DELIVERABLE

The following is a description of items that are vital to the development of Federally Qualified Community Health Centers. The Performance Measures (Form L) and the Deliverables and Payment Schedule (Form M) references some or all of the items below as evidence of a completed deliverable. The information below will be used by the Primary Care Office to determine whether or not deliverables are acceptable.

I. Feasibility Study

Analysis of whether FQHC funding is viable for the community – a written analysis of factors supporting or hindering FQHC development. The analysis, at minimum, must:

a. Describe proposed service area(s) and communities to be served by a FQHC/330 grant or FQHC-LA application:

i. Identify counties, census tracts, minor civil/governmental subdivisions, schools/school districts, etc. in service area;

ii. Identify geographic barriers and/or culturally specific population characteristics that impact access to and the delivery of health care services;

iii. Identify other barriers to providing care and other social, cultural, transportation, and communication factors impacting how the community will access care;

b. Describe target population(s) (e.g., general community members, migrant/seasonal agricultural workers, residents of public housing, homeless persons, low-income school children, etc.) within service area/community:

i. Identify the un-served and underserved populations in community;

ii. Describe unique demographic characteristics of the target population (e.g., age, gender, insurance status, unemployment, poverty level, ethnicity/culture, etc.);

iii. Define special health care needs of target population; iv. Identify other populations that are in need of access to primary

health care (e.g. migrant/seasonal farm workers, homeless populations, residents of public housing, low-income school children/adolescents and their families;

v. Describe relevant access to care and health status indicators of target population/community and complete the FQHC New Access Point Need for Assistance Worksheet;

vi. Describe any unique characteristics and other factors of target population; and,

vii. All of the above must include the most recent data available with source citation.

c. Identify how many people will be served and the number of projected


encounters (user population) that will be generated after the first year of operation and at full operational capacity (within two years).

d. Identify, describe, and support, using the most recent data available with source citation, the most significant barriers to care, gaps in services, significant health disparities, and major health care problems in the user population that will be addressed in a FQHC-LA, New Access Point, Expanded Medical Capacity, or Service Expansion application. This information will be the basis for the Health Care Plan.

e. Identify any health care providers, resources and/or services of other public and private organizations within the same service area that provide care to the target population(s), and evaluate the effectiveness of available resources and/or services in providing care to the target community/population.

f. Describe collaborations with other providers, including other FQHC’s, rural health centers, and other providers within the service area.

g. If not collaborating with other providers serving the target population, provide an explanation with evidence of attempts to collaboration.

h. Demonstrate an understanding of the health care environment, including the impact of recent legislative changes in SCHIP, Medicaid, mental health, relevant welfare reform initiatives, and the effect these changes have on the target population(s)/community’s access to services or demand for services.

i. Describe the organization’s role and relationship within the community, including how the organization fits into community and its service delivery network.

j. Describe how the organization’s health care services will be culturally and linguistically appropriate to the user population.

k. Describe how the organization’s efforts to obtain new or additional federal funding will be integrated into the existing health care system. For situations that involve a currently operational clinic, whether or not owned or operated by the Incubator grantee, and the operational clinic is converting to an FQHC:

1. Define the relationships between all organizations involved, including roles and responsibilities; and

2. Identify current financial resources of the operational clinic. Letter(s) of Agreement must accompany this feasibility study documenting that financial resources committed to the clinic will remain after FQHC or FQHC-LA designation is secured.

ii. Describe any plans to contract out a significant portion of the required services and how this plan does not violate BPHC policies. Provide a brief overview of the service, the provider, and anticipated terms (payment, referral process, tracking, etc.).


l. Submit a specific plan for community participation in the development of new or additional services including but not limited to: timeline, location, goals and objectives, meeting content, speakers, ability to meet cultural competency commitments, etc.

m. If the plan is to convert an existing clinic into a new FQHC or a new satellite of an existing FQHC, provide a discussion of how current resources committed to the clinic will continue once the federal designation has been secured.

n. Attach a Memorandum Of Understanding (MOU) with the governing board of directors of the existing clinic documenting current resources committed to the clinic and how much of those resources will continue once the FQHC Incubator Program grant and federal designation are secured.

o. If resources currently committed to the clinic will not continue, then an explanation must be provided.

p. Demonstrate knowledge of and participation in the Texas Association of Community Health Centers’ (TACHC) annual statewide strategic planning process.

q. Discussion of how the above issues support and hinder the development of an FQHC.

TPCO may require additional information for the purpose BPHC funding

application viability.

A. Governance Requirements The FQHC’s organizational governing board must have full authority over clinic operations and meet the responsibilities and functions as prescribed in all legislation/regulations/Bureau Primary Health Care guidelines effecting FQHCs. (RECEIVEING AGENCY should refer to PIN 98-23 as well as any updates to this PIN during FY 2005 or FY 2006)

a. Board Composition. The organizational governing board of directors for a non-profit entity or the co-applicant board for a governmental entity must:

i. Be composed of at least 9 but not more than 25 individuals, a majority of whom are consumers of the clinic services and who, as a group, represent the individuals being served by the center in terms of demographic factors such as race, ethnicity and sex;

ii. No more that half (two-thirds for migrant health centers) of the non-consumer representatives may derive more that 10% of their annual income from the health care industry;

iii. Be representative of the community in which the service area is located, and non-consumer members must have appropriate expertise in community affairs, local government, finance and banking, legal affairs, trade unions, and other commercial and


industrial concerns, or social service agencies within the community;

iv. Not be related to an employee of the center (spouse or child, parent, brother or sister by blood or marriage of such an employee);

v. Retain, and not be restricted in, its prescribed authorities, functions and responsibilities, such as: meeting at least once a month; selecting the services to be provided by the center; scheduling the hours during which such services will be provided; approving the center's annual budget and other major resource decisions; approving the selection and dismissal of a director for the center; adopting health care policies; evaluating center activities; assuring that the center is operated in compliance with applicable laws and regulations; and, except in the case of a governing board of a public center, establishing general policies for the center; and

vi. All board members are chosen through one selection process by a nominating committee of the governing board of directors, prescribed in the by-laws of the health center/clinic.

b. The roles and responsibilities of the FQHC governing board of directors for either a non-profit or governmental entity must include:

i. Meeting monthly and keeping minutes; ii. Executive committee function and composition; iii. Selection of board president, vice-president, treasurer and

secretary; or chair, vice-chair, treasurer and secretary;

iv. Selection of members; v. Strategic planning; vi. Approval of the annual budget of the center; vii. Approves grant applications; viii. Directly employs, selects/dismisses and evaluates the Chief

Executive Officer (CEO)/Executive Director; ix. Adopts all policies and procedures for the operation of a FQHC

or FQHC-LA; x. Regarding the health center governing board of a

governmental entity, it must meet all the selection and composition requirements and perform all the responsibilities expected of governing boards except that the public entity may retain the responsibility of establishing fiscal and personal policies. The health center’s board should be a formally incorporated entity, and it and the public entity board are co-applicants for the health center program. When there are 2 boards, each board’s responsibilities must be specified in writing so that the responsibilities for carrying out the governance functions are clearly understood;

xi. Establishes center priorities;


xii. Establishes eligibility requirements for partial payment of services;

xiii. Provides for an independent audit; xiv. Evaluates center activities; xv. Adopts center’s health care policies, including scope and

availability of services, location, hours of operation, and quality of care audit procedures;

xvi. Establishes and maintains collaborative relationships with other health care providers in the service area;

xvii. Adopts a conflict of interest statement as part of the by-laws; and,

xviii. No other organization or entity can have overriding influence or veto authority in any aspect of these roles and responsibilities.

c. Evidence of Compliance i. Organization By-Laws. ii. Monthly board meeting minutes that include, at minimum,

identification of members present and absent, agenda items and outcome, noted abstentions on any vote of the board, financial statement discussion and review, committee reports, and approval of previous minutes.

iii. Board list identifying ethnicity, officers, consumers, and non-consumers.

iv. Monthly financial statements, including expense and revenue, variance, and a plan to address the variance.

v. Monthly productivity report for users, encounters, and payment type.

vi. Monthly productivity report for clinic staff identifying service hours.

vii. CEO job description; and viii. Memorandum of Understanding (MOU), Memorandum of

Agreement (MOA), contract for services, collaborative service delivery plans, or any type of affiliation agreement.

TPCO may require additional information for the purpose of BPHC funding application viability.

III. Health Care Plan

a. The Health Care Plan must be specific to new services and sites for which federal funding is sought and must include, but is not limited to:

i. Problem/Needs Statement; ii. Time-framed Goals; iii. Time-framed Objective(s); iv. Key Action Steps (steps which must be accomplished to meet the

objective); v. Data Source and Evaluation Model (list the source and how

agency will use to assess progress in meeting objective);


vi. Expected Outcomes; vii. Responsible Parties; and viii. The Health Care Plan must be submitted using the FQHC

application recommended tabular format. ix. Governing board approved health care plan.

b. Problem statements related to clinical goals and objectives must be included and must address:

i. Any special populations; ii. Clinical measures by life cycle; iii. Chronic conditions and health disparities for target population; iv. Dental; v. Mental health and substance abuse; and vi. Elimination of health disparities.

c. Problem statements related to quality management and performance improvement must be included and address:

i. Quality of service (e.g. appointment availability, visit cycle time, patient satisfaction); ii. Quality of clinical care (e.g. immunization rates, prenatal enrollment, diabetes); iii. Quality of work life (e.g. staff satisfaction, turn-over rates); iv. Cost/Efficiency (e.g. productivity, utilization rates, cost/visit); v. Provider recruitment and retention plan; vi. Risk management plan; and vii. Senior Management (Medical Director, Clinic Administrator,

Quality Management Director) plan with timelines to accomplish these measures at each practice unit, site or program.


IV. Service Delivery Plan

a. Service Delivery Plan must include, but is not limited to:

i. A written mission statement that includes commitment to provide primary care, comprehensive oral health care, mental health care and substance abuse services to the underserved;

ii. Detailed description of how service delivery model will assure that all persons will have ready access to all required primary, preventive, and supplemental health care services without regard to ability to pay;

iii. Description of the service model that demonstrates how comprehensive oral health care; mental health care and substance abuse services are available and accessible to all persons without regard to ability to pay;

iv. Description of ability and commitment to meet cultural and language competency requirements of BPHC 330/FQHC funding;

v. Detailed description of patient feedback procedures;


vi. Detailed description of proposed service delivery model (e.g. freestanding, single or multi-site, migrant voucher, or combination);

vii. Description of how this model is appropriate and responsive to the target population. Description should include but is not limited to services and staffing that addresses the priority health and social problems of the target population. Services and description should include health care for life cycle and meet the requirements of the BPHC PINs;

viii. Detailed description of services that will be coordinated and integrated with the activities of other federally funded, state and local health services delivery projects and programs serving the organization’s target population;

ix. Description of service delivery plan that assures a seamless continuum of care and access to appropriate specialty care for the target population;

x. Description of formal and informal arrangements, including copies of all relevant contracts, Memorandum of Understanding (MOU), letters of commitment, referral agreements, etc.;

xi. Description of how service delivery model will increase access to primary health care services and reduce health disparities for the medically underserved in the community/target population;

xii. Description of procedures and tracking mechanisms for referring patients for specialty care/diagnostic services;

xiii. Written description of system for after-hour clinical consultation/care, including how this system is communicated to patients;

xiv. Board approved Patient Bill of Rights and Responsibility; and xv. Board approved minutes indicating the adoption of the service delivery

plan

b. If health care center is operational, the service delivery plan must include how FQHC Incubator Program funds will augment/supplement existing services, resources and providers either directly or indirectly (i.e. expanded facilities so that is sufficient space to submit an Expanded Medical Capacity application). Transitional Operating Support (TOS) must be used to meet the minimum level of services required for an FQHC-LA including mental health, dental, and substance abuse. TPCO may require additional information for the purpose of BPHC funding application viability. V. Sustainability and Business Plans

a. Sustainability and Business Plans must include, but are not limited to:

ii. Problem/Needs Statement; iii. Goal; iv. Objective(s); v. Key Action Steps (steps which must be accomplished to meet the

objective); vi. Data Source and Evaluation Model (list the source and how agency will


use to assess progress in meeting objective); vii. Progress; viii. Expected Outcomes; ix. Responsible Parties; x. The above 8 items should be submitted in the appropriate FQHC/330

application (New Access Point, etc.) tabular format; xi. Documentation that board of directors has approved a fee schedule and

schedule of discounts that covers the cost of all types of visits, procedures, lab tests, and other ancillary services performed;

xii. Detailed description of organizational structure, management systems, and lines of authority that are appropriate and adequate for the size and scope of an FQHC-LA and/or FQHC/330 funding application;

xiii. Description of accounting and internal controls in accordance with sound financial management procedures appropriate to the size of the organization, funding requirements, and staff skills available;

xiv. Two-year (FY 2005 and FY 2006) detailed operating budget, including the identification of potential patient fees, Texas Department of Health grant awards (FY 2005 only), as well as potential FQHC/330 and FQHC-LA funding. Budget adopted by governing board of directors must be reflective of the organization’s history, internal resources ability as well as available community resources;

xv. Application for and notification of Medicare and Medicaid billing numbers; Documentation of monthly financial statements prepared for review by Finance Committee and governing board of directors. Statements must include but not are limited a comparative balance sheet, income statement, encounter activity as compared to budget by payer type, etc.;

o Copy of governing board of directors approved plan for collections; o Copy of governing board of directors adopted operating and sustainability

plan that must include, but is not limited to: o The purpose of the plan; o The market and the documented “assumptions” that planners have made

by means of primary market research (volume-defined target service area and population, market share, annual demand for primary care, etc.);

o Review of key operating aspects of the health center, how business will be managed (including governance) and organized. Description should include but is not limited to organizational charts: first, depicting the relationship between the governing board of the health center, its committees and senior management; and, a chart that clearly demonstrates the relationship between senior management and all the health center functions and staff;

o Plan implementation steps, and a contingency plan if projected targets fall short;

o Other items must include but are not limited to: expenses for provider and support staff, revenues, fee for service, managed care including both non-Medicaid and Medicaid; government funding such as Ryan White Comprehensive AIDS Resources Emergency Act, Title I Family Planning,


etc.; o Detailed accounting of Program Income in the two-year operating budget; o Program Income generated while receiving Transitional Operating Support

(TOC) grants must be used towards the sustainability of the organization; therefore, a financial plan detailing how TOS Program Income will be used to sustain operations during and for two years after receiving FQHC Incubator Program TOS support;

xv. Timeline for annual independent financial audit; and, xvi. Documentation of MIS/data system needs and solutions;

TPCO may require additional information for the purpose of BPHC funding application viability. VI. Collaboration Plan a. Collaboration Plan must include, but is not limited to:

i. Identification and participation of appropriate management staff in all local health care delivery system improvement coalitions or collaborations that would assist the organization with the FQHC/330 funding requirements;

ii. Participation in all community collaboration efforts conducted by the TPCO, the TACHC, or any meetings with any other entities, if the geographic area to be discussed includes all or part or is in proximity to the grantees proposed service area;

iii. Documentation that all parties involved agreed upon target areas. If agreement is not possible, then evidence of multiple attempts to reach an agreement must be provided;

Documentation of collaboration and coordination attempts includes: Meeting agendas, minutes, and list of attendees; and Proposals by the FQHC Incubator grantee outlining collaboration and coordination plans; identifying pros and cons for each entity involved; and, documentation that other entities involved received the proposals including any response they had.

b. Any collaboration or coordination plan must be based on a comprehensive assessment of all relevant data including, but not limited to:

i. Clinic data documenting where current users live, a patient origin map; ii. Socio-economic census data such as poverty levels, low-income levels,

limited English proficient population, and ethnicity; iii. Number of providers in the area serving the target population; iv. Number of eligible Medicaid and Medicaid consumers; and, v. Market penetration rates of existing clinics in the proposed service area for

the target population and projected penetration rates for 2 and 5 years out. TPCO may require additional information for the purpose of BPHC funding application viability.


VII. Staff and Contractor Job Description

a. Organization must submit to the Texas Primary Care Office for approval a job description for positions or contracts for development support such as grant writers funded through the FQHC Incubator Program.

b. All job descriptions must include the percentage of time to be spent on FQHC Incubator activities.

c. All contracts must identify the product or service to be delivered, the quantity or expected timeframe for delivery of the product or service, provider qualifications, the contract amount, and when applicable, the limit of time or payment for the service or product. The Texas Primary Care Office (TPCO) may require additional information for the purpose of Bureau of Primary Health Care (BPHC) funding application viability.

TPCO may require additional information for the purpose of BPHC funding application viability. VII. Technical Assistance Plan

a. Organization must submit for review and recommendations a technical assistance plan for health center management staff including the Chief Executive Director, Chief Financial Director, Clinical Director and the Chief Information Officer, governing board of director members, and the co-applicant entity.

b. Technical assistance and training activities may include: administration; governance; managed care; financial management; Management Information Systems (MIS); clinical management, and cluster clinical collaborative(s).

c. Grant writing technical assistance must include: i. Review of completed BPHC applications by an FQHC

knowledgeable grant writer/reviewer with comments copied to Texas Primary Care Office;

ii. Expanded Medical Capacity and Service Expansion Grants must be reviewed at least 10 days before submission to BPHC;

iii. New Access Point applications must be reviewed at least 30 days before submission to the BPHC; and

d. Applications submitted for review must be complete including any attachments, MOUs, or other documentation.

e. Attendance by at least 1 management staff member and 1 governing board member at the annual conference of the Texas Association of Community Health Centers (http: //www.tachc.org) regardless of the FQHC Incubator Program grant support level.


http://www.tachc.org/

APPENDIX C CONTACT AND REFERENCE INFORMATION

Bureau of Primary Health Care

U.S. Department of Health and Human Services East West Towers 4350 East West Highway Bethesda, Maryland 20814 Tel: 301-594-4300 Web Page: http://bphc.hrsa.gov/ Policy Information Notice 98-23 Program Expectations o ftp://ftp.hrsa.gov/bphc/docs/1998PINS/PIN98-23.PDF

Texas Department of State Health Services Texas Primary Care Office

1100W 49th Street G-106 Austin, TX 78756 Tel: 512-458-7518 E-mail: [email protected] or [email protected] Web Page: http://www.DSHS.state.tx.us/chpr/

Medically Underserved Area Designations

Texas Association of Community Health Centers

5900 South West Parkway Building 3 Austin, TX 78735 Tel: (512) 329-5959 Web Page: http://www.tachc.org/

National Association of Community Health Centers 7200 Wisconsin Ave. Suite 210 Bethesda, MD 20814 Tel: 301-347-3100 Web Page: http://www.nachc.org/


http://bphc.hrsa.gov/


http://www.tachc.org/

APPENDIX D BPHC POLICY INFORMATION NOTICE 98-23

OVERVIEW-

This document describes expectations of entities funded by the Bureau of Primary Health Care (BPHC) under Section 330 of the Public Health Service Act as amended by the Health Centers Consolidation Act of 1996. All health centers authorized to receive grants under Section 330 are covered by these expectations including community health centers providing care to diverse underserved populations – Section 330; those serving migratory and seasonal farm workers and their families - Section 330 (g); those serving homeless people including homeless children - Section 330(h); and those serving residents of public housing - Section 330(i). The expectations also apply to school-based health centers funded through the Healthy Schools, Healthy Communities program. Federally Qualified Health Center (FQHC) look-alikes, by definition must meet the requirements for health centers under Section 330. Thus, they are governed by these expectations to the same extent as health centers, subject to any waivers. Migrant Voucher Programs are not covered by the expectations.

The term "health center" is used throughout the Program Expectations to refer to all the diverse types of organizations and programs covered by the various subsections of Section 330, including organizations funded to serve migrant and seasonal agricultural workers, the homeless, and residents of public housing. The expectations emphasize the similarities but recognize the differences among health centers. There is no "model" health center, yet all health centers share many attributes including: their mission to provide primary and preventive health services to underserved populations, while working with constrained resources; the imperative to maintain strong leadership, finances and infrastructure in order to adapt and survive the challenges of a transforming health care environment; and the delivery of high quality clinical services which have a demonstrated impact on health outcomes. Health centers have been a critical component of our country’s health care safety net for more than 30 years and will continue to be essential for the foreseeable future. The Program Expectations are intended to ensure that health centers not only survive but thrive as they move into the twenty-first century.

The Program Expectations recognize that health centers serve culturally and linguistically diverse populations. Some health centers receive funding for the specific purpose of providing services to a distinct underserved population such as homeless people, migratory and seasonal farmworkers, or residents of public housing. The expectations state that all health centers must provide services which are culturally and linguistically appropriate for the diverse populations they serve. Health centers which receive funding to serve a defined special population, however, have additional requirements they must meet, and these are identified in the expectations.

The Program Expectations address requirements of law and regulation as well as BPHC policies. In general, expectations which have a basis in law1 and regulation2 are indicated in the document by the word "must" and must be met for entities to be eligible for funds. Expectations that reflect BPHC priorities and preferences for program funding or elements associated with successful programs are referred to by "should" or similar wording. In evaluating new and continued funding applications, consideration will be given to the extent to which applicants comply with those expectations identified by


"should". Most importantly, the expectations highlight aspects of health center programs associated with success.

The Program Expectations provide the basis for other BPHC processes and documents including the grant application instructions, grant review criteria, and program reviews including the Primary Care Effectiveness Review (PCER). Policy Information Notices (PIN) and Program Assistance Letters (PAL), which are issued periodically by the Bureau, provide additional detail and guidance on selected topics addressed in the expectations. In addition, these expectations may be supplemented for classes of health centers whose unique organizational/operational style demand that the expectations be adapted to their way of doing business (i.e., school-based health centers).

The Program Expectations are comprised of four sections. Section I., "Mission and Strategy" addresses the importance of adapting to health care trends and remaining financially viable, while fulfilling the essential health center mission of providing preventive and primary care services which improve the health Section II., "Clinical Program" highlights the services, staffing and systems which contribute to the provision of high quality health care. Section III., "Governance" summarizes the structure, composition and responsibilities of health center governing bodies. Section IV., "Management and Finance" describes the management team, systems and infrastructure which lead and support the health center in the pursuance of its mission. Because all components work together to make a health center successful, the Program Expectations should be reviewed in their entirety. However, a table of contents is provided to assist with reference to a particular section.

1Section 330 of the Public Health Service Act (PHS), as amended by Public Law 104-299, the Health Centers Consolidation Act of 1996 242 CFR Part 51c and 42 CFR Part 56. These regulations apply only to health centers funded under Sections 330(e) and Section 330(g) of the PHS Act, respectively. While health center programs funded to serve homeless people or residents of public housing are not bound by these regulations, these programs may wish to look to these regulations for guidance. Where new provisions of the Health Centers Consolidation Act of 1996 conflict with requirements specified in the regulations, the provisions of the Act take precedence.

TABLE OF CONTENTS


I. MISSION AND STRATEGY........................... 5

A. EXPECTATION

B. EXPLANATION

1. Underserved Populations................................5

2. Cultural Competency.......................................5

3. Strategic Positioning .......................................5

4. Needs Assessment..........................................7

5. Continuous Quality Improvement

and Performance Measurement .........................8

II. CLINICAL PROGRAM ....................................8

A. EXPECTATION

B. EXPLANATION

1. The System of Care ..........................................8

2. Service Delivery Models ..................................10

3. Contracting for Health Services .......................10

4. Health Care Planning .......................................11

5. Clinical Staff ......................................................11

6. Consumer Bill of Rights and Responsibilities ....12

7. Clinical Systems and Procedures.......................13

III. GOVERNANCE....................................................13

A. EXPECTATION

B. EXPLANATION

1. Overview of Requirements ....................................13


2. Board Composition ................................................14

3. Governing Board Functions and Responsibilities...15

4. Exceptions..............................................................17

5. Network Grantees...................................................17

6. Affiliations...............................................................17

IV. MANAGEMENT AND FINANCE...........................18

A. EXPECTATION

B. EXPLANATION

1. Management and Staff Structure ...........................18

2. Management Role in Planning & Strategic Positioning ...19

3. Managed Care Contracting ....................................19

4. Management Systems.............................................20

5. Financial System......................................................21

6. Facilities...................................................................23

Please note: In the interest of brevity and paperwork reduction, this document is a re-formatted version of the U. S. Bureau of Primary Health Care’s Program Information Notice 98-23 (PIN 98-23). Therefore, page numbers in this version may not match those of the original PIN 98-23. Otherwise, its text is identical to the original PIN 98-23.


I. MISSION AND STRATEGY

A. EXPECTATION

In order to fulfill the health centers’ mission of improving the health status of underserved populations, health centers must continue to survive and thrive through health care reforms, marketplace changes and advances in clinical care. Health centers must assess the needs of underserved populations and design programs and services which are culturally and linguistically appropriate to those populations. They must measure the effectiveness and quality of their services and continuously evolve their programs to achieve the greatest impact. They must operate as efficiently as possible. Health centers must collaborate with other organizations, at the same time maintaining their integrity as federally-funded health centers by continuing to fulfill their mission, and complying with applicable law, regulation and expectations.

B. EXPLANATION

1. Underserved Populations

Federally funded health centers provide health services to underserved populations. This includes all people who face barriers in accessing services because they have difficulty paying for services, because they have language or cultural differences, or because there is an insufficient number of health professionals/resources available in their community. Underserved populations also include people who have disparities in their health status. Some health centers may focus on specific special populations such as homeless people, migratory and seasonal farmworkers, residents of public housing, or at-risk school children, while most serve a cross-section of the population in their communities. The specific population groups to be served by a health center are defined by that health center through a process of assessing the needs, resources and priorities in their community.

For many health centers, the need for services far exceeds available resources. Health centers are faced with extremely difficult choices regarding which underserved population groups to serve and/or which needed services to provide. An inclusive and informed planning process frames the decisions every health center must make.

2. Cultural Competency

Health centers serve culturally and linguistically diverse communities and many serve multiple cultures within one center. Although race and ethnicity are often thought to be dominant elements of culture, health centers should embrace a broader definition to include language, gender, socio-economic status, sexual orientation, physical and mental capacity, age, religion, housing status, and regional differences. Organizational behaviors, practices, attitudes, and policies across all health center functions must respect and respond to the cultural diversity of communities and clients served. Health centers should develop systems that ensure participation of the diverse cultures in their community, including participation of persons with limited English-speaking ability, in programs offered by the health center. Health centers should also hire culturally and linguistically appropriate staff.

3. Strategic Positioning


Significant changes are occurring throughout the country in the way in which health care is being financed and delivered. Health centers need to understand their health care marketplace and be willing and able to adapt and reposition themselves to survive. Understanding the health care marketplace requires looking beyond the health center’s service area to what is occurring with key players in the larger marketplace and identifying opportunities and challenges for health centers.

a. Planning

In order to succeed, health centers must engage in active, ongoing planning processes. Planning should include both long term strategic planning and annual operational planning. Strategic planning should establish long term strategic goals. Operational planning focuses on short-term objectives within the context of the strategic plan.

Planning should be based on collecting and analyzing data, as well as on input from diverse stakeholders: health center governing board members, staff at all levels, community members, clients and organizations involved in providing or paying for health care in the marketplace. Recipients of funding to provide services to residents of public housing must consult with residents as part of their planning and grant application processes.

Planning should include ongoing evaluation, feedback and adjustment based on environmental, operational, or clinical change. While remaining flexible and allowing for response to new opportunities and pressures, plans should describe the health center’s goals and priorities sufficiently to guide members of the organization in strategic and operational decision-making.

b. Collaboration and Affiliation

Health centers must collaborate appropriately with other health care and social service providers in their area. Such collaboration is critical to ensuring the effective use of limited health center resources, providing a comprehensive array of services for clients, and gaining access to critical assistance and support (e.g. housing, food, jobs). In many instances, health centers may consider more formal affiliation opportunities such as contractual relationships, certain types of joint ventures or mergers. Affiliations are desirable when they lead to integrated systems of care which strengthen the safety net for underserved clients.

Health centers may join other organizations such as other health centers, hospitals, specialty groups and social service providers to form integrated delivery systems. An integrated system may be formed through contractual relationships or memoranda of agreement. In these situations, each partner in the affiliation retains its organizational autonomy and integrity and the health center governing board continues to meet expectations. In other situations, a new organization may be formed.

While health centers are encouraged to collaborate with other entities, they must ensure that all the laws, regulations and expectations regarding the health center governing board member selection, composition, functions and responsibilities are protected if the health center wants to retain eligibility for federal funding. The resulting delivery system must contribute to the desired outcomes of availability, accessibility, quality, comprehensiveness, and coordination.

c. Cost-effectiveness/cost-competitiveness


Many decisions in the health care arena are being driven by economic considerations, and it is imperative that health centers strive to be cost-competitive. All health centers must be as efficient as possible, understand the costs of the services they provide, and bring costs in line with other providers in the marketplace providing comparable services. Health centers should be able to document the value, i.e., cost and quality, of the services they provide and demonstrate the impact of their services on the health and well-being of the communities they serve.

As part of becoming cost effective, health centers are expected to evaluate their management and delivery systems in order to be able to increase efficiency and to maintain operations in the competitive, cost conscious marketplace. Health centers will need to manage the care of their patients in accordance with their managed care risk arrangements and be able to monitor their financial risk related to managed care contracting requirements.

4. Needs Assessment

a. Understanding Community Needs and Resources

Crafting strategy demands a thorough knowledge of the community and population groups a health center intends to serve. In order to use limited resources effectively, this requires both an understanding of the health care needs of the target community, as well as resources available to meet those needs. Needs and available resources should be monitored on an ongoing basis and comprehensively assessed on a periodic basis, or when environmental changes dictate reassessment.

Although there is no prescribed way to conduct a needs assessment, each program should be able to describe: 1) the geographic area and/or population groups which constitute their principal target population; 2) the characteristics of this population in terms of age, sex, socioeconomic status, health insurance status, ethnicity/culture, language, health status,housing status and health care utilization patterns; 3) perceptions of the target population about their own health care needs and barriers to accessing needed services; 4) other providers of health and social services accessible to the population; and 5) gaps in services that the health center proposes to address.

b. Description of Current and Potential Users of Services

All needs assessments should examine both people currently using services and those in the target population who are not using needed services. In order for health centers to be able to document their achievement of health care outcome goals, health centers should be able to describe their current clients in terms of demographics, utilization patterns and health care status. Health centers should not lose sight of people in their target population who are not using needed services. Sometimes, they have the greatest health needs and require extra effort to bring into care.

c. Special Populations

All health centers serve diverse populations and must understand the differing needs of these populations. Some health centers receive federal funding designated to serve special medically underserved populations including homeless people, migratory and seasonal farmworkers and their families, at-risk school children, or residents of public housing. For those health centers receiving federal funding to serve homeless people, these funds may be used to provide services to formerly homeless people for up to


twelve months after housing has been obtained. Programs receiving federal funding to serve special populations must specifically assess needs and resources for these populations. Federal grant funds may not be used to supplant other funds or in-kind contributions from state and local sources for centers serving homeless people or residents of public housing.

Health centers also serve populations with specific health needs such as those related to HIV, pregnancy, mental health or substance abuse. All health centers must be able to provide or arrange for a full spectrum of primary care services. Health centers serving large numbers of individuals with a particular health care need should specifically assess service needs, develop outcome and services goals, and provide or arrange for access to needed services.

5. Continuous Quality Improvement and Performance Measurement

Performance measurement and quality improvement are critical elements for excellence in the health care industry. The environment is driving the use of data to increase accountability, support quality improvement, facilitate and support clinical decisions, monitor the population’s health status, empower patients and families to make informed health care decisions, and provide evidence to eliminate wasteful practices. Similarly, both federal and state governments are requiring programs to document performance and improvement as a condition of continued support. All health centers must have a quality improvement system that includes both clinical services and management.

Quality depends upon the health center’s commitment to its community and its dedication to quality improvement. Quality of health center services also requires effective clinical and administrative leadership and functioning clinical and administrative systems. The organization should support and establish a locus of responsibility, such as an interdisciplinary quality improvement committee, for the quality improvement program. Quality improvement activities and results should be reported to the clinical and management staff as well as the governing board.

Health center quality improvement systems should have the capacity to examine topics such as patient satisfaction and access; quality of clinical care; quality of the work force and work environment; cost and productivity; and health status outcomes. In addition, quality improvement systems should have the capacity to measure performance using standard performance measures and accepted scientific approaches. Centers are encouraged to establish performance standards in concert with other health centers serving similar populations. In analyzing performance data, health centers should compare their results with other comparable providers at the state and national level, and set realistic goals for improvement. Periodic reassessment enables health centers to measure progress toward these improvement goals and respond to advances or changes in clinical care. Since successful utilization management is an effective

means of delivering appropriate services and maximizing value, quality improvement studies addressing utilization management of appropriate specialty, pharmacy, hospital and other services is key.

II. CLINICAL PROGRAM

A. EXPECTATION


Improving health status among underserved populations is the ultimate goal of health center programs. Health centers must have a system of care that ensures access to primary and preventive services, and facilitates access to comprehensive health and social services. Services must be responsive to the needs and culture of the target community and/or populations. Quality of health center services is paramount. Health centers must have effective clinical and administrative leadership, systems and procedures to guide the provision of services, and ongoing quality improvement programs to ensure continuous performance improvement.

B. EXPLANATION

1. The System of Care

a. Required Services

Health centers must provide required health care services as described in statute and regulation. All health center programs must provide, directly or through contracts or cooperative arrangements, basic health services including: primary care; diagnostic laboratory and radiologic services; preventive services including prenatal and perinatal services; cancer and other disease screening; well child services; immunizations against vaccine-preventable diseases; screening for elevated blood lead levels, communicable diseases and cholesterol; eye, ear and dental screening for children; family planning services and preventive dental services; emergency medical and dental services; and pharmaceutical services as appropriate to a particular health center.

All health centers must also provide services which help ensure access to these basic health services as well as facilitate access to comprehensive health and social services. Specifically, health centers must provide: case management services; services to assist the health center’s patients gain financial support for health and social services; referrals to other providers of medical and health-related services including substance abuse and mental health services; services that enable patients to access health center services such as outreach, transportation and interpretive services; and education of patients and the community regarding the availability and appropriate use of health services.

Programs receiving funding to serve homeless individuals and families also must provide substance abuse services. Substance abuse services include treatment for alcohol and/or drug abuse and may use a variety of treatment modalities such as: non-hospital and social detoxification, non-hospital residential treatment and case management and counseling support in the community. While these service requirements are specific to programs receiving funding for this special population, all health centers are encouraged to ensure access to these services for all their patients.

Required services may be provided by health center staff or through defined arrangements with other individuals or organizations. When a required service is not provided directly by health center staff, written agreements should be developed specifying how the service is provided.

b. Additional Services

Additional services may be critical to improve the health status of a specific community or population group. For example, health centers serving migratory and seasonal farmworkers should provide programs which reduce environmental and occupational risks for farm workers. Migrant health centers should be knowledgeable of the


Environmental Protection Agency’s Worker Protection Standard and other pesticide safety regulations. A program serving homeless people may decide that the provision of mental health services is critical to the effective provision of primary care. Services beyond the required health center services should be provided based on the needs and priorities of the community, the availability of other resources to meet those needs and the resources of the health center.

c. Hospitalization and Continuum of Care

The focus of health center services is primary and preventive care. However, all health centers are expected to assess the full health care needs of their target populations, form a comprehensive system of care incorporating appropriate health and social services, and manage the care of their patients throughout the system. All health centers must have ongoing referral arrangements with one or more hospitals. Health center clinicians should obtain admitting privileges and hospital staff membership at their referral hospital(s) so health center patients can be followed by health center clinicians. When this is not possible, the health center must have firmly established arrangements for hospitalization, discharge planning and patient tracking.

The health center should assure that quality specialty medical, diagnostic and therapeutic services are available to patients through a system of organized referral arrangements. The effectiveness of these referral arrangements depends on timely exchange of information about the patients between the specialists and health center clinicians. Health centers should consider forming or joining integrated delivery systems to gain improved access to hospital and other services for their patients.

After-Hours Coverage

The provision of comprehensive and continuous care includes care during hours in which the health center is closed. Although specific arrangements for after-hours coverage vary by community, all health centers should establish firm arrangements for after hours coverage. Wherever possible, coverage should include the health center clinicians and may also include other community clinicians. At a minimum, the coverage system should ensure telephone access to the covering clinician, have established mechanisms for patients needing care to be seen in an appropriate location, and assure timely follow-up by health center clinicians for patients seen after-hours. Health centers should consider the linguistic needs of their patients when designing their after-hours coverage system.

2. Service Delivery Models

Health centers serve diverse populations, have differing levels of resources and varying marketplace dynamics. This variety has led to a range of service delivery models. Health centers vary across many characteristics including location and hours of services, mix of services and type of staff providing services.

Location: Health centers must provide services at locations and times that ensure services are accessible to the community being served. Health center governing boards are responsible for deciding on the locations and times services are available. Many health centers operate primarily fixed-site locations. Others offer services in locations ranging from homeless shelters to migrant farmworker camps to public housing communities to schools. Some use vans to bring specific services to a broad audience


or reach a highly mobile population. Many operate from several locations, including off-site locations. Programs serving people who are homeless or mobile engage in extensive outreach to provide services wherever the patients are.

Hours: A health center’s hours of operation should facilitate access to services and should include some early morning, evening and/or weekend hours. Health centers should also provide for access to needed care when the health center is closed.

Mix of services: The specific mix of services offered by health centers is influenced by demographic, epidemiological, resource and marketplace factors. For example, health centers serving a population that is primarily women of child-bearing age and young children will offer services appropriate to those populations. In contrast, health centers serving primarily adult men will focus their services on the needs of that population. Communities with high prevalence of certain health problems (e.g., tuberculosis, HIV, diabetes, hypertension, mental illness, substance abuse) should design their mix of services to best address those issues.

Type of service provider: The types of service providers utilized by health centers will depend on the mix of services the health center offers. Many health centers benefit from an inter-disciplinary team of providers. As appropriate, health centers should utilize various disciplines and levels of providers. Physicians, physician assistants, nurse practitioners and nurse midwives, as well as staff skilled in providing mental health, social work and substance abuse services may all be part of the provider team. Programs may also select staff members who are members of the community to provide education and outreach services.

3. Contracting for Health Services

Health centers may have contracts or other types of agreements to secure services for health center patients that it does not provide directly. The service delivery arrangement must contribute to the desired outcomes of availability, accessibility, quality, comprehensiveness, and coordination. Arrangements for the provision of services that the grantee organization provides through a subcontractor should be in writing and clearly state: the time period during which the agreement is in effect; the specific services it covers; any special conditions under which the services are to be provided; and the terms and mechanisms for billing and payment. Other areas that should be addressed in the written agreement include but are not limited to: credentialing of contracted service providers; the extent to which the contracted services and/or providers are subject to the health center’s quality improvement and risk management guidelines and requirements; and any data reporting requirements.

4. Health Care Planning

In order to ensure that human and financial resources are being applied in the most effective and efficient way possible to improve the health status of the community and meet the community’s identified needs, each health center must develop health care goals and objectives as part of the organization’s planning process. The health care goals and objectives should address the highest priority health care needs of the community served and consider both the role of the health center in the community’s system of care and the specific actions the health center will undertake on behalf of its patients and the community. The objectives and action steps should be specific,


reasonable, measurable and achievable. Collaboration and affiliations with other agencies and providers should be utilized to achieve health care goals when possible.

5. Clinical Staff

The composition and structure of a health center’s clinical staff are central to the health center’s ability to provide high quality care and assure continuity of care for its patients. All health centers are expected, through aggressive recruitment and retention, to maintain a core staff of primary care clinicians with training and experience appropriate to the culture and identified needs of the community.

a. Leadership

Strong clinical leadership is essential for all health centers. Health centers should have a Clinical Director with training and skills in leadership and management who works closely with other members of the health center’s management team. Typically, the Clinical Director is a physician, although other types of clinicians may fulfill the role, particularly in very small programs which may be staffed by non-physicians. In some marketplaces, a physician Clinical Director may be essential to effectively position the health center. Clinical Directors are expected to: 1) provide leadership and management for all health center clinicians whether employees, contractors or volunteers; 2) work as an integral part of the management team; and 3) establish, strengthen and negotiate relationships between the health center and other clinicians, provider organizations and payers in its marketplace. Because it is critical that the Clinical Director always represent the interests of the health center, its patients and the community it serves, it is preferred that a health center directly employ its Clinical Director. If this individual is not directly employed, the Chief Executive should retain authority to select and dismiss the individual.

b. Staffing

Clinical staffing patterns vary among health centers. All staffing arrangements must lead to the desired outcomes of availability, accessibility, quality, comprehensiveness and coordination of services for health center patients. Physician staff should be board certified or residency trained. Other clinicians should be licensed and certified as appropriate under state law.

It is preferred that the health center directly employ its core clinical staff (at least the majority of the health center’s providers). If the core staff are not directly employed, then the Chief Executive Officer should retain the authority to select and dismiss individual providers. Also, except in very small

health centers or certain special population programs, it is expected that the employed core staff work only for the health center. Staff who work for the health center on a contract or volunteer basis may augment the employed core staff as appropriate.

The recruitment and retention of high quality health professionals are the foundation of a successful health center and require a multi-faceted approach. Health center systems and policies should support clinicians with the tools and systems appropriate for quality care, including high patient satisfaction. Management based collaboration, work structured to be meaningful and challenging, as well as a commitment to share information and ensure participation in decision- making are key strategies for a stable and productive staff committed to the mission and future of the health center.


A fair compensation and benefit package also supports long-term retention, and enhances productivity and quality. Appropriate incentive plans and deferred compensation plans which are compatible with fiscal resources, the health center mission and management philosophy, and are in accord with state and federal laws, should be explored as methods to maximize the retention of productive, quality and committed health professionals.

c. Credentialing and Privileging

The health center should define standards for assessing training, experience and competence of clinical staff in order to assure the clinicians’ ability to qualify for hospital privileges and payer credentialing. Credentialing should follow a formal process which includes querying the National Practitioner Data Bank and verifying education and licenses. Credentialing and privileging processes should meet the standards of national accrediting agencies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the Accreditation Association for Ambulatory Health Care, Inc., (AAAHC) as well as requirements for coverage under the Federal Tort Claims Act (FTCA). Quality assurance findings should be specifically considered in ongoing credentialing of clinical staff.

d. Continuing Professional Education

Continuing professional education (CPE) is critical to the provision of quality care. Health centers are expected to ensure access to CPE that maintains licensure of the provider and is appropriate to the needs of each health center, its staff and the community served.

e. Affiliation with Teaching Programs

When appropriate, health centers are encouraged to develop affiliations with clinical training programs. The purpose of successful affiliations should be to contribute to the mission and objectives of the health center, to meet the educational objectives of health professionals in training and to increase understanding of the health care needs of underserved populations. Health centers making the decision to develop teaching affiliations are encouraged to seek compensation for the costs of training provided.

6. Consumer Bill of Rights and Responsibilities

With the health system in a state of continual change, the rights and responsibilities of people using the health services, especially underserved and minority populations, need to be reaffirmed. Therefore, health centers should implement a Consumer Bill of Rights and Responsibilities: 1) to strengthen consumer confidence in health centers and a health care system that is fair, responsive and accountable to consumer concerns; 2) to encourage consumers to take an active role in improving their health; 3) to strengthen the strong relationship between patients and health care professionals; and 4) to reinforce the critical role consumers play in safeguarding their own health. Health centers should review the Consumer Bill of Rights and Responsibilities established by the Advisory Commission on Consumer Protection and Quality in the Health Care Industry and adopt and implement the precepts applicable to their operations.

7. Clinical Systems and Procedures

a. Policies and Procedures


Health centers must have written policies and procedures which address at least the following elements: hours of operation; patient referral and tracking systems; the use of clinical protocols; risk management procedures; procedures for assessing patient satisfaction; consumer bill of rights; and,

patient grievance procedures. Health center clinical protocols should reflect the current guidelines established by health agencies or professional organizations such as the Agency for Health Care Policy and Research, the American College of Obstetrics and Gynecology, the Advisory Committee on Immunization Practices, etc.. Health centers intending to seek accreditation should ensure that their policies and procedures address all the elements expected by the accrediting agency.

b. Clinical Systems

Patient flow and appointment systems should foster access and continuity of care, and minimizing waiting time and "no-shows." Patient flow and appointment systems should also provide for emergent problems and call-in or walk-in patients.

A clinical information system centered around a medical record must be in place. Confidentiality of records and data must be protected at all levels. The health center should utilize a medical records system that promotes thorough documentation and quality of care such as the Problem Oriented Medical Record (POMR) and uses flow sheets and recording forms when appropriate. A clinical system which incorporates recall for routine preventive services and chronic disease management, and a system that allows tracking of patients who are referred to specialists and other off-site services, require x-ray or lab, or who are hospitalized, are essential to a quality program. The clinical information system feeds data and information into the health center’s quality improvement program.

III. GOVERNANCE

A. EXPECTATION

Governance by and for the people served is an essential and distinguishing element of the health center program. Except as noted below, health centers must have a governing body which assumes full authority and oversight responsibility for the health center. The governing board must maintain an acceptable size, composition and meeting schedule. Strategic thinking and planning are essential functions for the board within the context of the environment in which the health center operates, as well as pursuing its mission, goals and operating plan. The board carries out its legal and fiduciary responsibility by providing policy level leadership and by monitoring and evaluating the health center’s performance.

B. EXPLANATION

1. Overview of Requirements

Governance requirements for health centers are addressed in law, regulation and policies. Requirements in the law apply to all health centers. The regulations set forth in 42 CFR Part 51c and 42 CFR Part 56 apply only to community health centers and migrant health centers respectively, though they provide useful guidance for other types of health centers. Section 330 requires that the health center has a governing body which: is composed of individuals, a majority of whom are being served by the center


and who, as a group, represent the individuals being served by the center; meets at least once a month; schedules the services to be provided by the center; schedules the hours during which services will be provided; approves the center’s grant application and annual budget; approves the selection of the director for the center; and except in the case of public entities, establishes general policy for the center.

2. Board Composition

a. Consumer Board Members

Health center governing boards are comprised of individuals who volunteer their time and energy to create a fiscally and managerially strong organization for the purpose of improving the health status of their communities. A majority of members of the board must be people who are served by the health center and who, as a group, represent the individuals being served.

Health center programs that have had the consumer majority requirement waived by the Secretary are still expected to meet the intent of the legislation of ensuring strong consumer input into the policies of the health center program. In there situations consumer input may be achieved in varying ways

such as through formal advisory boards, regularly constituted focus groups, or by including persons who have previously been consumers but no longer meet the special population definition.

Since the intent is for consumer board members to give substantive input into the health center’s strategic direction and policy, these members should utilize the health center as their principal source of primary health care. A consumer member should have used the health center services within the last two years. A legal guardian of a consumer who is a dependent child or adult, or a legal sponsor of an immigrant, may also be considered a consumer for purposes of board representation.

Additionally, as a group, consumer members of the board must reasonably represent the individuals served by the health center in terms of race, ethnicity, and gender. When a health center receives BPHC funding solely to support the delivery of services to a special population (homeless, migratory or seasonal farmworkers, residents of public housing or at-risk school children) the consumer majority must come from the target group, unless a waiver has been granted. When a health center receives both community health center funding and funding designated for a special population, representation should be reasonably proportional to the percentage of consumers the special population group represents. However, there should be at least one representative from the special population group. The intent is not to impose quotas on board membership but to ensure that boards are sensitive to the needs of all health center consumers.

b. Other Board Members

Since health centers are complex organizations working in dynamic environments, the board should be comprised of members with a broad range of skills and expertise. Finance, legal affairs, business, health, managed care, social services, labor relations and government are some examples of the areas of expertise needed by the board to fulfill its responsibilities. Regulations for community and migrant health centers place limitations on the percent of non-consumer members who represent the health care


industry. No more than half (two-thirds for migrant health centers) of the non-consumer representatives may derive more than 10% of their annual income from the health care industry. All health centers should strive for diversity of expertise and perspective among their board members.

c. Number of Members

The number of board members must be specified in the bylaws of the organization. The bylaws may define a specific number or provide a limited range if there are reasons for not maintaining a specific number of members. The size should be related to the complexity of the organization and the diversity of the community served.

Regulations for community and migrant health centers specify boards must have at least 9 and no more than 25 members. These size parameters are designed to ensure a large enough board to achieve diverse representation across the consumer groups and expertise while maintaining a size that effectively functions and makes decisions.

d. Selection of Board Members

The organization’s bylaws or other internal governing rules must specify the process for board member selection. The bylaws should specify the number of terms a member may serve and provide for regular election of officers and periodic changes in board leadership.

e. Conflict of Interest

The organization’s bylaws or written corporate board-approved policy must include provisions that prohibit conflict of interest or the appearance of conflict of interest by board members, employees, consultants and those who furnish goods or services to the health center. No board members shall be an employee of the health center or an immediate family member of an employee. The Chief Executive may serve as ex-officio member of the board.

3. Governing Board Functions and Responsibilities

The governing board of a health center provides leadership and guidance in support of the health center’s mission. The board is legally responsible for ensuring that the health center is operating in accordance with applicable federal, state and local laws and regulations and is financially viable. Day-to-day leadership and management responsibility rests with staff under the direction of the chief executive or Program Director.

a. Bylaws

Bylaws which are approved by the health center’s governing board must be established. The bylaws should be reviewed and modified as necessary to remain current. At a minimum, health center bylaws should address: the heath center’s mission; membership (size, composition, responsibilities, terms of office and selection/removal processes); officers (responsibilities, terms of office, selection/removal processes); committees (standing, ad-hoc, membership and responsibilities); meeting schedule, quorum and acceptable meeting venues; recording, distribution and storage of minutes; and provisions regarding conflict of interest, executive session and dissolution.


b. Responsibilities

A governing board is responsible for assuring that the health center survives in its marketplace while it pursues its mission. This is a massive challenge in an extremely dynamic health care environment which is placing increasing financial and service delivery pressures on all providers. Boards must be knowledgeable about marketplace trends and be willing to adapt their policies and position to reflect these trends. In addition to approving annual grant applications, plans, and budgets, boards should work with health center management and community leaders to actively engage in long-term strategic planning to position the health center for the future.

Success is dependent on the health center’s ability to effectively adapt to marketplace trends while remaining financially viable. Boards must not only plan effectively but also measure and evaluate the health center’s progress in meeting its annual and long-term programmatic and financial goals. The health center’s mission, goals, and plans should be revised as appropriate to the feedback gained through the evaluation process.

The governing board must select the services provided by the health center. While certain services are mandated by law, health center boards have a great deal of latitude in deciding which additional services should be offered by the health center and whether the services should be offered directly or through referral and collaboration with other service providers. Resources are always limited and a major challenge confronting health center boards is deciding which services should be supported with available resources. Effective needs assessment and planning processes are essential for making informed decisions about service configuration. The governing board must determine the hours during which services are provided at health center sites. Health centers are expected to schedule hours that are appropriate for their community. Generally this means some early morning, evening and/or weekend hours should be offered to accommodate people who cannot easily access services during normal business hours.

The board must approve the annual budget and grant application. The intent is not that the board simply sign-off on documents but that it understands the substance and implications of the budget and application. Ensuring the financial health of the organization and aligning the goals of the project application with the strategic direction of the health center are critical functions for the board. In order to effectively fulfill these functions, the board must be involved in health center planning throughout the year.

The board must approve the selection and dismissal of the chief executive or Program Director of the health center. Because the chief executive is the primary connection between board established policy and health center operations, the board must evaluate the performance of the chief executive and hold him or her accountable for the performance of the health center. Together, the board, the chief executive and other members of the management team comprise the leadership for the health center. To succeed, they must work together to ensure a strong organization and move forward into the future.

Except in the case of public entities funded under Section 330(e), the board must establish general policies for the health center. These include personnel, health care, fiscal, and quality assurance/improvement policies. These policies provide the framework under which health center staff conduct the day-to-day operations of the organization.


c. Board Meetings

Health center governing boards must meet at least monthly. Where geography or other circumstances make monthly, in-person meetings burdensome, the meetings may be held by telephone or other means of electronic communication.

The board must keep minutes of each meeting which are approved at a subsequent meeting. The board should also maintain a systematic tracking system of approval/disapproval of board policies and procedures as well as other records to verify and document its functioning.

d. Board training and development

It is expected that governing board members have sufficient knowledge and information to make informed decisions about the health center’s strategic direction, policies and financial position. Board members should be provided with opportunities for training and development, as well as conducting self evaluations. The board is responsible for identifying and assuring it meets its educational and training needs including orientation and training of new board members.

e. Committees

The board should have a committee structure which facilitates carrying out its responsibilities. Appropriate committees may include executive, finance, quality improvement, personnel, and planning. However, only the executive committee should be authorized to act for the Board.

4. Exceptions

a. Waivers for Special Population Health Centers

The law permits the Secretary to grant waivers for all or part of the requirements, for good cause, for health centers serving special populations; those serving migratory and seasonal farmworkers and their families - Section 330(g); those serving homeless people including homeless children - Section 330(h); and those serving residents of public housing - Section 330(i).

Health centers requesting waivers for all or any governance requirement must provide a compelling argument as to why the program cannot meet the statutory requirement, as well as alternative strategies detailing how the program intends to meet the intent of the law. Community health centers funded under the authority of Section 330 (e), with or without funding for a special population program, are not eligible for a waiver of any part of the governance requirements.

b. Public Entities

Community health centers funded under Section 330(e) of the Act that are sponsored by public entities, such as health departments, public hospitals, public universities, etc., may meet the governing board requirements in one of two ways. The public entity’s board may meet health center board composition requirements including having a consumer majority. In this case, no special considerations are needed. When the public entity’s board does not meet health center composition requirements, a separate health center governing board must be established. The health center board must meet all the


selection and composition requirements and perform all the responsibilities expected of governing boards except that the public entity may retain the responsibility of establishing fiscal and personnel policies. The health center board should be a formally incorporated entity and it and the public entity board are co-applicants for the health center program. When there are two boards, each board’s responsibilities must be specified in writing so that the responsibilities for carrying out the governance functions are clearly understood.

c. Tribal Entities

There is no governing board requirement for health centers operated by an Indian tribe or tribal or Indian organization under the Indian Self-Determination Act or an urban Indian organization under the Indian Health Care Improvement Act.

5. Network Grantees

Health centers are forming and participating in networks for many purposes. In most cases, participating health centers retain their own governing boards and these boards continue to be subject to applicable law, regulation and expectations. When health centers come together in a network, and the network is a Section 330(e) grantee, with the health centers operating as sub-recipients, the governing board at the network level, must meet the governing board requirements and expectations. Furthermore, the network must have sufficient staff and other resources to ensure the network board carries out its functions.

6. Affiliations

In some organizational affiliations, the selection, composition and/or responsibilities of the health center governing board may be altered. This may happen through formation of a new board for an integrated delivery system or through the participation of affiliate representatives on health center boards. There may also be various arrangements where a portion of the scope of the project is being provided by an entity other than the grantee. With any such arrangement the governing board must retain its full authorities, meet selection and compositional requirements and exercise all responsibilities and functions prescribed in legislation and regulations.

IV. MANAGEMENT AND FINANCE

A. EXPECTATION

A strong management team is essential to health center success. The management team must work with the governing board, leading organizational changes to adapt to marketplace trends. Health center management must operationalize the health center’s mission and strategic objectives. They must do this within available resources ensuring that the health center is financially viable and cost-competitive. Health center management must be supported by strong personnel, financial, information, and clinical systems.

B. EXPLANATION

1. Management Staff and Structure


a. Relationship of Management Staff to Board

The health center should have a line of authority from the board to a chief executive (President, Chief Executive Officer - Chief Executive, Executive Director, Project Director) who delegates as appropriate to other management and professional staff. As head of the management team, the Chief Executive should have the authority, responsibility and skills to: communicate with the board and management team; operationalize board policies; manage personnel and systems; allocate resources and operate within available resources; identify and resolve problems; interact with the community and providers and payers in the marketplace; respond to opportunities and; plan for future events. The Chief Executive is accountable to board-established long-term goals and operating plans.

The governing board must select, dismiss and directly employ the Chief Executive or director of the health center. It is preferred that other key management staff and core primary care provider staff also be directly employed by the health center. However, a grant recipient may contract for or enter into other arrangements for these positions. In all arrangements, the Chief Executive must be given an appropriate level of authority to lead and manage the health center, and should have full control over selecting and dismissing all staff assigned to the Health Center.

The demands of leading a health center usually require a health center to employ a full-time Chief Executive. In some instances, however, the director functions may be performed in combination with other responsibilities. For example, small health centers may employ one person who fulfills the Director function along with financial or clinical management functions.

An organization that operates other lines of business related to and supportive of the health center may have a Chief Executive who is responsible for overall corporate management and effectively works part-time on other health center activities and part-time on activities of the organization.

b. Management Team

The quality of the management team is a critical predictor of health center success. Recruitment and retention of management staff should be a health center priority. Health centers are most effectively managed by a team of individuals with the skills to provide leadership, fiscal management, clinical direction and management information system expertise. The management team usually consists of a Chief Executive or Program Director in lead of a team that includes a Clinical Director, Chief Financial Officer, and a Chief Information Officer. The functions associated with these positions may be combined and performed by one or more individuals, as appropriate. In larger health centers, additional management staff may be part of the management team. In situations where the health center is collaborating with other health centers in its marketplace, some of these positions may be shared. Management training and expertise is desirable for all members of the management team, and is essential for the Executive and Clinical Directors.

Position descriptions and an organizational chart reflecting these functions and their relationships should be maintained by management and provided to the board. It is


critical that the organizational structure and processes facilitate a team approach to management.

c. Staff Development

The health center should have an active plan for recruitment and retention of all staff, including volunteers. All staff should be qualified by training and/or experience for their scope of duty. Positions that require licensure must be filled by appropriately licensed professionals. Position descriptions should be developed for all staff. The descriptions should include professional and interpersonal skills that will ensure staff fulfill their responsibilities within the language and cultural context of the area. A staff development program should be developed for all staff to improve skills critical to health center success. Staff in management positions should have and maintain leadership skills. Continuing professional education is critical to the provision of quality care. All appropriate staff must receive training to maintain licensure and meet regulatory requirements such as Occupational and Safety Health Administration (OSHA) and Clinical Laboratory Improvement Amendments (CLIA).

2. Management Role in Planning and Strategic Positioning

All members of the management team play a key role in strategic and operational planning. The team should work closely with board, community members and other providers and payers in the marketplace to provide leadership in shaping the health center’s strategy. The management team is most familiar with the health center’s internal capabilities and constraints, and they provide a critical perspective to the planning process. Health center management is also responsible for assessing progress and providing critical information to the Board for revising the health center’s strategic direction.

The health center’s annual operating plan is developed by health center staff under the direction of the management team. The plan reflects the board’s established mission and goals and guides management in day-to-day decision-making. The operating plan is approved by the board and is monitored and adjusted throughout the year by health center management.

3. Managed Care Contracting

Many health centers are impacted by managed care contracting. Health centers should be able to demonstrate that they have engaged in an assessment of the adequacy of the reimbursement for the specific range of services included in their contracts. The appropriate systems should be in place to manage the risk associated with the contracts. The health center should also have implemented activities related to responsibilities for utilization management and/or quality improvement activities for which it will be held accountable.

These responsibilities should be clearly stated in the contract or other agreement. Health centers should have in place data systems for the collection of required types of data, the sharing of information with managed care organizations and the initiation of utilization management and quality improvement activities.

4. Management Systems

a. Information Management


The quality of every decision made in health centers is critically dependent upon the availability of accessible, accurate, relevant and current information. Information management defines a strategy for getting the right information into the hands of the decision-maker at the right time, whether for care delivery, health care access coordination, internal monitoring, quality assurance and improvement, financial management, risk management, or management decisions and planning. An information management strategy establishes the policies and procedures for data collection, organization, storage, maintenance (including backups), security, presentation (displays and reports), and communication and exchange with other organizations. The policies and procedures cover all formats of data, from charts, notes and images, to all forms of electronic storage.

Health centers must have systems in place which accurately collect and organize data for required reporting of program related statistics, as well as for internal monitoring, quality improvement and the support of management decisions and planning. The health center should be able to integrate clinical, administrative, and financial information to allow monitoring of the operations and status of the organization as a whole. Ability to collect and analyze service data based on Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes and utilize a system based on relative value units (RVU) to analyze production and costs are considered essential in today’s environment. Health centers are expected to utilize information to monitor performance compared to internal and external benchmarks, as well as for tracking trends.

Financial information systems must be capable of tracking, analyzing, and reporting key aspects of the organization’s financial status. These include revenue generation by source, billing and collections, cash flow, expenditures (by category or cost center) and unit costs. The system must provide sufficient information to support necessary accounting functions. Financial information systems should be capable of adapting to changing reimbursement mechanisms in the health care marketplace, including prepaid (at risk) contracts, and supporting accounting and monitoring of all reimbursement mechanisms in which the organization participates. Cost information should be collected and reported such that it informs management decisions concerning potential financial arrangements. The health center should secure cost information to determine whether its managed care contracts are profitable.

The information system should also be capable of supporting the health center’s clinical operations, both as a provider of routine, acute, and preventive health and health related services, and in its role as a care manager and coordinator of health care access. The information should be collected and presented in a manner which provides timely and pertinent clinical information to clinicians concerning individual clients, and should feed into the health center’s quality improvement and utilization management program. The system must be designed in a way which protects the confidentiality of client information.

Most of the information needs of today’s health care providers are best met using electronic (computerized) data systems. Due to the complexity and volume of information required in the modern health care environment, as well as the power of these systems to manage and process data, automated data processing offers most health centers significant advantages in terms of the efficiency and effectiveness of meeting its information needs. Health centers are encouraged to employ computerized data technology wherever practical given the organization’s size, resources, and the nature of services provided. Timely access to information and the capacity to


communicate and network with other providers and appropriate agencies and organizations are critical for survival in the information age. Computer systems should be designed to provide Internet access for all appropriate management and clinical staff.

b. Risk Management

The health center must have risk management policies and procedures in place. Such policies and procedures should pro-actively identify, and plan for, potential and actual risks to the health center in terms of its facilities, staff, clients, financial, clinical and organizational well-being. Risk management policies and procedures should include statements concerning quality assurance and improvement, fire and life-safety, regulatory compliance, and other potential areas of liability. They should also address issues of bonding, insurance, and professional and general liability. Risk management protocols must be incorporated in health center policies to assure that appropriate standards of care and clinical guidelines are established and followed. These protocols must be reviewed and revised. Periodic training in risk management and yearly continuing education is necessary for all providers of primary care services to assure that quality is maintained and improved. Health centers should explore participation in professional liability coverage available to them under the Federal Tort Claims Act.

5. Financial System

At a minimum, health center programs must maintain financial systems which provide for internal controls, safeguard assets, ensure stewardship of federal funds, maintain adequate cash flow to support operations, assure access to care, and maximize revenue from non-federal sources. Financial systems should be routinely reviewed and updated to assure that the organization remains financially sound, competitive, and attuned to changes in the local, state, and national health care environment.

a. Accounting and Internal Controls

Health centers must have accounting and internal control systems appropriate to the size and complexity of the organization. An accounting system, based on Generally Accepted Accounting Principles (GAAP), must be in place and designed to accurately reflect the financial performance of the organization. Within the constraints of organizational and staff size, separation of financial functions should be implemented to safeguard assets.

A set of routine financial reports must be generated and reviewed by appropriate management staff and members of the health center’s governing body on a regular basis. Reports will vary depending on organizational size, complexity, and services, but should reflect the current financial status of the health center and allow for comparisons to past and projected financial position.

b. Budget

The budget is the culmination of negotiations among health center managers, clinicians, and board members as they determine the level and scope of services to be provided within the constraints of the organization’s resources. The budget, as part of the health center’s operating plan, must attempt to accurately project both the resources available in the coming budget period and the expenditures required to achieve the health center’s goals and objectives. The annual operating budget must be approved by the board.


In order to realistically project revenues and expenses, health centers should be able to draw upon past budgetary experience and to identify significant changes anticipated in the coming period, both internally and in the health care marketplace in which the organization operates. The health center’s managers should pay careful attention to changes in the centers’ key sources of revenue, including all federal, state, local, and private sources of grant and service-based funding. Particular attention should be focused on changes in the state Medicaid system. Changes in the level and mechanism of Medicaid reimbursement and enrollment criteria can have significant impacts on the reimbursement to the health center and on the level and type of demand it experiences. The health center’s budget should be reviewed regularly by appropriate members of the health center’s management and governing board, and adjustments made as necessary.

c. Billing and Collections

Health centers must provide access to services without regard for a person’s ability to pay. Given the limited availability of federal resources, an important component of fulfilling this mandate is the maximization of revenue from all sources. Revenue maximization requires an adequate and competitive fee schedule and a corresponding schedule of discounts, prompt and accurate billing of third party payers, billing of patients in accordance with the schedule of discounts, and timely follow-up on all uncollected amounts.

Participation in insurance programs used by the health center’s population is of critical importance, as is assuring that reimbursement under such arrangements is adequate to cover the costs of services provided. Health centers must maximize revenue and participate in favorable enhanced or cost-based reimbursement programs for which they are eligible. Billing of clients without insurance, collection of co-payments and minimum fees, and screening for financial status, must be done in a culturally appropriate manner to assure that these important administrative steps do not, themselves, present a barrier to care. This aspect is particularly important for organizations working with special populations facing particular socio-economic barriers. The steps outlined should not conflict with the mission and mandate of health center programs, but rather assure that the federal grant resources available to the organization are used to address true financial access barriers to the maximum degree possible.

Health centers must have written, board approved, billing, credit, and collections policies and procedures which, at a minimum, include: a fee schedule for all billable services covering reimbursable costs and comparable to prevailing local rates; a method of discounting or adjusting fees based upon the patient’s income and family size from current Federal Poverty Guidelines; and, a system of billing patients and third-party payers within a reasonable period of time after services are provided, typically within 30 days. Health centers should establish a target for days in receivables for collections on billable services by payer, monitor collection rates on outstanding balances and follow-up or write-off such balances as appropriate. Where possible, health centers are encouraged to utilize electronic systems for billing and insurance verification.

Health centers participating in prepaid plans should have a system in place to receive timely notification of enrolled members, and to tie receipts of capitation payments to enrolled members regardless of utilization of services. Health centers are encouraged to develop expanded fee schedules to reflect the costs associated with non-billable services provided to patients. Health centers also should establish policies and procedures for out-of-plan services for capitated patients, and for required pre-


authorization of services and referrals to patients based on managed care contractual agreements. To the extent that health centers are at risk for services performed outside their facilities, ‘Incurred But Not Reported’ (IBNR) expenses -- the unpaid cost of services already provided to a plan member -- must be tracked carefully as a liability that can threaten the financial stability of a health center. These steps will help assure that health centers can remain viable and provide ready access to care for all patients in light of changing marketplace pressures.

d. Independent Financial Audit

Health centers must ensure that an annual independent financial audit is performed in accordance with federal audit requirements. Audits on non-profit health centers must follow the most recent federal guidelines pertaining to the auditing of non-profit institutions and, specifically, to the auditing of recipients of federal awards to such institutions. Health centers should issue a memorandum of engagement for an annual independent financial audit, which will be performed in compliance with the applicable federal guidelines. In addition, the Financial Status Report (FSR) and reconciliation between the audit and FSR must be prepared.

The audit report must provide an opinion, in writing, on the scope of the audit, the fairness of the grantee’s financial statements, and an evaluation of the organization’s system of internal accounting controls. The auditor shall determine whether the health center is operating in accordance with Generally Accepted Accounting Principles, and should provide the grantee with an opinion on their findings. Where significant audit exceptions and/or internal accounting control findings exist, the health center must implement a time-phased corrective action plan and may be subject to grant award conditions.

6. Facilities

The site(s) at which the health center delivers its services to clients are central to the image and acceptability of the health center to the clients, the staff, and the community. The appearance, layout, and location of facilities have implications for access, efficiency, quality, recruitment, and reimbursement in terms of participation in closed panel payer arrangements. Facilities used by health center programs should be appropriately located to promote access by its target population, adequate in size and layout to provide the services located there, and designed to promote the delivery of high quality, effective, and efficient health services and related services in a safe environment. Facilities owned or leased by a health center must conform to fire and life safety codes, handicapped access codes, and applicable building codes and regulations.

The health center should assure that any facility it uses is adequately insured, and should manage its facilities to ensure cleanliness, security, and routine maintenance and repair. The health center should plan for its facilities and major equipment needs for the foreseeable future and make arrangements for procuring needed capital and other resources to meet those needs.


APPENDIX E 200 POOREST COUNTIES

Counties identified as “200 Poorest Counties” in the United States that are located in Texas. This is a proposed list, as the final list has not yet been released. These are counties that currently do not have a FQHC. Counties over 100,000 in population: Ector County, TX Nueces County, TX Taylor County, TX Gregg County, TX Smith County, TX Bell County, TX Grayson County, TX Counties under 100,000 in population Presidio County, TX Hudspeth County, TX Kenedy County, TX Reeves County, TX Edwards County, TX Culberson County, TX Hall County, TX McCulloch County, TX Garza County, TX Terry County, TX Dallam County, TX Lynn County, TX Menard County, TX Haskell County, TX Knox County, TX Karnes County, TX Kleberg County, TX Martin County, TX Gaines County, TX Collingsworth County, TX Yoakum County, TX Parmer County, TX Falls County, TX


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