Request for Proposals: Vermont Long-Term Care Consumer Survey
Division of Disability & Aging Services Department of Disabilities, Aging & Independent Living Vermont Agency of Human Services Mailing address: 103 South Main Street, Waterbury, Vermont 05671-1601 Physical address: 94 Harvest Lane, Williston, Vermont Contact: Bard Hill Voice: (802) 760-0852 TTY: (802) 241-3557 Fax: (802) 871-3052 E-mail: [email protected]
DEADLINE FOR SUBMISSION OF PROPOSALS: 12:00 noon, Monday, April 1, 2013
Significant dates:
Friday March 1, 2013 Bid document distributed to minimum of three qualified bidders, posting on Electronic Bulletin Board/Vermont Bid Opportunities website Monday April 1, 2013 12:00 noon: Deadline for submission of proposals Monday April 15, 2013 Target date for selecting contractor/begin contract negotiations Wednesday May 1, 2013 Target date for notification to bidders of selection of contractor Monday July 1, 2013 Target date for beginning of contract
Contents Page A. Introduction 2 B. Purpose of Request 2 C. Specifications of Work to be Performed 2 D. Contract Specifications 5 E. Proposal Submission Requirements 5 F. Selection Criteria 6 Attachment 1: 2012 LTC Consumer Survey 7 Attachment 2: Customary State Grant Provisions 68
This RFP is available in alternate formats upon request.
LTC Consumer Survey RFP 2013 Page 1 of 83 A. INTRODUCTION
The Department of Disabilities Aging and Independent Living (DAIL, or the State) manages Medicaid long-term care services in Vermont. DAIL has sponsored previous surveys to measure consumer satisfaction with services and overall quality of life. DAIL uses this data to evaluate current consumer perceptions of long-term care program and service quality as part of broader quality management and evaluation efforts. This includes comparisons of current consumer perceptions to previous consumer perceptions.
The State seeks a contractor to replicate previous surveys by conducting a consumer satisfaction survey of individuals receiving long-term care programs and services. The survey shall be conducted between September 1, 2013 and December 31, 2013.
B. PURPOSE OF REQUEST
The State seeks to compare current consumer perceptions of long term care services with the intended outcomes of services, and with previous consumer perceptions of long term care services. The programs and services of interest are Choices for Care home and community based services (formerly known as ‘Medicaid Waiver’ services), Adult Day services, Homemaker services, the Attendant Services Program, and the Traumatic Brain Injury Program. For those participants who have received home-delivered meals, data regarding individual perceptions of home delivered meals will also be collected.
The State is also interested in comparing the responses of long term care service consumers with the responses of the general Vermont population to questions in the 2012 Vermont Behavioral Risk Factor Surveillance Survey (BRFSS): During the past month, participated in physical activities or exercise? Have one person you think of as your personal doctor? Time during last 12 months when you needed to see a doctor but couldn't because of the cost? Would you say that in general your health is… Now thinking about physical health, how many days in past 30 days was physical health not good? Now thinking about mental health, how many days in past 30 days was mental health not good? Past 30 days, how many days did poor physical or mental health keep you from doing usual activities? How often do you get the social and emotional support you need? http://healthvermont.gov/research/brfss/brfss.aspx http://healthvermont.gov/research/brfss/documents/Table-BRFSS2000- 2012upd.8.12.pdf
C. SPECIFICATIONS OF WORK TO BE PERFORMED
The contractor will collaborate with the State and with the Choices for Care independent evaluation contractor in developing a survey instrument. The contractor will replicate the core
LTC Consumer Survey RFP 2013 Page 2 of 83 elements of previous surveys (Attachment 1) and include questions that address measures within the Choices for Care evaluation plan (http://www.ddas.vermont.gov/ddas-publications/publications- cfc/evaluation-reports-consumer-surveys/cfc-revised-evaluation-plan-june-2012)
The survey will seek responses from representative samples of the groups of consumers using each of these services: Choices for Care case management services Choices for Care personal care services Choices for Care Adult Day services Choices for Care Homemaker services Choices for Care ‘Flexible Choices’ Attendant Services Traumatic Brain Injury services
The contractor will be responsible for drawing random samples that meet statistical confidence levels of 5% standard error with a 95% confidence interval at a statewide level of analysis. DAIL estimates that approximately 1000 consumers must be surveyed to obtain the desired statewide statistical confidence, as follows: Moderate High Highest Est. # Est. # for needs needs needs people sample (95% confidence, Program/service 5% error) 1 CFC case management 2,200 330 2 Consumer-Directed Personal Care 300 170 3 Surrogate-Directed Personal Care 450 210 4 Home health agency Personal Care 570 230 5 Flexible Choices 100 80 6 CFC Adult Day services 350 185 7 CFC Homemaker services 1,000 280 8 Attendant Services Program n/a n/a n/a 175 120 9 Traumatic Brain Injury Program n/a n/a n/a 75 65 10 Home-delivered meals n/a n/a n/a unknown n/a TOTAL 5,200 TBD (duplicated count)
The State will provide lists of current consumers by program/service from current State records, corresponding to each of the programs/services of interest. The contractor shall draw representative samples from these lists.
The contractor may use a combination of mail and/or telephone survey methods to reach the selected samples of consumers. The combination of both approaches can be expected to produce the most satisfactory response rate. Past experience suggests that response rates of approximately 70% can be expected.
LTC Consumer Survey RFP 2013 Page 3 of 83 The State expects the contractor to use computer-assisted telephone interviewing (CATI) equipment in completing telephone surveys. The State requires the contractor to abide by all applicable federal and state laws and regulations regarding the confidentiality of individually identifiable information.
Previous survey reports including methodology and results are available at: http://www.ddas.vermont.gov/ddas-publications/publications-cfc/evaluation-reports-consumer-surveys/cfc-evaluation- rpts-consumer-surveys
Tasks: The contractor will perform the following tasks to carry out the survey:
1. Design survey methodology Meet with State staff and Choices for Care Independent Evaluation staff arrive at a shared understanding of the background, purpose, and objectives of the proposed survey. Develop survey methodology including survey instrument(s), sample sizes, and data collection procedures. Develop workplan and timeline. Prepare materials summarizing the methodology and workplan, and submit to State staff for review and approval. 2. Select survey sample Obtain lists of participating consumers from the State. Draw representative samples of consumers for each service. 3. Conduct survey Conduct survey using approved survey instrument(s) and methodology to achieve results from customers receiving each type of service with a level of precision of plus or minus 5%. 4. Provide survey results Submit to the State: a complete dataset of survey responses, including unique identifiers assigned to each individual by the State. a summary profile (data compendium) of survey responses by service group a verbatim transcription of comments and responses to open-ended questions. a data dictionary associating coding of questions with the content of the questions 5. Prepare draft report Submit to the State a draft report showing results by service and region. The report shall include an executive summary describing results, including changes from previous results. The report shall include a summary of results by service and by region. The report shall include appendices that include the survey instrument and a description of the survey methodology. The State shall review the draft report and forward comments to the Contractor. 6. Prepare final report Submit to the State a final report showing results by service and region, including the elements described in the preceding #5. The final annual evaluation report will incorporate or otherwise address the State’s comments regarding the draft report, including findings and recommendations.
LTC Consumer Survey RFP 2013 Page 4 of 83 D. CONTRACT SPECIFICATIONS
The contract format will be the State of Vermont Standard Contract for Personal Services, with relevant attachments, describing the tasks to be performed. The Contractor is expected to comply with the customary State contract provisions (current provisions appear in Attachment 2).
The State of Vermont assumes no responsibility and no liability for costs incurred by respondents in responding to the RFP or in responding to any further requests for interviews, additional data, etc. prior to the issuance of a contract. The State reserves the right to waive portions of this RFP, to waive any informalities in proposals, to reject any or all proposals and/or to negotiate terms and conditions of the awarded contract. The State reserves the right to negotiate specific terms and provisions of the proposal. The contract, if approved, may be renewed by amending the contract up to a period not to exceed two years, for an aggregate maximum of three years.
E. PROPOSAL SUBMISSION REQUIREMENTS
Interested bidders must submit a proposal, which must include the following: 1. Describe the organization’s relevant expertise, including a description of the individuals who will complete core tasks and their individual curriculum vitae or resumes, and at least three references. 2. Overview of proposed methodology, including: proposed survey method(s), sample sizes, and data collection procedures draft workplan with timelines 3. Price quotation/proposed reimbursement for each task, as described in Section C of this document: 1. Design survey methodology: $______2. Select survey sample: $______3. Conduct survey: $______4. Provide survey results: $______5. Vermont general population- quality of life survey questions: $______TOTAL: $______Proposals may not exceed twenty (20) pages. Proposals must be submitted to: Bard Hill, Director, Data and Planning Unit 802-760-0852 Email: [email protected] Division of Disability and Aging Services Mailing address: 103 South Main Street, Waterbury, Vermont 05671-1601 Physical address: 94 Harvest Lane, Williston, Vermont Complete proposals must be received by 12:00 noon on April 1, 2013. If a proposal is submitted by email, it must be submitted in pdf format and must include the signature of the individual who is authorized to submit the proposal on behalf of the organization. It is the bidder’s responsibility to ensure that a submission (including electronic submission) is received by the State before the deadline date and time. The State will not be responsible for any submission (including electronic submission) that is not received by the deadline, regardless of cause
LTC Consumer Survey RFP 2013 Page 5 of 83 (including but not limited to the failure of electronic communication). Bidders are encouraged to confirm that a proposal has been received by the State before the deadline. F. SELECTION CRITERIA
DAIL anticipates selecting a Contractor under the terms of this Request for Proposals (RFP). The Contractor that is judged to best meet the criteria of the RFP will be awarded the contract. The selection of a Contractor will be made using the following criteria:
1. Qualifications: Qualifications and experience of the Contractor including staff, subcontractors, and personnel availability, knowledge of survey accommodations and techniques for individuals with disabilities and elders, specific previous experience in successfully completing such surveys, and strength/credibility of references (30%) 2. Proposed methodology including proposed survey method(s), sample sizes, data collection procedures, and draft workplan/timeline (35%) 3. Proposed Reimbursement (35%)
DAIL reserves the right to reject any or all proposals. Bidders that submit a proposal will be notified of the results of the selection process.
Attachments: . Attachment 1: 2012 LTC Consumer Survey . Attachment 2: State of Vermont Customary State Contract Provisions
LTC Consumer Survey RFP 2013 Page 6 of 83 Attachment 1 2012 LTC Consumer Survey
Vermont Department of Disabilities, Aging and Independent Living
Long-Term Care Services and Programs Customer Survey
Questionnaire
September, 2012
LTC Consumer Survey RFP 2013 Page 7 of 83 Survey Introduction
Q:LEAD T:
Hello, I’m ___ and I’m calling on behalf of the Vermont Agency of Human Services, Department of Disabilities, Aging and Independent Living. We’re doing a study of customer satisfaction of Vermonters who use their services. Could you answer some questions for me?
AS NEEDED:
You were chosen to participate in the survey because you receive help or have received help in the past, from a long-term care program such as the Attendant Services Program, Adult Day Services Choices for Care Personal Care Services, or Homemaker Services.
11 YES 12 NOT ABLE TO ANSWER QUESTIONS ON THEIR OWN (GOTO PROXY) 13 NO 15 NOT NOW, CALL BACK [Wait - Schedule Time] 17 OTHER 19 CONTACT ONLY 21 BUSINESS 23 LANGUAGE 25 INFIRM 27 GROUP QUARTERS, INSTITUTION (DORMS) 29 WRONG NUMBER 31 HANG UP 33 RESPONDENT NOT AVAILABLE DURING DATA COLLECTION PERIOD 34 WANTS TO COMPLETE SURVEY BY MAIL, MAIL VERSION (GOTO MAIL) 88 HOUSEHOLD REFUSAL 99 NEED MORE INFORMATION - OR TO PROVIDE MORE INFORMATION
Information and Persuader Screen
Q:INFOQ T:
INFORMATION: GENERAL RELUCTANCE We are interested in hearing your opinions. Your participation is important because you will be helping to improve the quality of our long-term care programs in Vermont.
You can be assured that your responses to this survey will be confidential. Your responses will never be shared with your caregivers or local agencies. Your responses will have no effect on your eligibility for services or the services that you receive.
STUDY LENGTH LTC Consumer Survey RFP 2013 Page 8 of 83 The study will take between 10 and 15 minutes, depending on your answers.
HOW WAS I SELECTED Your phone number has been chosen at random from among all residents receiving services through the Department of Disabilities, Aging and Independent Living.
For specific information about this study, please ask for Dr. Brian Robertson of Market Decisions at our Toll Free Number, 1-800-293-1538 ext. 102.
Answering Machine Message
Q:ANMACH T:
INTS: LEAVE MESSAGE ON IDENTFIED RESIDENTIAL ANSWERING MACHINES ON THE 1st, 3rd, and 7th ATTEMPTS!
Hello, I’m ___ and I’m calling on behalf of the Vermont Agency of Human Services, Department of Disabilities, Aging and Independent Living. We’re doing a study of customer satisfaction of Vermonters who use their services.
Another interviewer will be contacting your household in the next few days to participate in this important study.
If you have any questions about the survey or need to verify it as legitimate, please feel free to call:
Dr. Brian Robertson at 1-800-293-1538, extension 102.
Thank you and goodbye.
INTS CODING FOR ANSWERING MACHINES
1 IDENTIFIED RESIDENTIAL ANSWERING MACHINE 2 UNKNOWN IF RESIDENTIAL ANSWERING MACHINE
Statement of Implied Consent
Q:INTO T:
Thank you. I want to assure you that this study is confidential and the results of this study will be reported in combined form only.
Your responses will never be shared with your caregivers or local agencies.
If there are questions you do not wish to answer, let me know and we will skip them.
LTC Consumer Survey RFP 2013 Page 9 of 83 My supervisor may listen in on calls to evaluate my performance if that is all right with you.
1 PROCEED WITH STUDY 5 NOT A GOOD TIME, CALL BACK 9 REFUSED
Screener for Proxy
Q:PROXY T:
It is important that we obtain information about FILL NAME’s experiences with long-term care services in the state.
We’d like to conduct this survey with whoever is best able to answer for {Name}. May I speak to that person?
1 SPEAKING (GOTO PROXY1) 2 YES (GOTO PROXY2) 3 NOT AVAILABLE (CALLBACK)
Q:PROXY1 T:
Could you answer a few questions about the services that FILL NAME receives?
1 YES 3 NO, NOT A GOOD TIME (SCHEDULE CALLBACK) 5 NO, NOT A GOOD TIME (CANNOT SCHEDULE CALLBACK) 9 REF
Q:PROXY2 T:
Hello, I’m ___ and I’m calling on behalf of the Vermont Agency of Human Services, Department of Disabilities, Aging and Independent Living. We’re doing a study of customer satisfaction of Vermonters who use their services.
FILL NAME was chosen to participate in the survey because FILL NAME receives help or has received help in the past from a long-term care program such as Adult Day Services, Choices for Care/Personal Care Services, Homemaker Services, or Attendant Services.
Could you answer some questions for me about the services FILL NAME receives?
1 YES 2 NOT APPROPRIATE PERSON 3 NO, NOT A GOOD TIME (SCHEDULE CALLBACK) 5 NO, NOT A GOOD TIME (CANNOT SCHEDULE CALLBACK) LTC Consumer Survey RFP 2013 Page 10 of 83 9 REF
Questions for Proxies
Q:PQ01 T:
Are you a paid caregiver for FILL NAME?
1 YES 2 NO
8 DK 9 REF
Q:PQ02 T:
What is your relationship to PERSON?
1 SPECIFY (SPECIFY)
8 DK 9 REF Information and Awareness of LTC Programs
Q:NQ01 T:
First, how did you first learn about the long-term care services you receive?
PROMPT: Was there anywhere else?
10 AGENCY OF HUMAN SERVICES 11 ASSISTANCE DEPARTMENT, ASSISTANCE OFFICE 12 COMMUNITY GROUPS/ADVOCACY GROUPS/CHURCH 13 DEPT OF DISABILITIES, AGING AND INDEPENDENT LIVING 14 DIVISION FOR THE BLIND AND VISUALLY IMPAIRED 15 DIVISION OF AGING AND DISABILITY SERVICES 16 DIVISION OF VOCATIONAL REHABILITATION 17 DOCTOR, AT OFFICE OF HEALTH CARE PROVIDER 18 GOVERNMENT OFFICE - GENERAL 19 HEALTH FAIR/COMMUNITY EVENT 20 HOSPITAL 21 PERSON - FRIEND/FAMILY/WORD OF MOUTH/OTHER CHILDREN
LTC Consumer Survey RFP 2013 Page 11 of 83 22 SOCIAL SERVICES 23 TV/RADIO/NEWSPAPER ADVERTISEMENT 24 WEBSITE - DAIL 25 WEBSITE – OTHER (SPECIFY) 26 WELFARE OFFICE, SOCIAL WELFARE 95 OTHER (SPECIFY) 98 DK/REF
Q:NQ02 T:
Did someone talk with you about ways of getting the help you needed with daily activities?
IF YES ASK: Who did you speak with?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Q:NQ03 T:
How satisfied were you with the information you were given? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:NQ04 T:
Please let me know how familiar you are with the following:
The LTC ombudsman program, which protects the health, welfare and rights of people who live in long-term care facilities in Vermont.
Would you say you are…? (READ RESPONSES)
LTC Consumer Survey RFP 2013 Page 12 of 83 1 Very Familiar 2 Somewhat Familiar 3 Not Very Familiar, or 4 Not at all Familiar
8 DK 9 REF
Q:NQ05 T:
The Adult Protective Services program, which protects adults from abuse, neglect and exploitation?
(READ RESPONSES AS NEEDED)
1 Very Familiar 2 Somewhat Familiar 3 Not Very Familiar, or 4 Not at all Familiar
8 DK 9 REF General Ratings of Services Provided by DAIL
Q:Q3 T:
For these next few questions, please think about ALL of the services you receive and ALL programs in which you participated in the past 12 months.
For example, if you participated in more than one program, try to think about your experiences with all of the programs as a group.
I am going to read some statements that describe various aspects of long-term care programs. Please give each statement a letter grade using a letter grade scale where A means Excellent, B means Good, C means Fair, and D means Poor.
ENTER <1> TO CONTINUE
Q:Q3A T:
The amount of choice and control you had when you planned the services or care you would receive.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
LTC Consumer Survey RFP 2013 Page 13 of 83 1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3B T:
The overall quality of the help you receive.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3C T:
The timeliness of your services. For example, did your services start when you needed them?
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3D T:
When you receive your services or care. For example, do they fit with your schedule?
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent LTC Consumer Survey RFP 2013 Page 14 of 83 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3E T:
The communication between you and the people who help you.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3F T:
The reliability of the people who help you. For example, do they show up when they are supposed to be there?
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3G T:
The degree to which the services meet your daily needs such as bathing, dressing, meals, and housekeeping.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent LTC Consumer Survey RFP 2013 Page 15 of 83 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3H T:
How well problems or concerns you have with your care are taken care of.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3I T:
The courtesy of those who help you.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:Q3J T:
How well people listen to your needs and preferences.
PROMPT: Which letter grade would you give this aspect of your long-term care experience where (READ RESPONSES)
1 A means Excellent LTC Consumer Survey RFP 2013 Page 16 of 83 2 B means Good 3 C means Fair 4 D means Poor
8 DK 9 REF
Q:NQ13 T:
Overall, how do you rate the value of the services you receive? Would you rate the value as…? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
NNQ01 T:
Next, please tell me how strongly you agree or disagree with the following statement. Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
I receive all the services I need and want exactly when and how I need and want the services.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:SNQ04 T:
My services help me to achieve my personal goals.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree LTC Consumer Survey RFP 2013 Page 17 of 83 8 DK 9 REF
SNQ01 T:
My current residence is the setting in which I choose to receive services.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
SNQ03 T:
I receive services exactly where I need and want services.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:NNQ02 T:
Is there anything that could improve the services offered to you and others?
IF YES ASK: what could be improved?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Q:NNQ02a T:
If you had complete choice, control and flexibility, would your service plan look different? LTC Consumer Survey RFP 2013 Page 18 of 83 IF YES ASK: HOW WOULD YOUR SERVICE PLAN LOOK DIFFERENT?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Improvement in Quality of Life
Q:Q5 T:
Has the help you received made your life…? (READ RESPONSES)
1 Much Better 2 Somewhat Better 3 About the Same 4 Somewhat Worse, or 5 Much Worse
8 DK 9 REF
Q:Q6 T:
How easy would it be for you to stay in your home if you didn’t receive services? Would you say…? (READ RESPONSES
1 Very Easy 2 Easy 3 About the Same 4 Difficult, or 5 Very Difficult
8 DK 9 REF
Q:SNQ05 T:
Please tell me how strongly you agree or disagree with the following statement. Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree. LTC Consumer Survey RFP 2013 Page 19 of 83 My services help me to maintain or improve my health.
1 Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Strongly Disagree
8 DK 9 REF
Quality of Life Measures
Q:Q7 T:
The next questions refer to how you feel about your life now. Please indicate how well the statements describe your life with either yes, somewhat, or no.
ENTER <1> TO CONTINUE
Q:Q7A T:
I feel safe in the home where I live.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7B T:
I feel safe out in my community.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
LTC Consumer Survey RFP 2013 Page 20 of 83 8 DK 9 REF
Q:Q7C T:
I can get to where I need or want to go.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7D T:
I can get around inside my home as much as I need to.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7E T:
I am satisfied with how I spend my free time.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7F T:
LTC Consumer Survey RFP 2013 Page 21 of 83 I am satisfied with the amount of contact I have with my family and friends.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7G T:
I have someone I can count on in an emergency.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7H T:
I feel satisfied with my social life.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q7I T:
I feel valued and respected.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT LTC Consumer Survey RFP 2013 Page 22 of 83 3 NO
8 DK 9 REF
Q:NQ7J T:
I really feel a part of my community.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:NQ7K1 T:
I have someone I can count on to listen to me when I need to talk.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:NQ7K2 T:
I have someone to do something enjoyable with.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 23 of 83 Q:NQ7L T:
In my leisure time, I usually don’t like what I am doing, but I don’t know what else to do.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:NQ7M T:
During my leisure time, I almost always have something to do.
PROMPT: Please indicate how well this statement describes your life with either yes, somewhat, or no.
1 YES 2 SOMEWHAT 3 NO
8 DK 9 REF
Q:Q8A T:
The next two questions are about emotional support and your satisfaction with life. How often do you get the social and emotional support you need? (READ RESPONSES)
PROMPT: If asked, say “please include support from any source.”
1 Always 2 Usually 3 Sometimes 4 Rarely 5 Never
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 24 of 83 Q:Q8B T:
In general, how satisfied are you with your life?
1 Very satisfied 2 Satisfied 3 Dissatisfied 4 Very dissatisfied
8 DK 9 REF Health Status
Q:Q8C T:
In general, compared to other people your age, would you say your health is…? (READ RESPONSES)
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor
8 DK 9 REF
Q:Q8D T:
Compared to one year ago, how would you rate your health in general now? (READ RESPONSES)
1 Much Better Now than One Year Ago 2 Somewhat Better Now than One Year Ago 3 About the Same 4 Somewhat Worse Now than One Year Ago, or 5 Much Worse Now than One Year Ago
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 25 of 83 Q:SNQ06 T:
Next, please think about how well your manager or support coordinator understands your HEALTH needs.
Based on his or her knowledge of my health needs, my case manager or support coordinator helps me understand the different service options that would be good for me. Would you say… (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
7 N/A NO CASE MANAGER 8 DK 9 REF Questions to Ask of Those with Dual Medicare and Medicaid Coverage
Q:DU01 T:
For these next few questions I would like to ask you about your health insurance and the health care you receive. According to our information you currently have health insurance coverage through Medicare AND Medicaid. Is this correct?
IF NEEDED:
Medicare is federal health insurance for people 65 or older and people with disabilities and is run by the Social Security Administration.
Medicaid is a state program that pays for medical insurance for certain individuals and families with low incomes and resources. It's for certain eligible seniors 65 or older, people who are blind or disabled, children, pregnant women and parents.
1 YES 2 NO
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 26 of 83 Q:DU02 T:
How would you rate the range of services covered by your current health insurance coverage? Would you say… (READ RESPONSES)
PROMPT IF NEEDED: The range of services means the types of medical services that are covered, such as acute care, preventive care, specialty care, and surgical care.
1 Excellent 2 Very good 3 Good 4 Fair, or 5 Poor
7 Did not receive care 8 DK 9 REF
Q:DU03 T:
How would you rate the quality of care available under your current health insurance coverage? (READ RESPONSES AS NEEDED)
1 Excellent 2 Very good 3 Good 4 Fair, or 5 Poor
7 Did not receive care 8 DK 9 REF
Q:DU04a T:
Please tell me how much you agree or disagree with the following statements.
I think that the amount that I pay for my premium is reasonable. Would you say you... (READ RESPONSES)
1 Strongly Agree 2 Agree 3 Neither Agree nor Disagree LTC Consumer Survey RFP 2013 Page 27 of 83 4 Disagree 5 Strongly Disagree
8 DK 9 REF
Q:DU04b T:
The amount of my co-pay for doctor's visits is reasonable. (READ RESPONSES AS NEEDED)
PROMPT: Please tell me how much you agree or disagree with the following statement.
1 Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Strongly Disagree
8 DK 9 REF
Q:DU04c T:
The amount of my co-pay for prescription drugs is reasonable. (READ RESPONSES AS NEEDED)
PROMPT: Please tell me how much you agree or disagree with the following statement.
1 Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Strongly Disagree
8 DK 9 REF
Q:DU05 T:
During the past 12 months, was there any time that you did not get or postponed…
(READ AND SELECT ALL MENTONED)
10 Medical care from a doctor or surgery 11 Mental health care or counseling LTC Consumer Survey RFP 2013 Page 28 of 83 12 Dental care including checkups 13 A diagnostic test such as a CAT scan, MRI, lab work, or x-ray 14 Prescription Medicines 15 Over the counter medicines 16 Dentures or eyeglasses 17 Durable medical equipment or assistive technology 18 Modifications to make your home more accessible
97 NONE OF THESE 98 DK 99 REF
ASK FOR EACH SELECTED ABOVE IN DU05 Q:DU05a T:
You indicated there were times that you did not get or postponed getting care.
Why did you not get or postpone getting FILL FROM DU05? Was this because of… (READ RESPONSES)
1 The Cost 2 Trouble finding a doctor or other health care provider who would see you 3 Trouble getting an appointment with a doctor or other health care provider 4 Trouble finding a pharmacist to fill your prescriptions 7 Some other reason (SPECIFY)
8 DK 9 REF
Note response categories will be based on specific type of care or service.
Q:DU06 T:
During the past 12 months, was there any time that you skipped doses or took smaller amounts of your prescription drugs to make them last longer?
1 YES 2 NO
8 DK 9 REF
Q:DU07 T:
LTC Consumer Survey RFP 2013 Page 29 of 83 Has your ever delayed or not gotten care because you could not find or did not know a doctor or other health care provider who would accept your health insurance or was accepting patients with your type of health insurance?
1 YES 2 NO
8 DK 9 REF
Q:DU08 T:
During the last 12 months, were there times that there were problems paying for medical bills?
1 YES 2 NO
8 DK 9 REF
Q:DU09 T:
If you had more flexibility in using Medicaid and Medicare funding, how might you use these funds? Are there other services or supports that you currently CANNOT get that you need or want?
1 SPECIFY (SPECIFY) 2 NONE, NOTHING
8 DK 9 REF
Case Management
Q:CM01 T:
These next few questions are about your case management. First, who is your case manager or support coordinator?
1 SPECIFY (SPECIFY) 2 DO NOT HAVE CASE MANAGER, SUPPORT COORDINATOR (GOTO SERTRAN)
8 DK (GOTO SERTRAN) 9 REF (GOTO SERTRAN)
LTC Consumer Survey RFP 2013 Page 30 of 83 Q:CM02 T:
How satisfied are you with your case manager or support coordinator? Would you say…? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:CM03 T:
The following series of questions are about your experiences with your case manager or support coordinators.
Please rate each statement using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
ENTER <1> TO CONTINUE
Q:CM04 T:
I feel I have a part in planning my care with my case manager or support coordinator. Would you say…? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:SNQ02 T:
LTC Consumer Survey RFP 2013 Page 31 of 83 My case manager or support coordinator coordinates my services to meet my needs
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:CM05 T:
My case manager or support coordinator understands which services I need to stay in my current living situation. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:CM06 T:
I can talk to my case manager or support coordinator when I need to. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 32 of 83 Q:CM07 T:
My case manager or support coordinator helps me when I ask for something. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:CM08 T:
My case manager or support coordinator asks me what I want. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:CM09 T:
My case manager or support coordinator helps me understand the different service options that are available. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or LTC Consumer Survey RFP 2013 Page 33 of 83 5 Never
8 DK 9 REF
Q:SERTRAN T:
For the next few questions, I would like you to think SPECIFICALLY about the services you receive from each one of the state-sponsored programs in which you participate.
ENTER <1> TO CONTINUE Attendant Services Program
Q:Q9 T:
The following series of questions are about your experiences with the Attendant Services Program.
PROMPT: The Attendant Services Program provides assistance with personal care for adults with disabilities. Participants hire, train, and supervise their attendants.
According to our information, you are currently receiving or have received services through the Attendant Services Program in the past. Is this correct?
1 YES 2 NO (GOTO Q10)
8 DK (GOTO Q10) 9 REF (GOTO Q10)
Q:NQ9A1 T:
How satisfied are you with the services you receive from the Attendant Services Program? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 34 of 83 Q:NQ9A2 T:
How do you rate the quality of the services you receive from the Attendant Services Program? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:Q9B
Please rate each statement about using the Attendant Services Program using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The services I receive from the Attendant Services Program meet my needs. Would you say…? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q9C T:
My caregivers in the Attendant Services Program treat me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 35 of 83 Q:Q9D T:
I know who to contact if I have a complaint about the Attendant Services Program or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q9E T:
The Attendant Services Program provides services to me when and where I need them. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:NQ9F T:
Have you experienced any problems with the Attendant Services Program during the past 12 months?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
LTC Consumer Survey RFP 2013 Page 36 of 83 8 DK 9 REF
Ask if yes to NQ9F Q:NQ9G T:
Did the Attendant Services Program work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:NQ9H T:
Is there anything that could improve services offered to you and others by the Attendant Services Program?
IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK 9 REF Homemaker Services
Q:Q10 T:
The following series of questions are about your experiences with Homemaker Services.
PROMPT: Homemaker services provide help at home with activities such as cleaning, laundry, shopping, respite care, and limited personal care.
According to our information, you are currently receiving or have received services through Homemaker Services in the past. Is this correct?
1 YES 2 NO (GOTO Q11)
8 DK (GOTO Q11) 9 REF (GOTO Q11)
LTC Consumer Survey RFP 2013 Page 37 of 83 Q:NQ10A1 T:
How satisfied are you with Homemaker Services? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:NQ10A2 T:
How do you rate the quality of Homemaker Services? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:Q10B
Please rate each statement about Homemaker Services using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The Homemaker Services I receive meet my needs. Would you say…? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK LTC Consumer Survey RFP 2013 Page 38 of 83 9 REF
Q:Q10C T:
My caregivers providing Homemaker Services treat me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q10D T:
I know who to contact if I have a complaint about Homemaker Services or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q10E T:
The Homemaker Services are provided to me when and where I need them. (READ RESPONSES AS NEEDED)
PROMPT: Would you say...?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or LTC Consumer Survey RFP 2013 Page 39 of 83 5 Never
8 DK 9 REF
NNQ10A T:
Next, please tell me how strongly you agree or disagree with the following statements. Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
I was able to choose my Homemaker Services.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10B T:
I was able to choose the provider of my Homemaker Services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10C T:
I was able to choose the scheduling of Homemaker Services that meets my needs.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree LTC Consumer Survey RFP 2013 Page 40 of 83 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10D T:
I was able to select my Homemaker Services provider from a variety of providers.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10E T:
Having more providers who offer Homemaker Services would allow me to better meet my needs.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10F T:
There are Homemaker Services that I need that I CAN’T GET.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
LTC Consumer Survey RFP 2013 Page 41 of 83 IF RATED 4 or 5 ASK: WHAT ARE THESE SERVICES YOU CANNOT GET?
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:NQ10F T:
Have you experienced any problems with Homemaker Services during the past 12 months?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to NQ10F Q:NQ10G T:
Did Homemaker Services work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:NQ10H T:
Is there anything that could improve the Homemaker Services offered to you and others?
IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK LTC Consumer Survey RFP 2013 Page 42 of 83 9 REF
Q:NNQ10I T:
Vermont is looking at possibly adding new providers of Homemaker Services.
Based on your experience, how helpful would adding new providers of Homemaker Services be to you? Please rate on a scale where one means not at all helpful and five means very helpful.
1 Not at all helpful 2 2 3 3 4 4 5 Very Helpful
8 DK 9 REF
NNQ10J T:
How strongly do you agree or disagree with the following statements. Again, rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
Adding new providers of Homemaker Services would improve my ability to have services where and when I need them.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10K T:
Adding new providers of Homemaker Services would improve the cost effectiveness of my services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 LTC Consumer Survey RFP 2013 Page 43 of 83 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ10L T:
Adding new providers Homemaker Services would improve the quality of my services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:NNQ10M T:
Do you have any other comments about adding new providers?
1 YES (SPECIFY) 2 NO, NO COMMENTS
8 DK 9 REF Personal Care Services
Q:Q11 T:
The following series of questions are about your experiences with Choices for Care Personal Care Services.
PROMPT: These services provide assistance with personal care for seniors and adults with disabilities.
According to our information, you are currently receiving or have received Personal Care Services in the past. Is this correct?
LTC Consumer Survey RFP 2013 Page 44 of 83 1 YES 2 NO (GOTO Q12)
8 DK (GOTO Q12) 9 REF (GOTO Q12)
Q:NQ11A1 T:
How satisfied are you with the Personal Care Services you receive? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:NQ11A2 T:
How do you rate the quality of the Personal Care Services you receive? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:Q11B
Please rate each statement about the Personal Care Services you receive using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The Personal Care Services I receive meet my needs. Would you say…? (READ RESPONSES)
1 Always LTC Consumer Survey RFP 2013 Page 45 of 83 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q11C T:
My personal caregiver treats me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q11D T:
I know who to contact if I have a complaint about Personal Care Services or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q11E T:
Personal Care Services are provided to me when and where I need them. (READ RESPONSES AS NEEDED)
LTC Consumer Survey RFP 2013 Page 46 of 83 PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
NNQ11A T:
Next, please tell me how strongly you agree or disagree with the following statements. Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
I was able to choose my Personal Care Services.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ11B T:
I was able to choose the provider of my Personal Care Services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ11C T:
LTC Consumer Survey RFP 2013 Page 47 of 83 I was able to choose the scheduling of Personal Care Services that meets my needs.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ11D T:
I was able to select my Personal Care Services provider from a variety of providers.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ11E T:
Having more providers who offer Personal Care Services would allow me to better meet my needs.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 48 of 83 NNQ11F T:
There are Personal Care Services that I need that I CAN’T GET.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
IF RATED 4 or 5 ASK: WHAT ARE THESE SERVICES YOU CANNOT GET?
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:NQ11F T:
Have you experienced any problems with Personal Care Services during the past 12 months?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to NQ11F Q:NQ11G T:
Did Personal Care Services work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:NQ11H T: LTC Consumer Survey RFP 2013 Page 49 of 83 Is there anything that could improve the Personal Care Services offered to you and others?
PROMPT: Is there anything else?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Q:NNQ11I T:
Vermont is looking at possibly adding new providers of Personal Care Services.
Based on your experience, how helpful would adding new providers of Personal Care Services be to you? Please rate on a scale where one means not at all helpful and five means very helpful.
1 Not at all helpful 2 2 3 3 4 4 5 Very Helpful
8 DK 9 REF
NNQ11J T:
How strongly do you agree or disagree with the following statements. Again, rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
Adding new providers of Personal Care Services would improve my ability to have services where and when I need them.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 50 of 83 NNQ11K T:
Adding new providers of Personal Care Services would improve the cost effectiveness of my services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
NNQ11L T:
Adding new providers Personal Care Services would improve the quality of my services.
PROMPT: Rate on a scale from one to five where one is strongly DIS-agree and five is strongly agree.
1 Strongly Disagree 2 2 3 3 4 4 5 Strongly Agree
8 DK 9 REF
Q:NNQ11M T:
Do you have any other comments about adding new providers?
1 YES (SPOECIFY) 2 NO, NO COMMENTS
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 51 of 83 Adult Day Centers
Q:Q12 T:
The following series of questions are about your experiences with Adult Day Centers.
PROMPT: Adult Day Centers provide social interaction, meals, personal care, and health services.
According to our information, you are currently attending or have attended an Adult Day Center in the past. Is this correct?
1 YES 2 NO (GOTO HT01)
8 DK (GOTO HT01) 9 REF (GOTO HT01)
Q:NQ12A1 T:
How satisfied are you with the Adult Day Center you attend? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:NQ12A2 T:
How do you rate the quality of the services provided by the Adult Day Center you attend? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 52 of 83 Q:Q12B
Please rate each statement about the Adult Day Center you attend using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The services I receive from the Adult Day Center meet my needs. Would you say…? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q12C T:
My caregivers at the Adult Day Center treat me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q12D T:
I know who to contact if I have a complaint about the Adult Day Center or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or LTC Consumer Survey RFP 2013 Page 53 of 83 5 Never
8 DK 9 REF
Q:Q12E T:
The Adult Day Center provides services to me when and where I need them. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:NQ12F T:
During the past 12 months, have you experienced any problems with the Adult Day Center you attend?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to NQ12F Q:NQ12G T:
Did the Adult Day Center work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 54 of 83 Q:NQ12H T:
Is there anything that could improve services offered to you and others by the Adult Day Center?
IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK 9 REF High Technology Home Care Program
Q:HT01 T:
The following series of questions are about your experiences with the High Technology Home Care Program.
PROMPT: The High Technology Home Care Program provides skilled nursing care to people of any age who are Medicaid-eligible and technology-dependent. Services includes coordinating treatments, medical supplies and sophisticated medical equipment.
According to our information, you are currently receiving or have received services through the High Technology Home Care Program. Is this correct?
1 YES 2 NO (GOTO TBI01
8 DK (GOTO TBI01) 9 REF (GOTO TBI01
Q:HT02 T:
How satisfied are you with the services you receive from the High Technology Home Care Program? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
LTC Consumer Survey RFP 2013 Page 55 of 83 8 DK 9 REF
Q:HT03 T:
How do you rate the quality of the services you receive from the High Technology Home Care Program? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:HT04
Please rate each statement about using the High Technology Home Care Program using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The services I receive from the High Technology Home Care Program meet my needs. Would you say…? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:HT05 T:
My caregivers in the High Technology Home Care Program treat me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
LTC Consumer Survey RFP 2013 Page 56 of 83 8 DK 9 REF
Q:HT06 T:
I know who to contact if I have a complaint about the High Technology Home Care Program or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:HT07 T:
The High Technology Home Care Program provides services to me when and where I need them. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:HT08 T:
Have you experienced any problems with the High Technology Home Care Program during the past 12 months?
IF YES ASK: What problems did you experience?
LTC Consumer Survey RFP 2013 Page 57 of 83 1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to HT08 Q:HT09 T:
Did the High Technology Home Care Program work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:HT10 T:
Is there anything that could improve services offered to you and others by the High Technology Home Care Program?
IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK 9 REF Traumatic Brain Injury Program
Q:TBI01 T:
The following series of questions are about your experiences with the Traumatic Brain Injury Program.
PROMPT: The Traumatic Brain Injury Program helps Vermonters, with moderate to severe traumatic brain injuries, move from hospitals and facilities to community-based settings.
This is a rehabilitation-based, choice-driven program, intended to support individuals to achieve their optimum independence and help them return to work.
LTC Consumer Survey RFP 2013 Page 58 of 83 According to our information, you are currently receiving or have received services through the Traumatic Brain Injury Program. Is this correct?
1 YES 2 NO (GOTO Q13)
8 DK (GOTO Q13) 9 REF (GOTO Q13
Q:TBI02 T:
How satisfied are you with the services you receive from the Traumatic Brain Injury Program? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
Q:TBI03 T:
How do you rate the quality of the services you receive from the Traumatic Brain Injury Program? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:TBI04
Please rate each statement about using the Traumatic Brain Injury Program using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
The services I receive from the Traumatic Brain Injury Program meet my needs. Would you say…? (READ RESPONSES)
LTC Consumer Survey RFP 2013 Page 59 of 83 1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:TBI05 T:
My caregivers in the Traumatic Brain Injury Program treat me with respect and courtesy. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:TBI06 T:
I know who to contact if I have a complaint about the Traumatic Brain Injury Program or if I need more help. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 60 of 83 Q:TBI07 T:
The Traumatic Brain Injury Program provides services to me when and where I need them. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:TBI08 T:
Have you experienced any problems with the Traumatic Brain Injury Program during the past 12 months?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to TBI08 Q:TBI09 T:
Did the Traumatic Brain Injury Program work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:TB10 T:
Is there anything that could improve services offered to you and others by the Traumatic Brain Injury Program? LTC Consumer Survey RFP 2013 Page 61 of 83 IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK 9 REF Home Delivered Meals Program
Q:Q13 T:
The following series of questions are about your experience with the Home Delivered Meals Program, or Meals on Wheels.
PROMPT: The Home Delivered Meals Program provides nourishing meals to seniors in their homes who are unable to attend a community meal site.
Do you currently receive meals through the Home Delivered Meals Program?
1 YES 2 NO (GOTO Q22)
8 DK (GOTO Q22) 9 REF (GOTO Q22)
Q:NQ13A1 T:
How satisfied are you with the Home Delivered Meals Program? (READ RESPONSES)
IF DISSATISFIED ASK: Why were you dissatisfied?
1 Very Satisfied 2 Somewhat Satisfied 3 Somewhat Dissatisfied (SPECIFY) 4 Very Dissatisfied (SPECIFY)
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 62 of 83 Q:NQ13A2 T:
How do you rate the quality of the services provided by the Home Delivered Meals Program? (READ RESPONSES)
1 Excellent 2 Good 3 Fair, or 4 Poor
8 DK 9 REF
Q:Q15 T:
Please rate each statement about the Home Delivered Meals Program using the following scale: Always, Almost Always, Sometimes, Seldom, or Never.
ENTER <1> TO CONTINUE
Q:Q15A T:
The food tastes good. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15B T:
The food looks good. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
LTC Consumer Survey RFP 2013 Page 63 of 83 1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15C T:
The meals provide a variety of foods. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15D T:
When the meal arrives, the hot food is hot. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15E T:
When the meal arrives, the cold food is cold. (READ RESPONSES AS NEEDED)
LTC Consumer Survey RFP 2013 Page 64 of 83 PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15F T:
The meal is delivered on time. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
Q:Q15G T:
I eat the meals that are delivered. (READ RESPONSES AS NEEDED)
PROMPT: Would you say…?
1 Always 2 Almost Always 3 Sometimes 4 Seldom, or 5 Never
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 65 of 83 Q:NQ15H T:
Have you experienced any problems with the Home Delivered Meals Program during the past 12 months?
IF YES ASK: What problems did you experience?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Ask if yes to NQ15H Q:NQ15I T:
Did the Home Delivered Meals Program work to resolve any problems?
1 YES 2 NO
8 DK 9 REF
Q:NQ15J T:
Is there anything that could improve services offered to you and others by the Home Delivered Meals Program?
IF YES ASK: WHAT COULD BE IMPROVED?
1 YES (SPECIFY) 2 NO
8 DK 9 REF
Q:Q17 T:
How often do foods offered through the Home Delivered Meals Program meet your specific dietary needs? (READ RESPONSES)
1 Always 2 Almost Always 3 Sometimes LTC Consumer Survey RFP 2013 Page 66 of 83 4 Seldom, or 5 Never
8 DK 9 REF
Q:NQ17A T:
To what degree do you feel that the home delivered meals have helped you financially? Would you say…? (READ RESPONSES)
1 A lot 2 Somewhat 3 A little, or 4 Not at all
8 DK 9 REF
Q:NQ17B T:
To what degree do you feel that home delivered meals have improved the nutritional value of the food you eat? (READ RESPONSES)
1 A lot 2 Somewhat 3 A little, or 4 Not at all
8 DK 9 REF Additional Comments
Q:Q22 T:
And finally, do you have any comments you would like to make about the help you receive?
1 SPECIFY (SPECIFY) 2 NO ADDITIONAL COMMENTS
8 DK 9 REF
LTC Consumer Survey RFP 2013 Page 67 of 83 ATTACHMENT 2
The State of Vermont requires the use of several standard attachments for contracts. The current versions of these attachments appear on subsequent pages. Please note that these attachments are subject to revision.
LTC Consumer Survey RFP 2013 Page 68 of 83 ATTACHMENT C CUSTOMARY PROVISIONS FOR CONTRACTS AND GRANTS
1. Entire Agreement. This Agreement, whether in the form of a Contract, State Funded Grant, or Federally Funded Grant, represents the entire agreement between the parties on the subject matter. All prior agreements, representations, statements, negotiations, and understandings shall have no effect. 2. Applicable Law. This Agreement will be governed by the laws of the State of Vermont. 3. Definitions: For purposes of this Attachment, “Party” shall mean the Contractor, Grantee or Subrecipient, with whom the State of Vermont is executing this Agreement and consistent with the form of the Agreement. 4. Appropriations: If appropriations are insufficient to support this Agreement, the State may cancel on a date agreed to by the parties or upon the expiration or reduction of existing appropriation authority. In the case that this Agreement is funded in whole or in part by federal or other non-State funds, and in the event those funds become unavailable or reduced, the State may suspend or cancel this Agreement immediately, and the State shall have no obligation to fund this Agreement from State revenues. 5. No Employee Benefits For Party: The Party understands that the State will not provide any individual retirement benefits, group life insurance, group health and dental insurance, vacation or sick leave, workers compensation or other benefits or services available to State employees, nor will the state withhold any state or federal taxes except as required under applicable tax laws, which shall be determined in advance of execution of the Agreement. The Party understands that all tax returns required by the Internal Revenue Code and the State of Vermont, including but not limited to income, withholding, sales and use, and rooms and meals, must be filed by the Party, and information as to Agreement income will be provided by the State of Vermont to the Internal Revenue Service and the Vermont Department of Taxes. 6. Independence, Liability: The Party will act in an independent capacity and not as officers or employees of the State. The Party shall defend the State and its officers and employees against all claims or suits arising in whole or in part from any act or omission of the Party or of any agent of the Party. The State shall notify the Party in the event of any such claim or suit, and the Party shall immediately retain counsel and otherwise provide a complete defense against the entire claim or suit. The Party shall notify its insurance company and the State within 10 days of receiving any claim for damages, notice of claims, pre-claims, or service of judgments or claims, for any act or omissions in the performance of this Agreement. After a final judgment or settlement the Party may request recoupment of specific defense costs and may file suit in Washington Superior Court requesting recoupment. The Party shall be entitled to recoup costs only upon a showing that such costs were entirely unrelated to the defense of any claim arising from an act or omission of the Party. The Party shall indemnify the State and its officers and employees in the event that the State, its officers or employees become legally obligated to pay any damages or losses arising from any act or omission of the Party. 7. Insurance : Before commencing work on this Agreement the Party must provide certificates of insurance to show that the following minimum coverage is in effect. It is the responsibility of the Party to maintain current certificates of insurance on file with the state through the term of the Agreement. No warranty is made that the coverage and limits listed herein are adequate to cover and protect the interests of the Party for the Party’s operations. These are solely minimums that have been established to protect the interests of the State.
LTC Consumer Survey RFP 2013 Page 69 of 83 Workers Compensation: With respect to all operations performed, the Party shall carry workers’ compensation insurance in accordance with the laws of the State of Vermont. General Liability and Property Damage: With respect to all operations performed under the Agreement, the Party shall carry general liability insurance having all major divisions of coverage including, but not limited to: Premises - Operations Products and Completed Operations Personal Injury Liability Contractual Liability The policy shall be on an occurrence form and limits shall not be less than: $1,000,000 Per Occurrence $1,000,000 General Aggregate $1,000,000 Products/Completed Operations Aggregate $ 50,000 Fire/ Legal/Liability Party shall name the State of Vermont and its officers and employees as additional insureds for liability arising out of this Agreement. Automotive Liability: The Party shall carry automotive liability insurance covering all motor vehicles, including hired and non-owned coverage, used in connection with the Agreement. Limits of coverage shall not be less than: $1,000,000 combined single limit. Party shall name the State of Vermont and its officers and employees as additional insureds for liability arising out of this Agreement. Professional Liability: Before commencing work on this Agreement and throughout the term of this Agreement, the Party shall procure and maintain professional liability insurance for any and all services performed under this Agreement, with minimum coverage of $___N/A ______per occurrence, and $___NA ______aggregate.
8. Reliance by the State on Representations: All payments by the State under this Agreement will be made in reliance upon the accuracy of all prior representations by the Party, including but not limited to bills, invoices, progress reports and other proofs of work. 9. Requirement to Have a Single Audit: In the case that this Agreement is a Grant that is funded in whole or in part by federal funds, the Subrecipient will complete the Subrecipient Annual Report annually within 45 days after its fiscal year end, informing the State of Vermont whether or not a single audit is required for the prior fiscal year. If a single audit is required, the Subrecipient will submit a copy of the audit report to the granting Party within 9 months. If a single audit is not required, only the Subrecipient Annual Report is required. A single audit is required if the subrecipient expends $500,000 or more in federal assistance during its fiscal year and must be conducted in accordance with OMB Circular A-133. The Subrecipient Annual Report is required to be submitted within 45 days, whether or not a single audit is required. 10. Records Available for Audit: The Party will maintain all books, documents, payroll papers, accounting records and other evidence pertaining to costs incurred under this agreement and make them available at reasonable times during the period of the Agreement and for three years thereafter for inspection by any
LTC Consumer Survey RFP 2013 Page 70 of 83 authorized representatives of the State or Federal Government. If any litigation, claim, or audit is started before the expiration of the three year period, the records shall be retained until all litigation, claims or audit findings involving the records have been resolved. The State, by any authorized representative, shall have the right at all reasonable times to inspect or otherwise evaluate the work performed or being performed under this Agreement. 11. Fair Employment Practices and Americans with Disabilities Act: Party agrees to comply with the requirement of Title 21V.S.A. Chapter 5, Subchapter 6, relating to fair employment practices, to the full extent applicable. Party shall also ensure, to the full extent required by the Americans with Disabilities Act of 1990, as amended, that qualified individuals with disabilities receive equitable access to the services, programs, and activities provided by the Party under this Agreement. Party further agrees to include this provision in all subcontracts. 12. Set Off: The State may set off any sums which the Party owes the State against any sums due the Party under this Agreement; provided, however, that any set off of amounts due the State of Vermont as taxes shall be in accordance with the procedures more specifically provided hereinafter. 13. T axes Due to the State: a. Party understands and acknowledges responsibility, if applicable, for compliance with State tax laws, including income tax withholding for employees performing services within the State, payment of use tax on property used within the State, corporate and/or personal income tax on income earned within the State. b. Party certifies under the pains and penalties of perjury that, as of the date the Agreement is signed, the Party is in good standing with respect to, or in full compliance with, a plan to pay any and all taxes due the State of Vermont. c. Party understands that final payment under this Agreement may be withheld if the Commissioner of Taxes determines that the Party is not in good standing with respect to or in full compliance with a plan to pay any and all taxes due to the State of Vermont. d. Party also understands the State may set off taxes (and related penalties, interest and fees) due to the State of Vermont, but only if the Party has failed to make an appeal within the time allowed by law, or an appeal has been taken and finally determined and the Party has no further legal recourse to contest the amounts due. 14. Child Support: (Applicable if the Party is a natural person, not a corporation or partnership.) Party states that, as of the date the Agreement is signed, he/she: a. is not under any obligation to pay child support; or b. is under such an obligation and is in good standing with respect to that obligation; or c. has agreed to a payment plan with the Vermont Office of Child Support Services and is in full compliance with that plan. Party makes this statement with regard to support owed to any and all children residing in Vermont. In addition, if the Party is a resident of Vermont, Party makes this statement with regard to support owed to any and all children residing in any other state or territory of the United States. 15. Sub-Agreements: Party shall not assign, subcontract or subgrant the performance of his Agreement or any portion thereof to any other Party without the prior written approval of the State. Party also agrees to include in subcontract or subgrant agreements a tax certification in accordance with paragraph 13 above.
LTC Consumer Survey RFP 2013 Page 71 of 83 Notwithstanding the foregoing, the State agrees that the Party may assign this agreement, including all of the Party's rights and obligations hereunder, to any successor in interest to the Party arising out of the sale of or reorganization of the Party.
16. No Gifts or Gratuities: Party shall not give title or possession of any thing of substantial value (including property, currency, travel and/or education programs) to any officer or employee of the State during the term of this Agreement. 17. Copies: All written reports prepared under this Agreement will be printed using both sides of the paper. 18. Certification Regarding Debarment: Party certifies under pains and penalties of perjury that, as of the date that this Agreement is signed, neither Party nor Party’s principals (officers, directors, owners, or partners) are presently debarred, suspended, proposed for debarment, declared ineligible or excluded from participation in federal programs, or programs supported in whole or in part by federal funds. Party further certifies under pains and penalties of perjury that, as of the date that this Agreement is signed, Party is not presently debarred, suspended, nor named on the State’s debarment list at: http://bgs.vermont.gov/purchasing/debarment 19. Certification Regarding Use of State Funds: In the case that Party is an employer and this Agreement is a State Funded Grant in excess of $1,001, Party certifies that none of these State funds will be used to interfere with or restrain the exercise of Party’s employee’s rights with respect to unionization.
State of Vermont – Attachment C Revised AHS – 11-7-2012
LTC Consumer Survey RFP 2013 Page 72 of 83 ATTACHMENT D MODIFICATION OF CUSTOMARY PROVISIONS OF ATTACHMENT C OR ATTACHMENT F
1. The insurance requirements contained in Attachment C, Section 7 are hereby modified:
(Example: Automotive)
2. Requirements of other Sections in Attachment C are hereby modified:
(Example: The Contractor is required to maintain automotive liability at a minimum in the amount of $300,000.)
3. Requirements of Sections in Attachment F are hereby modified:
4. Reasons for Modifications:
(Example: The Contractor will not be providing transportation to clients of the State or transporting other individuals as a State official, and does not have access to clients of the State, or to confidential information regarding clients of the State.)
Approval:
Assistant Attorney General: ______
Date: ______
State of Vermont – Attachment D Revised AHS – 12-08-09
LTC Consumer Survey RFP 2013 Page 73 of 83 ATTACHMENT E BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement (“Agreement”) is entered into by and between the State of Vermont Agency of Human Services operating by and through its Department, Office, or Division of (______Insert Department, Office, or Division) (“Covered Entity”) and (______Insert Name of the Contractor) (“Business Associate”) as of (______Insert Date) (“Effective Date”). This Agreement supplements and is made a part of the Contract to which it is an attachment.
Covered Entity and Business Associate enter into this Agreement to comply with standards promulgated under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) including the Standards for the Privacy of Individually Identifiable Health Information at 45 CFR Parts 160 and 164 (“Privacy Rule”) and the Security Standards at 45 CFR Parts 160 and 164 (“Security Rule”), as amended by subtitle D of the Health Information Technology for Economic and Clinical Health Act.
The parties agree as follows:
1. Definitions. All capitalized terms in this Agreement have the meanings identified in this Agreement, 45 CFR Part 160, or 45 CFR Part 164.
The term “Services” includes all work performed by the Business Associate for or on behalf of Covered Entity that requires the use and/or disclosure of protected health information to perform a business associate function described in 45 CFR 160.103 under the definition of Business Associate.
The term “Individual” includes a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).
The term “Breach” means the acquisition, access, use or disclosure of protected health information (PHI) in a manner not permitted under the HIPAA Privacy Rule, 45 CFR part 164, subpart E, which compromises the security or privacy of the PHI. “Compromises the security or privacy of the PHI” means poses a significant risk of financial, reputational or other harm to the individual.
2. Permitted and Required Uses/Disclosures of PHI.
2.1 Except as limited in this Agreement, Business Associate may use or disclose PHI to perform Services, as specified in the underlying contract with Covered Entity. Business Associate shall not use or disclose PHI in any manner that would constitute a violation of the Privacy Rule if used or disclosed by Covered Entity in that manner. Business Associate may not use or disclose PHI other than as permitted or required by this Agreement or as Required by Law.
2.2 Business Associate may make PHI available to its employees who need access to perform Services provided that Business Associate makes such employees aware of the use and disclosure restrictions in this Agreement and binds them to comply with such restrictions. Business Associate may only disclose PHI for the purposes authorized by this Agreement: (a) to its agents (including subcontractors) in accordance with Sections 8 and 16 or (b) as otherwise permitted by Section 3.
3. Business Activities. Business Associate may use PHI received in its capacity as a “Business Associate” to Covered Entity if necessary for Business Associate’s proper management and administration or to carry out LTC Consumer Survey RFP 2013 Page 74 of 83 its legal responsibilities. Business Associate may disclose PHI received in its capacity as “Business Associate” to Covered Entity for Business Associate’s proper management and administration or to carry out its legal responsibilities if a disclosure is Required by Law or if (a) Business Associate obtains reasonable written assurances via a written agreement from the person to whom the information is to be disclosed that the PHI shall remain confidential and be used or further disclosed only as Required by Law or for the purpose for which it was disclosed to the person and (b) the person notifies Business Associate, within three business days (who in turn will notify Covered Entity within three business days after receiving notice of a Breach as specified in Section 5.1), in writing of any Breach of Unsecured PHI of which it is aware. Uses and disclosures of PHI for the purposes identified in this Section must be of the minimum amount of PHI necessary to accomplish such purposes.
4. Safeguards. Business Associate shall implement and use appropriate safeguards to prevent the use or disclosure of PHI other than as provided for by this Agreement. With respect to any PHI that is maintained in or transmitted by electronic media, Business Associate shall comply with 45 CFR sections 164.308 (administrative safeguards), 164.310 (physical safeguards), 164.312 (technical safeguards) and 164.316 (policies and procedures and documentation requirements). Business Associate shall identify in writing upon request from Covered Entity all of the safeguards that it uses to prevent impermissible uses or disclosures of PHI.
5. Documenting and Reporting Breaches.
5.1 Business Associate shall report to Covered Entity any Breach of Unsecured PHI as soon as it (or any of its employees or agents) become aware of any such Breach, and in no case later than three (3) business days after it (or any of its employees or agents) becomes aware of the Breach, except when a law enforcement official determines that a notification would impede a criminal investigation or cause damage to national security.
5.2 Business Associate shall provide Covered Entity with the names of the individuals whose Unsecured PHI has been, or is reasonably believed to have been, the subject of the Breach and any other available information that is required to be given to the affected individuals, as set forth in 45 CFR §164.404(c), and, if requested by Covered Entity, information necessary for Covered Entity to investigate the impermissible use or disclosure. Business Associate shall continue to provide to Covered Entity information concerning the Breach as it becomes available to it.
5.3 When Business Associate determines that an impermissible acquisition, use or disclosure of PHI by a member of its workforce does not pose a significant risk of harm to the affected individuals, it shall document its assessment of risk. Such assessment shall include: 1) the name of the person(s) making the assessment, 2) a brief summary of the facts, and 3) a brief statement of the reasons supporting the determination of low risk of harm. When requested by Covered Entity, Business Associate shall make its risk assessments available to Covered Entity.
6. Mitigation and Corrective Action. Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to it of an impermissible use or disclosure of PHI, even if the impermissible use or disclosure does not constitute a Breach. Business Associate shall draft and carry out a plan of corrective action to address any incident of impermissible use or disclosure of PHI. If requested by Covered Entity, Business Associate shall make its mitigation and corrective action plans available to Covered Entity.
7. Providing Notice of Breaches.
LTC Consumer Survey RFP 2013 Page 75 of 83 7.1 If Covered Entity determines that an impermissible acquisition, access, use or disclosure of PHI for which one of Business Associate’s employees or agents was responsible constitutes a Breach as defined in 45 CFR §164.402, and if requested by Covered Entity, Business Associate shall provide notice to the individuals whose PHI was the subject of the Breach. When requested to provide notice, Business Associate shall consult with Covered Entity about the timeliness, content and method of notice, and shall receive Covered Entity’s approval concerning these elements. The cost of notice and related remedies shall be borne by Business Associate.
7.2 The notice to affected individuals shall be provided as soon as reasonably possible and in no case later than 60 calendar days after Business Associate reported the Breach to Covered Entity.
7.3 The notice to affected individuals shall be written in plain language and shall include, to the extent possible, 1) a brief description of what happened, 2) a description of the types of Unsecured PHI that were involved in the Breach, 3) any steps individuals can take to protect themselves from potential harm resulting from the Breach, 4) a brief description of what the Business associate is doing to investigate the Breach, to mitigate harm to individuals and to protect against further Breaches, and 5) contact procedures for individuals to ask questions or obtain additional information, as set forth in 45 CFR §164.404(c).
7.4 Business Associate shall notify individuals of Breaches as specified in 45 CFR §164.404(d) (methods of individual notice). In addition, when a Breach involves more than 500 residents of Vermont, Business associate shall, if requested by Covered Entity, notify prominent media outlets serving Vermont, following the requirements set forth in 45 CFR §164.406.
8. Agreements by Third Parties. Business Associate shall ensure that any agent (including a subcontractor) to whom it provides PHI received from Covered Entity or created or received by Business Associate on behalf of Covered Entity agrees in a written agreement to the same restrictions and conditions that apply through this Agreement to Business Associate with respect to such PHI. For example, the written contract must include those restrictions and conditions set forth in Section 14. Business Associate must enter into the written agreement before any use or disclosure of PHI by such agent. The written agreement must identify Covered Entity as a direct and intended third party beneficiary with the right to enforce any breach of the agreement concerning the use or disclosure of PHI. Business Associate shall provide a copy of the written agreement to Covered Entity upon request. Business Associate may not make any disclosure of PHI to any agent without the prior written consent of Covered Entity.
9. Access to PHI. Business Associate shall provide access to PHI in a Designated Record Set to Covered Entity or as directed by Covered Entity to an Individual to meet the requirements under 45 CFR 164.524. Business Associate shall provide such access in the time and manner reasonably designated by Covered Entity. Within three (3) business days, Business Associate shall forward to Covered Entity for handling any request for access to PHI that Business Associate directly receives from an Individual.
10. Amendment of PHI. Business Associate shall make any amendments to PHI in a Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR 164.526, whether at the request of Covered Entity or an Individual. Business Associate shall make such amendments in the time and manner reasonably designated by Covered Entity. Within three (3) business days, Business Associate shall forward to Covered Entity for handling any request for amendment to PHI that Business Associate directly receives from an Individual.
11. Accounting of Disclosures. Business Associate shall document disclosures of PHI and all information LTC Consumer Survey RFP 2013 Page 76 of 83 related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 CFR 164.528. Business Associate shall provide such information to Covered Entity or as directed by Covered Entity to an Individual, to permit Covered Entity to respond to an accounting request. Business Associate shall provide such information in the time and manner reasonably designated by Covered Entity. Within three (3) business days, Business Associate shall forward to Covered Entity for handling any accounting request that Business Associate directly receives from an Individual.
12. Books and Records. Subject to the attorney-client and other applicable legal privileges, Business Associate shall make its internal practices, books, and records (including policies and procedures and PHI) relating to the use and disclosure of PHI received from Covered Entity or created or received by Business Associate on behalf of Covered Entity available to the Secretary in the time and manner designated by the Secretary. Business Associate shall make the same information available to Covered Entity upon Covered Entity’s request in the time and manner reasonably designated by Covered Entity so that Covered Entity may determine whether Business Associate is in compliance with this Agreement.
13. Termination.
13.1 This Agreement commences on the Effective Date and shall remain in effect until terminated by Covered Entity or until all of the PHI provided by Covered Entity to Business Associate or created or received by Business Associate on behalf of Covered Entity is destroyed or returned to Covered Entity subject to Section 17.7.
13.2 If Business Associate breaches any material term of this Agreement, Covered Entity may either: (a) provide an opportunity for Business Associate to cure the breach and Covered Entity may terminate this Contract without liability or penalty if Business Associate does not cure the breach within the time specified by Covered Entity; or (b) immediately terminate this Contract without liability or penalty if Covered Entity believes that cure is not reasonably possible; or (c) if neither termination nor cure are feasible, Covered Entity shall report the breach to the Secretary. Covered Entity has the right to seek to cure any breach by Business Associate and this right, regardless of whether Covered Entity cures such breach, does not lessen any right or remedy available to Covered Entity at law, in equity, or under this Contract, nor does it lessen Business Associate’s responsibility for such breach or its duty to cure such breach.
14. Return/Destruction of PHI.
14.1 Business Associate in connection with the expiration or termination of this Contract shall return or destroy all PHI received from Covered Entity or created or received by Business Associate on behalf of Covered Entity pursuant to this Contract that Business Associate still maintains in any form or medium (including electronic) within thirty (30) days after such expiration or termination. Business Associate shall not retain any copies of the PHI. Business Associate shall certify in writing for Covered Entity (1) when all PHI has been returned or destroyed and (2) that Business Associate does not continue to maintain any PHI. Business Associate is to provide this certification during this thirty (30) day period.
14.2 Business Associate shall provide to Covered Entity notification of any conditions that Business Associate believes make the return or destruction of PHI infeasible. If Covered Entity agrees that return or destruction is infeasible, Business Associate shall extend the protections of this Agreement to such PHI and limit further uses and disclosures of such PHI to those purposes that make the return LTC Consumer Survey RFP 2013 Page 77 of 83 or destruction infeasible for so long as Business Associate maintains such PHI.
15. Penalties and Training. Business Associate understands that: (a) there may be civil or criminal penalties for misuse or misappropriation of PHI and (b) violations of this Agreement may result in notification by Covered Entity to law enforcement officials and regulatory, accreditation, and licensure organizations. If requested by Covered Entity, Business Associate shall participate in training regarding the use, confidentiality, and security of PHI.
16. Security Rule Obligations. The following provisions of this Section apply to the extent that Business Associate creates, receives, maintains or transmits Electronic PHI on behalf of Covered Entity.
16.1 Business Associate shall implement and use administrative, physical, and technical safeguards in compliance with 45 CFR sections 164.308, 164.310, and 164.312 with respect to the Electronic PHI that it creates, receives, maintains or transmits on behalf of Covered Entity. Business Associate shall identify in writing upon request from Covered Entity all of the safeguards that it uses to protect such Electronic PHI.
16.2 Business Associate shall ensure that any agent (including a subcontractor) to whom it provides Electronic PHI agrees in a written agreement to implement and use administrative, physical, and technical safeguards that reasonably and appropriately protect the Confidentiality, Integrity and Availability of the Electronic PHI. Business Associate must enter into this written agreement before any use or disclosure of Electronic PHI by such agent. The written agreement must identify Covered Entity as a direct and intended third party beneficiary with the right to enforce any breach of the agreement concerning the use or disclosure of Electronic PHI. Business Associate shall provide a copy of the written agreement to Covered Entity upon request. Business Associate may not make any disclosure of Electronic PHI to any agent without the prior written consent of Covered Entity.
16.3 Business Associate shall report in writing to Covered Entity any Security Incident pertaining to such Electronic PHI (whether involving Business Associate or an agent, including a subcontractor). Business Associate shall provide this written report as soon as it becomes aware of any such Security Incident, and in no case later than three (3) business days after it becomes aware of the incident. Business Associate shall provide Covered Entity with the information necessary for Covered Entity to investigate any such Security Incident.
16.4 Business Associate shall comply with any reasonable policies and procedures Covered Entity implements to obtain compliance under the Security Rule.
17. Miscellaneous.
17.1 In the event of any conflict or inconsistency between the terms of this Agreement and the terms of the Contract, the terms of this Agreement shall govern with respect to its subject matter. Otherwise the terms of the Contract continue in effect.
17.2 Business Associate shall cooperate with Covered Entity to amend this Agreement from time to time as is necessary for Covered Entity to comply with the Privacy Rule, the Security Rule, or any other standards promulgated under HIPAA.
17.3 Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply with the Privacy Rule, Security Rule, or any other standards promulgated under HIPAA. LTC Consumer Survey RFP 2013 Page 78 of 83 17.4 In addition to applicable Vermont law, the parties shall rely on applicable federal law (e.g., HIPAA, the Privacy Rule and Security Rule) in construing the meaning and effect of this Agreement.
17.5 As between Business Associate and Covered Entity, Covered Entity owns all PHI provided by Covered Entity to Business Associate or created or received by Business Associate on behalf of Covered Entity.
17.6 Business Associate shall abide by the terms and conditions of this Agreement with respect to all PHI it receives from Covered Entity or creates or receives on behalf of Covered Entity under this Contract even if some of that information relates to specific services for which Business Associate may not be a “Business Associate” of Covered Entity under the Privacy Rule.
17.7 The provisions of this Agreement that by their terms encompass continuing rights or responsibilities shall survive the expiration or termination of this Agreement. For example: (a) the provisions of this Agreement shall continue to apply if Covered Entity determines that it would be infeasible for Business Associate to return or destroy PHI as provided in Section 14.2 and (b) the obligation of Business Associate to provide an accounting of disclosures as set forth in Section 11 survives the expiration or termination of this Agreement with respect to accounting requests, if any, made after such expiration or termination.
(Rev: 1/31/11)
LTC Consumer Survey RFP 2013 Page 79 of 83 ATTACHMENT F AGENCY OF HUMAN SERVICES’ CUSTOMARY CONTRACT PROVISIONS 1. Agency of Human Services – Field Services Directors will share oversight with the department (or field office) that is a party to the contract for provider performance using outcomes, processes, terms and conditions agreed to under this contract. 2. 2-1-1 Data Base: The Contractor providing a health or human services within Vermont, or near the border that is readily accessible to residents of Vermont, will provide relevant descriptive information regarding its agency, programs and/or contact and will adhere to the "Inclusion/Exclusion" policy of Vermont's United Way/Vermont 211. If included, the Contractor will provide accurate and up to date information to their data base as needed. The “Inclusion/Exclusion” policy can be found at www.vermont211.org 3. Medicaid Program Contractors: Inspection of Records: Any contracts accessing payments for services through the Global Commitment to Health Waiver and Vermont Medicaid program must fulfill state and federal legal requirements to enable the Agency of Human Services (AHS), the United States Department of Health and Human Services (DHHS) and the Government Accounting Office (GAO) to: Evaluate through inspection or other means the quality, appropriateness, and timeliness of services performed; and Inspect and audit any financial records of such Contractor or subcontractor. Subcontracting for Medicaid Services: Having a subcontract does not terminate the Contractor, receiving funds under Vermont’s Medicaid program, from its responsibility to ensure that all activities under this agreement are carried out. Subcontracts must specify the activities and reporting responsibilities of the Contractor or subcontractor and provide for revoking delegation or imposing other sanctions if the Contractor or subcontractor’s performance is inadequate. The Contractor agrees to make available upon request to the Agency of Human Services; the Department of Vermont Health Access; the Department of Disabilities, Aging and Independent Living; and the Center for Medicare and Medicaid Services (CMS) all contracts and subcontracts between the Contractor and service providers. Medicaid Notification of Termination Requirements: Any Contractor accessing payments for services under the Global Commitment to Health Waiver and Medicaid programs who terminates their practice will follow the Department of Vermont Health Access, Managed Care Organization enrollee notification requirements. Encounter Data: Any Contractor accessing payments for services through the Global Commitment to Health Waiver and Vermont Medicaid programs must provide encounter data to the Agency of Human Services and/or its departments and ensure that it can be linked to enrollee eligibility files maintained by the State. Federal Medicaid System Security Requirements Compliance: All contractors and subcontractors must provide a security plan, risk assessment, and security controls review document within three months of the start date of this agreement (and update it annually thereafter) to support audit compliance with 45CFR95.621 subpart F, ADP (Automated Data Processing) System Security Requirements and Review Process. 4. Non-discrimination Based on National Origin as evidenced by Limited English Proficiency. The Contractor agrees to comply with the non-discrimination requirements of Title VI of the Civil Rights Act of 1964, 42 USC Section 2000d, et seq., and with the federal guidelines promulgated pursuant to Executive Order 13166 of 2000, which require that contractors and subcontractors receiving federal funds must assure that persons with limited English proficiency can meaningfully access services. To the extent the Contractor
LTC Consumer Survey RFP 2013 Page 80 of 83 provides assistance to individuals with limited English proficiency through the use of oral or written translation or interpretive services in compliance with this requirement, such individuals cannot be required to pay for such services. 5. Voter Registration. When designated by the Secretary of State, the Contractor agrees to become a voter registration agency as defined by 17 V.S.A. §2103 (41), and to comply with the requirements of state and federal law pertaining to such agencies. 6. Drug Free Workplace Act. The Contractor will assure a drug-free workplace in accordance with 45 CFR Part 76. 7. Privacy and Security Standards. Protected Health Information: The Contractor shall maintain the privacy and security of all individually identifiable health information acquired by or provided to it as a part of the performance of this contract. The Contractor shall follow federal and state law relating to privacy and security of individually identifiable health information as applicable, including the Health Insurance Portability and Accountability Act (HIPAA) and its federal regulations. Substance Abuse Treatment Information: The confidentiality of any alcohol and drug abuse treatment information acquired by or provided to the Contractor or subcontractor shall be maintained in compliance with any applicable state or federal laws or regulations and specifically set out in 42 CFR Part 2. Other Confidential Consumer Information: The Contractor agrees to comply with the requirements of AHS Rule No. 08-048 concerning access to information. The Contractor agrees to comply with any applicable Vermont State Statute, including but not limited to 12 VSA §1612 and any applicable Board of Health confidentiality regulations. The Contractor shall ensure that all of its employees and subcontractors performing services under this agreement understand the sensitive nature of the information that they may have access to and sign an affirmation of understanding regarding the information’s confidential and non- public nature. Social Security numbers: The Contractor agrees to comply with all applicable Vermont State Statutes to assure protection and security of personal information, including protection from identity theft as outlined in Title 9, Vermont Statutes Annotated, Ch. 62. 8. Abuse Registry. The Contractor agrees not to employ any individual, use any volunteer, or otherwise provide reimbursement to any individual in the performance of services connected with this agreement, who provides care, custody, treatment, transportation, or supervision to children or vulnerable adults if there is a substantiation of abuse or neglect or exploitation against that individual. The Contractor will check the Adult Abuse Registry in the Department of Disabilities, Aging and Independent Living. Unless the Contractor holds a valid child care license or registration from the Division of Child Development, Department for Children and Families, the Contractor shall also check the Central Child Protection Registry. (See 33 V.S.A. §4919(a)(3) & 33 V.S.A. §6911(c)(3)). 9. Reporting of Abuse, Neglect, or Exploitation. Consistent with provisions of 33 V.S.A. §4913(a) and §6903, any agent or employee of a Contractor who, in the performance of services connected with this agreement, has contact with clients or is a caregiver and who has reasonable cause to believe that a child or vulnerable adult has been abused or neglected as defined in Chapter 49 or abused, neglected, or exploited as defined in Chapter 69 of Title 33 V.S.A. shall make a report involving children to the Commissioner of the Department for Children and Families within 24 hours or a report involving vulnerable adults to the Division of Licensing and Protection at the Department of Disabilities, Aging, and Independent Living within 48 hours. This requirement applies except in those instances where particular roles and functions are exempt from reporting under state and federal law. Reports involving children shall contain the information required by 33 V.S.A. §4914. Reports involving vulnerable adults shall contain the information required by LTC Consumer Survey RFP 2013 Page 81 of 83 33 V.S.A. §6904. The Contractor will ensure that its agents or employees receive training on the reporting of abuse or neglect to children and abuse, neglect or exploitation of vulnerable adults. 10. Intellectual Property/Work Product Ownership. All data, technical information, materials first gathered, originated, developed, prepared, or obtained as a condition of this agreement and used in the performance of this agreement - including, but not limited to all reports, surveys, plans, charts, literature, brochures, mailings, recordings (video or audio), pictures, drawings, analyses, graphic representations, software computer programs and accompanying documentation and printouts, notes and memoranda, written procedures and documents, which are prepared for or obtained specifically for this agreement - or are a result of the services required under this grant - shall be considered "work for hire" and remain the property of the State of Vermont, regardless of the state of completion - unless otherwise specified in this agreement. Such items shall be delivered to the State of Vermont upon 30 days notice by the State. With respect to software computer programs and / or source codes first developed for the State, all the work shall be considered "work for hire,” i.e., the State, not the Contractor or subcontractor, shall have full and complete ownership of all software computer programs, documentation and/or source codes developed. The Contractor shall not sell or copyright a work product or item produced under this agreement without explicit permission from the State. If the Contractor is operating a system or application on behalf of the State of Vermont, then the Contractor shall not make information entered into the system or application available for uses by any other party than the State of Vermont, without prior authorization by the State. Nothing herein shall entitle the State to pre- existing Contractor’s materials. 11. Security and Data Transfers. The State shall work with the Contractor to ensure compliance with all applicable State and Agency of Human Services' policies and standards, especially those related to privacy and security. The State will advise the Contractor of any new policies, procedures, or protocols developed during the term of this agreement as they are issued and will work with the Contractor to implement any required. The Contractor will ensure the physical and data security associated with computer equipment - including desktops, notebooks, and other portable devices - used in connection with this agreement. The Contractor will also assure that any media or mechanism used to store or transfer data to or from the State includes industry standard security mechanisms such as continually up-to-date malware protection and encryption. The Contractor will make every reasonable effort to ensure media or data files transferred to the State are virus and spyware free. At the conclusion of this agreement and after successful delivery of the data to the State, the Contractor shall securely delete data (including archival backups) from the Contractor's equipment that contains individually identifiable records, in accordance with standards adopted by the Agency of Human Services. 12. Computing and Communication: The Contractor shall select, in consultation with the Agency of Human Services’ Information Technology unit, one of the approved methods for secure access to the State’s systems and data, if required. Approved methods are based on the type of work performed by the Contractor as part of this agreement. Options include, but are not limited to: 1. Contractor’s provision of certified computing equipment, peripherals and mobile devices, on a separate Contractor’s network with separate internet access. The Agency of Human Services’ accounts may or may not be provided. 2. State supplied and managed equipment and accounts to access state applications and data, including State issued active directory accounts and application specific accounts, which follow the National Institutes of Standards and Technology (NIST) security and the Health Insurance Portability & Accountability Act (HIPAA) standards.
LTC Consumer Survey RFP 2013 Page 82 of 83 The State will not supply e-mail accounts to the Contractor. 13. Lobbying. No federal funds under this agreement may be used to influence or attempt 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, continuation, renewal, amendments other than federal appropriated funds. 14. Non–discrimination. The Contractor will prohibit discrimination on the basis of age under the Age Discrimination Act of 1975, on the basis of handicap under section 504 of the Rehabilitation Act of 1973, on the basis of sex under Title IX of the Education Amendments of 1972, or on the basis of race, color or national origin under Title VI of the Civil Rights Act of 1964. No person shall on the grounds of sex (including, in the case of a woman, on the grounds that the woman is pregnant) or on the grounds of religion, be excluded from participation in, be denied the benefits of, or be subjected to discrimination, to include sexual harassment, under any program or activity supported by state and/or federal funds. The Contractor will also not refuse, withhold from or deny to any person the benefit of services, facilities, goods, privileges, advantages, or benefits of public accommodation on the basis of disability, race, creed, color, national origin, marital status, sex, sexual orientation or gender identity under Title 9 V.S.A. Chapter 139. 15. Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used routinely or regularly for the provision of health, child care, early childhood development services, education or library services to children under the age of 18, if the services are funded by federal programs either directly or through state or local governments, by federal grant, contract, loan or loan guarantee. The law also applies to children's services that are provided in indoor facilities that are constructed, operated, or maintained with such Federal funds. The law does not apply to children's services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & Children (WIC) coupons are redeemed. Failure to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the responsible entity. Contractors are prohibited from promoting the use of tobacco products for all clients. Facilities supported by state and federal funds are prohibited from making tobacco products available to minors.
Attachment F - Revised AHS -12/10/10
LTC Consumer Survey RFP 2013 Page 83 of 83