Office of Urban Indian Health Programs Proposed Single Source Grant With Native American Lifelines, Inc. Notice Posted in Federal Register
Targeted News Service |
Office of Urban Indian Health Programs Proposed Single Source Grant With
A Notice by the
Publication Date:
Agencies:
Dates:
Effective Date:
Entry Type: Notice
Document Citation: 78 FR 48441
Page: 48441 -48454 (14 pages)
Document Number: 2013-19113
Shorter URL: https://federalregister.gov/a/2013-19113
Funding Announcement Number: HHS-2013-IHS-UIHP-0002.
Catalogue of Federal Domestic Assistance Number: 93.193.
Key Dates
Application Deadline Date:
Review Period:
Earliest Anticipated Start Date:
I. Funding Opportunity Description
Statutory Authority
The
Purpose
Under this grant opportunity, the IHS proposes to award a single source grant to
Single Source Justification
1. As required by law, the grants authorized by 25 U.S.C. 1653(c)-(f), 1660a may only be awarded to those urban Indian organizations that have a current contract with the IHS to provide health care to urban Indians, in the urban center identified in the contract.
2. Native American Lifelines is the urban Indian organization IHS currently contracts with to provide health care and referral services to urban Indians residing in the
II. Award Information
Type of Awards
Grant.
Estimated Funds Available
The total amount of funding identified for the current fiscal year (FY) 2013 is
Anticipated Number of Awards
One single source award will be issued under this program announcement.
Project Period
The project periods for this award will be as follows:
Year One: Six Months Budget Period from
Year Two: Twelve Months Budget Period from--
Year Three: Twelve Months Budget Period from--
IIII. Application and Submission Information
1. Obtaining Application Materials
The application package and detailed instructions for this announcement can be found at http://www.Grants.gov or https://www.ihs.gov/dgm/index.cfm?module=dsp_dgm_funding. Questions regarding the electronic application process may be directed to Mr.
2. Content and Form Application Submission
The applicant must include the project narrative as an attachment to the application package. Mandatory documents for all applicants include:
* Table of contents.
* Abstract (one page) summarizing the project.
* Application forms:
a-- SF-424, Application for Federal Assistance.
a-- SF-424A, Budget Information--Non-Construction Programs.
a-- SF-424B, Assurances--Non-Construction Programs.
* Budget Justification and Narrative (must be single-spaced and not exceed five pages).
* Project Narrative (must be single spaced and not exceed ten pages).
a-- Background information on the organization.
a-- Proposed scope of work, objectives, and activities that provide a description of what will be accomplished, including a one-page Timeframe Chart.
* 501(c)(3) Certificate.
* Disclosure of Lobbying Activities (SF-LLL).
* Certification Regarding Lobbying (GG-Lobbying Form).
* Copy of current Negotiated Indirect Cost rate (IDC) agreement (required) in order to receive IDC.
* Documentation of current OMB A-133 required Financial Audit (if applicable).
Acceptable forms of documentation include:
a-- Email confirmation from Federal Audit Clearinghouse (FAC) that audits were submitted; or
a-- Face sheets from audit reports. These can be found on the FAC Web site: http://harvester.census.gov/sac/dissem/accessoptions.html?submit=Go+To+Database.
Public Policy Requirements
All Federal-wide public policies apply to IHS grants with exception of the Discrimination policy.
Requirements for Project and Budget Narratives
A. Project Narrative: This narrative should be a separate Word document that is no longer than ten pages and must: be single-spaced, be typewritten, have consecutively numbered pages, use black type not smaller than 12 characters per one inch, and be printed on one side only of standard size 81/2" x 11" paper. These narratives will assist the Objective Review Committee (ORC) in becoming more familiar with the grantee's activities and accomplishments prior to this possible grant award. If the narrative exceeds the page limit, only the first ten pages will be reviewed. The 10-page limit for the narrative does not include the work plan, standard forms, table of contents, budget, budget justifications, narratives, and/or other appendix items.
B. Budget Narrative: This narrative must describe the budget requested and match the scope of work described in the project narrative. The budget narrative should not exceed five pages.
3. Submission Dates and Times
Applications must be submitted electronically through Grants.gov by
If technical challenges arise and assistance is required with the electronic application process, contact Grants.gov Customer Support via email to [email protected] or at (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays). If problems persist, contact Mr.
If the applicant needs to submit a paper application instead of submitting electronically via Grants.gov, prior approval must be requested and obtained (see Section IV.6 below for additional information). The waiver must be documented in writing (emails are acceptable), before submitting a paper application. A copy of the written approval must be submitted with the hardcopy that is mailed to the DGM. Once the waiver request has been approved, the applicant will receive a confirmation of approval and the mailing address to submit the application. Paper applications that are submitted without a waiver from the Acting Director of DGM will not be reviewed or considered further for funding. The applicant will be notified via email of this decision by the Grants Management Officer of DGM. Paper applications must be received by the DGM no later than
4. Intergovernmental Review
Executive Order 12372 requiring intergovernmental review is not applicable to this program.
5. Funding Restrictions
* Pre-award costs are not allowable.
* The available funds are inclusive of direct and appropriate indirect costs.
* IHS will not acknowledge receipt of applications.
6. Electronic Submission Requirements
All applications must be submitted electronically. Please use the http://www.Grants.gov Web site to submit an application electronically and select the "Find Grant Opportunities" link on the homepage. Download a copy of the application package, complete it offline, and then upload and submit the completed application via the http://www.Grants.gov Web site. Electronic copies of the application may not be submitted as attachments to email messages addressed to IHS employees or offices.
If the applicant receives a waiver to submit paper application documents, the applicant must follow the rules and timelines that are noted below. The applicant must seek assistance at least ten days prior to the Application Deadline Date listed in the Key Dates section on page one of this announcement.
Applicants that do not adhere to the timelines for System for Award Management (SAM) and/or http://www.Grants.gov registration or that fail to request timely assistance with technical issues will not be considered for a waiver to submit a paper application.
Please be aware of the following:
* Please search for the application package in http://www.Grants.gov by entering the CFDA number or the Funding Opportunity Number. Both numbers are located in the header of this announcement.
* If technical challenges are experienced while submitting the application electronically, please contact Grants.gov Support directly at: [email protected] or (800) 518-4726. Customer Support is available to address questions 24 hours a day, 7 days a week (except on Federal holidays).
* Upon contacting Grants.gov, obtain a tracking number as proof of contact. The tracking number is helpful if there are technical issues that cannot be resolved and waiver from the agency must be obtained.
* If it is determined that a waiver is needed, the applicant must submit a request in writing (emails are acceptable) to [email protected] with a copy to [email protected]. Please include a clear justification for the need to deviate from the standard electronic submission process.
* If the waiver is approved, the application should be sent directly to the DGM by the Application Deadline Date listed in the Key Dates section on page one of this announcement.
* An applicant is strongly encouraged not to wait until the deadline date to begin the application process through Grants.gov as the registration process for SAM and Grants.gov could take up to fifteen working days.
* Please use the optional attachment feature in Grants.gov to attach additional documentation that may be requested by the DGM.
* An applicant must comply with any page limitation requirements described in this Funding Announcement.
* After electronically submitting the application, the applicant will receive an automatic acknowledgment from Grants.gov that contains a Grants.gov tracking number. The DGM will download the application from Grants.gov and provide necessary copies to the appropriate agency officials. Neither the DGM nor the OCPS will notify the applicant that the application has been received.
* Email applications will not be accepted under this announcement.
All IHS applicants and grantee organizations are required to obtain a DUNS number and maintain an active registration in the SAM database. The DUNS number is a unique 9-digit identification number provided by D&B which uniquely identifies each entity. The DUNS number is site specific; therefore, each distinct performance site may be assigned a DUNS number. Obtaining a DUNS number is easy, and there is no charge. To obtain a DUNS number, please access it through http://fedgov.dnb.com/webform, or to expedite the process, call (866) 705-5711.
All HHS recipients are required by the Federal Funding Accountability and Transparency Act of 2006, as amended ("Transparency Act"), to report information on subawards. Accordingly, all IHS grantees must notify potential first-tier subrecipients that no entity may receive a first-tier subaward unless the entity has provided its DUNS number to the prime grantee organization. This requirement ensures the use of a universal identifier to enhance the quality of information available to the public pursuant to the "Transparency Act."
System for Award Management (SAM)
Organizations that were not registered with Central Contractor Registration (CCR) and have not registered with SAM will need to obtain a DUNS number first and then access the SAM online registration through the SAM home page at https://www.sam.gov (U.S. organizations will also need to provide an Employer Identification Number from the
Additional information on implementing the "Transparency Act," including the specific requirements for DUNS and SAM, can be found on the IHS Grants Management, Grants Policy Web site: https://www.ihs.gov/dgm/index.cfm?module=dsp_dgm_policy_topics.
IV. Application Review Information
The instructions for preparing the application narrative also constitute the evaluation criteria for reviewing and scoring the application. Weights assigned to each section are noted in parentheses. The 10-page narrative should include only the first year of activities; information for multi-year projects should be included as an appendix. See "Multi-year Project Requirements" at the end of this section for more information. The narrative section should be written in a manner that is clear to outside reviewers unfamiliar with prior related activities of the applicant. It should be well organized, succinct, and contain all information necessary for reviewers to understand the project fully. Points will be assigned to each evaluation criteria adding up to a total of 100 points. A minimum score of 75 points is required for approval and funding. Points are assigned as follows:
1. Criteria
The instructions for preparing the application narrative also constitute the evaluation criteria for reviewing the application.
The narrative should address program progress for the seven months budget period activities,
The narrative should be written in a manner that is clear to outside reviewers unfamiliar with prior related activities of the urban Indian health programs (UIHP). It should be well organized, succinct, and contain all information necessary for reviewers to fully understand the project.
Points assigned for the criteria are as follows:
* UNDERSTANDING OF THE NEED AND NECESSARY CAPACITY (30 Points)
* WORK PLANS (40 Points)
* PROJECT EVALUATION (15 Points)
* ORGANIZATIONAL CAPABILITIES AND QUALIFICATIONS (10 Points)
* CATEGORICAL BUDGET AND BUDGET JUSTIFICATION (5 Points)
A. PROJECT NARRATIVE: UNDERSTANDING OF THE NEED AND NECESSARY CAPACITY (30 points)
1. Facility Capability:
The UIHPs provide health care services within the context of the HHS Strategic Plan, Fiscal Years 2010-2015; the IHS Strategic Plan 2006-2011, and four IHS priorities.
Describe the UIHP: Define activities planned for the 2013 budget period
(a) IHS Priorities for American Indian/Alaska Native Health Care Current governmental trends and environmental issues impact urban Indians and require clear and consistent support by the IHS funded UIHP. The IHS Web site is http://www.ihs.gov.
(1) Renew and Strengthen Partnerships with Tribes and the UIHPs: The UIHPs have a hybrid relationship with the IHS. With the passage of Public Law 111-148, the Indian Health Care Improvement Act was made permanent.
* Identify what the UIHP is doing to strengthen its partnerships with Tribes and other UIHPs.
(a)
(b) List the top ten Tribes whose members are seen by the program.
2. Bring Health Care Reform to the UIHPs: In order to support health care reform, it must be demonstrated there is a willingness to change and improve, i.e., in human resources and business practices.
* Describe activities the UIHP is taking to ensure health care reform is being implemented.
(a)
3. Improve the Quality of and Access to Care: Customer service is the key to quality care. Treating patients well is the first step to improving quality and access. This area also incorporates Best Practices in customer service.
* Identify activities that demonstrate the UIHP is improving quality of and access to care.
(a)
4. Ensure all UIHP work is Transparent, Accountable, Fair, and Inclusive: Quality health care needs to be transparent, with all parties held accountable for that care. Accountability for services is emphasized.
* Describe activities that demonstrate how this is implemented in the UIHP program.
(a)
5. HHS Priorities for Health Care:
Current governmental trends and environmental issues impact urban Indians and require clear and consistent support by the IHS funded UIHP.
(a) Health Care Value Incentives: The growth of health care costs is restrained because consumers know the comparative costs and quality of their health care--and they have a financial incentive to care.
* Identify what the UIHP is doing to help its consumers gain control of their health care and have the knowledge to make informed health care decisions.
(1)
6. Health Information Technology: Secure interoperable electronic records are available to patients and their doctors anytime, anywhere.
* Describe Resource Patient Management Systems (RPMS)/Electronic Health Record (EHR) or non-RPMS activities the UIHP is taking to ensure immediate access to accurate information to reduce dangerous medical errors and help control health care costs.
(a)
7. Medicare Rx: Every senior has access to affordable prescription drugs. Consumers will inspire plans to provide better benefits at lower costs.
* Identify activities the UIHP is taking to implement Medicare Rx.
(a)
8. Personalized Health Care: Health care is tailored to the individual. Prevention and wellness is emphasized. Propensities for disease are identified and addressed through preemptive intervention.
* Describe activities that demonstrate how this is implemented in the UIHP program.
(a)
9. Obesity Prevention: The risk of many diseases and health conditions are reduced through actions that prevent obesity. A culture of wellness deters or diminishes debilitating and costly health events. Individual health care is built on a foundation of responsibility for personal wellness.
* Describe activities that demonstrate how the UIHP program is implementing this priority.
(a)
10. Tobacco Cessation: The only proven strategies to reduce the risks of tobacco-caused disease are preventing initiation, facilitating cessation, and eliminating exposure to secondhand smoke.
* Describe activities that demonstrate how the UIHP is implementing this priority.
(a)
11. Pandemic Preparedness:
* Describe activities that demonstrate how the UIHP is prepared and identify changes, if any, made to the UIHP pandemic preparedness plan.
12. Emergency Response: We have learned from the past and are better prepared for the future. There is an ethic of preparedness at the urban program and throughout the Nation.
* Describe activities that demonstrate how the UIHP is prepared and identify changes, if any, made to the UIHP emergency preparedness plan.
13. Hours of Operation Ensure Access to Care:
* Identify the urban program hours of operation and provide assurance that services are available and accessible at times that meets the needs of the urban Indian population, including arrangements that assure access to care when the UIHP is closed.
14. UIHP Collaboration with the Veteran's
In 2007, the UIHPs contacted their local VA Veterans Integrated Services Network and established agreements to collaborate at the local level to expand opportunities to enhance access to health services and improve the quality of health care of urban Indian veterans.
(a) Describe plan of action to develop a partnership with the local VA and plans to establish a Memorandum of Understanding for serving urban Indian veterans.
(b) Identify areas of collaboration and activities that will be conducted between your UIHP and your local area VA for budget period
15. GPRA Reporting:
All UIHPs report on IHS GPRA/Government Performance Rating Act Modernization Act (GPRAMA) clinical performance measures. This is required using the Resource and Patient Management System (RPMS). RPMS users must use the Clinical Reporting System (CRS) for reporting. Questions related to GPRA reporting may be directed to the IHS Area Office GPRA Coordinator, or the OUIHP on (301) 443-4680.
The 2014 GPRA Reporting Period is
(a) The following GPRA measures are priority focus areas for target achievement: Good Glycemic Control, Childhood Immunizations and Depression Screening. Briefly describe the steps/activities you will take to ensure your program meets the 2014 target rates for these measures.
(b) Describe at least two actions you will complete to meet the 2014 desired performance outcomes/results. For programs using RPMS, a Performance Improvement Toolbox is available on the CRS Web site at http://www.ihs.gov/cio/crs_performance_improvementtoolbox.asp.
(c)
(d) Document your ability to collect and report on the required performance measures to meet GPRA requirements. Include information about your health information technology system.
FY 2014 GPRA MEASURES
1. Diabetes DX Ever (not a GPRA measure, used for context only).
2. Documented A1c (not a GPRA measure, used for context only).
3. Diabetes: Good Glycemic Control.
4. Diabetes: Controlled Blood Pressure.
5. Diabetes: Dyslipidemia (LDL) Assessment.
6. Diabetes: Nephropathy Assessment.
7. Diabetes: Retinopathy Assessment.
8. Influenza Immunization 65+.
9. Pneumovax Immunization 65+.
10. Childhood Immunizations.
11. Pap Screening Rates.
12. Mammography Screening Rates.
13. Colorectal Cancer Screening Rates.
14. Cardiovascular Disease (CVD Screening Rates).
15. Tobacco Cessation.
16. Alcohol Screening (FAS Prevention).
17. Domestic Violence/Intimate Partner Violence Screening.
18. Depression Screening.
19. Prenatal Human Immunodeficiency Virus (HIV) Screening.
20. Childhood Weight Control.
21. Breast Feeding Rates.
22. Topical Fluorides.
23. Dental Assessment.
24. Dental Sealants.
25. Suicide Surveillance.
16. Schedule of Charges and Maximization of Third Party Payments.
(a) Describe the UIHP established schedule of charges and consistency with local prevailing rates.
(1) If the UIHP is not currently billing for billable services, describe the process the UIHP will take to begin third party billing to maximize collections.
(2) Describe how reimbursement is maximized from
(b) Describe how the UIHP achieves cost effectiveness in its billing operations with a brief description of the following:
(1) Establishes appropriate eligibility determination.
(2) Reviews/updates and implements up-to-date billing and collection practices.
(3) Updates insurance at every visit.
(4) Maintains procedures to evaluate necessity of services.
(5) Identifies and describes financial information systems used to track, analyze and report on the program's financial status by revenue generation, by source, aged accounts receivable, provider productivity, and encounters by payor category.
(6) Indicate the date the UIHP last reviewed and updated its Billing Policies and Procedures.
B. PROGRAM PLANNING: WORK PLANS (40 Points)
A program narrative and a program specific work plan are required for each health services program: (1) Health Promotion/Disease Prevention, (2) Immunizations, (3) Alcohol/Substance Abuse, and (4) Mental Health. The IHCIA, Public Law 111-148, as amended, identified eligibility for health services as follows.
The grantee shall provide health care services to eligible urban Indians living within the urban center. An "Urban Indian" eligible for services, as codified at 25 U.S.C. 1603(13), (27), (28), includes any individual who:
1. Resides in an urban center, which is any community that has a sufficient urban Indian population with unmet health needs to warrant assistance under subchapter IV of the IHCIA, as determined by the Secretary, HHS; and who
2. Meets one or more of the following criteria:
(a) Irrespective of whether he or she lives on or near a reservation, is a member of a Tribe, band, or other organized group of Indians, including: (i) Those Tribes, bands, or groups terminated since 1940, and (ii) those recognized now or in the future by the State in which they reside; or
(b) Is a descendant, in the first or second degree, of any such member described in (A); or
(c) Is an Eskimo or Aleut or other Alaska Native; or
(d) Is a California Indian; [1]
(e) Is considered by the Secretary of the
(f) Is determined to be an Indian under regulations pertaining to the Urban Indian Health Program that are promulgated by the Secretary, HHS.
[1] Eligibility of California Indians may be demonstrated by documentation that the individual:
(1) Is a descendent of an Indian who was residing in
(2) Holds trust interests in public domain, national forest, or Indian reservation allotments in
(2) Is listed on the plans for distribution of assets of California Rancherias and reservations under the Act of
The grantee is responsible for taking reasonable steps to confirm that the individual is eligible for IHS services as an urban Indian.
PROGRAM NARRATIVES AND WORKPLANS
1. HP/DP
Program Narrative and Work Plan
Contact your IHS Area Office HP/DP Coordinator to discuss and identify effective and innovative strategies to promote health and enhance prevention efforts to address chronic diseases and conditions. Identify one or more of the strategies you will conduct during budget period
(a) Applicants are encouraged to use evidence-based and promising strategies which can be found at the IHS best practice database at http://www.ihs.gov/hpdp/and the National Registry for Effective Programs at http://modelprograms.samhsa.gov/.
(b) Program Narrative. Provide a brief description of the collaboration activities that: (1) Will be planned and will be conducted between the UIHP and the IHS Area Office HP/DP Coordinator during the budget period
(c) An example of an HP/DP work plan is provided on the following pages. Develop and attach a copy of the UIHP HP/DP Work Plan for
2. IMMUNIZATION SERVICES
Program Narrative and Work Plan
(a) Program Management Required Activities
(1) Provide assurance that your facility is participating in the Vaccines for Children program.
(2) Provide assurance that your facility has look up capability with State/regional immunization registry (where applicable). Please contact
(b) Service Delivery Required Activities--For Sites using RPMS
(1) Provide trainings to providers and data entry clerks on the RPMS Immunization package.
(2) Establish process for immunization data entry into RPMS (e.g., point of service or through regular data entry).
(3) Utilize RPMS Immunization package to identify 3-27 month old children who are not up to date and generate reminder/recall letters.
(c) Immunization Coverage Assessment Required Activities
(1) Submit quarterly immunization reports to Area Immunization Coordinator for the 3-27 month old, Two year old and Adolescent, Influenza and Adult reports. Sites not using the RPMS Immunization package should submit a Two Year old immunization coverage report--an excel spreadsheet with the required data elements that can be found under the "Report Forms for non-RPMS sites" section at: http://www.ihs.gov/Epi/index.cfm?module=epi_vaccine_reports.
(d) Program Evaluation Required Activities
(1) Report coverage with the 4313314 [**] vaccine series for children 19-35 months old.
(2) Report coverage with influenza vaccine for adults 65 years and older.
(3) Report coverage with at least one dose of pneumococcal vaccine for adults 65 years and older.
(4) Report coverage for patients (6 months and older) who received at least one dose of seasonal flu vaccine during flu season.
(5) Establish baseline coverage on adult vaccines, specifically: 1 dose of Tdap for adults 19 yrs and older; 1 dose of Human Papillomavirus (HPV) for females 19-26 years old; 3 doses HPV for females 19-26 yrs; 1 dose of HPV for males 19-21 years old; 3 doses HPV for males 19-21 years; and 1 dose of Zoster for patients 60+ years.
3. ALCOHOL/SUBSTANCE ABUSE
Program Narrative and Work Plan
(a) Narrative Description of Program Services for
(1) Program Objectives
(a) Clearly state the outcomes of the health service.
(b) Define needs related outcomes of the program health care service.
(c) Define who is going to do what, when, how much, and how you will measure it.
(d) Define the population to be served and provide specific numbers regarding the number of eligible clients for whom services will be provided.
(e) State the time by which the objectives will be met.
(f) Describe objectives in numerical terms--specify the number of clients that will receive services.
(g) Describe how achievement of the goals will produce meaningful and relevant results (e.g., increase access, availability, prevention, outreach, pre-services, treatment, and/or intervention).
(h) Provide a one-year work plan that will include the primary objectives, services or program, target population, process measures, outcome measures, and data source for measures (see work plan sample in Appendix 2).
(i) Identify Services Provided: Primary Residential; Detox; Halfway House; Counseling; Outreach and Referral; and Other (Specify)
(ii) Number of beds: Residential __, Detox__; or Half way House __.
(iii) Average monthly utilization for the past year.
(iv) Identify Program Type:
(i) Address methamphetamine-related contacts:
(i) Estimate the number patient contacts during the budget period,
(ii) Describe your formal methamphetamine prevention and education program efforts to reduce the prevalence of methamphetamine abuse related problems through increased outreach, education, prevention and treatment of methamphetamine-related issues.
(iii) Describe collaborative programming with other agencies to coordinate medical, social, educational, and legal efforts.
(2) Program Activities
(a) Clearly describe the program activities or steps that will be taken to achieve the desired outcomes/results. Describe who will provide (program, staff) what services (modality, type, intensity, duration), to whom (individual characteristics), and in what context (system, community).
(b) State reasons for selection of activities.
(c) Describe sequence of activities.
(d) Describe program staffing in relation to number of clients to be served.
(e) Identify number of Full Time Equivalents (FTEs) proposed and adequacy of this number:
(i) Percentage of FTEs funded by IHS grant funding; and
(ii) Describe clients and client selection.
(f) Address the comprehensive nature of services offered in this program service area.
(g) Describe and support any unusual features of the program services, or extraordinary social and community involvement.
(h) Present a reasonable scope of activities that can be accomplished within the time allotted for program and program resources.
(3) Accreditation and Practice Model
(a) Name of Program Accreditation.
(b) Type of evidence-based practice.
(c) Type of practice-based model.
(4) Attach the Alcohol/Substance Abuse Work Plan.
4. MENTAL HEALTH SERVICES
Program Narrative and Work Plan
Use the alcohol/substance abuse program narrative description template to develop the
RPMS Suicide Reporting Form
Instructions for Completing
This form is intended as a data collection tool only. It does not replace documentation of clinical care in the medical record and it is not a referral form. HRN, Date of Act and Provider Name are required fields. If the information requested is not known or not listed as an option, choose "Unknown" or "Other" (with specification) as appropriate. The form can be partially completed, saved and completed at a later time if needed.
LOCAL
Indicate internal tracking number if used, not required.
DATE FORM COMPLETED:
Indicate the date the Suicide Reporting Form was completed.
PROVIDER NAME:
Record the name of Provider completing the form.
DATE OF ACT:
Record Date of Act as mm/dd/yy. If exact day is unknown, use the month, 1st day of the month (or another default day), year. If exact date of act is unknown, all providers should use the same default day of the month.
HEALTH RECORD NUMBER:
Record the patient's health record number.
DOB/AGE:
Record Date of Birth as mm/dd/yy and patient's age.
SEX:
Indicate Male or Female.
COMMUNITY WHERE ACT OCCURRED:
Record the community code or the name, county and state of the community where the act occurred.
EMPLOYMENT STATUS:
Indicate patient's employment status, choose one.
RELATIONSHIP STATUS:
Indicate patient's relationship status, choose one.
EDUCATION:
Select the highest level of education attained and if less than a High School graduate, record the highest grade completed. Choose one.
SUICIDAL BEHAVIOR:
Identify the self-destructive act, choose one. Generally, the threshold for reporting should be ideation with intent and plan, or other acts with higher severity, either attempted or completed.
LOCATION OF ACT:
Indicate location of act, choose one.
PREVIOUS ATTEMPTS:
Indicate number of previous suicide attempts, choose one.
METHOD:
Indicate method used. Multiple entries are allowed, check all that apply. Describe methods not listed.
SUBSTANCE USE INVOLVED:
If known, indicate which substances the patient was under the influence of at the time of the act. Multiple entries allowed, check all that apply. List drugs not shown.
CONTRIBUTING FACTORS:
Multiple entries allowed, check all that apply. List contributing factors not shown.
DISPOSITION:
Indicate the type of follow-up planned, if known.
NARRATIVE:
Record any other relevant clinical information not included above.
Last Updated
C. PROJECT EVALUATION (15 Points)
1. Describe your evaluation plan. Provide a plan to determine the degree to which objectives are met and methods are followed.
2. Describe how you will link program performance/services to budget expenditures. Include a discussion of Uniform Data System (UDS) and GPRA Report Measures here.
3. Include the following program specific information:
(a) Describe the expected feasibility and reasonable outcomes (e.g., decreased drug use in those patients receiving services) and the means by which you determined these targets or results.
(b) Identify dates of reviews by the internal staff to assess efficacy:
(1) Assessment of staff adequacy.
(2) Assessment of current position descriptions.
(3) Assessment of impact on local community.
(4) Involvement of local community.
(5) Adequacy of community/governance board.
(6) Ability to leverage IHS funding to obtain additional funding.
(7) Additional IHS grants obtained.
(8) New initiatives planned for funding year.
(9) Customer satisfaction evaluations.
4. Quality Improvement Committee (QIC).
The UIHP QIC, a planned, organization-wide, interdisciplinary team, systematically improves program performance as a result of its findings regarding clinical, administrative and cost-of-care performance issues, and actual patient care outcomes including the FY 2012 GPRA report and 2011 UDS report (results of care including safety of patients).
(a) Identify the QIC membership, roles, functions, and frequency of meetings. Frequency of meetings shall be at least quarterly.
(b) Describe how the results of the QIC reviews provide regular feedback to the program and community/governance board to improve services.
(1)
(c) Describe how your facility is integrating the improving patient care model into your health delivery structure:
(1) Identify specific measures you are tracking as part of the Improvements in Patient Care (IPC) work.
(2) Identify community members that are part of your IPC team.
(3) Describe progress meeting your program's goals for the use of the IPC model within your healthcare delivery model.
D. PROGRESS REPORT: ORGANIZATIONAL CAPABILITIES AND QUALIFICATIONS (10 Points)
This section outlines the broader capacity of the organization to complete the project outlined in the application and program specific work plans. This section includes the identification of personnel responsible for completing tasks and the chain of responsibility for successful completion of the project outlined in the work plans.
1. Describe the organizational structure with a current approved one page organizational chart that shows the board of directors, key personnel, and staffing. Key personnel positions include the Chief Executive Officer or Executive Director, Chief Financial Officer, Medical Director, and Information Officer.
2. Describe the board of directors that is fully and legally responsible for operation and performance of the 501(c)(3) non-profit urban Indian organization:
(a) List all current board members by name, sex, and Tribe or race/ethnicity.
(b) Indicate their board office held.
(c) Indicate their occupation or area of expertise.
(d) Indicate if the board member uses the UIHP services.
(e) Indicate if the board member lives in the health service area.
(f) Indicate the number of years of continuous service.
(g) Indicate number of hours of Board of Directors training provided, training dates and attach a copy of the Board of Directors training curriculum.
3. List key personnel who will work on the project.
(a) Identify existing key personnel and new program staff to be hired.
(b) For all new key personnel only include position descriptions and resumes in the appendix. Position descriptions should clearly describe each position and duties indicating desired qualifications, experience, and requirements related to the proposed project and how they will be supervised. Resumes must indicate that the proposed staff member is qualified to carry out the proposed project activities and who will determine if the work of a contractor is acceptable.
(c) Identify who will be writing the progress reports.
(d) Indicate the percentage of time to be allocated to this project and identify the resources used to fund the remainder of the individual's salary if personnel are to be only partially funded by this grant.
E. CATEGORICAL BUDGET AND BUDGET JUSTIFICATION (5 Points)
This section should provide a clear estimate of the project program costs and justification for expenses for the budget period
1. Categorical Budget (Form SF 424A, Budget Information Non-Construction Programs).
(a) Provide a narrative justification for all costs, explaining why each line item is necessary or relevant to the proposed project. Include sufficient details to facilitate the determination of cost allowability.
(b) If indirect costs are claimed, indicate and apply the current negotiated rate to the budget. Include a copy of the current rate agreement in the appendix.
V. Award Administration Information
Reporting Requirements
Failure to submit required reports within the time allowed may result in suspension or termination of an active agreement, withholding of additional awards for the project, or other enforcement actions such as withholding of payments or converting to the reimbursement method of payment. Continued failure to submit required reports may result in one or both of the following: (1) The imposition of special award provisions; and (2) the non-funding or non-award of other eligible projects or activities. This requirement applies whether the delinquency is attributable to the failure of the organization or the individual responsible for preparation of the reports.
The reporting requirements for this program are noted below:
A. Program Progress Report
Program progress reports are required quarterly. These reports will include a brief comparison of actual program accomplishments to the goals established for the period, reasons for slippage (if applicable), and other pertinent information as required. A final program report must be submitted within 90 days of expiration of the budget/project period.
B. Financial Report
Federal Financial Report, (FFR-SF-425), Cash Transaction Reports are due every calendar quarter to the
Grantees are responsible and accountable for accurate information being reported on all required reports; the Progress Reports, and Federal Financial Report.
C. Federal Subaward Reporting System (FSRS)
This award may be subject to the Transparency Act subaward and executive compensation reporting requirements of 2 CFR part 170.
The Transparency Act requires the
IHS has implemented a Term of Award into all IHS Standard Terms and Conditions, NoAs and funding announcements regarding the FSRS reporting requirement. This IHS Term of Award is applicable to all IHS grant and cooperative agreements issued on or after
D. Annual Audit Report
In accordance with 25 U.S.C. 1657, the reports and records of the urban Indian organization with respect to a contract or grant under subchapter IV, shall be subject to audit by the Secretary,
The Secretary shall allow as a cost to any contract or grant entered into under section 1653 of this title the cost of an annual private audit conducted by a certified public accountant.
E. GPRA Report
GPRA reports are required quarterly. These reports are submitted to the IHS Area GPRA Coordinator. RPMS users must use CRS for reporting. Non-RPMS users must use the interface system to transfer data from their current data system to RPMS for CRS reporting.
F. Quarterly Immunization Report
Immunization reports are required quarterly. These reports are submitted to the IHS Area Immunization Coordinator.
G. Unmet Needs Report
An unmet needs report is required quarterly. These reports will include information gathered to: (1) Identify gaps between unmet health needs of urban Indians and the resources available to meet such needs; and (2) make recommendations to the Secretary and Federal, State, local, and other resource agencies on methods of improving health service programs to meet the needs of urban Indians.
VI. Agency Contacts
1. Questions on the programmatic issues may be directed to:
2. Questions on grants management and fiscal matters may be directed to: Pallop Chareonvootitam, Grants Management Specialist,
3. Questions on systems matters may be directed to:
VII. Other Information
The
Date:
Acting Director,
Footnotes
*. The 4:3:1:3:3:1:4 vaccine series is defined as: 4 doses diphtheria and tetanus toxoids and pertussis vaccine, diphtheria and tetanus toxoids, or diphtheria and tetanus toxoids and any pertussis vaccine, 3 doses of oral or inactivated polio vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type b vaccine, 3 doses of hepatitis B vaccine, 1 dose of varicella vaccine, and 4 doses of pneumococcal conjugate vaccine(PCV).
TNS 30TagarumaMar-130808-4451214 30TagarumaMar
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