For Office Use Only:
Application Number:
Instructions for applying for a Regional Healthcare Coalition (RHCC) Grant:
Grant project period is from July 1 to June 30 of the following year.
Grant Applicationsmust be submitted to the Healthcare Preparedness Program (HPP) notlater than December 31st. Email (or mail) to one of the following:
Don
Bryan
Cindee
PO Box 202951
Helena MT 59620
Grants Applicationsare applicable to the following agencies and organization categories:
Hospitals , Religious Nonmedical Health Care Institutions (RNHCIs), Ambulatory Surgical Centers (ASCs) , Hospices, Psychiatric Residential Treatment Facilities (PRTFs), All-Inclusive Care for the Elderly (PACE), Transplant Centers, Long-Term Care (LTC) Facilities, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID), Hospice, Home Health Agencies (HHAs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Critical Access Hospitals (CAHs), Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services, Community Mental Health Centers (CMHCs), Organ Procurement Organizations (OPOs), Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), End-Stage Renal Disease (ESRD) Facilities, Emergency Medical Services (EMS).
Grants Applications must provide a benefit to all within the RHCC.The following are not allowed: Salaries,non-motorized vehicles, furniture, research, clinical care, reimbursement of previous year purchases, publicity, lobbying, construction, backfilling staff, staff clothing, animals, living quarters, single facility benefit, nor supplanting other federal required activities.
Grant applicants must commit to partnering with the Regional Healthcare Coalition (RHCC) to improve patient and staff safety for the betterment of all.
On a separate page, provide a list of your top 10 threats or hazards from your Hazard Vulnerability Analysis (HVA).
Failure to provide information will delay your grant application.
Part A – Administrative Information
Fill in appropriate sections.
Part B – Project Activity Description. Fill in the appropriate section(s) you are applying for funding. Attempt to provide 3 bids if available. If not available or if sole-source is preferred, provide justification.
Exercise – Must include partner agencies.
Training – Must benefit all within the RHCC.
Physical . This includes resources / items that benefit all within the RHCC.
Miscellaneous – Must benefit all within the RHCC.
PART C – Summary of Costs
Attachment A – Letter of Commitment
Attachment B –Executive Committee Review and Approval.For Executive Committee use only.
Failure to provide information will delay your grant application.
Montana Regional Healthcare Coalition(RHCC) GRANTS application.APPLICATIONS ARE DUE by DECEMBER 31st
PART A – ADMINISTRATIVE (Complete all sections of Part A)
Facility Name (requesting grant):
Facility Type:
Contact Name:
Address:
City:
Phone:
Email:
In a few short sentences, tell us your objectives for this RHCC grant.
Who will benefit from this RHCC grant?
How does the expenditure align with any current or ongoing regional initiatives?
Identify the estimated partner agencies.
How will this grant benefit the coalition as a whole?
Describe any cost match your facility or other participants will contribute to the endeavor.
Agency Staff Salaries
Other Agency expenses
PART B - PROJECT
Only fill out the applicable sections.
Exercises, Training, Physical Items (Resources), Misc.Can be one, two, three, or all sections.
EXERCISES
In a few short sentences, tell us your exercise objectives for this RHCC grant.
How will this exercise benefit the coalition as a whole?
What will the exercise be? (E.g. a tabletop pediatric surge exercise)
How much will the exercise cost?
Where will your exercise take place?
When do you anticipate your exercise will take place?
From: / Until:Attach a separate document describing you tentative exercise schedule
What regional healthcare needs will your exercise address and how were these needs identified?
Provide any relevant data or survey results.
Detail how your exercise will address these regional healthcare needs.
Who will conduct the exercise?
Identify Partner agencies for collaboration and participation.
How will you share lessons learned? Provide to HPP an AAR/IP no later than 30 days after the exercise or June 30th,whichever comes first.
TRAINING
In a few short sentences, tell us your training objectives for this RHCC grant.
How will this training benefit the coalition as a whole?
What training would you like to host? Please include a complete itinerary if available.
How much will the training cost?Provide bids as appropriate.
Identify the training team(s)
Detail the specific objectives for the training, including expected positive changes in participant knowledge, abilities, and/or skills.
How will you support training participants so that skills received through training are kept up-to-date?
Provide training rosters to HPP no later than 30 days after the event or June 30th, whichever comes first
PHYSICAL ITEMS
How will these items benefit the coalition as a whole?
List the item(s) in detail.
What is the cost of the item?
No. / Description / Supplier / New/Used / Cost per Unit / Total Cost1:
In what ways will this item benefit the RHCC?
MISCELLANEOUS ACTIVITIES OR NEEDS
In a few short sentences, tell us your objectives for this RHCC grant.
How will this grant benefit the coalition as a whole?
Describe the activity/need in detail?
What is the estimated cost of the activity/need?
Which goals will your activity/need support? How will these goals benefit the RHCC?
How will you meet these goals?
How will you measure your impact?
No. / Measure / Measurement Method / Measurement Schedule / Target1:
2:
3:
Who will be responsible for collecting information for monitoring and evaluation?
Identify any partner agency participating or collaborating in your activity/need.
Describe your process for selecting this. What resources or expertise will this agency contribute?
PART C – SUMMARY OF COSTS
Cost Summary
EXERCISE COSTS:
TRAINING COSTS:
PHYSICAL COSTS:
MISCELLANEOUS COSTS:
TOTAL COST AMOUNTS OF GRANT:
Attachment A – Letter of Commitment
Montana Regional Healthcare Coalition
Letter of Commitment
By signing this letter of commitment and participating in the Montana Hospital Preparedness Program FY17 Awards this facility will:
- Utilize award funds in accordance with federal guidelines and will maintain files of all purchases that will be available upon request during site visits from a representative of the Montana Healthcare Preparedness Program (HPP) office.
- Participating in the Annual Coalition Surge Test (CST), if tasked.
Must submit documentation of executive participation in AAR’s and Hot-Wash after an exercise.
- Participating in Semi-Annual Redundant communication exercises initiated by the MT HPP Office.
- Implementing and maintaining the 11 components of the National Incident Management Systems (NIMS).
- Participating in HAvBED as initiated by the MT HPP Office.
Healthcare facilities that have bed capacity must participate in this exercise
- Participating in Montana Healthcare Mutual Aid System (MHMAS) Exercises as initiated by the MT HPP Office.
- Participating in sharing Essential Elements of Information (EEI)
- Submit a copy of your facilities Evacuation Plan to the MT HPP Office by June 30, 2018.
- Submit a copy of your facilities Mass Casualty/Surge Plan to the MT HPP Office by June 30, 2018.
- Hospitals must ensure that they are prepared to receive, stabilize, and manage pediatric patients. More information can be obtained at
- Hospitals must collaborate with local Public Health to develop policies and procedures for implementing Facility Closed Point of Dispensing (POD) and provide copies to the MT HPP Office.
- Attend Local Emergency Planning Committee (LEPC) meetings or local Emergency Support Function (ESF)-8 meetings.
- Incorporate Access and Functional needs populations into the facility Emergency Operations Plan (EOP) to include Family Reunification procedures utilizing emPOWERdata and Social Vulnerability index provided by the MT HPP Office every 6 months.
- Participating in Regional Healthcare Coalition Meetings as scheduled.
- Share upcoming exercises with the MT HPP Office.
- Develop, maintain, and improve understanding of Infection Prevention Program.
- Submit an End of Year Report by July 30.
FY 2017 Hospital Preparedness Program
Letter of Commitment
We understand that participation in the Montana Hospital Preparedness Program FY2017 Awards requires participation in the above listed grant deliverables.
______
CEO/Administrator Name Printed
______
(Signature)(DATE)
______
Facility Emergency Planner Name Printed
______
(Signature)(DATE)
Attachment B – Executive Committee Review and Approval
EXECUTIVE COMMITTEE APPROVAL/DISAPPROVAL
This must be signed by the RHCC Chairperson and Co-chair regardless of the decision, before being sent to State of Montana HPP office.
WE, THE UNDERSIGNEDMEMBERS OF THE MONTANA REGIONAL HEALTHCARE COALITION COMMITTEE, HAVE APPROVED THIS GRANT APPLICATION.
______
RHCC Chairperson Name Printed
______
(Signature)(DATE)
______
RHCC Co-Chair Name Printed
______
(Signature)(DATE)
ACCEPTED AND APPROVED ON BEHALF OF THE STATE OF MONTANA
HEALTHCARE PREPAREDNESS PROGRAM
______
HPP Officer Date
WE, THE UNDERSIGNED MEMBERS OF THE MONTANA
______REGIONAL HEALTHCARE COALITION COMMITTEE,
HAVE NOT APPROVED THIS GRANT APPLICATION FOR THE FOLLOWING REASONS
______
RHCC Chairperson Name Printed
______
(Signature)(DATE)
______
RHCC Co-Chair Name Printed
______
(Signature)(DATE)
DECISION ACCEPTED ON BEHALF OF THE STATE OF MONTANA
HEALTHCARE PREPAREDNESS PROGRAM
______
HPP Officer (Date)
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