Item D18
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
MEETING DATE: 6-21-2006
DIVISION: COMMUNITY SERVICES
BULK ITEM:
YES X
NO
DEPARTMENT: IN-HOME SERVICES
AGENDA ITEM \VORDING: Approval of Contract # KG058- Community Care for Disabled Adults
(CCDA) Contract between the State of Florida, Department of Children & Families and the Monroe County
Board of County Commissioners/Monroe County In-Home Services. This contract is for Fiscal Year July 1,
2006 through June 30, 2007.
ITEM BACKGROUND: The approval of this contract will enable Monroe County In-Home Services to
continue providing services to Monroe County's disabled adult's ages 18 to 59 under the Community Care for
Disabled Adults (CCDA) program.
PREVIOUS RELEVANT BOCC ACTION: Prior approval granted to the previous years Community Care for
Disabled Adults (CCDA) Contract #KG052 on June 15,2005.
CONTRACT/AGREEMENT CHANGES: N/A
ST AJ:1'F RECOMMENDATION: Approval
TOTAL COST: $81,733.00
COST TO COUNTY: $9,081.44 (Required Match)
$19.970.71(Additional Match)
Total Match $ 29,052.15
REVENUE PRODUCING: YES NO~ AMT.PER MONTH
BUDGETED:YES~NO
SOURCE OF FUNDS: Ad Valorem
Taxes
YEAR
APPROVED BY: COUNTY A TTY.l OMB/Purchasing..1L RISK MANAGEMENT -K
DIVISION DIRECTOR APPROVAL:
/
\/11/;>, ~ L.. A J
~-/U~.c," LACL/V
SHEILA BARKER
DOCUMENTATION:
INCLUDED X
TO FOLLOW
NOT REQUIRED ~~
DISPOSITION:
AGENDA ITEM#:
Revised l!O3
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: State ofFloridaiDepartment of
Children & Families
Contract: #KG058
Effective Date: July 1, 2006
Expiration Date: June 30, 2007
Contract PurposelDescription: Approval of Contract #KG058 - Community Care for Disabled Adults (CCDA)
Contract between the Department of Children & Families and the Monroe County Board of County
Commissioners (Monroe County ill-Home $,ervices Program) for Fiscal Year July 1, 2006 through June 30,2007.
/ ~.
//.~/~/~:/' ~.
De]ori~r~~
(Namef'"
Contract Manager:
For BOCC meeting on 6/21/2006
4589
(Ext.)
Social Services/Stop 1
(Department/Stop #)
Agenda Deadline:
6/612006
CONTRACT COSTS
Total Dollar Value of Contract: $110,785.15
Budgeted? Yes X No Account Codes:
Grant: $ 81,733.00 (Fiscal Year)
County Match: $ 9,081.44 (Fiscal Year) (Required)
$19,970.71 (Additional)
$29,052.15 (Total Match)
Estimated Ongoing Costs: $ /yr
(Not included in dollar value above)
Current Year Portion: $
- (915-370~
ADDITIONAL COSTS
For:
(eg. Maintenance, utilities, janitorial, salaries, dC)
CONTRACT REVIEW
Date ill
Chan ges
Need~,
Yes ~~~No/
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Yes (;)
Yes @
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Yes INo)
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Division Director
Risk Management
8'
o .M:BJPurchasing
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Wi'"
County Attorney
Comments:
Date Out
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OMB Form Revised 2/27/011'vICP #
04/01/2006
CFDA No.
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
Client [SJ Non-Client 0
Multi-District 0
THiS CONTRACT is entered into between the Florida Department of Children and Families, hereinafter referred to as the
"Department," and Monroe County (Monroe County In Horne Services), hereinafter referred to as the "Provider."
I. THE PROVIDER AGREES:
A Contract Document
To provide services in accordance with the terms and conditions specified in this contract including alf attachments and exhibits, which
constitute the contract document
B. Requirements of Section 287.058 F.S.
To provide units of deJiverables, including reports, findings, and drafts, as specified in this contract, which must be received and
accepted by the contract manager in writing prior to payment To submit bills for fees or other compensation for services or expenses
in sufficient detail for a proper pre-audit and post-audit. Where itemized payment for travel expenses are permitted in this contract, to
submit bills for any travel expenses in accordance with section 112.061, F.S. or at such lower rates as may be provided in this
contract To allow public access to alf documents, papers, letters, or other public records as defined in subsection 119.011 (11),F.S.,
made or received by the Provider in conjunction with this contract except that public records which are made confidential by law must
be protected from disclosure. It is expressly understood that the Provider's failure to comply with this provision shall constitute an
immediate breach of contract for which the Department may unilaterally terminate the contract.
C. Governing Law
1. State of Florida Law
Thai this contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in all respects
in accordance wilh the Florida law including Florida provisions for conflict of laws.
2. Federal Law
8. That if this contract contains federal funds the Provider shall comply with the provisions of 45 CFR, Part 74, and/or 45 CFR,
Part 92, and other applicable regulations.
b. That if this contract contains federal funds and is over $100,000, the Provider shall comply with all applicable standards,
orders, or regulations issued under section 306 of the Clean Air Act, as amended (42 U.S.C. 7401 et seq.), section 508 of the Federal
Water Pollution Control Act as amended (33 U.S.C. 1251 et seq.), Executive Order 11738 as amended and where applicable, and
Environmental Protection Agency regulations (40 CFR, Part 30). The Provider shall report any violations of the above to the
Department.
c. That no federal funds received in connection with this contract may be used by the Provider, or agent acting for the
Provider, to influence legis!ation or appropriations pending before the Congress or any State legislature. If this contract contains
federal funding in excess of $100,000, the Provider must, prior to contract execution, complete the Certification Regarding lobbying
form, Attachment N/A. If a Disclosure of Lobbying Activities form, Standard Form LLl, is required, it may be obtained from the
contract manager. AJJ disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to
the contract manager, prior to payment under this contract.
d. That unauthorized aliens shall nol be employed~ The Department shall consider the employment of unauthorized aliens a
violation of section 274A(e) of the Immigration and Nationality Act (8 U.S.C. 1324 a). Such violation shall be cause for unilateral
cancellation of this contract by the Department
e. That if this contract contains $10,000 or more of federal funds, the Provider shall comply with Executive Order 11246, Equal
Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in Department of Labor regulation
41 CFR, Part 60 and 45 CFR, Part 92, if applicable.
t That if this contract contains federal funds and provides services 10 children up to age 18, the Provider shalf comply with the
Pro-Children Act of 1994 (20 U.S.C. 6081). 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.
D. Audits, Inspections, Investigations, Records and Retention
1. To establish and maintain books, records and documents (including electronic storage media) sufficient to reflect all income
and expenditures of funds provided by the Department under this contract
2. To retain all cHent records, financial records, supporting dOCUments, statistical records, and any other documents (including
electronic storage media) pertinent to this contract for a period of six (6) years after completion of the contract or longer when required
by law~ In the event an audit is required by this contract records shall be retained for a minimum period of six (6) years after the audit
report is issued or until resolution of any audit findings or litigation based on the terms of this contract, at no additional cost to the
Department
3~ Upon demand, at no additional cost to the Department, the Provider wiil facifitate the duplication and transfer of any records or
docurnents during the required retention period in Subsection L Paragraph 0.2.
4. To assure that these records shall be subject at all reasonable times to inspection, review, copying, or audit by Federal, State,
or other personnel duly authorized by the Department
CONTRACT #KG058
04/01/2006
5. At all reasonable times for as long as records are maintained, persons duly authorized by the Department and Federal auditors,
pursuant to 45 CFR, Section 92.36(i) (10), shall be allowed full access to and the right to examine any of the Provider's contracts and
related records and documents, regardless of the form in which kept
6. To provide a financial and compliance audit to the Department as specified in this contract and in Attachment!L and to ensure
that all related party transactions are disclosed to the auditor.
70 To comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by the office
of The Inspector General (Section 20.055, Florida Statutes).
E. Monitoring by the Department
To permit persons duly authorized by the Department to inspect and copy any records, papers, documents, facilities, goods and
services of the Provider which are relevant to this contract, and to interview any clients, employees and subcontractor employees of
the Provider to assure the Department of the satisfactory performance of the terms and conditions of this contract Following such
review, the Department will deliver to the Provider a written report of its findings and request for development, by the Provider of a
corrective action plan where appropriate. The Provider hereby agrees to timely correct all deficiencies identified in the corrective
action plan.
F. Indemnification
NOTE: Except to the extent permitted by s.768.28 , F.S.. or other applicable Florida Law, Paragraph IF 10 and 2. are not applicable to
contracts executed between state agencies or subdivisions, as defined in subsection 768.28(2), F.S.
1. To be liable for and indemnify, defend, and hold the Department and all of its officers, agents, and employees harmless from all
claims, suits, judgments, or damages, including attorneys' fees and costs, arising out of any act, actions, neglect, or omissions by the
Provider, its agents, employees and subcontractors during the performance or operation of this contract or any subsequent
modifications thereof.
2. That its inability to evaluate its liability or its evaluation of liability shall not excuse the Provider's duty to defend and to indemnify
within seven (7) days after notice by the Department by certified mail. After the highest appeal taken is exhausted, only an adjudication
or judgment specifically finding the Provider not liable shall excuse performance of this provision. The Provider shall pay all costs and
fees including attorneys' fees related to these obligations and their enforcement by the Department The Department's failure to notify
the Provider of a claim shall not release the Provider from these duties. The Provider shall not be liable for the sole negligent acts of
the Department
G. Insurance
To provide continuous adequate liability insurance coverage during the existence ofthis contract and any renewal(s) and extension(s)
of it By execution of this contract, unless it is a state agency or subdivision as defined by subsection 768.28(2), F.S., the Provider
accepts full responsibility for identifying and determining the type(s) and extent of liability insurance necessary to provide reasonable
financial protections for the Provider and the clients to be selVed under this contract. Upon the execution of this contract, the Provider
shall furnish the Department written verification supporting both the determination and existence of such insurance coverage. Such
coverage may be provided by a self-insurance program established and operating under the laws of the State of Florida. The
Department reserves the right to require additional insurance as specified in this contract
H. Confidentiality of Client Information
Not to use or disclose any information concerning a recipient of services under this contract for any purpose prohibited by state or
federal law or regulations (except with the written consent of a person legally authorized to give that consent or when authorized by
law).
I. Assignments and Subcontracts
1. To neither assign the responsibility for this contract to another party nor subcontract for any of the work: contemplated under this
contract without prior written approval of the Department which shall not be unreasonably withheld. Any sublicense, assignment or
transfer othelWise occurring without prior approval of the Department shall be null and void.
20 To be responsible for all work performed and for all commodities produced pursuant to this contract whether actually furnished
by the Provider or its subcontractors. Any subcontracts shall be evidenced by a written document. The Provider further agrees that
the Department shall not be liable to the subcontractor in any way or for any reason. The Provider, at its expense, will defend the
Department against such claims.
3. To make payments to any subcontractor within seven (7) working days after receipt of full or partial payments from the
Department in accordance with section 287.0585, F.S., unless otherwise stated in the contract between the Provider and
2
CONTRACT #KG058
04/01/2006
subcontractor. Failure to pay within seven (7) working days will result in a penalty that shall be charged against the Provider and paid
to the subcontractor in the amount of one-half of one percent (005) of the amount due per day from the expiration of the period
allowed for payment. Such penalty shall be in addition to actual payments owed and shall not exceed fifteen (15%) percent of the
outstanding balance due,
4. That the State of Florida shall at all times be entitled to assign or transfer its rights, duties, or obligations under this contract to
another governmental agency in the State of Florida. upon giving prior written notice to the Provider. In the event the State of Florida
approves transfer of the Provider's obligations, the Provider remains responsible for aU work performed and all expenses incurred in
connection with the contract. This contract shall remain binding upon the successors in interest of either the Provider or the
Department.
J. Return of Funds
To return to the Department any overpayments due to unearned funds or funds disallowed pursuant to the terms and conditions of this
contract that were disbursed to the Provider by the Department In the event that the Provider or its independent auditor discovers that
an overpayment has been made, the Provider shall repay said overpayment immediately without prior notification from the
Department. In the event that the Department first discovers an overpayment has been made, the contract manager, on behalf of the
Department, will notify the Provider by letter of such findings. Should repayment not be made forthwith, the Provider will be charged at
the lawful rate of interest on the outstanding balance after Department notification or Provider discovery.
K. Client Risk Prevention and Incident Reporting
1. That if services to clients are to be prOVided under this contract, the Provider and any subcontractors shall, in accordance with
the cHent risk prevention system, report those reportable situations listed in CFOP 215-6 in the manner prescribed in CFOP 215-6 or
district operating procedures.
2. To immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or disabled
adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ABUSE). As required by Chapters 39 and
415, F.S., this provision is binding upon both the Provider and its employees.
L. Purchasing
1. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative Industries and
Diversified Enterprises, Inc., (PRIDE) identified under Chapter 946, F.S., in the same manner and under the procedures set forth in
subsections 946.515(2} and (4), FS. For purposes of this contract, the Provider shall be deemed to be substituted for the Department
insofar as dealings with PRIDE. This clause is not applicable to subcontractors unless otherwise required by law. An
abbreviated list of products/services available from PRIDE may be obtained by contacting PRIDE, (850) 487-3774.
2. To procure any recycled products or materials, which are the subject of or are required to carry out this contract, in accordance
with the provisions of sections 403.7065, and 287.045, FS.
M. Civil Rights Requirements
1. Not to discriminate against any employee in the performance of this contract or against any applicant for employment because
of age, race, religion, color, disability, national origin, marital status or sex in accordance with CFOP 60-16.. The Provider further
assures that all contractors. subcontractors, subgrantees, or others with whom it arranges to provide services or benefits to clients or
employees in connection with any of its programs and activities are not discriminating against those clients or employees because of
age, race, religion, color, disability, national origin, marital status or sex. This is binding upon the Provider employing fifteen (15) or
more individuals.
2. To complete the Civil Rights Compliance Questionnaire, CF Forms 946 A and 8, in accordance with CFOP 60-16. This is
binding upon Providers that have fifteen (15) or more employees.
3. Subcontractors who are on the discriminatory vendor list, may not transact business with any public entity, in accordance with
the provisions of section 287.134 F.S.
N. Independent Capacity of the Contractor
1. To act in the capacity of an independent contractor and not as an officer, employee of the State of Florida, except where the
Provider is a state agency. Neither the Provider nor its agents, employees, subcontractors or assignees shall represent to others that
it has the authority to bind the Department unless specifically authorized in writing to do so.
2. This contract does not create any right to state retirement, leave benefits or any other benefits of state employees as a result of
performing the duties or obligations of this contract.
3. To take such actions as may be necessary to ensure that each subcontractor of the Provider will be deemed to be an
independent contractor and will not be considered Of permitted to be an agent servant, venturer, or partner of the State of Fiorid2L
4. The Department wW not furnish services of support (ELg., office space, office supplies, telephone service, secretarial or clerical
support) to the Provider, or its subcontractor or assignee, unless specifically agreed to by the Department in this contract
5, All deductions for social security, withholding taxes, income taxes, contributions to unemployment compensation funds and all
necessary insurance for the Provider, the Provider's officers, employees, agents, subcontractors, or assignees shall be the sole
responsibility of the Provider.
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CONTRACT #KG058
04/01/2006
O. Sponsorship
As required by section 286.25, F.S., if the Provider is a non-governmental organization which sponsors a program financed wholly or in
part by state funds, including any funds obtained through this contract, it shall, in publicizing, advertising, or describing the sponsorShip
of the program, state: "Sponsored by (provider's name) and the State of Florida, Department of Children and Families:' If the
sponsorship reference is in written material, the words "State of Florida, Department of Children and Families" shall appear in the
same size letters or type as the name of the organization.
P< Publicity
Without limitation, the Provider and its employees, agents, and representatives will not, without prior Departmental written consent in
each instance, use In advertising, publicity or any other promotional endeavor any State mark, the name of the State's mark, the name
of the State or any State aftlliate or any officer or employee of the State, or represent, directly or indirectly, that any product or service
provided by the Provider has been approved or endorsed by the State, or refer to the existence of this contract in press releases,
advertising or materials distributed to the Provider's prospective customers.
Q. Finallnvoice
To submit the final invoice for payment to the Department no more than 45 days after the contract ends or is terminated. If the
Provider fails to do so, all rights to payment are forfeited and the Department will not honor any requests submitted after the aforesaid
time period. Any payment due under the terms of this contract may be withheld until all reports due from the Provider and necessary
adjustments thereto have been approved by the Department
R. Use of Funds for Lobbying Prohibited
To comply with the provisions of sections 11 <062 and 216.347, F.S., which prohibit the expenditure of contract funds for the purpose of
lobbying the Legislature, judicial branch, or a state agency.
S. Public Entity Crime
Pursuant to section 287.133, F$, the following restrictions are placed on the ability of persons convicted of public entity crimes to
transact business with the Department: When a person or affiliate has been placed on the convicted vendor list foHowing a conviction
for a public entity crime, he/she may not submit a bid on a contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or the repair of a public building or public work, may not submit bids on
leases of real property to a public entity, may not be awarded or pertorm work as a contractor, supplier, subcontractor, or consultant
under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount
provided in section 287.017, F.S., for CATEGORY TWO for a period of thirty-six (36) months from the date of being placed on the
convicted vendor list
T. Gratuities
The Provider agrees that it will not offer to give or give any gift to any Department employee< As part of the consideration for this
contract. the parties intend that this provision will survive the contract for a period of two years. In addition to any other remedies
available to the Department, any violation ofthis proviSion will result in referral of the Provider's name and description of the violation of
this term to the Department of Management Services for the potential inclusion of the Provider's name on the suspended vendors list
for an appropriate period. The Provider will ensure that its subcontractors, if any, comply with these provisions.
U. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course of or as a result of work or services performed under this
contract, or in anyway connected herewith, the Provider shall refer the discovery or invention to the Department to be referred to the
Department of State to determine whether patent protection will be sought in the name of the State of Florida, Any and all patent rights
accruing under or in connection with the performance of this contract are hereby reserved to the State of Florida.
2< In the event that any books, manuals, films, or other copyrightable materials are produced, the Provider shall notify the
Department of State. Any and all copyrights accruing under or in connection with performance under this contract are hereby reserved
to the State of Florida.
3< The Provider, if not a state agency, as that term is defined in subsection 768.28, F.S., shall indemnify and save the Department
and its employees harmless from any liability whatsoever, including costs and expenses. arising out of any copyrighted, patented, or
unpatented invention, process, or article manufactured or used by the Provider in the performance of this contract
4. The Department will provide prompt written notification of any claim of copyright or patent infringement Further, if such claim is
made or is pending, the Provider may, at its option and expense, procure for the Department, the right to continue use of, replace, or
modify the article to render it non-infringing. If the Provider uses any design, device, or materials covered by letters, patent, or
copyright, it is mutually agreed and understood without exception that the compensation paid pursuant to this contract includes all
royallles or costs arising from the use of such design, device, or materials in any way involved in the work contemplated by this
contract
5. All applicable subcontracts shall include a provision that the Federal awarding agency reserves all patent rights with respect to
any discovery or invention that arises or is developed in the course of or under the subcontract
V. Construction or Renovation of Facilities Using State Funds
That any state funds provided for the purchase of or improvements to real property are contingent upon the Provider granting to the
state a security interest in the property at least to the amount of the state funds provided for at least five (5) years from the date of
purchase or the completion of the improvements or as further required by law. As a condition of receipt of state funding for this
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CONTRACT #KG058
04/01/2006
purpose, the Provider agrees that, if it disposes of the property before the Department's interest is vacated, the Provider will refund the
proportionate share of the state's initial investment, as adjusted by depreciation.
W. Information Security Obligations
1. To identify an appropriately skilled individual to function as its Data Security Officer who shall act as the liaison to the
Department's Security Staff and who will maintain an appropriate level of data security for the information the Provider is 'collecting or
using in the performance of this contract An appropriate level of security includes approving and tracking all Provider employees that
request system or information access and ensuring that user access has been removed from all terminated Provider employees.
2. To hold the Department harmless from any loss or damage incurred by the Department as a result of information technology
used, provided or accessed by the Provider.
3. To provide the latest Departmental Security Awareness Training to its' staff and subcontractors.
4. To ensure that alf Provider employees who have access to Departmental information are provided a copy of CFOP 50-6 and
that they sign the DCF Security Agreement form (CF 114), a copy of which may be obtained from the contract manager.
X. Accreditation
That the Department is committed to ensuring provision of the highest quality services to the persons we serve. Accordingly, the
Department has expectations that where accreditation is generally accepted nationwide as a clear indicator of quality service, the
majority of our Providers will either be accredited, have a plan to meet national accreditation standards, or will initiate one within a
reasonable period of time.
Y. Agency for Workforce Innovation and Workforce Florida
That it understands that the Department, the Agency for Workforce Innovation, and Workforce Florida, Inc. have jointly implemented
an initiative to empower recipients in the Temporary Assistance to Needy Families Program to enter and remain in gainful
employment. The Department encourages Provider participation with the Agency for Workforce Innovation and Workforce Florida.
Z. Health Insurance Portability and Accountability Act
Where applicable, to comply with the Health Insurance Portability and Accountability Act (42 U. S. C. 1320d.) as well as alf regulations
promulgated thereunder (45 CFR Parts 160, 162, and 164).
AA. Emergency Preparedness
If the tasks to be performed pursuant to this contract include the physical care and control of clients, the Provider shall, within 30 days
of the execution of this contract, submit to the contract manager an emergency preparedness plan which shall include provisions for
pre-disaster records protection, alternative accommodations for clients in substitute care, supplies, and a recovery plan that will alfow
the Provider to continue functioning in compliance with the executed contract in the event of an actual emergency. The Department
agrees to respond in writing within 30 days of receipt of the plan accepting, rejecting, or requesting modifications. In the event of an
emergency, the Department may exercise oversight authority over such Provider in order to assure implementation of agreed
emergency relief provisions.
BB. PUR 1000 Form
The PUR 1000 Form is hereby incorporated by reference. In the event of any conflict between the PUR 1000 Form, and any terms or
conditions of this contract (including the Department's Standard Contract), the terms or conditions of this contract shall take
precedence over the PUR 1000 Form. However, if the conflicting terms or conditions in the PUR 1000 Form is required by any section
of the Florida Statutes, the terms or conditions contained in the PUR 1000 Form shall take precedence.
II. THE DEPARTMENT AGREES:
A Contract Amount
To pay for contracted services according to the terms and conditions of this contract in an amount not to exceed N/A or the rale
schedule, subject to the availability of funds~ The State of Florida's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the Legislature. Any costs or services paid for under any other contract or from any other source are
not eligible for payment under this contract
8. Contract Payment
Pursuant to section 215.422, F.S., the Department has five (5) working days to inspect and approve goods and services, unless the
bid specifications, purchase order, or this contract specify otherwise. With the exception of payments to health care Providers for
hospital, medical, or other health care services, if payment is not available within forty (40) days, measured from the latter of the date a
properly completed invoice is received by the Department or the goods or services are received, inspected, and approved. a separate
interest penalty set by the Comptroller pursuant to section 55.03, FS., wi!! be due and payable in addition to the invoice amounl.
Payments to health care Providers for hospital, medical, or other health care services, shall be made not more than thirty-five (35)
days from the date eligibility for payment is determined, Financial penalties will be calculated at the daily interest rate of 03333%.
Invoices returned to a Provider due to preparation errors will result in a non-interest bearing payment delay. Interest penalties less
than one (1) doHar will not be paid unless the Provider requests payment.
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CONTRACT #KG058
04/01/2006
C. Vendor Ombudsman
A Vendor Ombudsman has been established within the Department of Financial Services. The duties of this office are found in
subsection 215.422, F.S., which include disseminating information relative to the prompt payment of this state and assisting vendors in
receiving their payments in a timely manner from a state agency. The Vendor Ombudsman may be contacted at (850) 413~5516.
D. Notice
Any notice, that is required under this contract shall be in writing, and sent by U.S. Postal Service or any expedited delivery service
that provides verification of delivery or by hand delivery. Said notice shaH be sent to the representative of the Provider responsibie fOf
administration of the program, to the designated address contained in this contract.
Ill. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A Effective and Ending Dates
This contract shall begin on JulV 1, 2006, or on the date on which the contract has been signed by the last party required to sign it,
whichever is later. It shall end at midnight. local time in Monroe County, Florida, on June 30,2007.
B. Financial Penalties for Failures to Comply with Requirement for Corrective Action.
1. In accordance with the provisions of Section 402.73(7), Florida Statutes, and Section 65-29.001, Florida Administrative Code,
corrective action plans may be required for noncompliance, nonperformance, or unacceptable performance under this contract
Penalties may be imposed for failures to implement or to make acceptable progress on such corrective action plans.
2. The increments of penalty imposition that shall apply, unless the Department determines that extenuating circumstances exist,
shalf be based upon the severity of the noncompliance, nonperformance, or unacceptable performance that generated the need for
corrective action plan. The penalty, if imposed, shalf not exceed ten percent (10%) of the total contract payments during the period in
which the corrective action plan has not been implemented or in which acceptable progress toward implementation has not been
made. Noncompliance that is determined to have a direct effect on client health and safety shall result in the imposition of a ten
percent (10%) penalty of the total contract payments during the period in which the corrective action plan has not been implemented or
in which acceptable progress toward implementation has not been made.
3. Noncompliance involving the provision of service not having a direct effect on client health and safety shall result in the
imposition of a five percent (5%) penalty. Noncompliance as a result of unacceptable periormance of administrative tasks shall result
in the imposition of a two percent (2%) penalty.
4, The deadline for payment shall be as stated in the Order imposing the financial penalties. In the event of nonpayment the
Department may deduct the amount of the penalty from invoices submitted by the Provider.
c. Termination
1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the
other party unless a sooner time is mutually agreed upon in writing. Said notice shall be delivered by U.S. Postal Service or any
expedited delivery service that provides verification of delivery or by hand delivery to the contract manager or the representative of the
Provider responsible for administration of the program.
2. In the event funds for payment pursuant to this contract become unavailable, the Department may terminate this contract upon
no less than twenty-four (24) hours notice in writing to the Provider. Said notice shall be sent by U.S. Postal Service or any expedited
delivery service that provides verification of delivery. The Department shall be the final authority as to the availability and adequacy of
funds. In the event of termination of this contract, the Provider will be compensated for any work satisfactorily completed.
3. This contract may be terminated for the Provider's non-performance upon no less than twenty-four (24) hours notice in writing
to the Provider. If applicable, the Department may employ the default provisions in Rule 60A-1.006(3), FAC. Waiver of breach of any
provisions of this contract shall not be deemed to be a waiver of any other breach and shall not be construed to be a modification of
the terms and conditions of this contract. The provisions herein do not limit the Department's right to remedies at law or in equity.
4. Failure to have performed any contractual obligations with the Department in a manner satisfactory to the Department will be a
sufficient cause for termination~ To be terminated as a Provider under this provision, the Provider must have: (1) previously failed to
satisfactorily periorm in a contract with the Department, been notified by the Department of the unsatisfactory periormance. and failed
to correct the unsatisfactory performance to the satisfaction of the Department; or (2) had a contract terminated by the Department for
cause.
D. Renegotiations or Modifications
Modifications of provisions of lhis conlract shall be valid only when they have been reduced to writing and duly signed by both parties.
The rate of payment and the total dollar amount may be adjusted retroactively to reflect price leve! increases and changes in the rate
of payment when these have been established through the appropriations process and subsequently identified in the Department's
operating budget.
6
CONTRACT #KC058
04/01/2006
E. Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
1. The Provider name, as shown on page 1 of this
contract, and mailing address of the official payee to
whom the payment shall be made is:
Mo.nroe County (Monroe County In Home Services)
11 00 Simonton Street
__ Key West, Fl 33040
2. The name of the contact person and street address
where financial and administrative records are
maintained is:
Deloris Simpson, Senior Administrator
Monroe County In Home Services
1100 Simonton Street
Key West, FL 33040
305.292-4589
3. The name, address, and telephone number of the contract manager
for the Department for this contract is:
Theresa Phelan
1111 12m Street
Key West, Fl 33040
305.292.6810
4. The name, address, and telephone number of the representative of
the Provider responsible for administration of the program under this
contract is:
Deloris Simpson
Monroe County In Home Services
1100 Simonton Street
Key West, Fl 33040
305.292-4589
5. Upon change of representatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the
other party and the notification attached to the originals of this contract.
F. All Terms and Conditions Included
This contract and its attachments. I. II and exhibits A, S, C, 0 and E to Attachment l. and any exhibits referenced in said attachments,
together with any documents incorporated by reference, contain all the terms and conditions agreed upon by the parties, There are no
provisions, terms, conditions, or obligations other than those contained herein, and this contract shall supersede all previous
communications, representations, or agreements, either verbal or written between the parties, If any term or provision of this contract
is legally determined unlawful or unenforceable, the remainder of the contract shall remain in full force and effect and such term or
provision shall be stricken,
By signing this contract, the parties agree that they have read and agree to the entire contract, as described in Paragraph
III.F. above.
IN WITNESS THEREOF, the parties hereto have caused this 36 page contract to be executed by their undersigned officials as duly
authorized.
PROVIDER: Monroe County
PRINT
NAME:
SIGNED
BY:
NAME:
TITLE:
DATE:
Charles McCoy
Mayor
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal EID # (or SSN): 59-0600749
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
PRINT
NAME:
SIGNED
BY:
NAME:
TITLE:
DATE:
Provider Fiscal Year Ending Date: 09/30,
7
CONTRACT #KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
A 11 ACHMEN1 I
A Services to be Provided
1. Definition of T arms
a. Contract T arms
(Refer to the Glossary in CFOP 75-2, Contract Management System for Contractual
Services, which is incorporated by reference herein)
b. Program or Service Specific Terms
(1) Activities of Daily Living - Basic activities performed in the course of daily
living, such as dressing, bathing, grooming, eating, using a commode or urinal,
and ambulating around one's own home.
(2) Case Management Providers - Private, for-profit, nonprofit or local
government agencies designated to provide coordination of care for eligible
cHents, This includes ongoing assessment of client needs and eligibility, ongoing
development of care plans, and the arrangement for appropriate services to meet
those needs. Case management providers integrate all available services
through department-approved direct service providers into a sole program of
service delivery uniquely patterned to meet the client's varying service needs,
Case management providers may choose to deliver only case management
services or choose to be dually responsible as both a direct service provider and
a case management provider.
(3) Client - Any person who is eligible and is at least eighteen (18) years through
age fifty-nine (59), has one (1) or more permanent physical or mental limitations
that restrict the client's ability to perform normal activities of daily living, and
impede the client's capacity to live independently or with relatives or friends
without the provision of community~based services.
(4) Direct Service Providers - Private, for-profit, nonprofit or local government
agencies that are registered or licensed to provide direct service support to
eligible clients. Direct services range from the provision of hearth services
delivered by physicians, nurses, physiotherapists, occupational therapists,
speech therapists, and dietitians, to services delivered by workers such as
homemakers, chore and transportation worker and personal care aides. The
direct service provider may choose to deliver only direct services or choose to be
dually responsible as both a case management provider and a direct service
provider.
(5) Medicaid Institutional Care Program (MICP) - A program that serves
Medicaid recipients who are determined eligible for a nursing home level of care,
which provides primary, acute, and long-term care services at capitated
federally-matched rates.
(6) Nursing home - Any facility which provides nursing services as defined in
Chapter 464, F!orida Statutes., and which is licensed in accordance with Chapter
400, Florida Statutes.
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(7) Outcomes - Means the result, impact, or benefit of a program's activities on
the clients, customers, or users of the services.
(8) Outputs - Means the actual service or product delivered.
(9) Performance Measures - Quantitative indicators used to assess whether the
activities the provider is performing are achieving the desired results.
2. General Description
a. General Statement
(1) The Community Care for Disabled Adults (CCDA) Program is designed to
assist disabled adults, age eighteen (18) through fifty-nine (59), in utilizing
available community and personal resources enabling them to remain in their
own homes, and preventing their premature or inappropriate institutionalization.
(2) Service providers will ensure that appropriate community-based services are
provided to clients in a manner designed to meet the cHent's changing needs, to
assist the client in avoiding or reducing unnecessary dependence on the
delivered services, and to increase the cfient's self-reliance.
b. Authority
Sections 410.601-410.606, Florida Statutes (F .S.), Chapter 65C-2, Florida Administrative
Code, and the annual appropriations act, with any proviso language or instructions to the
department, constitute the legal basis for services to be delivered through the CCDA
program.
c. Scope of Service
Services will be targeted toward eligible adults in Monroe County.
d. Major Program Goal
Community-based services provided under this contract are designed to prevent
inappropriate institutionalization of disabled adults.
3. Clients to be Served
a. General Description
Adults with disabilities, age eighteen (18) through fifty-nine (59), who are no longer
eligible to receive children's sentices, and are too young to qualify for community and
home-based services for the elderly, if authorized by the Adult Services Program Office,
may be served under the provisions of this contract
b. Client Eligibility
(1) Applicants must have one or more permanent physical or menta! limitations,
that restrict the ability to perform normal activities of daily living, as determined
through the initial functional assessment and medical documentation of disability.
Determination of a permanent disability must be established and evidenced in
one of the following ways:
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(a) An applicant may present a check, awards letter, or other proof
showing receipt of Social Security Disability Income, or some other
disability payment (e.g., Worker's Compensation); or
(b) An applicant may present a written statement from a licensed
physician, iicensed nurse practitioner, or mental health professional,
which meets the district's criteria for evidence of a disability. This written
statement must, at a minimum, include the applicant's diagnosis,
prognosis, a broad explanation of level of functioning, and the
interpretation of need for services based on identified functional barriers
caused by the applicant's disabling condition.
(2) Applicants must have an individual income at or below the prevailing MICP
eligibility standard in order to receive free CCDA services.
(3) Applicants with incomes above the standard will be assessed a fee for a
share of the costs, or may be required to provide volunteer services in lieu of
payment.
c. Client Determination
(1) Clients will be assessed for eligibility determination, and prioritized for
services by district Department of Children and Families staff, in accordance with
subsection 410.604 (2), Florida Statutes.
(2) The Adult Services Program Office will make the final determination of
service authorization.
d. Contract Limits
(1) The total annual cost estimated or actual, for an individual receiving CCDA
services, shall not exceed the average, annual general revenue portion of a
Medicaid nursing home bed within the district area.
(2) Clients must not be receiving comparable services from any other state
entity. In order to prevent duplication of services, client files must contain
documentation verifying that all comparable community services and funding
sources have been explored and exhausted.
(3) The provider shall deliver services only to those persons who have
compteted the Adutt Services Screening for Consideration for new Community
Based Services, Exhibit A, have been scored by that instrument, and were
referred to the provider by the District/Region Program Office, and only to the
extent that funds are avaifable.
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Adult Services Program
B. Manner of Service Provision
1, Service Tasks
a. Task List
(1) The following tasks will be performed under this contract (check all that
apply [2J),
DAdult Day Care X Case Management DEmergency Alert Response
X Personal Care DHome Health Aide DGroup Activity Therapy
X Homemaker DHome Nursing X Home Delivered Meals
Dlnterpreter DTransportation DMedical Therapeutic
Services
DChore DRespite DPhysical and Exams
o Escort DAdult Day Care
(2) Details of the service tasks to be provided under this contract and the
negotiated parameters of those services are fisted in CFOP 140-8, Community
Care for Disabled Adults Operating Procedures, herein incorporated by
reference,
(3) Each district CCDA program shall include case management services and at
least one other community service.
b. Task Limits
The following task limits apply to the services specified in 8.1.a, above.
(1) Respite Care services may be provided for up to two hundred forty (240)
hours per cHent per calendar year, depending upon individual need. The service
may be extended to three hundred sixty (360) hours, as recommended by the
case manager and approved by Adurt Services Program Office. Documentation
of approval must be evident in the case narrative section of the case manager's
file.
(2) Personal Care services will not substitute for the care usually provided by a
registered nurse, licensed practical nurse, therapist, or home health aide, The
personal care aide will not change sterile dressings, irrigate body cavities,
administer medications, or perform other activities prohibited by Chapter 59A-8,
Florida Administrative Code.
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(3) Homemaker service time does not include time spent in transit to and from
the client's place of residence except when providing shopping assistance,
performing errands or other tasks on behalf of a client
(4) Several restrictions apply to persons providing Homemaker service activities.
Persons providing services must not:
(a) engage in work that is not specified in the Homemaker assignment;
(b) accept gifts from clients;
(c) lend or borrow money or artides from clients;
(d) handle client money, unless authorized in writing by a supervisor or
case manager (documented in the personnel file) and unless bonded or
insured by the employer;
(e) transport clients, unless authorized in writing by a supervisor or case
manager.
(5) The parameters of service delivery, by type of service, are detailed in CFOP
140~8, Community Care for Disabled Adults Operating Procedures.
(6) District task JJmits, which exceed those in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures, and are distinctive to this contract, are
listed here: N/A.
2. Staffing Requirements
a. Staffing Levels
(1) The provider will meet the minimum staffing requirements for each service,
as specified in CFOP 140~8, Community Care for Disabled Adults Operating
Procedures.
(2) The provider will notify the department, in writing, within thirty calendar (30)
days whenever the provider is unable, or expects to be unable to provide the
required quality or quantity of service due to staff turnovers or shortages.
b. Professional Qualifications
The provider will ensure that staff meets the professional quajjfications for each service,
as specified in CFOP 140~8, Community Care for Disabled Adults Operating Procedures.
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c. Staffing Changes
The provider agrees to notify the department's contract manager within two (2) working
days if a key administrative position (e.g., executive director) becomes vacant. Planned
staffing changes that may affect the delivery of services to be provided under this
contract, must be presented in writing to the contract manager for approval at least ten
(10) working days prior to the implementation of the change.
d. Subcontractors
This contract does not allow the provider to subcontract for the provision of any services
under this contract.
3. Service Location and Equipment
a. Service Delivery Location and Times
(1) CCDA services may be delivered in the client's home or on-site at a facility,
as negotiated by the department and the provider.
(2) Facilities delivering on-site services to clients shall pass an annual inspection
by the local environmental health and fire authorities.
(3) Service providers will meet the minimum service location and time
requirements as specified in CFOP 140~8, Community Care for Disabled Adults
Operating Procedures.
(4) Services for this contract will be delivered at the following locations and
times:
SERVICE LOCATION TIME(S)
Case Manaqement Client's Home As needed
Homemakina Client's Home As needed
Personal Care Client's Home As needed
Home Delivered Meals Client's Home As needed
b. Changes in Location
The provider must notify the department of changes in the location of service delivery.
Once the service delivery location is agreed upon, any proposed change must be
presented in writing to the contract manager for approval, fifteen (15) working days prior
to implementation of that proposed change. In the event of an emergency, temporary
changes in location may necessitate waiver of this designated standard by the district's
program office. Such a waiver will take into consideration the continuity, safety, and
welfare of the department's clients, and is at the department's sole discretion.
c. Equipment
(1) The provider must comply with CFOP 140-8 and submit an equipment Jist as
applicable to a specific provider's contract The equipment required to perform
the contracted services must be determined by the department and the provider
and documented on the equipment list, if applicable. To ensure uniformity,
safety, and quality of service to clients, any requests for equipment change must
be presented in writing to the contract manager who wilf confer with the Adult
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Services District Program staff, for approval at least ten (10) days prior to any
proposed change.
(2) The provider must inventory all equipment acquired under this contract
annually. The inventory fist must be made available within seven (7) days upon
receipt of written request by the contract manager. The provider must list the
items of equipment on the equipment listing, Exhibit B, as applicable to the
provider's contract for specific services.
4. Deliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which may include, but
is not limited to, an hour of direct service delivery; a meal; an episode of travel; or a
twenty-four (24) hour period of Emergency Alert Response maintenance, as defined in
CFOP 140-8, Community Care for Disabled Adults Operating Procedures. All service
units, as well as their description, are listed in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures.
b. Records and Documentation
(1) Case management agency individual client files shall contain the following:
(a) a completed Adult Services Client Assessment (not more than one
(1) year old);
(b) a District Program Office approved care plan (not more than one (1)
year old);
(c) a departmental release of information form;
(d) a copy of a completed Client Information System (CIS) form;
(e) documentation of the client's age, disability, and income;
(f) a completed and scored copy of the Adult Services Screening for
Consideration for Community Based Services; and
(9) gn ongoing, dynamic case narrative section.
(2) Providers shalf maintain information on each client served by this contract,
which includes the following:
(a) documentation of the client by name or unique identifier;
(b) current documentation of eligibility for services;
{c) dates or service provision and service biifing;
(d) information documenting the client's need for service increase;
(e) the number of service units provided; and
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Adult Services Program
(f) all other forms or records necessary for program operation and
reporting, as set forth by the department.
(3) Providers must ensure that all client records accurately match the invoices
submitted for payment Records must cross reference to each invoice for
payment.
(4) Providers must maintain documentation necessary to facilitate monitoring
and evaluation by the department.
(5) The case management provider must maintain documentation in the client's
file that all comparable community services and funding sources have been
explored and exhausted before using CCDA funding.
c. Reports
(1) Reporting requirements for this contract include Exhibit C, Monthly
Cumulative Summary Reports. Districts will negotiate with the provider on
specific submission requirement criteria for these reports.
(2) Providers of case management services agree to submit Monthly Cumulative
Summary Reports, which include management program data (e.g., client
identifiable data) to the department, according to negotiated instructions provided
by the districts.
(3) In the event of early termination of this contract, the provider will submit the
final Monthly Cumulative Summary Report within forty-five (45) days after the
contract is terminated.
d. Reports Table
Report
Title
Monthly
Cumulati
ve
Summary I
I
Reports I
Reporting
Frequency
I Report Date
I Due
I
J
I
I
!
i
!
I
i
j i
I Number of I
I copies
i due I
I 2 I
I I
J I
i I
I I
I
!
I
j
I
i
DCF Offices
to receive report
Monthly
The 10th of
month
immediately
following the
reporting
period
Contract
Manager
&
Program
Office
I
~
5. Performance Specifications
3. Performance Measures
03/03/06
(1) 100 % of adults with disabilities receiving services will not be placed in a
nursing home.
(2) Twenty qualified disabled adults (ages 18~59) wHl be provided
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case management by the CCDA program.
(3) Twenty~one qualified disabled adults (ages 18-59) will receive daify living
services from the CCDA and Aged and Disabled Adults (ADA) Medicaid Waiver
Programs.
b. Description of Performance Measurement Terms
Placed - The result of an assessment of an individual who is no longer able to remain in
his present place of residence. (To place a client involves preparation for and follow up
of moving a client into a more restrictive alternative living environment).
c. Performance Evaluation Methodology
(1) Measuring Outcomes. The department will measure the outcomes found in
paragraph 8.5.a. above as follows;
(a) The outcome measurement contained in paragraph 8.5.a. (1) above
will be calculated by dividing the total, fiscal year-to-date number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs not
transferred to a nursing home, by the total, fiscal year-to-date number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid wavier programs.
(b) The outcome measurement contained in paragraph 8.5.a. (2) above
will be calculated as the total number clients actively receiving case
management from the Community Care for Disabled Adults, Home Care
for Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs.
(c) The outcome measurement contained in paragraph 8.5.a(3) above
will be calculated as the total number clients actively receiving daily living
services from the Community Care for Disabled Adults and the Medicaid
waiver programs.
(2) By execution of this contract the provider hereby acknowledges and agrees
that its performance under the contract must meet the standards set forth above
and wilt be bound by the conditions set forth in this contract. If the provider fails
to meet these standards, the department, at its exclusive option, may allow a
reasonable period, not to exceed 6 months, for the provider to correct
performance deficiencies. If performance deficiencies are not resolved to the
satisfaction of the department within the prescribed time, and if no extenuating
circumstances can be documented by the provider to the department's
satisfaction, the department must terminate the contract. The department has
the sole authority to determine whether there are extenuating or mitigating
circumstances.
6. Provider Responsibilities
3. Direct Service Provider Unique Activities
(1j The provider will be required to use volunteers to the fullest extent feasible in
the provision of services and program operations. The provider is required to
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train, supervise, and appropriately support all volunteers with insurance
coverage,
(2) The provider will maintain an accurate and current active caseload list
(3) The provider will maintain a current monthly billing ledger of all provider
claims submitted to the case management agency or Adult Services local office,
including all corrected claims and adjustments to claims for services that were
delivered to consumers being served through this contract.
(4) The provider will notify the Adult Services local office of all service
terminations, service increase requests and monthly expenditure trends with
regards to the terms of this contract within two weeks immediately following
identification of such action.
(5) The provider will explain to each individual requesting consideration for
CCDA services that the program maintains a centralized Waiting List on which
the individual will be placed according to his or her score received through an
Adult Services Screening conducted by department Adult Services staff.
(6) If required by 45 CFR Parts 160, 162, and 164, the following provisions shall
apply [45 CFR 164.504(e)(2)(ii)]:
(a) The provider hereby agrees not to use or disclose protected health
information (PHI) except as permitted or required by this contract, state
or federal law.
(b) The provider agrees to use appropriate safeguards to prevent use or
disclosure of PHI other than as provided for by this contract or applicable
law.
(e) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(e) The provider agrees to make PHI available in accordance with 45
C.F.R 164.524.
(f) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R
164.526.
(9) The provider agrees to make available the information to
provide an accounting of disclosures in accordance with 45 CFR
164.528,
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider on behalf of the
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department available for purposes of determining the provider's
compliance with these assurances.
(I) The provider agrees that at the termination of this contract. if feasible
and where not inconsistent with other provisions of this contract
concerning record retention, it will return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form, If not feasible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
m A violation or breach of any of these assurances shall constitute a
material breach of this contract
b. Case Management Provider Unique Activities
(1) The case management provider will accept all District Program Office
referrals through the Adult Services Program Office. The initial referral package
to the case management provider will include the Initial Adult Services Client
Assessment (CF-AA 3019) and care plan completed by department staff and all
required supporting documentation.
(2) The case management provider will complete all ongoing face~to-face
assessments on all pre-screened individuals referred by the District Program
Office for service consideration and program application, using the Adult
Services Client Assessment, CF-AA 3019,
(3) The case management provider will maintain an accurate and current active
caseload list
(4) The CCDA case management provider will maintain a current monthly billing
ledger of all provider claims submitted to the agency or the local Adult Services
office, induding all corrected daims and adjustments to claims for services that
were dellvered to consumers being served through this contract
(5) The case management provider will notify the local Adult Services office of
all service terminations, service increase requests and monthly expenditure
trends with regards to the terms of this contract within two weeks immediately
following identification of such action,
(6) The case management provIder will explain to each individual requesting
consideration for CCDA services that the program maintains a centralized
Waiting List on which the individual will be placed according to his or her score
received through an Adult Services Screening to be completed by an Adult
Services counselor.
(7) If required by 45 CFR Parts 160, 162, and 164, the following
provisions shall apply [45 CFR 164.504(8)(2)(ii)]:
(a) The provider hereby agrees not to use or disclose protected health
information (PHi) except as permitted or required by this contract, state
or federal law.
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(b) The provider agrees to use appropriate safeguards to prevent use or
disclosure of PHI other than as provided for by this contract or applicable
law.
(c) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(e) The provider agrees to make PHI available in accordance with 45
C.F.R. 164.524.
(f) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R.
164.526.
(g) The provider agrees to make available the information required to
provide an accounting of disclosures in accordance with 45 C.F.R.
164.528.
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider on behalf of the
department available for purposes of determining the provider's
compliance with these assurances.
(i) The provider agrees that at the termination of this contract, if feasible
and where not inconsistent with other provisions of this contract
concerning record retention. it will return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form. If not feasible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
(j) A violation or breach of any of these assurances shaH constitute a
materia! breach of this contract
c. Coordination with Other Providers/Entities
The case management provider must coordinate, as necessary, with the Agency for
Persons with Disabilities, the Department of Children and Families, the Department of
Education. the Department of Health, and the Florida Statewide Advocacy Council, to
serve those clients who are eligible for services through two (2) or more
continuums.
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7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply aU new providers with a copy of
the Community Care for Disabled Adults Operating Procedures, CFOP 140-8.
(2) The department will provide CCDA technical assistance to the provider,
relative to the negotiated terms of this contract and instructions for submission of
required data.
(3) The department will screen all clients referred for CCDA services and will
complete the initial assessment and care plan for all new clients.
b. Department Determinations
Should a dispute arise, the department will make the final determination as to whether
the contract terms are being fulfilled according to the contract specifications.
c. Monitoring Requirements
The provider will be monitored in accordance with existing departmental procedures
(CFOP 75-8).
C. Method of Payment
1. Payment Clauses
a. This is a fixed price (unit cost) contract. The department shall pay the provider for the
delivery of service units provided in accordance with the terms of this contract for a total
dollar amount not to exceed $N/A, subject to the availability of funds.
b. The department shall make payments to the provider for the provision of services up
to the maximum number of units of service at the rates shown below.
c. The department agrees to pay for the service units at the unit price(s) and limits listed
below.
Service Units Unit Price Maximum # of Units
Case Management $ 54.39 200
Personal Care $ 40.70 160
Homemaker Services $ 33.47 1,250
Home Delivered Meals $ 7.00 3,215
d. The provider's dollar match for this contract is 10% of total contract expenditures..
13, Cash or in kind resources may be used to meet this match requirement
2, Invoice Requirements
The provider shall request payment through submission of a properly completed Invoice, Exhibit
0, within 10 (ten) days following the end of the month for which payment is being requested, The
20
PSMAI No. GAO?
Contract # KG058
03/03/06
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
provider shall submit to the contract manager an original Invoice, Exhibit 0, and no copies, along
with supporting documentation. Payment due under this contract will be withheld until the
department has confirmed delivery of negotiated services.
Payments may be authorized only for service units on the invoice which are in accordance with
the above list and other terms and conditions of this contract The service units for which
payment is requested may not either by themselves, or cumulatively by totaling service units on
previous invoices, exceed the total number of units authorized by this contract
3. Supporting Documentation
a. It is expressly understood by the provider that any payment due the
provider under the terms of this contract may be withheld pending the receipt and
approval by the department of all financial and program reports due from the provider as
a part of this contract and any adjustments thereto. Requests for payment, which cannot
be documented with supporting evidence, will be returned to the provider upon inspection
by the department
b. The provider must maintain records documenting the total number of recipients and
names (or unique identifiers) of recipients to whom services were provided and the dates
the services were provided so that an audit trail documenting service provision can be
maintained.
4. MyFloridaMarketPlace
This contract is exempt from the MyFloridaMarketPiace Transaction Fee in accordance with
Chapter 60A-1.032(1 )(e), Florida Administrative Code.
D. Special Provisions
1. Fees
a. The case management provider will collect fees for services provided according to
Rule 65C~2.007, Florida Administrative Code.
b. No fees shall be assessed other than those established by the department Fees
collected in compliance with the department directives will be reinvested in a manner
prescribed by the department
2. Florida Statewide Advocacy Council
The provider agrees to allow properly identified members of the Florida Statewide Advocacy
Council access to the facility or agency and the right to communicate with any client being
served, as well as staff or volunteers who serve them in accordance with subsections 402.165(8)
(a) & (b), Florida Statutes. Members of the Florida Statewide Advocacy Council shall be free to
examine all records pertaining to any case unless legal prohibition exists to prevent disclosure of
those records.
3. Non~Expe!'H::Iabie Property
a. Non-expendable property is defined as tangible personal property of a nonconsumable
nature that has an acquisition cost of $1,000 or more per unit, and an expected useful life
of at least one year; and hardback bound books that are not circulated to students or the
general public, the value of cost of which is $250 or more. HardbacK books with a value
or cost of $25 or more should be classified as an aco expenditure if they are circulated
03/03/06
21
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
to students or to the general public. The provider will use the Provider Inventory List,
Exhibit B to report all capital assets purchased through funding provided by the
Department for prior and current year contract
b. All such property, purchased under this contract, shall be listed on the property
records of the provider. Said listing shall include a description of the property, model
number, manufacturer's serial number, funding source, information needed to calculate
the federal and/or state share, date of acquisition, unit cost, property inventory number,
and information on the location, use condition, transfer, replacement, or disposition of the
property.
c, All such property, purchased under this contract, shall be inventoried annually, and an
inventory report shall be submitted to the department along with the final expenditure
report. A report of non-expendable property shall be submitted to the department along
with the expenditure report for the period in which it was purchased.
d. Title (ownership) to all non-expendable property acquired with funds from this contract
shall be vested in the department upon completion or termination of the contract
e, At no time shall the provider dispose of non-expendable property purchased under
this contract except with the permission of, and in accordance with instructions from the
department
f. A forma! contract amendment is required prior to the purchase of any item of non-
expendable property not specifically listed in the approved contract budget.
4. Morals Clause
The provider understands that performance under this contract involves the expenditure of
public funds from both the state and federal governments, and that the acceptance of such
funds obligates the provider to perform its services in accordance with the very highest
standards of ethical and moral conduct Public funds may not be used for purposes of
lobbying, or for political contributions, or for any expense related to such activities, pursuant
to Section I R of the Standard Contract of this contract. The provider understands that the
Department is a public agency which is mandated to conduct business in the sunshine,
pursuant to Florida Law, and that all issues relating to the business of the Department and
the provider are public record and subject to full disclosure. The provider understands that
attempting to exercise undue influence on the Department and its employees to allow
deviation or variance from the terms of this contract other than negotiated, publicly disclosed
amendment, is prohibited by the State of Florida. The provider's conduct is subject to all
state and federal laws governing the conduct of entities engaged in the business of providing
services to government
5, Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, Florida Statutes., Part I,
Transportation Services, and Chapter 41-2, Florida Administrative Code, Commission for the
Transportation Disadvantaged, jf public funds provided under this contract will be used to
transport cHants.
6. Incident Reporting
The Provider is required to document all reportable incidents, as defined in the District 1 1
Uniform Incident Reporting Protocol for Incident Reporting and Client Risk Prevention For
Critical and Non-Critical Incidents which is incorporated herein by reference.
03/03/06
22
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
For each critical incident occurring during the administration of its program, the Provider
must, within 24 hours of the incident, complete and submit the District's approved Incident
Report (Exhibit E) to the respective department program incident report liaison. it is the
Provider's responsibility to use the most current District 11 approved incident report for this
purpose. A copy of the incident report must also be placed in a central file marked
"Confidential Incident Report". Dissemination of the report within the department will be the
responsibility of the department's program incident report liaison.
incidents that threaten the health, safety or welfare of any person or that place any person in
imminent danger must be reported immediately to the department by telephonic contact. The
information contained in the incident report is confidential. The dissemination, distribution or
copying of the report is strictly prohibited, unless authorized by the Department.
7. MyFloridaMarketPlace Transaction Fee
The State of Florida, through the Department of Management Services, has instituted
MyFloridaMarketPlace, a statewide eProcurement system. Pursuant to subsection
287.057(23), Florida Statutes (2002), all payments shall be assessed a Transaction Fee of
one percent (1.0%), which the provider shall pay to the State.
For payments within the State accounting system (FLAiR or its successor), the Transaction
Fee shall, when possible, be automatically deducted from payments to the provider, If
automatic deduction is not possible, the provider shall pay the Transaction Fee pursuant to
Rule 60A-1 ,031 (2), Florida Administrative Code. By submission of these reports and
corresponding payments, provider certifies their correctness, All such reports and payments
shall be subject to audit by the State or its designee.
The provider shall receive a credit of any Transaction Fee paid by the provider for the
purchase of any item(s) if such item(s) are returned to the provider through no fault, act, or
omission of the provider. Notwithstanding the foregoing, a Transaction Fee is non-refundable
when an item is rejected or returned, or declined, due to the provider's failure to perform or
comply with specifications or requirements of the agreement.
Failure to comply with these requirements shall constitute grounds for declaring the provider
in default and recovering procurement costs from the provider in addition to all outstanding
fees. PROVIDERS DELINQUENT IN PAYING TRANSACTION FEES MAY BE EXCLUDED
FROM CONDUCTING FUTURE BUSINESS WITH THE STATE.
8. Contract Term
The department and the provider agree that this contract shall be for a one year term due to
compliance concerns. If the provider fails to meet these standards, the department, at its
exclusive option, may allow a reasonable period, not to exceed six months, for the provider to
correct performance deficiencies. The six month period for the provider to come into
compliance with current concerns witt end on September 22.2006. If performance
deficiencies are not resolved to the satisfaction of the department within the prescribed time,
and if no extenuating circumstances can be documented by the provider to the department's
satisfaction, the department must terminate the contract. The department has the sole
authority to determine whether there are extenuating or mitigating circumstances,
03/03/06
23
PSMAI No. GAOl
Contract # KG058
EXHIBIT A
f~ri~~~:: AS Screening for Consideration for Community-Based Programs
PART I
1 . Name:
A. Date of Referral (Initial Contact):
8. D Walk In 0 Phone D Other:
2. Address:
C Referral Source (include phone number):
OistricURegion:
3 Phone:
D. Relationship to Individual Being Referred:
4. Race:_ Gender:_ Age/DOB:
5 Marital Status:
E. Is Individual Aware of Referral? 0 Yes 0 No
6 Social Security Number:
7. Primary Language:
8. Medicaid 0 Number:
9. Medicare 0 Number:
10. Other Insurance:
11. Financial: (for Placement
& Supportive Services only)
12. Other Essential Person(s): physician, family member(s}, POA, guardian, caregiver
(include address and phone number)
(85DI)
(SS!)
(Workers Camp)
(Other) Emergency Contact (and phone):
(Other) 13. Directions to Home (as needed):
$
$
$
$
$
14. Problem/Diagnosis:
15. How Long a Problem?
17, Services Requested:
16. Urgency of Need:
18 Other Agencies Contacted for Help:
19. AS Counselor's Signature:
Date:
20. Disposition: 0 Protective Intervention Placement 0 Protective Intervention Supportive Services 0 Short-Term Case Mgmt
information & Referral
o CCDA
o ADA Medicaid Waiver Application
o HCDA Applicat,on
CCDA Waiting List ~ Score
ADA MedIcaid Waiver Waiting List> Score _ 0 HCD/', Waiting List ~ Score -
Date:
23. Reviewed/Approved by:
By:
Date:
Date:
21. Due Process Pamphlet (CF/PI140-43) Given/Mailed by:
22 Given to Supervisor for Review by:~~",,<~ Date:
24. PART f sent to:
25. Referred to AS Counselor/Case Manager:
CF-AA 1022~ PDF 0912005
Date:
Page 1 of 4
:J!{
PART II
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26~ Check sources of information used for FUNCTIONAL ASSESSMENT Section.
o Individual Requesting Services
D Other (specify):
27. Has individual requesting services had any ongoing problems with memory or confusion that seriously interfere with
daily living activities?
Describe:
Indicate name and phone number of physician/other who is treating individual for memory/confusion problem(s}:
(Address all questions to the individual requesting selVices if possible. The purpose of these questions is to
determine actual ability to do various activities. Sometimes, caregivers help the individual with an item regardless
of the person's ability. Ask enough questions to make sure the individual requesting selVices is telling you what
he/she can or cannot do.)
Response Definitions:
No help: Individual can perform activity without assistance from another person.
Some help: Needs physical help, reminders or supervision during part of the activity.
Can't do it at all: Individual cannot complete activity without total phYSical assistance from another person.
Total Score: Add numbers from "Some help" and "Can't do it at alf" columns to points given in question #33, and put
sum in Total Score boxes.
ACTIVITIES OF DAILY LIVING (ADLs)
(Read all choices before taking answer)
Would you say that you need help from another person?
(Does not include assistance from devices)
0= No help 2 = Some help 3 = Can't do it at all
Comments/Care Plan Implications:
(Include services, supplies, eauipment, ete.)
28. Dressing (includes getting out clothes and putting
them on and fastening them, and putting on shoes) 0
29. Bathing (includes running the water, taking the bath or
shower and washing all parts of the body including 0
halr)
30. Eating (includes eating, drinking from a cup and
cutting foods) 0
31. Transferring (includes getting in and out of a bed or
chair) 0
32. ToHeting (independently includes adjusting clothing,
getting to and on the toilet, and cleaning one's self If 0
accidents occur and person manages alone, count it
as independent. If reminders are needed to clean up,
change diapers, or use the toilet this counts as some
helo)
33, Bladder/Bowel Control - How well can you control
i your bladder or bowe!? I 0 I
I -- Never have accident (0)
I !
-- Occasionally have accidents (21 Enter Score
-- Often have aCCidents (3)
-- Alwavs have accidents (4)
ADL Total Score
(Total possible score::: 19) 0
Page 2 of 4
:J-~
INSTRUMENTAL ACTIVITES OF DAILY LIVING (IADLs)
(Read all choices before taking answer) Would you say that you need help from another person?
(Does not include assistance from devices)
o = No help 1 = Some help 2 = Can't do it at all
Comments/Care Plan Implications:
(Include services, suoolies, eauioment, etc)
34. Transportation Abillty (includes using local
transportation, paratransit, or driving to places beyond 0
walking distance)
35, Prepare Meals (includes preparing meals for yourself
including sandwiches, cooked meals and TV dinners) 0
36. Housekeeping (dusting, vacuuming, sweeping,
laundry) 0
IADL Total Score 0
(Total possible score = 6)
SUPPORT AND SOCIAL RESOURCES OF INDIVIDUAL REQUESTING SERVICES
(No Score for Questions 37-46)
37. Check source(s) of information used for this section.
D Individual Requesting Services
D Other (specify):
SERVICES/HELP
Yes No NOTES
Do you receive ...
38. Personal Care
Assistance (bathing,
dressing, getting out of
bed, toileting and eating)
39. Housekeeping (laundry,
cleaning, meals, etc)
40. Transportation
41. Shopping/Errands
42, Personal Finances
(money management)
43. Services from a health
professional such as an
RN or Therapist?
44. Adult Day Care I
I
I
45. Home delivered meals I
I (Formal only)
146. Any other kind of help I
I (Specify) I
I I
Page 3 of 4
J~
PART III - SCORING MATRIX
For items 1,2,3.4,5 and 6 in the scoring matrix below, enter the value (in parenthesis) following the question response
which corresponds to the response obtained during the interview or through reviews. Example: If the answer was "yes" to
the question "Is individual homebound?", a score of 1 point is placed on the line next to the answer line marked "Yes."
F or item 7, enter the score for ADLs and IADLs from the screen ing form. For item 8, subtract 40 points if the i ndi vidual
interested in HCDA or CCDA services appears eligible or is receiving comparable services from other programs. See the
Adult Services Waiting List Policy for Community-Based Programs for a definition/description of "comparable services."
Comments From Individual Requesting Services That May Result in Re-Adjustment of Score:
Total Score: Add and subtract (as appropriate) the individual scores for each item to determine the total score and place
the score in the box marked Total Score
DomainfQuestion
1. Is individual requesting services a victim and at high risk of abuse,
neglect, or exploitation based on Protective Investigator's report?
Score
Yes (4 pt.)
2. Is individual requesting services a victim and at intermediate risk
of abuse, neglect, or exploitation based on Protective
Investigator's Report?
Yes (2 pt.)
3. Does individual live alone or is individuai solely responsible for
minor children (under the age of 12) in the home?
Yes (1 pt)
4. Is individual homebound? (See AS Screening for Consideration
for Community.8ased Programs INSTRUCTIONS for definition of
homebound)
Yes (1 pt)
5. Does individual have ongoing memory/confusion problems?
Yes (2 pt)
6. Is individual receiving SSI or SSD because of primary diagnosis
of sensory impairment?
IADLs...
Yes (3 pt)
o (enter ADL total score)
o (enter IADL total score)
7. Functional Assessment:
ADLs.....
8. Support for Individual Requesting Services:
Does individual currently receive help/services (formal/informal) in
ADL or lADL deficit areas noted?
No help (4 pt)
Help is available but overall inadequate or
changing, fragile or problematic (2 pl.)
Help is adequate overall in deficit areas (0 pt)
For HCDA and CCDA Programs Only:
Individual appears eligible or is receiving comparable services
from other departmental programs, APD, or vocational rehabil.
itation. (Does not include AS programs - see waiting list policy
for definition of ~'comparable services. H) Specify program(s) to
which individual is being referred for eligibility determination and
steps taken to refer individual to other prog'am(s)~
Minus 40 pI
ceDA
o
ADA MW
o
HCDA
o
TOTAL SCORE
(Total Possibie Score = 40 to +40)
Page 4 of 4
:J1
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DEPARTMENT OF CHILDREN AND FAMILIES
ADULT SERVICES OFFICE
MONTHLY INVOICE
Exhibit 0
PROVIDER FED. !D #
NAME AND MAILING ADDRESS OF PAYEE:
CONTRACT AMNT.:_
REIMBURSEMENT YTD.:_
CONTRACT BALANCE:_
DATE:
CONTRACT#:
PERIOD OF SERVICE PROVISION:
NAME OF SERVICE
OR DESCRIPTION OF MATERIALS
UNITSI
QUANTITY
AMOUNT PER UNITI
EPISODE
TOTAL AMOUNT
DUE
TOTAL MATCH REQUIRED
FOR CONTRACT:
TOTAL
PAYMENT
REQUESTED
THIS MNTH. YTD.
LOCAL CASH MATCH
LOCAL IN-KIND
TOTAL DEDUCT!ONS
REMAINING MATCH BALANCE
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
~T -rH!& ~NVOICE !8 FOR A ~IXED PRICE CONTRACT, 1HE REOUEST FOR PA YMEN-r W~LL 8E DETERM!NED
fjY G!'JIOiNC THE LENGTH G~ rHE CCN7RP.CT ~NTo- ThE CONfRACTE,O M-AOl!NT {!;;X_-$12,DOCIAlLOCA T1CN} D,'J~DEO 8y
;:: MONTHS !THE LENGTH OF ThE COI-.tfRACTl'-:$t ,COO PAYMENY REQUE;:Sn ON A COST R2JM5URSEMENT CONTRACT
THE PAYMENr REQUEST Wilt BE THE MONTHLY REaUEST EXPENSE
CHILDREN AND FAMILIES USE ONLY
DATE INV. RCD.
APPROVED BY:
DATE
!ORG
EO
OBJ
DESC
AMNT
]OeA
I
:1
30
District Tracking Number (for CRITICAL incidents)
Horida Department of
CHILDREN
& FAMILIES
11,66 (eOL), 59
(SFETC)
YEAR
Sequence Code
Check if CLOSED
DISTRICT 11 INCIDENT REPORT
Exhibit E
(Critical incidents must be reported to District Administrator within 24 hours of notification.) CHECK IF CRITICAL 0
I WARNING, The 'nfonn,t'on ~ontau'ed m tI," <epon i, ~~~~~~~~~~~~ he<ehy notified that d',,,mination, d,,'ibution, 0'
I copymg of thIS document IS strIctly prolublted, unless authOrized by the Department of Children & Farmhes.
I. IDENTIFYING INFORMATION
Reporting Party Phone #:~~..._____~~_m Date of Incident --.J _/_ Time of Incident
Reporting Party Name ~----'------- _._.__.~---_._---~
District Program Area: Specific Program:
Please respond to one of the following as appropriate.
a. Contract Provider Name Contract Facility Name (if appropriate)
b. Foster Home Name c. OS Home Name
d. DCF Facility Name e, Other Name
Is this a licensed facility? DYes D No 0 Don't know.
Specific location/address where incident occurred:
DCF Unit #
II. TYPE OF INelDENT
Check one box only.
1. 0 Abuse/Neglect/Exploitation
2. 0 Altercation
3. 0 Bomb Threat
4, 0 Client Injury 0 Illness
5.0 Client Death
6.0 Contraband DDrugs
7. 0 Elopement
8, 0 Escape
g. 0 Media Coverage
10. 0 Misconduct DCriminal Activity
11. 0 Sexual Battery
12. 0 Suicide Attempt
13, 0 Theft OVandalism OOamage DSabotage
14.0 Other Incidents
15.0 Non-Critical Other
LAST Name Add SS# if Birth Date Race Gender Client Employee Participant Witness
employee or cHent
is a participant
~_._i~/~ 0 0 0 0
~_/~/- 0 0 0 0
~/~~ 0 0 0 0
~i~/~. 0 n 0 n
LJ u
IV. DESCRIPTION OF INCIDENT
\..:lIve Detailed Account - (Who, What, When, Where, Why, How) - Add Pages If Necessary
hi
CONFIDENTIAL
v. CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow-up action needed? NoD
YEsD
If yes, specify:
-~~-~-~_._-~~~"~~---~--~
^~,~,~,.".,_.....'.M_"__~~~~~~ ~'.'~.~."M'C'C'Ccc_~_~_~~~~~~~"~~n-_----_~M~'~~r~~~-~
,~cc,_~__~~~~"_^"~n_~'___~~~"~~~~~~"_._-~-~-~~----~--.~MC_C~_~~^_
~~__~_,____~~~~~~"~"___~~~~-r--~-,",,~-^,----~_~_c"~r~~---~--~~~-~~~~,---~-~~~--~"~~---
_~_~.~"~^_~~"~~~_~__~~~~_r_~~-----~~~~"'~~~-~_c'_cr_--___~~~,~~".__~_~~_r_~c-r"-~~^~"~^~__'__'_C"_~_~__~~~~~"~^~-------~-,~,~~~~--~-
______________^_~^~'m'^~~__~_~~"_"__C,__,_____~_~^"_"~___~o_c_~_~~~_~^~m"~'__,_~~~___'~r~_n~____~~~_~_~__"~_~~---~~~~~
3t
A enc Notified
Abuse Registry
1-800-962-2873
CONFIDENTIAL
. I .
EXTERNAL NOTIFICATION
Person Contacted
Status
Report Accepted
DatelTime Called Copy
Name
o 0
Yes 0 NoD
ID#
Agency for Health Care
Adm i njstration Name: N/A 0 D
Law Enforcement-Department Officer's Name
Badge # Case # (if avail) N/A D 0
Parent/Guardianl
Family Member Name Name: N/A 0 0
Other (please Spec,fy)
Name: NfA 0 0
DCF (for providers only) Name: N/A 0 0
SIGNATURE TITLE
REPORTING _1_1-
EMPLOYEE
SUPERVISOR _1_1_
0 0
District Administrator 0 0 Florida Local Advocacy Committee 0
Division Director! H.R Workers' Compensation
Facility Director 0 Coordinator (employ"" related incidents only) 0 0
District Legal Counsel 0 0 Program Office/Risk Manager 0
DS Support Coordinator/Case 0 0 Others - (Please specify) 0 0
Manager
EEOC 0 0 Contract Manager
VIU. DCF REVIEW AND SIGNATURES
NAME
SIGNATURE
TITLE PHONE # DATE
IR Liaison Review:
Initial if complete.
ADMINISTRATOR!
ON CALL MANAGER
DIVISION DIRECTOR!
, FACILITY DIRECTOR I
I i
! I
---
-'-'-
~~
ATTACHMENT I I
The administration of resources awarded by the Department of Children & Families to the provider may be
subject to audits as described in this attachment.
lVI0NITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-I 33 and Section 215.97,
F,S., as revised, the department may monitor or conduct oversight reviews to evaluate compliance with
contract, management and programmatic requirements. Such monitoring or other oversight procedures
may include, but not be limited to, on-site visits by department staff, limited scope audits as defined by
OMB Circular A-133, as revised, or other procedures. By entering into this agreement, the recipient agrees
to comply and cooperate with any monitoring procedures deemed appropriate by the department. In the
event the department determines that a limited scope audit of the recipient is appropriate, the recipient
agrees to comply with any additional instructions provided by the department regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews, investigations, or audits
deemed necessary by the department's inspector general, the state's Chief Financia! Officer or the Auditor
General.
AUDITS
PART I: FEDERAL REQUIREMENTS
This part is applicable if the recipient is a State or local government or a non-profit organization as defined
in OMB Circular A-133, as revised.
In the event the recipient expends $500,000 or more in Federal awards during its fiscal year, the recipient
must have a single or program-specific audit conducted in accordance with the provisions ofOMB Circular
A-133, as revised. In determining the Federal awards expended during its fiscal year, the recipient shall
consider all sources of Federal awards, including Federal resources received from the Department of
Children & Families. The determination of amounts of Federal awards expended should be in accordance
with guidelines established by OMB Circular A-133, as revised. An audit of the recipient conducted by the
Auditor General in accordance with the provisions ofOMB Circular A-133, as revised, will meet the
requirements of this part. In connection with the above audit requirements, the recipient shall fulfill the
requirements relative to auditee responsibilities as provided in Subpart C ofOMB Circular A-B3, as
revised.
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during the audit period. The financial statements should disclose whether or not
the matching requirement was met for each applicable contract All questioned costs and liabilities due the
department shall be fuBy disclosed in the audit report package with reference to the specific contract
number.
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/
PART II: STATE REQUIREMENTS
This part is applicable ifthe recipient is a nonstate entity as detlned by Section 215.97(2), Florida Statutes"
In the event the recipient expends $500,000 or more in state financial assistance during its fiscal year, the
recipient must have a State single or project-specific audit conducted in accordance with Section 215.97,
Florida Statutes; applicable rules of the Department of Financial Services; and Chapters 10.550 (local
governmental entities) or 10.650 (nonprofit and for-profit organizations), Rules of the Auditor General. In
determining the state financial assistance expended during its fiscal year, the recipient shall consider all
sources of state financial assistance, including state financial assistance received from the Department of
Children & Families, other state agencies, and other nonstate entities. State financial assistance does not
include Federal direct or pass-through awards and resources received by a nonstate entity for Federal
program matching requirements.
In connection with the audit requirements addressed in the preceding paragraph, the recipient shall ensure
that the audit complies with the requirements of Section 215.97(8), Florida Statutes. This includes
submission of a financial reporting package as defined by Section 215.97(2), Florida Statutes, and Chapters
10.550 or 10.650, Rules of the Auditor GeneraL
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during the audit period. The financial statements should disclose whether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due the
department shall be fully disclosed in the audit report package with reference to the specific contract
number.
P ART III: REPORT SUBMISSION
Any reports, management letters, or other information required to be submitted to the department pursuant
to this agreement shall be submitted within 180 days after the end of the provider's fiscal year or within 30
days of the recipient's receipt ofthe audit report, whichever occurs first, directly to each ofthe following
unless otherwise required by Florida Statutes:
A. Contract manager for this contract (2 copies)
B. Department of Children & Families
Office of the Inspector General, Provider Audit Unit
Building 5, Room 237
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
C Copies ofthe reporting packages for audits conducted in accordance with OMB A.I as
revised, and required by Part I ofthis agreement shall be submitted, when required by Section 320(d),
OMB Circular A-133, as revised, by or on behalf of the recipient directly to the Federal Audit
Clearinghouse designated in OMB Circular A-133, as revised (the number of copies required by
Sections .320(d)(1) and (2), OMB Circular A-133, as revised, should be submitted to the Federal
Auditing Clearinghouse), at the foHowing address:
02/01/06
l{
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
and other Federal agencies and pass-through entities in accordance with Sections .320(e) and (t),
OMB Circular A- 133, as revised,
D. Copies of reporting packages required by Part n ofthis agreement shall be submitted by or on behalf
ofthe recipient directly to the following address:
Auditor General's Office
Room 40 I, Pepper Building
III West Madison Street
Tallahassee, Florida 32399-1450
providers, when submitting audit report packages to the department for audits done in accordance with
OMB Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650 (nonprofit or for-profit
organizations), Rules ofthe Auditor General, should include, when available, correspondence from the
auditor indicating the date the audit report package was delivered to them. When such correspondence is
not available, the date that the audit report package was delivered by the auditor to the provider must be
indicated in correspondence submitted to the department in accordance with Chapter 10.558(3) or Chapter
10.657(2), Rules of the Auditor GeneraL
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the terms of this agreement
for a period of six years from the date the audit report is issued and shall allow the department or its
designee, Chief Financial Officer or Auditor General access to such records upon request The recipient
shall ensure that audit working papers are made available to the department or its designee, Chief Financial
Officer or Auditor General upon request for a period ofthree years from the date the audit report is issued,
unless extended in writing by the department.
02/01/06
hl
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