Rural Health Center Program

CAPITAL PROJECT SFY 2015 – 2016

Scope of Work Form

(Maximum of 50 points)

Background

Detail who will be involved in the development, implementation, and execution of this capital project. Provide background of the applying organization and provide relevance of the background to the request for capital funding.

Purpose (20 point max)

Detail specifics of the capital project and anticipated outcome(s). Outcome specific details should include the impact of the capital project on a least one of the following categories:

  1. Patient and/or staff comfort and safety
  2. Quality of services provided
  3. Efficiency of services provided
  4. Compliance with current state and federal regulations
  5. Health Information Technology (with prior approval).

In addition, detail the location(s) where tasks/goals of the capital project will be met.

Performance Requirements (10 point max)

Detail the timeline for specific tasks/goals to be completed during the capital project period ending May 31, 2016. Additionally, provide information about the following:

  1. Detail how the capital project activities previously outlined above in the “Purpose” section above will be accomplished. This section should be an in-depth description of the process that will be used to complete the capital project within the grant period
  2. Describe how progress toward meeting the outlined performance measures will be tracked. Include details of process, tools used, funding sources and any other pertinent information.

Program Success (20 point max)

Detail the expected gain for the applicant through this capital project. Will the result of this capital project impact the long-term sustainability of the applicant? If yes, detail the anticipated impact. If no, provide a detailed explanation.

The following section will be completed by ORHCC if funding is awarded.

  1. The Contractor will successfully complete the capital projected as described above in the following manner:

B.The Contractor will demonstrate measureable progress toward completion of this projectnolaterthanApril 15,2016, and monthly thereafter through the end of the contract term, by:

Performance Standards

The Contractor will ensure compliance with the policies and procedures developed by the Division.These include but are not limited to:

  • Submitting financial invoices within ten (10) days of receipt
  • Submitting final financial and performance reports within 30 days following the end of the contract term
  • Submitting any documentation requested for review within five (5) days of request

The Contractor will maintain all relevant records (e.g., invoices, payroll records, etc.) in accordance with the approved budget and performance measures and will make such records available to the Division upon request.

Performance Monitoring/Quality Assurance Plan

The contract will be monitored according to the following plan:

  • On-site reviews: The Division will conduct on-site reviews, interview Contractor staff regarding goals and accomplishments, and review key performance and financial documentation to ensure compliance with the contract terms.
  • Financial reporting and review: The Contractor will submit financial reports to the Division for reimbursement. The Division will review these reports against contract terms to ensure expenses are charged in accordance with the approved line item budget.
  • Other periodic contact with Contractor, consulting and referring sites/providers: Meetings, teleconferences, and other periodic contact with all stakeholders will be undertaken to facilitate participation, review progress and discuss any questions that may arise

If the contract performance is deemed to be out of compliance, the Division will work with the Contractor to correct any deficiencies. If performance issues are not resolved within 30 days of an identified deficiency, a corrective action plan will be developed and implemented within the ensuing 30 days. Failure to resolve deficiencies within the timeframe prescribed in the corrective action plan may result in suspension of funding or other alternative management decisions.

Reimbursement/Payment Schedule

Total payments will not exceed $______, and may be less than $_____ depending upon final reconciliation of monthly financial reports. Payments will be made exclusive of sales tax.

Applicant Name: ______1 8/7/2015