PROPOSAL FOR DRUG/ALCOHOL TESTING SERVICE Stearns County Human Services INSTRUCTIONS: Please provide information as detailed below. Please write directly on this document, attaching additional pages as needed. I. GENERAL INFORMATION Business Name (Corporate Name, if incorporated): Business Address: Home Office Address (if different): Business Telephone: Contact Person and Title: Business Fax: Business Email: Name and Title of Person Authorized to Execute Host County Contract: II. INSURANCE Attach a Certificate of Insurance with coverage and limits as set forth at Attachment A. The County of Stearns must be named as an Additional Insured for liability insurance coverage. (Note this can be provided by the selected provider prior to contracting). III. ORGANIZATIONAL STRUCTURE A. Please identify your organizational status: Sole Proprietorship Partnership For Profit Corporation Non-Profit Corporation LLC B. Please indicate your Taxpayer Identification Number: (Used for IRS and Minnesota Department of Revenue reporting only) C. If you are a partnership, please identify all partners: D. If you are incorporated or an LLC, please provide the following documents and information (or the equivalent for LLC): 1. Articles of Incorporation 2. By-Laws 1
3. Organizational Chart 4. Names of current Board of Directors 5. Names of current Officers, with position held. E. If you are a charitable organization that has filed or is required to file a registration statement pursuant to Minnesota Statutes, Section 309.52, please attach a copy of your most recent annual report to the Attorney General of the State of Minnesota. F. If you are a non-profit corporation, please attach a copy of your most recent tax and information returns (including schedules and amendments) submitted to the Internal Revenue Service, except schedules of contributors. IV. PERSONNEL Do you have employees: Yes No (If Yes, complete Items A. and B., below. If No, skip to Section V.) A. Describe required training and other training opportunities for your staff. B. How do you supervise staff? Include type and frequency of supervisory contacts. 2
Description of Credentials and Experience A. METHODOLOGY: Describe your drug/alcohol testing methodology/system including the type of technology used. Enclose a price list which includes the products and technologies you offer. B. CAPABILITY: Describe the capability of your organization to provide drug/alcohol Testing services and your related service history. If you have experience that is specifically related to corrections clients please describe. C. PROTOCOL: Describe your drug/alcohol testing protocol related to specimen collection, scheduling, notification of results, transporting specimens, and confirmation procedures on positive samples. D. CHAIN OF CUSTODY: Describe your chain of custody procedures. E. COURT TESTIMONY: Describe your capability and expertise to testify in court in the event of legal challenges and explain procedures for preserving all positive samples through the litigation process. F. DATA COLLECTION SYSTEM: Describe your tracking data base and system for profiling the populations tested. If your database can merge with the Court Services Tracking System (CSTS) please note. G. FACILITIES: Describe your laboratory testing facilities/sites and equipment and how the integrity of the specimen collection process is ensured. 3
H. AVAILABILITY OF SERVICE: Are you able to provide service throughout the entire county at all times including holidays, evenings, and weekends? If not, list any geographical or time limitations. I. FIELD SERVICE: Describe your ability to provide field services personnel to facilitate equipment hook up, troubleshooting, home visits, and equipment pick up. Is your staff able to do collections at a county site? J. TRAINING: Describe training and inservice programs you are able to provide. K. POST REFERRAL PROCEDURE: How soon after a client is referred do you initiate the drug testing process and what is the turnaround time from receipt of sample to receipt of test results. L. STAFF CREDENTIALS/EXPERIENCE: Describe the credentials and experience of Supervisory staff and laboratory personnel who will be providing the service. M. QUALITY ASSURANCE/CONTROL: Describe specific measures for quality assurance and quality control. N. PROPOSED SERVICE RATES: Provide service rates. 4
O. FACILITY CERTIFICATION/LICENSURE: Attach a copy of current licenses/certification which pertain to services you are proposing to provide, e.g. Medical Lab certification, SAMSHA, College of American Pathologists, Drug Enforcement Agency (DEA), Health Care Financing Administration (HCFA), Department of Health License, etc. Below please list the items you will be attaching. P. REGULATORY/MONITORING DOCUMENTS: Attach a copy of applicable regulatory/monitoring documents (e.g., U.S. Department of Transportation, Internal Revenue Service (IRS), MN Department of Health, Department of Human Service (DHS) etc.) Also address any formal complaints, licensing deficiencies, corrective action orders, or audits which had involvement from a regulatory agency, and your responses. 5
FINANCIAL RESPONSIBILITY Please answer the following questions. For purposes of this Section VI., the term you shall mean and include all partners, officers and directors, if any. A. Are your financial books and records audited by an independent accounting service? If Yes, please attach a copy of your most recent audit and management letter. B. Are all of your state and federal tax obligations, including payroll and income taxes, current? If No, please describe: C. If you have access to or responsibility for safeguarding client funds, please describe how you do so. If you do not have such access or responsibility, please so indicate. D. Are you presently debarred, suspended, ineligible or excluded from transacting business by or with any federal, state or local governmental department or agency? E. Within the past six years, have you been convicted of or had a civil judgment rendered against you for the commission of fraud or any criminal offense in connection with obtaining or performing a public contract? F. Within the past six years, have you been adjudicated a bankrupt or filed for relief in the United States Bankruptcy Court? G. Within the past six years, have you been or are you presently a party to a lawsuit or administrative proceeding related to the ownership and operation of your business? H. If you answered Yes to any of Questions D., E., F. or G., above, please describe (Use additional paper if required): Yes No 6
V. FINANCIAL MANAGEMENT AND INTERNAL CONTROL Check the appropriate answer to each Question. If the response is No, please YES NO COMMENTS explain in the Comments section. (Attach additional sheets, if necessary) Is there a formal accounting structure with chart of accounts established? Are accounting procedures reviewed at least annually and revised as necessary? Is there monthly monitoring of planned versus actual expense and obligation of funds to determine balances and possible overspending? Are numerical sequences of pre-numbered documents accounted for? Is it prohibited to issue checks to cash or bearer? Is it prohibited to sign checks in advance? Are disbursements, except those from petty cash, made by check? Are bank statements reconciled on a monthly basis? Are there policies or written documentation designating which individuals are authorized to sign time and attendance reports, etc.? Complete the following questions if you employ staff: Are accounting policies and procedures easily accessible by those required to follow those policies and procedures? Are there measures in place limiting unauthorized personnel from storage areas of such things as inventory, petty cash, blank checks, voided checks, etc.? Are employees who are authorized to deal with company funds bonded? Is it identified in writing who is authorized to sign checks and/or use signature stamp and/or complete wire transfers? Are all tax payments current, i.e. payroll taxes, sales tax, income taxes, Social Security, FICA,? Are all insurance premium payments current, including workman s compensation insurance premiums? Is the incoming mail opened by someone other than the person(s) having access to cash receipts or accounts receivable records? Are authorized check signers independent of check preparation, cash receiving and petty cash. Are bank reconciliations completed by someone other than persons participating in the receipt or disbursement of cash or those authorized to issue checks or handle cash. 7
VI. CERTIFICATION I hereby certify that each answer set forth on this Proposal and all other information I have furnished is true and correct. Dated: (Signature and Title) THE STEARNS COUNTY HUMAN SERVICES BOARD RESERVES THE RIGHT TO REQUIRE ADDITIONAL INFORMATION. 8
ATTACHMENT A As part of establishing a Lead County Contract with the Stearns County Human Services Board, a provider must submit certain documents. These documents may include but are not necessarily limited to: 1. Proof of current insurance.* a. General liability insurance with limits in an amount not less than $1,500,000 for any number of claims arising out of a single occurrence. b. Professional liability insurance with limits in an amount not less than $1,500,000 for any number of claims arising out of a single occurrence. c. Automobile liability insurance (if provider will transport client), covering agency-owned, non-owned, and hired vehicles used regularly in the provision of services, with limits in an amount of not less than $1,500,000 for any number of claims arising out of a single occurrence. d. Worker s Compensation Insurance as required by Minnesota law including a certificate of compliance pursuant to Minnesota Statute 176.182. e. Unemployment Compensation Insurance as required by law. 2. Proof of authority to sign contracts. 3. Proof of appointment of Responsible Authority for Data Practices requirements. * The County of Stearns must be named as an additional insured by a provider s general and professional liability insurance, in the amounts indicated in Paragraph 1 a., b., and c., above.