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PROPOSAL (COVER PAGE) To MN Department of Employment and Economic Development, Rehabilitation Services, Extended Employment Program, for the provision of ongoing employment support services to begin Jan. 1, 2006, pursuant to Minn. Rules 3300.2005 to 3300.2055
Organization: Address: Date of Incorporation: Chief Operating Executive: Signature of Chief Operating Executive: CARF Accreditation Period: Contact Person: CARF Accredited Services: Telephone: Title: Type of Legal Entity: Joint Proposal:
YES
NO
TARGETED AREAS OF INTEREST: This proposal addresses the following (checked) target areas: (See page
one of the RFP for definitions of these target areas.)
Rural areas with lost EE basic funds SMI Employability projects with lost funds Selfsufficiency Local workforce needs Un-served populations Under-served populations
PROPOSAL SUMMARY: The table below projects data for an annual period (52 weeks).
Community Employment Supported Employment Total
(A) Persons Served (B) Average Work Hours/Week (C) Average Weeks in Program (D) Total Work Hours (E) Funds Requested $ (F) Average Wage Per Hour $ (G) Total Wages Earned $ (H) Number of Full-time Staff (I) Counties Served (J) Number Served By Primary Disability
Disability Developmental Disabilities Mental Illness Number Served Percent % %
$ $ $
$ $
(K) Number Served by Referral Source
Referral Source Vocational Rehabilitation County Social Services Number Served Percent %
% % Total 100% Total 100%
% % %
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I. GOALS & DUTIES This proposal represents a commitment to the goals and duties checked below: A. GOALS:
Proposed services will begin by January 1, 2006; Community employment will be provided only as a short-term service to achieve a supported employment goal; and We will work closely with DEED Extended Employment, DEED Vocational Rehabilitation, counties, other local funders, and local employers to ensure employment of extended employment workers encompasses the broad range of employment choices available to all persons and promotes the individual’s self-sufficiency and financial independence. B. DUTIES:
We will provide “person-centered” services, and will engage the consumer, family and/or advocates, the social worker, and/or the VR counselor, as applicable, in every step of the vocational process; We will develop extended employment program support plans that conform to the standards identified in Minnesota Rules, 3300.2025, subparts 4,5, 6, and 8; We are CARF accredited in Community Employment Services and we will maintain compliance with each of the certification criterion in Minnesota Rules, Chapter 3300.2010, subpart 4 (A-I); or We are NOT CARF accredited in Community Employment Services, but we will achieve that accreditation within 18 months, in accordance with Minnesota rules, chapter 3300.2010, subpart 5, and we will maintain compliance with each of the certification criterion in Minnesota Rules, Chapter 3300.2010, subpart 4 (A-I). We will report to DEED only those eligible consumers, pursuant to Minnesota Rules, Chapter 3300.2015; We will report to DEED consumer data necessary to make payments and evaluate the program in accordance with Minnesota Rules, Chapter 3300.2020 in accordance with the Provider Reporting System (PRS) standards and specifications; We will submit to DEED a compliance audit annually, pursuant to Minnesota Rules, Chapter 3300.2035, subpart 8(C)(1); We will submit to DEED annual audited financial statements, including the Extended Employment Program - Schedule of Revenue and Expenses, and Management Letter within six months of the end of the vendor’s fiscal year; and We will maintain compliance with all applicable state and federal laws, rules, and regulations.
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II. ORGANIZATIONAL REQUIREMENTS These funds are applied for to establish or operate a community rehabilitation facility, pursuant to Minnesota Statutes, 268A.06. The applying entity is an eligible legal entity, with a governing board that meets statutory requirements of Minnesota Statutes, 268A.08, and the ability to be certified as an extended employment provider, as follows: A. Eligible Legal Entity
City of: Town of: County of: Nonprofit corporation State regional center Combination; check all that apply
We have provided evidence of the above legal entity and labeled it Appendix A.
B. Governing Boards
We have appointed a governing board of Insert Number members; Appendix B will identify the members and representation according to the following applicable requirements: CITY, TOWN, OR COUNTY ESTABLISHED REHABILITATION FACILITY with board appointed by the chief executive officer of the city or the chair of the governing board of the county or town Membership on the board is representative of the community served Membership on the board includes a person with a disability. One-third to one-half of the board is representative of industry or business. The remaining members are representative of lay associations for persons with a disability, labor, the general public, and education, welfare, medical, and health professions. COMBINATION OF CITIES, TOWNS, COUNTIES, OR NONPROFIT CORPORATIONS with the chief officers of the cities, nonprofit corporations and the chairs of the governing bodies of the counties or towns appointing the board. Membership on the board is representative of the community served Membership on the board includes a person with a disability. One-third to one-half of the board is representative of industry or business. The remaining members are representative of lay associations for persons with a disability, labor, the general public, and education, welfare, medical, and health professions. NONPROFIT CORPORATION with a board appointed by the corporation. Membership on the board is representative of the community served Membership on the board includes a person with a disability. One-third to one-half of the board is representative of industry or business. The remaining members are representative of lay associations for persons with a disability, labor, the general public, and education, welfare, medical, and health professions. STATE REGIONAL CENTER with a chief executive officer that performs the functions of the rehabilitation facility board, as described in M.S. Chapter 268A.08, subd 2, and has established an advisory committee. Membership on the advisory committee is representative of the community served Membership on the advisory committee includes a person with a disability. One-third to one-half of the advisory committee is representative of industry or business. The remaining members are representative of lay associations for persons with a disability, labor, the general public, and education, welfare, medical, and health professions. COUNTY ESTABLISHED REHABILITATION FACILITY with a governing board comprised of the county board of commissioners.
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C. State Certification We are currently certified by the DEED as an Extended Employment (EE) provider. Provisional Probationary We are not a certified EE provider, but will apply for certification if this proposal is funded. Our application is attached as Appendix C. We meet all of the state certification requirements, as follows: We are CARF accredited in Community Employment Services under the Employment and Community Services’ Standards from to , pursuant to Minn. Rules, 3300.2010, subpart 4 (A); or We will demonstrate a reasonable likelihood that we will meet the requirements for CARF accreditation in Community Employment Services within 18 months, pursuant to Minn. Rules, 3300.2010, subpart 5. We will provide fundamental personnel benefits, as described in part 3300.2015, subpart 4, to workers in community and supported employment when the provider is the payroll agent, pursuant to Minn. Rules, 3300.2010, subpart 4 (B). We will provide written grievance procedures for workers in community, and supported employment, pursuant to Minn. Rules, 3300.2010, subpart 4 (C). We will provide information to workers on program planning and service delivery, as described in 3300.2025, subpart 7, in the worker’s primary language using appropriate modes of communication, pursuant to Minn. Rules, 3300.2010, subpart 4 (D). We will provide workers with extended employment support plans, as described in 3300.2025, subpart 4, in worker’s primary language using appropriate modes of communication, pursuant to Minn. Rules, 3300.2010, subpart 4 (E). Our governing board complies with Minnesota Statutes, 268A.08. Members of our governing board and management staff shall be provided a minimum of eight hours of continuing education and training each year, pursuant to Minn. Rules, 3300.2010, subpart 4 (G). Members of our governing board will also provide training to all members on fiduciary responsibilities of the directors of nonprofit organizations, pursuant to Minn. Rules, 3300.2010, subpart 4 (H). We comply with the U.S. Code, title 42, sections 12101, et seq., of the Americans with Disabilities Act of 1990, pursuant to Minn. Rules, 3300.2010, subpart 4 (I).
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III. PROGRAM NARRATIVE We propose to operate the checked Extended Employment subprogram(s) (#1) as defined in Minn. Rules, 3300.2005, subparts 10 and 35. Our proposal also addresses the checked DEED area(s) of interest (#2). Rural Areas with lost EE Basic Funds Un-served Populations Self-sufficiency SMI Employability projects with lost funds Under-served Populations Local work force needs
IV. SERVICES REQUIREMENTS We propose to provide Extended Employment services, pursuant to Minn. Rules, 3300.2005 to 3300.2055, to extended employment workers including but not limited to those checked below: Service Ongoing employment support services Extended Employment Support Plan Annual reassessment of Extended Employment Support Plan Minimum service contact by provider Definition Minn. Rules, 3300.2005, subpart 31 Minn. Rules, 3300.2025, subpart 4 Minn. Rules, 3300.2025, subpart 8 Minn. Rules, 3300.2025, subpart 5
In addition to those services required pursuant to Minn. Rules, 3300.2005 to 2055, we propose the following:
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V. POPULATION TO BE SERVED A. Extended Employment Program Eligibility Ongoing employment support services under this proposal shall be provided only when it has been determined that a person meets the following Extended Employment Program eligibility criteria: Residents of the state of Minnesota Persons meeting the definition of extended employment worker, pursuant to Minn. Rule, 3300.2005, subpart 18
B.
Target Population to be served. Check all those that apply. Rural Areas with lost EE Basic Funds SMI Employability Projects with lost funds Self-Sufficiency Local Workforce Needs Un-served populations Under-served populations
We would further describe the population to be served as follows:
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C.
Organizational Admission Criteria Our organization’s entrance or eligibility criteria for programs and services proposed is defined as follows, or attached.
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VI. OUTCOME MANAGEMENT A. Collecting Outcomes Management Data 1. Describe data gathered regarding (a) effectiveness, (b) efficiency, (c) overall satisfaction of persons receiving services with the results of services delivered, and (d) the overall satisfaction of other stakeholders with the results of services delivered (i.e. provide evidence that there is a system in place to provide data showing the effectiveness, efficiency, overall “results satisfaction” of persons receiving services and other stakeholders with regard to your program).
2. Describe how the data gathered is responsive to the information needs of (a) persons receiving services, (b) other internal stakeholders, and (c) external stakeholders. (In other words, what are your success indicators and how did you develop them?)
3. Describe the overall data on consumer characteristics gathered regarding (a) persons receiving services, (b) persons awaiting services, (c) persons not accepted for services, and (d) persons exiting services. (In other words, provide demographics related to points a - d.)
4. Describe how follow-up data from individuals who have exited the organization’s services is systematically obtained to assess (a) the benefits of services, and (b) aspects of service delivery, as the organization might determine useful.
5. Describe your methodology, explaining how these outcomes management data are (a) gathered according to a defined process, (b) collected on all persons receiving services or a representative sample, and (c) compiled in a timely fashion.
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B. Using Outcomes Information 1. Describe when outcome management reports are prepared, at minimum annually, and what is included, including but not limited to: (a) trends in the populations receiving services, (b) a comparison of actual results to identified goals for services seeking accreditation, (c) actions taken since the last outcomes management report, (d) an analysis of data for planning implications, and (e) other issues identified for services seeking accreditation.
2. Describe how the outcome management report guides decision making related to: (a) improving the results of services, (b) resource allocation, (c) staff development, (d) marketing or community outreach efforts, (e) strategic positioning of the organization, and (f) modifying the outcomes management system to ensure its relevancy.
3. Describe how information from the report is shared in an understandable manner; (a) at least annually, (b) with the persons receiving services, (c) with other internal stakeholders, (d) with funding and referral agencies, and (e) with other external stakeholders.
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VII. SUPPORTING DOCUMENTATION Our proposal includes the following appendixes in support of this proposal if required, which may be submitted via E-mail as attachments with your application: Appendix A: Evidence of legal entity and tax status; Appendix A is not required if applicant is already certified to provide Extended Employment services; Appendix B: Evidence of compliance with governing board requirements; Appendix B is not required if applicant is already certified to provide Extended Employment services ; Appendix B is not applicable to county established rehabilitation facilities); Appendix C: Application for state certification as an Extended Employment provider; see next page. If we accept your proposal, additional information for certification will be necessary; Appendix C is not required if applicant is already certified to provide Extended Employment services; Appendix D: Identification of local demonstrated need and attached independent source documentation, as described in the application instructions; Appendix E: A detailed work plan as described in the application instructions; Appendix F: Identification of collaborating and cooperating partners and letters of understanding, addressing roles and funding; Appendix G: A proposed budget and narrative of revenue and expenses; Appendix H: Evidence of the organization’s commitment to share project materials and staff expertise with DEED and other state certified extended employment providers to assist in the development of similar programs; Appendix H is not required if applicant is already certified to provide Extended Employment services; and Appendix I: Our organization’s most recent audited financial statements; Appendix I is not required if applicant is already certified to provide Extended Employment services.
MINNESOTA DEPARTMENT OF EMPLOYMENT AND ECONOMIC DEVELOPMENT Rehabilitation Services Branch SFY06 APPLICATION FOR STATE CERTIFICATION EXTENDED EMPLOYMENT PROVIDER
Rehabilitation Facility: Non-profit Status:
DEED-70089-11 (05/05) PAGE 1 OF 1
Mailing Street Address:
Contact Person:
City, State, Zip:
Telephone Number:
INSTRUCTIONS: For each location to be certified: (1) report the street address of the site (owned and/or operated by your agency) where staff who deliver EE services and persons who receive EE services report and are assigned, (2) select the type of employment services, and (3) report the counties where the majority of EE workers reside. Programs or locations that are not identified in your most recent CARF Survey Report, are not eligible for certification. Attach additional pages, if necessary. EMPLOYMENT SERVICES SERVICE LOCATIONS
1) 2) 3) 4) 5) 6) 7) 8) 9) 10)
Centerbased
Community
COUNTIES SERVED
Note: The following forms are required to complete your application for certification if your proposal is accepted and will be mailed or Emailed to you if applicable. Provider Assurance Statement Nonprofit Corporation – Rehabilitation Facility Board Attestation Nonprofit Corporation - Board Composition Worksheet County-Operated E.E. Program - Board Attestation
Nonprofit Corporations Required Required Required Not applicable
County-operated Extended Employment Programs Required Not applicable Not applicable Required
My signature constitutes a request for State Certification, based on my assurance that all statements made herein and by attachment, are true and accurately represented.
________________________________________
Signature, Chief Executive Officer/President Date __