SFY2010 08/19/2009DANNY Le KOLHAGE
CLERK OF THE CIRCUIT COURT
DA TE: August 2 7, 2009
TO: Community Services
ATTN: Dotti Albury
In -Home Services and Nutrition
FROM: Pamela G. Hanc ck, .C.
At the August 19, 2009, Board of County Commissioners' meeting the Board granted
approval and authorized execution of the following:
g
Amendment 001 to the Nutrition Services Incentive Program (NSIP) Contract US-951
between Monroe County and the Alliance for Aging, Inc. (Area Agency on Aging) and the
Monroe County Board of County Commissioners (Social Services/Nutrition Program) for Fiscal
Year 8/1/08 to 9/30/09.
✓Adult Services Home and Community Based Case Management Referral Agreement
between the Florida Department of Children &Families and the Monroe County Board of
County Commissioners (Social Services/In-Home Services Program) for State Fiscal Year (SFY)
July 1, 2009 to June 30, 2010.
Enclosed are four duplicate originals of each of the above -mentioned
, executed on behalf
of Monroe County, for your handling. Please be sure to return the "
�� fully executed Monroe Couty
Clerks Office Original as well as the "Monroe CountyFinance De ►�
Department's Original" as soon
as possible. Should you have an questions, g
Y y q ons, please do not hesitate to contact our office.
cc: Count,Y Attorney
Finance w/o documents
File ✓"
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Florida Oepattm~nt of
Children & Famities
ADULT SERVICES
HOME AND COMMUNITY BASED WAIVER
CASE MANAGEMENT REFERRAL AGREEMENT
This Referral Agreement made this 1st day of July, 2009, between the Florida Department of
Children and Families' (DCF) Circuit 11 Program Office, and Monroe Co. In-Home Services
hereinafter referred to as "case management agency", details the responsibilities and the expectations
associated w'ith the Medicaid Waiver for State Fiscal Year (SFY) 2009-2010. The case management
agency is a ~v1edicaid Waiver case management agency. This Referral Agreement is in effect from
the date of signature, through SFY 2009-2010 for as long as the Medicaid waiver case management
agency remains enrolled with the State of Florida's Medicaid fiscal agent. Case management agency
noncompliance, nonperformance, or unacceptable performance under this agreement may require a
corrective action plan addressing the problems identified by state agency Quality Assurance
Reviews. Failure of case management agencies to adhere to the Department of Children and Families'
guidance on eligibility and referral for services may result in recoupment of program funds or case
management agency dis-enrollment as a Medicaid Waiver program case management agency.
~ The purpose of this agreement is to enable eligible disabled adult participants to receive case
management services from qualified case management agencies with oversight of the quality of care
by the Florida Department of Children and Families' Circuit 11 Program Office and the Medicaid
Waiver Specialist employed by the Department of Elder Affairs (DOEA). These services are
authorized in order that the participant may remain in the least restrictive setting and avoid or delay
nursing home placement. Servi~es and care are to be furnished in a way that fosters the
independence of each participant and facilitates an increased functional capacity. All parties agree
that routines of care provision and service delivery must be consumer-driven to the maximum extent
possible. All parties agree to and will treat each participant with dignity and respect.
I. Objectives
A. To m.aintain a climate of cooperation and consultation with and between agencies, in order to
achieve maximum efficiency and effectiveness.
B. To participate together by means of shared information in the development and expansion
of services.
c. To promote programs and activities designed to prevent the premature institutionalization
of disabled adults.
D. To provide technical assistance to and consultation between agencies on matters
pertaining to actual service delivery and share appropriate assessment information and
care ]~lans to avoid duplication.
E. To establish an effective working relationship between the case management agency, the
service case management agency, and the Florida Department of Children and Families; the
case Inanagement agency being responsible for the development of care plans and
authorization of services available under the waiver, the case management agency being
responsible for the direct provision of those services to consumers served under the waiver
program, and the Department being responsible for management and oversight of the waiver
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program.
II. Under this Agreement, the Circuit (Regional) Program Office agrees to the following:
A. To provide technical assistance and training to the case management agency.
B. To J:~rovide or to assist the Medicaid Waiver Specialist in providing annual on site
monitoring of the case management agency and, when applicable, conduct the same
monitoring of circuit DCF staff performing case management activities, using the
approved DOEA Medicaid waiver programmatic monitoring tool.
C. To naonitor and project case management "agency expenditures.
D. To conduct telephone screenings on all new referrals requesting services through the
ADJ\-HCBS Medicaid waiver within the timeframes set forth in the Adult Services Wait
List Policy guidelines, and using the Adult Services Screening for Consideration for
COlYtmunity-Based Programs; CF-AAI022.
E. To accept all Budget Entity Team referrals for face-to face assessments.
F. To complete all initial face-to-face assessments on all pre-screened individuals referred
by tIle Budget Entity Team for service consideration and program application, using the
Adult Services Client Assessment, CF-AA 3019.
G. To nlaintain an accurate and current active waiver case list.
H. To notify, on a timely basis, the Adult Services Central Office budget staff of all waiver
service terminations, service increase requests and atypical monthly expenditure trends
with regards to the terms of this Agreement.
III. Under this Agreement, the Case Management Agency agrees to the following:
A. Adhere to the Department of Children and Families' guidance on eligibility and referral for
services, as established through the Aged and Disabled Adult (ADA) Waiver Handbook
policy and the ADA Waiver format 1915(c).
B. Assign qualified case managers in accordance with the Aged and Disabled Adult
Medicaid Waiver Handbook to provide case management under the Medicaid Home and
Community Based Waiver for Aged and Disabled Adults.
C. Explain to each individual requesting consideration for ADA-HCBS Medicaid waiver
services that the Medicaid waiver program maintains a centralized Waiting List on which
the illdividual will be placed according to his or her score received through the Adult
Services Screening for Consideration for Community Based Services.
D. SUPf1ly all new disabled adult referrals (individuals requesting Aged and Disabled Adult
Home and Community Based Waiver services) with the name of a DCF Adult Services
counselor and the phone number to the nearest DCF Adult Services unit for the individual
to pursue service consideration and program screening.
E. Mainltain and permit circuit access to:
1. A~ current and accurate log of all Medicaid waiver claims, activities and payments by
illdividual consumer;
2. AL listing of each Medicaid waiver consumer served by full name, Social.Security ID
aIld Medicaid ID;
3. C~urrent (within one year) Consumer Care Plans indicating present authorized
service(s) and cost analysis by service on each waiver consumer serviced through this
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contract; and,
4. Current log of consumer tenninations of service (if applicable) with cost analysis of
the terminated consumer's unexpended care plan budget, date of termination and
reason for termination.
F. I)evelop and implement the Plan of Care, which must be signed by the consumer, that
specifIcally outlines:
1. T'le conSllmer's health conditions and treatments;
2. Challenges and impediments to the consumer's daily living functionality identified by
the assessmerlt and to be addressed with the Plan of Care;
3. Service(s) authorized;
4. The frequency and intensity of the arranged service interventions;
5. Service gaps;
6. Expected outcomes to be achieved;
7. Cost analysis, by service, of those service units authorized for consumer delivery;
and,
8. The formal and informal support persons (agencies) responsible for delivering both
the DCF funded services authorized by the case manager and all other non-DCF
funded services.
G. l~eevaluate the Plan of Care at least every six months.
H. ~v1inimally reassess the client annually or more often if significant changes in the client's
situation warrant, with the Adult Services Client Assessment Instrument and amend the
I>lan of Care accordingly. Make the required changes to authorized services and/or
service case management agencies as needed.
I. l\dhere t6 the policies and procedures as outlined in the following manuals published by
the Agency for Health Care Administration: Aged and Disabled Adult Waiver Guidelines
and the Medicaid Case management agency Reimbursement Handbook (N on-
Institutional 081), including any and all attachments or updates.
J. J>rovide to the Agency for Health Care Administration, by the 15th of each month, a
completed Case management agency Monthly Report Form, CF-AA 1119, which is a
cletailed expenditure report showing the number of clients served, defined units and type
of services provided, cost of each service unit, number of units of service provided,
totaled monthly cost of services delivered, and a year to date total cost of services
clelivered. This report will also include the number of active clients at the beginning of
the month, t11e number added and deleted during the month, and the final COlInt at the end
of the month.
K. l~efer clients to the qualified direct service case management agency as selected by the client,
,;vhenever reasonable and possible.
L. Issue written service authorizations to subcontracted service case management agencies
'iVith at least 24 hours notice. The authorization will contain at a minimum:
1. Client's name;
2. Client's address (with directions if not easily accessible);
3. Pertinent information regarding client's health or disabilities and living situation; and,
LL Detailed service description including frequency, duration and specific tasks to be
IJerformed.
M. ~Evaluate quality of services and service documentation by the subcontracted service case
rnanagement agency.
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N. l-Iold the Department of Children and Families harmless from financial responsibility for
service clainls found out of compliance if they are the result of a failure by the case
nlanagement agency to update, rene\v, or terminate a client care plan or service
authorization.
o. Perform semi-annual administrative monitoring of subcontracted service case
Dlanagement agencies for adherence to allthorized 'care plans and authorized
reimbursement rates.
P. [)evelop and implement a policy to ensure that its employees, board members, and
nlanagement will avoid any conflict of interest or the appearance of a conflict of interest
when disbursing or using the funds described in this agreement or when contracting with
a~nother entity which will be paid by the funds described in this agreement. A eon.diet of
illterest includes, but is not limited to, receiving, or agreeing to receive, a direct or
illdirect benefit, or anything of value from a service case management agency, consumer,
vendor, or any person wishing to benefit from the use or disbursement of funds. To avoid
a conflict of interest, the case management agency must ensure that all case management
agency staff, volunteers, and board members bound by this service agreement make a
disclosure to the undersigned case management agency of any relationship which may be
a conflict of interest, within thirty (30) days of original appointment or placement on a
board, or if the individual is serving as an incumbent, within thirty (30) days of the
commencement of the contract.
Q. Follow-up with the undersigned on all billing errors identified by the Agency for Health
Care Administration and/or the Circuit DCF office to ensure that all void or adjustment
claims are submitted no later than 45 days after each billing error has been identified by
either party. Any case management agency error not adjusted or voided within 45 days
may be adjusted or voided by the Agency for Health Care Administration or Florida
Department of Children and Families' Circuit Program Office. The case management
agency's refusal to adjust or void erroneous claims will result in termination of this
agreement.
R. If required by 45 CFR Parts 160, 162, and 164, the following provisions shall apply [45
CFR 164.504(e)(2)(ii)]:
(a) The case management agency hereby agrees not to use or disclose protected
health information (PHI) except as permitted or required by this Agreement, state
or federal law.
(b) The case management agency agrees to use appropriate safeguards to prevent use
or disclosure of PHI other than as provided for by this Agreement or applicable
law.
( c) The case management agency agrees to report to the department an)' use or
disclosure of the information not provided for by this Agreement or applicable
law. J
(d) The case management agency hereby assures the department that if any PHI
received from the department, or received by the case management agency on the
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department's behalf, is furnished to case manageme11t agency's subcontractors or
agents in the performance of tasks required by this Agreement, that those
subcontractors or agents must first have agreed to the same restrictions and
conditions that apply to the case managemellt agency with respect to such
information.
(e) The case management agellcy agrees to make PHI available in accordance with 45
C.F.R. 164.524.
(f) The case management agency 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 case management agency agrees to make available the information re -luired
to provide an accounting of disclosures in accordance with 45 C.F.R. 164.528.
(h) The case management agency 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 case management agency on behalf of the department
available for purposes of determining the case manager's compliance with these
assurances.
(i) The case management agency agrees that at the termination of this Agreement, if
feasible and where not inconsistent with other provisions of this Agreement
concerning record retention, it will return or destroy all PHI received from the
department or received by the case management agency on behalf of the
department, that the case management agency still maintains regardless of form.
If not feasible, the protections of this Agreement are hereby extended to that PHI
which may then be used only for such purposes as make the return or destruction
infeasible.
G) A violation or breach of any of these assurances shall constitute a material breach
of this Agreement.
s. Adhere to the Adult Services' Preliminary In-house Procedures for transferring a
~l1edicaid waiver consumer and the consumer's budget from one circuit to another at the
consumer's request.
IV. l~ermination
In the event this agreement is terminated, the case management agency agrees to submit, at the
time notice of intent to terminate is delivered, a plan which identifies procedures to ensure
services to consumers will not be interrupted or suspended by the termination.
A. l~ermination at Will
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l'his agreement may be terminated by either party upon no less than thirty (30) calendar days
notice, without cause, unless a lesser time is mutually agreed upon by both parties, in \\Titing.
Said notice shall be delivered by certified mail, return receipt requested, or in person with
proof of delivery.
EL Termination for Breach
lJnless a breach is waived by the Florida Department of Children and Families in writing or
the parties fail to cure the breach within the time specified by the Florida Department of
C:hildren and Families, the Florida Department of Children and Families may, by wTitten
notice to the parties, terminate the agreement upon no less than twenty-four (24) hours notice.
Said notice shall be delivered by certified mail, return receipt requested, or in person with
proof of delivery.
In witness whereof, the parties have caused this 6 page agreement to be executed by their
undersigtled officials as duly authorized.
Florida Department of Children
and Families Circuit 11
Program Office
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6:;; LDA P ;;at2+J./JD.C
Print Name
L~rm ('t,Jttr,tJ (~r(2 fJ.70~
TItle .
9~i~() '1
Date
S TO FORM
UFFIC~ 2'- .6<1
,.. . te~a: Counsel
Monroe Co. In-Home Services
George Neugent.
Print Name
Mayor
T i tl e
8-19-09
Date
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