REQUEST FOR PROPOSALS

REQUEST FOR PROPOSALS HOME AND COMMUNITY-BASED SERVICES (HCBS) EMPLOYEE SCHOLARSHIP GRANT PROGRAM - FISCAL YEAR 2018 MINNESOTA DEPARTMENT OF HEALTH (MDH) - OFFICE OF RURAL HEALTH & PRIMARY CARE The Home and Community-Based Services (HCBS) employee scholarship grant program, authorized by Minnesota Statutes Section 144.1503, was established for the purpose of assisting qualified HCBS providers fund employee scholarships for education and training in nursing and other health care fields. Grant funds must be used by grantees to recruit and train caregiving staff through the establishment of a scholarship program. This Grant Application and Instruction document has two sections: Section I contains general information about the grant program, including criteria for funding, and instructions on how to submit an application. Section II is the application, which starts with a questionnaire that helps you determine if your organization is eligible to apply for an HCBS Employee Scholarship grant. A complete application must contain ALL the forms and additional attachments listed on the Application Checklist (FORM 2) in this Section. An incomplete application will not be considered for funding. Questions about the HCBS Employee Scholarship grant application should be directed to Lina Jau at lina.jau@state.mn.us or 651-201-3809 or 800-366-5424. SECTION I GENERAL INFORMATION, CRITERIA AND HOW TO APPLY A. ELIGIBILITY Eligible Grant Applicants Individuals are not eligible to apply for an HCBS Employee Scholarship grant from the Office of Rural Health and Primary Care, Minnesota Department of Health. Not-for-profit and for-profit organizations that meet all of the following criteria are eligible to apply for a HCBS Employee Scholarship grant: Is located in Minnesota; Primarily provides services in home and community-based settings to individuals who are 65 years of age or older; Is one of the following providers: 1

o Housing with Services establishment as defined in MN Statute 144D.01 o Adult Day Care facility as defined in MN Statute 245A.02 o Home Care Services providers as defined in MN Statute 144A.43, subd. 3 Offers an in-house employee scholarship program to its staff, or is in the process of developing a scholarship program. Eligible grant applicant organizations must further demonstrate that scholarship recipients, the proposed courses of study or trainings, and related expenses are eligible or allowable. Eligible Scholarship Recipients A scholarship recipient must be employed in a caregiving role, and must work an average of at least 16 hours per week for the grantee organization while receiving a scholarship funded by the HCBS Employee Scholarship grant funds. Eligible Courses of Study or Training Eligible courses of study for scholarship recipients include trainings, workshops and degree programs directly related to the delivery of patient or client care in home and community-based services settings. These may include: job-related training or degree programs in the field of long-term care, including care for persons with disabilities social work occupational therapy physical therapy nursing, or other relevant degrees client care-related trainings above and beyond those required for licensure of the organization training for medical care interpreter services job-related English as a Second Language Other Eligible/Allowable Expenses All expenses must be directly related to the employee s coursework or training, and may include: tuition (which may be paid directly to the educational institution or reimbursed to the employee upon completion of the course) course-related textbooks or fees childcare expenses while the employee is attending classes mileage reimbursement training consultant fees Non-Eligible Expenses Non-eligible expenses include: administrative expenses employee salary, fringe benefit or stipends while the employee is attending school (If the applicant organization wants to pay hourly wages or stipends for the hours that an employee is at school, the funds must come from other sources of funding and not from the HCBS Employee Scholarship grant dollars) 2

training, out-of-state travel or lodging supplies or equipment that are not directly related to classes/coursework of scholarship recipients capital improvements. Non-Eligible Courses of Study and Trainings Training or courses of study that are not eligible for HCBS Employee Scholarship funds include: Trainings not directly related to the improvement of patient or client care such as HIPAA training, coding, accounting, human resources and management. Required orientation or annual trainings for employees to maintain the HCBS license of the organization. Required training or continuing education for employees to maintain their current/annual professional certifications. B. DURATION OF GRANTS Grants will be for 24 months, starting January 1, 2018 and ending December 31, 2019. C. TOTAL AVAILABLE FUNDING and AWARD AMOUNTS Total funding available is approximately $1,450,000. Applicants may request up to $50,000 in each grant application. Organizations operating multiple facilities may submit more than one application but each application must cover a separate facility or group of facilities. Additional information on submitting more than one application is detailed in Section I.F below. D. CRITERIA FOR FUNDING Applications will be reviewed on a 100-point scale based on the following criteria: 1. Demonstrated ability of the applicant agency to administer a scholarship program 20 points Throughout the proposal, does the applicant agency demonstrate that it has the capacity or experience to administer a scholarship program for its employees? Does the proposal adequately define the process by which scholarships will be made available and recipients selected? 2. Demonstrated need for an employee scholarship program 20 points Throughout the proposal, does the applicant provide data and other information about its clients, unique business circumstances, and employees and their need for training or furthering their education? 3. Applicability of courses of study/trainings 40 points Is there sufficient information about the courses of study or trainings to be undertaken by employees, including information on the educational institution and trainers? Will the courses of study/training help recruit and retain employees in the applicant agency or the HCBS field, and enhance employees skills with client care in a HCBS setting? To what extent will the courses of study/training improve care for the clients served by the organization? 4. Reasonableness of the budget 20 points Given the courses of study/trainings, educational institutions, duration of courses and other expense descriptions, are the dollar amounts reasonable for each individual scholarships? Are there enough details to substantiate the costs? 3

E. ADDITIONAL INSTRUCTIONS FOR CURRENT GRANTEES If your organization currently receives HCBS Employee Scholarship grants from the fiscal years 2016 and/or 2017 cycles, include additional information on how the new Fiscal Year 2018 grant funds will be different or how it is an extension of the current grants in the narrative section (FORM 5). F. ADDITIONAL INSTRUCTIONS FOR ORGANIZATIONS SUBMITTING MORE THAN ONE APPLICATION Your organization may submit more than one HCBS Employee Scholarship grant application but each application must cover a separate facility/campus or group of facilities/campuses within your bigger umbrella organization. All information provided within each individual application must be customized for the specific facility/campus or group of facilities/campuses. You may also want to add additional information (example: city or street names) or numbers (example: Region 1) to the title and name of your organization on each of your application in order to help us identify and differentiate your applications. If you are planning to submit more than one application for your organization, you are strongly encouraged to contact Lina Jau (lina.jau@state.mn.us or 651-201-3809 or 800-366-5424). G. GRANT PROGRAM EVALUATION Grant recipients may be required to provide additional information and/or data for evaluation of the HCBS Employee Scholarship grant program. H. HOW GRANT RECIPIENTS WILL BE SELECTED o o o Review panels made up of professionals with expertise in grants and the HCBS field will read and rate all complete and eligible applications mailed to the ORHPC office by the deadline. Using the criteria for funding as a guide, the review panels will make a recommendation to the Commissioner as to which applications should be funded and for how much. Upon approval of the recommendation, award letters will be sent to the selected applicants, and nonaward letters will also be sent to applicants that did not get selected to receive an award. I. GRANT NEGOTIATION AND SIGNATURES o o o Before a grant contract can be executed, MDH staff will contact the award recipients to negotiate budgets and other terms of the contract. For example, if the award is less than what the applicant organization had applied for, revisions of the budget and activities may be negotiated. After the grant contract has been drafted, it will go through the signature process. It will be signed first by the grantee organization s authorized representative, then by MDH officials. This process may take 2 weeks or longer. The grant project may start only after all the signatures have been obtained. J. HOW FUNDS WILL BE DISTRIBUTED TO GRANT AWARD RECIPIENTS 4

Grant dollars will be distributed to a grantee organization on a reimbursement basis. A standard invoice and report form, due semi-annually, will be provided. Grantees will be required to provide the following information on the invoice and report form: o The total amount spent on scholarships during the invoice period o The number of employees who received scholarships o The amount paid for or awarded to each recipient o The names of scholarship recipients o The current position of scholarship recipients o Certification that each recipient has worked at least an average of 16 hours per week for the organization while studying o The name of the education institution attended by each recipient o The nature of the educational program into which each recipient has enrolled o The expected completion date of the educational program for each recipient o A brief narrative description of the implementation and management of the scholarship program K. HOW TO APPLY Application Forms Applicants must complete all the application forms provided in Section II and include the other required documents as listed on the Application Checklist (FORM 2) page. Incomplete applications will not be considered for funding. Requirements for a Complete Application Your grant application must include all of the following: 1 original plus 4 additional copies of these completed forms: FORM 1, FORM 2, FORM 3, FORM 4, FORM 5, FORM 6, FORMs 7A and 7B (and/or FORMs 8A and 8B, if applicable). The 4 copies must be collated and stapled. Only 1 copy of FORM 9 Due Diligence Review and Financial Questionnaire (plus additional attachments where indicated) Only 1 copy of your organization s financial statement as described in FORM 2 Only 1 copy of Proof of Active Licensure for each HCBS facility covered in your grant application Application Submission Your complete application packet must be mailed using the US Post Office (USPS). The envelope must be post-marked by the US Post Office no later than 4:00PM Central Standard Time on Friday, October 6, 2017. Mail your grant application packet to: Lina Jau, Grant Manager Minnesota Department of Health, ORHPC PO Box 64882 St. Paul, MN 55164-0882 5

L. TIMELINE Request for proposals announced: August 14, 2017 Applications due or postmarked by 4:00pm: October 6, 2017 Grants start date: Approximately January 1, 2018 Questions about the HCBS Employee Scholarship grant application should be directed to Lina Jau at lina.jau@state.mn.us or 651-201-3809 or 800-366-5424. All information and data submitted in an application will become public after grant awards are announced. SECTION II HCBS EMPLOYEE SCHOLARSHIP GRANT APPLICATION FORMS Please complete the following forms. Follow the instructions carefully on each form. Type in, fill in the blank spaces or mark an X where indicated. FORM 5 requires additional pages of narrative descriptions while FORM 9 requires additional attachments. After completing your application, print it out, place the authorized signature on FORM 3, and make the necessary copies according to the instruction in Section I.K. Please refer to FORM 2 Application Checklist to make sure you have all the necessary forms and additional documents to complete your grant application. 6

FORM 1 ORGANIZATION ELIGIBILITY QUESTIONNAIRE AND EMPLOYEES INFORMATION Is your organization/facility/group of facilities eligible to apply for a HCBS Grant? Your answer must be Yes to all the questions in the table below. If you answer No to any of them, your organization is not eligible to apply for and receive a grant under this grant program. Place an X in the corresponding boxes with your answer to each question. Questions Yes No Is the facility located in Minnesota? Does the facility primarily provide services to individuals who are 65 years of age or older? Is the facility one or more of these types of home and community-based services (HCBS) providers? a. A Housing with Services establishment as defined by MN Statute 144D.01 Link: https://www.revisor.mn.gov/statutes/?id=144d.01 b. An Adult Day Care facility as defined by MN Statute 245A.02 Link: https://www.revisor.mn.gov/statutes/?id=245a.02 c. A Home Care Service provider as defined by MN Statute 144A.43, sub. 3 Link: https://www.revisor.mn.gov/statutes/?id=144a.43 (NOTE: Nursing home establishments and hospice facilities are NOT eligible for this grant program.) Employees Information please answer the questions below. If information is not available, explain the circumstances. 1. How many caregiving employees are eligible for the scholarship program covered in this grant application? Eligible employees are those who are working at least 16 hours a week on average, are in a caregiving role, and are in need of further training as determined by your organization. 2. What was the turnover rate of caregiving staff in Calendar Year 2015? % 3. What was the turnover rate of caregiving staff in Calendar Year 2016? % 7

FORM 2 APPLICATION CHECKLIST A complete application must include all required forms and additional attachments listed below. Place an X in the boxes corresponding with the forms and additional documents as you complete your application. For specific instructions on the number of copies required in your application packet, please refer to Section I.K. How to Apply. A. Forms fill out these forms (which are attached): FORM 1 Organization Eligibility Questionnaire and Employees Information FORM 2 Application Checklist (this form) FORM 3 Business Information and Signature FORM 4 Client Information Summary FORM 5 Narrative Description of Organization, Clients, Employees and Scholarship Program (attach up to 5 pages of narrative) Budget Forms: Complete Form 6 Budget Summary, AND either FORMs 7A and 7B or FORMs 8A and 8B, or all of the budget forms: FORM 6 Budget Summary FORM 7A Employee Tuition Budget FORM 7B Employee Tuition Budget Explanation FORM 8A In-house Employee Training Budget FORM 8B In-house Employee Training Budget Explanation FORM 9 Due Diligence Review and Financial Questionnaire only one original copy of this form (plus additional attachments, where indicated) is required. B. Additional documents your application must also include one copy of these documents: A Financial Statement (attach only relevant documentation) Applicants must include a current financial statement of the organization, to demonstrate solvency. This can be a recent 990 form, a professionally prepared audit, balance sheet, or income statement that shows the most recently available annual revenue and expenses. Attached documentation must be specific to the HCBS provider where the scholarship program will be administered, not documentation from a larger organization. Proof of Active Licensure or Registration (attach only relevant documentation) Applications must include documentation of current registration as a housing with services establishment, or licensure as an adult day care facility or a home care agency. If your grant application is for multiple facilities, provide proofs of active licensure or registration for all those facilities. 8

FORM 3 BUSINESS INFORMATION AND SIGNATURE Please provide organization s name, business address, State Tax ID, Federal Tax ID and SWIFT Vendor Number (if known). Organization Formal Name (this is the name that your organization is registered as): Organization Name, if doing business as (dba): Business Address: State Tax ID: Federal Tax ID: State SWIFT Vendor Number (if known): Please provide the name and contact information of the person responsible for this grant application. Name: Position: Email address: Phone: Amount of Grant Funds Requested: $ Organization Authorized Signature: Position/Title: Date: 9

FORM 4 CLIENT INFORMATION SUMMARY Check all that apply by placing an X in the corresponding boxes below, and then provide additional client information where indicated. Type N/A and add an explanation for any data that is not available. Housing with services (assisted living) Number of clients: Percentage of clients/patients who are over the age of 65: % Percentage of clients who are self-paying: % Percentage of clients who are on elderly waiver: % Adult day care Number of clients: Percentage of clients/patients who are over the age of 65: % Percentage of clients who are self-paying: % Percentage of clients who are on elderly waiver: % Home care service Number of clients: Percentage of clients/patients who are over the age of 65: % Percentage of clients who are self-paying: % Percentage of clients who are on elderly waiver: % 10

FORM 5 NARRATIVE Using up to 5 pages, double spaced, and using Font 11 or 12, write a summary of your organization, clients, employees and the scholarship program you are proposing. Please limit your narrative to 5 pages additional pages will be removed. Below is an outline to guide your narrative. A. A brief statement of the need for state grant funds (1-2 paragraphs) o Why are you seeking state funds? o Why is there a need to enhance the education of your workforce? B. A description of the organization/facility, clients, and staff o Describe your organization s history, location, staff, administrative structure, and partnerships (if any). o Describe the clients served, including their age range, culture, and other unique characteristics or circumstances. o Describe the caregiving staff and their educational or training needs. Include staff retention concerns, staff turnover, and recruitment efforts. C. A description of the scholarship program o What is the process for determining which employees are eligible for scholarships? That is, how are scholarship recipients selected? What are the criteria? o If you will be using the scholarship program as a means to recruit employees to your program, provide a brief description of the process. o Do you have other sources of funding for scholarships? If so, please explain briefly. o What are the expected degrees, certificate or credentials obtained through the scholarship program? o What are your organization s plans to retain employees after they have completed their scholarshipfunded education? IMPORTANT: If your organization is a current recipient of HCBS Employee Scholarship grants from MDH, explain how the new Fiscal Year 2018 grant a) will be different, and/or b) is an extension of the current scholarship grant. 11

FORM 6 BUDGET SUMMARY Complete the table below by filling in the amount of HCBS Employee Scholarship grant funds you are requesting. HCBS Employee Scholarship Categories Grant Funds Requested Employee Tuition Scholarships* (provide additional information in FORMs 7A and 7B) $ In-house Employee Training Scholarships** (provide additional information in FORMs 8A and 8B) $ TOTALS: $ *Employee tuition scholarships pay for eligible costs associated with courses and trainings that individual employees take at an educational institution, and could also include costs for attending conferences. Employees salaries, fringes or stipends while attending school or conferences are not allowable expenses for the HCBS Employee Scholarship grant funds. **In-house employee training means contracting with a trainer to train a group of employees. 12

FORM 7A EMPLOYEE TUITION BUDGET Exhibit A page 1 Fill out this table if your scholarship program pays for tuition and related fees. You may add additional rows to the table, if needed. Total cost Number (number of recipients X Name of educational institution or course of Cost per cost per Scholarship title provider recipients recipient recipient) 1. $ $ 2. $ $ 3. $ $ 4. $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ TOTALS: $ $ 13

FORM 7B EMPLOYEE TUITION BUDGET EXPLANATION Exhibit A page 2 In the space below and up to two (2) additional pages, using font size 11 or 12, provide a more detailed description about the information supplied in FORM 7A. Include: More details about the courses that will be taken by the scholarship recipients, and A description or breakdown of cost per recipient (Example: a $250 scholarship may include $200 for tuition and $50 for test fees) 14

FORM 8A IN-HOUSE EMPLOYEE TRAINING BUDGET Exhibit B page 1 In-house Employee Training Fill out this table if you are proposing to use grant funds for in-house employee training. You may add additional rows to the table, if needed. Estimated number of employees attending training Title of training Training provider (name of person or institution coming in to provide training) Number of training sessions Cost per training session 1. $ $ 2. $ $ 3. $ $ 4. $ $ 5. $ $ 6. $ $ 7. $ $ 8. $ $ Cost per training type (number of sessions X cost per training session) TOTALS: $ $ 15

FORM 8B IN-HOUSE EMPLOYEE TRAINING BUDGET EXPLANATION Exhibit B page 2 In the space below and up to two (2) additional pages, using font size 11 or 12, provide a more detailed description on the information supplied in FORM 8A. Include: A more detailed description of each training listed. You may include information on the trainer qualification. A description or breakdown of cost of training. Example: Dementia 101 training for 20 employees for 4 hours includes payment to the trainer ($800) and handouts ($200). 16

FORM 9 DUE DILIGENCE REVIEW (3 PAGES) Purpose The Minnesota Department of Health (MDH) must conduct due diligence reviews for non-governmental organizations (NGOs) applying for grants, according to MDH Policy 240. Definition Due diligence refers to the process through which MDH researches an organization s financial and organizational health and capacity (MDH Policy 240). The due diligence process is not an audit or a guarantee of an organization s financial health or capacity. It is a review of information provided by an NGO and other sources to make an informed funding decision. Instructions As an applicant for MDH funds you must answer the following questions about your organization, and include the completed form with the grant application. Organization Information Questionnaire Question Response 1. How long has your organization been doing business? 2. How many employees does your organization have (both part time and full time)? 3. What was your organization's total revenue in the most recent 12- month accounting period? 4. How many different funding sources does the total revenue come from? 5. Does your organization have a current 501(c)(3) status from the IRS? Place an X in the appropriate box. 6. Has your organization done business under any other name(s) within the last five years? Place an X in the appropriate box. If yes, list name(s) used. 7. Is your organization affiliated with or managed by any other organizations, such as a regional or national office? Place an X in the appropriate box. If yes, provide details. Yes Yes Yes No No No 17

Question Response 8. Does your organization receive management or financial assistance from any other organizations? Place an X in the appropriate box. If yes, provide details. 9. Have you been a grantee of the Minnesota Department of Health within the last five years? Place an X in the appropriate box. If yes, from which division(s)? 10. Does your organization have written policies and procedures for accounting processes? Place an X in the appropriate box. If yes, please attach a copy of the table of contents. 11. Does your organization have written policies and procedures for purchasing processes? Place an X in the appropriate box. If yes, please attach a copy of the table of contents. 12. Does your organization have written policies and procedures for payroll processes? Place an X in the appropriate box. If yes, please attach a copy of the table of contents. Yes Yes Yes Yes Yes No No No No No Question 13. Which of the following best describes your organization's accounting system? Place an X in the appropriate box. 14. Does the accounting system identify the deposits and expenditures of program funds for each and every grant separately? Place an X in the appropriate box. Response Manual Automated Both Yes No Not sure 15. If your organization has multiple programs within a grant, does the accounting system record the expenditures for each and every program separately by budget line items? Place an X in the appropriate box. Yes or Not applicable No Not sure 16. Are time studies conducted for employees who receive funding from multiple sources? Place an X in the appropriate box. Yes or Not applicable No Not sure 18

Question 17. Does the accounting system have a way to identify overspending of grant funds? Place an X in the appropriate box. 18. If grant funds are mixed with other funds, can the grant expenses be easily identified? Place an X in the appropriate box. 19. Are the officials of the organization bonded? Place an X in the appropriate box. 20. Did an independent certified public accountant (CPA) ever examine the organization's financial statements? Place an X in the appropriate box. Response Yes No Not sure Yes No Not sure Yes No Not sure Yes No Not sure Question Response 21. Has any debt been incurred in the last six months? Place an X in the appropriate box. If yes, what was the reason for the new debt? Yes No What is the funding source for paying back the new debt? 22. What is the current amount of unrestricted funds compared to total revenues? 23. Are there any current or pending lawsuits against the organization? Place an X in the appropriate box. 24. If yes, could there be an impact on the organization's financial position? Place an X in the appropriate box. Yes Yes No No or Not applicable 19