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					                                                                         Bluegrass Area Agency on Aging & Independent Living
                                                                                          Request for Proposal FY 2012-2014




                               Ombudsman Program Score Sheet
                                  Does the proposal address the following:
                                                                                                                Page #
  I.        Organization Profile

       1. History and experience of the organization as it pertains to its work with seniors
          and the service category (ies) for which the organization is applying.                                ______

       2.   List of Board Members and/or other governing body of the organization applying
            for funds.                                                                                          ______

       3.   Availability of funds to support the cost of providing services throughout the contracted
            period and continuation of services occurs until reimbursement for services is
            made. Is the financial management system capable of tracking revenue and
            expenses by the funding stream or program?                                                          ______

       4.   Information about any services to be subcontracted.                                                 ______

       5.   A copy of the agency’s staff and client grievance procedures.                                       ______

       6.   The agency’s plan regarding weather related emergencies including: conditions
            under which the agency will be closed, weather related emergency plans to ensure
            elderly clients receive services they need during emergency situations, name of
            contact persons, plan for receiving emergency calls for assistance.                                 ______

 Total Points Available: 50                                                   Total Points Earned: ________


II.    Staffing and Personnel

       1.   Identify staff designated to oversee services and describe how oversight for services
            delivered in multiple counties will occur.                                                          ______

        2. Describe how supervisory staff will monitor and verify that services have been
           delivered.                                                                                           ______

        3. Describe how supervisory staff assures that staff adhere to service schedules,
           deliver services as outlined and complete documentation in a timely manner.                          ______

        4. Include an organizational chart delineating lines of authority for all staff who work
           on behalf of the BGADD Aging Services program.                                                       ______

        5. Describe procedures for internal monitoring and assessment which includes
           service to be monitored and evaluated, name of the person or position
           responsible for monitoring and evaluating each service, procedures for
           corrective action or follow-up. A copy of the monitoring tool has been submitted.                    ______

        6. Describe method for ensuring that back-up staff is available to serve clients
           in the event staff is not available at the scheduled time for services.                              ______

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                                                                                                              Title III Section
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                                                                        Bluegrass Area Agency on Aging & Independent Living
                                                                                         Request for Proposal FY 2012-2014


   7. Describe methods and procedures utilized to ensure services will be
      provided to the clients in a timely manner.                                                              ______

       8. Describe the plan for staff training including: orientation, in-service and training
          to be provided to staff and volunteers, who will provide the training, subject of
          the training and ensuring that all Certified Ombudsman will comply with training
          requirements.                                                                                        ______

       9. Are job descriptions and resumes for supervisory staff support staff and volunteers
          provided. Does it include a copy of appropriate licenses (if applicable)? If an
          employee is not currently on staff, is there a commitment letter with time frames
          for the hiring of the position.                                                                      ______

       10. Ensure compliance with KRS 216.793 Criminal Records Check.                                          ______

       11. Describe procedures for notifying BGADD when staffing problems occur that
          could affect the delivery of services.                                                               _____

       12. Describe procedures established to ensure confidentiality of information by, or on
           behalf of a client.                                                                                 ______

  Total Points Available: 30                                                 Total Points Earned: ______


III.      Quality Assurance

  1. Describe the documentation maintained related to delivery of services,
     complaints time records and resolution of complaints and data entry.                                      ______

  2. Identify staff who conducts presentations.                                                                ______

  3. Describe how and when BGADD is notified of changes in services, operating hours
     or locations.                                                                                             ______

 4. Describe how the Ombudsman will assure that clients are fairly represented
    and adequate and qualified staff to provide long-term care ombudsman services.                             ______

  5. Provide a contingency plan for the provision of services and when necessary,
     assisting clients in case of inclement weather, emergencies, disasters, or other
     events that may affect the provision of services. Describe how workers will
     communicate with supervisory staff during this time and information on
     actions taken by the provider will be communicated to BGADD.                                              ______

  6. Describe how client satisfaction surveys will be conducted and how the results
     of surveys will be used to improve or modify services.                                                    ______

  7. Include a transition plan.                                                                                ______

  8. Describe method for reporting incidents related to service delivery and client
     conditions to BGADD within confidentiality limits.                                                        ______

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                                                                                                             Title III Section
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                                                                              Bluegrass Area Agency on Aging & Independent Living
                                                                                               Request for Proposal FY 2012-2014




         9. Include a copy of the organizations personnel policies and procedures.                                   ______

         Total Points Available: 10                                                Total Points Earned ________


 IV.     Facilities and Operations

         1. Provide a description of agency’s communication capacity including telephone /
            toll free numbers, fax lines, and Internet capability.                                                   ______

          2. Chart listing facilities is completed and barriers noted if they exist.                                 ______

          3. Identify Service Area(s) to be covered by the applicant.                                                ______

          4. Explanation provided of where family members, guardians and caregivers
             of long term care facility residents will receive services is provided.                                 ______

   Total Points Available: 5                                                       Total Points Earned ________


       V. Reporting

          1. Describe the system used to obtain accurate time records, service units,
             description of services delivered, record of unduplicated clients served, record
              of match and record of program income.                                                                 ______

          2. Describe the process for maintaining volunteer hours and value for purposes of
             reporting in-kind match.                                                                                ______

          3. Explain how OmbudsManager software will be incorporated into the organization’s
              operation.                                                                                             ______

          4. Describe how records will be reviewed for accuracy.                                                     ______

          5. Describe the plan for obtaining and utilizing program income to enhance program
             services.                                                                                               ______

       Total Points Available: 5                                                   Total Points Earned ________


VI. Program Implementation/Scope of Work

          Services

          1. Describe how volunteer recruitment will be conducted to ensure that each long
             Term care facility (including family care homes) has adequate coverage.                                 ______

          2. Describe how volunteers will be utilized and supervised.                                                ______

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                                                                                                                   Title III Section
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                                                                       Bluegrass Area Agency on Aging & Independent Living
                                                                                        Request for Proposal FY 2012-2014




     3. Explain how agency maintains time records of staff and volunteers and validates                       ______
        accuracy of time and activities reported.

     4. Describe the process used to receive, investigate and resolve client
        complaints including approximate time frames and methods of resolution.                               ______

     5. Explain the procedures used to maintain the confidentiality of client information,
        complaints and record security.                                                                       ______

     6. Describe how services will be provided for individuals with limited English speaking
        ability.                                                                                              ______

     7. Describe how Elder Abuse information will be provided.                                                ______

Total Points Available: 20                                                  Total Points Earned _______


VII. Detailed Program Information

1. Describe the delivery of services for residents of long term care facilities. (face-to face
   meetings, phone interviews, investigations and court proceedings, etc.)                                    ______

2. Describe the intake process and prioritization of clients in the event a waiting list needs
   to be established.                                                                                         ______

3. Describe day-to-day services while visiting residents, outside of complaint resolution.                    ______

4. Describe the process of providing long-term care ombudsman services from initial
   complaint to final resolution.                                                                             ______

5. List the number and location of presentations about the Ombudsman Program
   and Elder Abuse Prevention services conducted and describe the information presented.                      ______

6. How are residents and the public informed and educated about issues in the
   long term and the prevention of elder abuse.                                                               ______

7. Describe how the organization will monitor the development and implementation
   of laws pertaining to Long Term Care Ombudsman services and Elder Abuse Prevention.                        ______

8. Describe method used to ensure adequate legal counsel to provide advice,
   consultation, and representation to long term care residents.                                              ______



Total Points Available: 20                                                  Total Points Earned _______




                                                                                                                  Section IV
                                                                                                            Title III Section
                                                                                                                Page 4 of 6
                                                                     Bluegrass Area Agency on Aging & Independent Living
                                                                                      Request for Proposal FY 2012-2014


VIII. Performance Expectations

1. Explain how the organization will distribute a client satisfaction survey
   to all clients receiving Ombudsman or Elder Abuse prevention services.                                   ______

2. Explain how the organization will accomplish the 24 hours of training required for
   volunteers that meets State requirements to pass the competency evaluation administered
   by the Ombudsman agency then sent on to Frankfort for certification.                                     ______

3. Describe how complaints will be investigated and required documentation will be completed
   monthly and complaints with care issues will be acted upon within two business days and not
   exceeding three calendar days.                                                                           ______

4. Describe how complaint investigation will be documented in Ombudsmanager and case
   closed after all complaints related to the case have been closed.                                        ______

5. Describe how an Ombudsmen will be made available to residents in response to resident’s
   needs; how complaint investigation are initiated in the absence of the District Ombudsman.               ______

6. Describe how and when the LTCO program and staff and volunteers will participate in
   Resident’s Rights groups at facilities, exhibit at health fairs, and make presentations
   to community groups on a monthly basis.                                                                  ______

7. Describe how BGADD and the State Ombudsman will be notified and provided contact
   information for the back-up Ombudsman in the absence of the District Ombudsman.                          ______

8. How will information be made available to the general public about the Long Term Care
   Ombudsman and Elder Abuse Prevention.                                                                    ______

9. Describe how the District Ombudsman will provide the BGADD with quarterly and
   annual performance reports within designated timeframes as required by the State
   Long Term Care Ombudsman.                                                                                ______

10. Describe how the District Ombudsman office will avoid conflict of interest concerns when
    dealing with the health, safety and welfare and rights of resents and will maintain a
    memorandum of agreement with the legal series provider.                                                 ______

11. Ensure that the District Ombudsman office will conduct quarterly advisory council meetings
    to address the advocacy needs and services for resents of long term care facilities
    throughout the region.                                                                                  ______

12. The Ombudsman program will be represented at Local Coordinating Councils on
    Elder Abuse Prevention in the region. At least two targeted elder abuse trainings will
    be coordinated and provided annually.                                                                   ______

.
Total Points Available: 30                                                Total Points Earned _______


IX. Budget and Unit Cost

                                                                                                                Section IV
                                                                                                          Title III Section
                                                                                                              Page 5 of 6
                                                                   Bluegrass Area Agency on Aging & Independent Living
                                                                                    Request for Proposal FY 2012-2014


The fixed price quotation which is deemed to be responsive to our Request for Proposal, shall be evaluated
as to the cost per unit. The value assigned to each quote shall be such a number, in the opinion of the
review committee, accurately reflects the value of the quote in comparison to other quotes. The lowest
acceptable responsible unit cost proposal shall be assigned a value of 20 points. Each subsequent quote
which is higher, shall be assigned a lesser relative value. The minimum difference between any two
proposals shall be 2 points

Total Points Available: 30                                              Total Points Earned ______




               ___________________________________________________

                                          Final Scoring Totals

Total Section I – Organization Profile                        _______
Total Section II – Staffing                                   _______
Total Section III- Quality Assurance                          _______
Total Section IV – Facilities and Operation                   _______
Total Section V – Reporting                                   _______
Total Section VI – Program Implementation                     _______
Total Section VII – Detailed Program Information              _______
Total Section VIII – Performance Expectations                 ______
Total Section IX. Budget and Unit Cost                        _______

    TOTAL SCORE POSSIBLE                                      _______

    TOTAL SCORE EARNED                                        _______


Comments:




______________________________________________________________
    Reviewed by                                          Date




                                                                                                              Section IV
                                                                                                        Title III Section
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