06/16/2010 Contract
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DA TE:
June 22,2010
TO:
Sheryl Graham, Director
Social Services
A TTN:
FROM:
Dotti Albury, In-Home
Services Programs
Pamela G. Han€tc.
At the June 16, 2010, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Community Care for Disabled Adults (CCDA) Contract
#KG-065 (7/1/10-6/30/11) between the Florida Department of Children & Families and the
Monroe County Board of County Commissioners (Social Services/In-Home Services).
Enclosed are five duplicate originals, executed on behalf of Monroe County, for your
handling. Please be sure to return two fully executed originals of each of the above-mentioned
to this office for the Official Record and for Finance. Should you have any questions, please
do not hesitate to contact our office.
cc: County Attorney
Finaqce
File I
Contract No. KG065
Client 181 Non-Client 0
CFDA No.
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES STANDARD CONTRACT
THIS CONTRACT is entered into between the Florida Department of Children and Families~ hereinafter referred to as the "department" and MONROE COUNTY,
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 all attachments and exhibits, which constitute the contract
document.
B. Requirements of Section 287.058, Florida Statutes (F.S.)
The provider shall provide units of deliverables, including reports, findings, and drafts, as specified in this contract. These deliverables must be received and
accepted by the contract manager in writing prior to payment. The provider shall submit bills for fees or other compensation tor services or expenses in sufficient detail
tor proper pre-audit and post-audit; where itemized payment for travel expenses are permitted in this contract, 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 all documents, papers, letters, or other public records as
defined in subsection 119.011 (12), F.S. and as prescribed by subsection 119.07( I) 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, Jurisdiction and Venue
1. State of Florida Law
This contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in all respects in accordance with Florida law,
without regard to Florida provisions for conflict of laws. Courts of competent jurisdiction in Florida shall have exclusive jurisdiction in any action regarding
this contract and venue shall be as provided in PUR 1000. (see Section I.BB)
2. Federal Law
a. If this contract contains federal funds, the provider shall comply with the provisions of 45 Code of Federal Regulations (CFR), Part 74,45 CFR, Part 92,
and other applicable regulations.
b. If this contract contains over $100,000 of federal funds, the provider shall comply with all applicable standards, orders, or regulations issued under section
306 of the Clean Air Act, as amended (42 United States Code (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. No federal funds received in connection with this contract may be used by the provider, or agent acting for the provider, or subcontractor to influence
legislation or appropriations pending before the Congress or any State legislature. If this contract contains federal funding in excess of $1 00,000, the provider
must, prior to contract execution, complete the Certification Regarding Lobbying form, Attachment Nt A. If a Disclosure of Lobbying Activities form,
Standard Form LLL, is required, it may be obtained from the contract manager. All 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. Unauthorized aliens shall not 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) and section 10 I of the Immigration Reform and Control Act of 1986. Such violation shall be cause for
unilateral cancellation of this contract by the department.
e. If th is 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] ] 375 and others, and as supplemented in Department of Labor regulation 41 CFR, Part 60 and 45 CFR, Part 92, if applicable.
f. If this contract contains federal funds and provides services to children up to age 18, the provider shall comply with the Pro-Children Act of 1994 (20 V.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 or the
imposition ofan administrative compliance order on the responsible entity, or both.
D. Audits, Inspections, Investigations, Records and Retention
I. The provider shall establish and maintain books, records and documents (including electronic storage media) sufficient to reflect aH income and
expenditures of funds provided by the department under this contract.
2. Retention of all client records~ financial records, supporting documents~ statistical records, and any other documents (including electronic storage media)
pertinent to this contract shall be maintained by the provider 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 will facilitate the duplication and transfer of any records or documents during the
required retention period in Section I, Paragraph D. 2.
4. These records shall be made available at all reasonable times for inspection, review, copying, or audit by Federal, State, or other personnel duly authorized
by the department.
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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)(lQ), 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. A financial and compliance audit shall be provided to the department as specified in this contract and in Attachment II.
7. The provider shall comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by The Office of the
Inspector General (section 20.055, F.S.).
E. Monitoring by the Department
The provider shall pennit all persons who are 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
I. The provider shall be fully liable for the actions of its agents, employees, partners, or subcontractors and shall fully indemnify, defend, and hold harmless
the department and its officers, agents, and employees, from suits, actions, damages, and costs of every name and description, including attorneys' fees,
arising from or relating to any alleged act or omission by the provider, its agents, employees, partners, or subcontractors, provided, however, that the
provider shall not indemnify for that portion of any loss or damages proximately caused by the negligent act or omission of the department.
2. Further, the provider shall, without exception, indemnify and save harmless the department and its employees from any liability of any nature or kind
whatsoever, including attorneys fees, costs and expenses, arising out of, relating to or involving any claim associated with any trademark, copyrighted,
patented, or unpatented invention, process, trade secret or intellectual property right, information technology used or accessed by the provider, or article
manufactured or used by the provider, its officers, agents or subcontractors in the performance of this contract or delivered to the department for the use of
the department, its employees, agents or contractors. The provider may, at its option and expense, procure for the department, its employees, agents or
contractors, the right to continue use of, replace, or modify the product or article to render it non-infringing. If the provider is not reasonably able to
modify or otherwise secure the department the right to continue using the product or article, the provider shall remove the product and refund the
department the amounts paid in excess of a reasonable rental for past use. However, the department shall not be liable for any royalties. The provider has
no liability when such claim is solely and exclusively due to the department's alteration of the product or article or the department's misuse or
modification of the provider's products or the department's operation or use of vendor's products in a manner not contemplated by this contract. The
provider shall provide prompt written notification to the department of any claim of copyright, patent or other infringement arising from the performance
of this contract.
3. Further, the provider shall protect, defend, and indemnify, including attorneys' fees and costs, the department for any and all claims and litigation
(including litigation initiated by the department) arising from or relating to provider's claim that a document contains proprietary or trade secret
information that is exempt from disclosure or the scope of the provider's redaction, as provided for under Section lEE.
4. The provider's inability to evaluate liability or its evaluation of liability shall not excuse its duty to defend and indemnify after receipt of notice. Only an
adjudication or judgment after the highest appeal is exhausted fmding the department negligent shall excuse the provider of perfonnance under this
provision, in which case the department shall have no obligation to reimburse the provider for the cost of their defense. If the Provider is an agency or
subdivision of the State, its obligation to indemnify, defend and hold harmless the department shall be to the extent permitted by law and without waiving
the limits of sovereign immunity.
G. Insurance
Continuous adequate liability insurance coverage shall be maintained by the provider during the existence of this contract and any renewal(s) and extension(s)
of it. By execution of this contract, unless it is a state agency or subdivision as defmed 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 served
under this contract. The limits of coverage under each policy maintained by the provider do not limit the provider's liability and obligations 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
The provider shall not 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
I. The provider shall not assign the responsibility for this contract to another party without prior written approval of the department, upon the department's
sole determination that such assignment will not adversely affect the public interest; however, in no event may provider assign or enter into any transaction
having the effect of assigning or transferring any right to receive paYment under this contract which right is not conditioned on full and faithful
performance of provider's duties hereunder. Any sublicense, assignment, or transfer otherwise occurring without prior approval of the department shall be
null and void. The provider shall not subcontract for any of the work contemplated under this contract without prior written approval of the department,
which shall not be unreasonably withheld.
2. To the extent permitted by Florida Law, and in compliance with Section l.F. of this Standard Contract, the provider is 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.
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3. The provider shall 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 subcontractor. Failure to pay within seven (7)
working days will result in a penalty that shall be charged against the provider and paid by the provider 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. The State of Florida shall at all times be entitled to assign or transfer, in whole or part, 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 all 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.
5. The provider shall include, or cause to be included, in all subcontracts (at any tier) the substance of all clauses contained in this Standard Contract that
mention or describe subcontract compliance.
J. Return of Funds
The provider shall return to the department any overpayments due to unearned funds or funds disallowed that were disbursed to the provider by the department
and any interest attributable to such funds pursuant to the terms and conditions of this contract. 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 frrst
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 interest at the lawful rate of interest on the outstanding balance after department notification or provider discovery.
K. Client Risk Prevention and Incident Reporting
I. If services to clients are to be provided under this contract, the provider and any subcontractors shall, in accordance with the client risk prevention system,
report those reportable situations listed in CFOP 215-6 in the manner prescribed in CFOP 215-6 or circuit or region operating procedures.
2. The provider shall immediately report any 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 (l-800-96ABUSE). As required by Chapters 39 and 415, F.S., this provision is
binding upon both the provider and its employees.
L. Purchasing
I. Articles which are the subject of or are required to carry out this contract shall be purchased 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),
F.S. 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, (800) 643-8459.
2. The provider shall 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, F.S.
M. Civil Rights Requirements
I. In accordance with Title VII of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, or the Florida Civil Rights Act of 1992, as
applicable the provider shall not discriminate against any employee (or applicant for employment) in the performance of this contract because of race,
color, religion, sex, national origin, disability, age, or marital status. Further, the provider agrees not to discriminate against any applicant, client, or
employee in service delivery or benefits in connection with any of its programs and activities in accordance with 45 CFR 80, 83, 84,90, and 91, Title VI
of the Civil Rights Act of 1964, or the Florida Civil Rights Act of 1992, as applicable and CFOP 60-16. These requirements shall apply to all contractors,
subcontractors, subgrantees or others with whom it arranges to provide services or benefits to clients or employees in connection with its programs and
activities.
2. Complete the Civil Rights Compliance Checklist, CF Form 946 in accordance with CFOP 60-16 and 45 CFR 80. This is required of all 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 of287.134,
F.S.
N. Independent Capacity of the Contractor
I. In performing its obligations under this contract, the provider shall at all times be acting in the capacity of an independent contractor and not as an officer,
employee, or agent 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. The provider shall 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 or permitted to be an agent, servant, joint venturer, or partner of the State of Florida.
4. The department will not furnish services of support (e.g., 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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o. Sponsorship
As required by section 286.25, F.S., if the provider is a non-governmental organization which sponsors a program fmanced 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 HState ofFlori~a, Department of
Children and Families" shall appear in at least 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 affiliate 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. Final Invoice
The final invoice for paYment shall be submitted 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
The provider shall comply with the provisions of sections I 1.062 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.S., 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 following a conviction for a public entity crime, he/she may not submit a bid,
proposal, or reply on a contract to provide any goods or services to a public entity; may not submit a bid, proposal, ot: reply on a contract with a public entity for the
construction or the repair of a public building or public work; may not submit bids, proposals, or replies on leases of real property to a public entity; may not be awarded
or perform 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 of this 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
I. It is agreed that all intellectual property, inventions, written or electronically created materials, including manuals, presentations, films, or other
copyrightable materials, arising in relation to provider's performance under this contract, and the performance of all of its officers, agents and
subcontractors in relation to this contract, are works for hire for the benefit of the department, fully compensated for by the contract amount, and that
neither the provider nor any of its officers, agents nor subcontractors may claim any interest in any intellectual property rights accruing under or in
connection with the performance of this contract. It is specifically agreed that the department shall have exclusive rights to all data processing software
falling within the terms of section 119.084, F.S., which 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. Notwithstanding the foregoing provision, if the provider is a university and a member of the State University
System of Florida, then section 1004.23, F.S., shall apply.
2. If the provider uses or delivers to the deparbnent for its use or the use of its employees, agents or contractors, 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
royalties or costs arising from the use of such design, device, or materials in any way involved in the work contemplated by this contract.
3. 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
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 purpose, the provider agrees that, ifit 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. An appropriately skilled individual shall be identified by the provider to function as its Data Security Officer. The Data Security Officer shall act as the
liaison to the department's security staff and 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 or have access to any
departmental data system or information. The Data Security Officer will ensure that user access to the data system or information has been removed from
all terminated provider employees.
2. The provider shall provide the latest departmental security awareness training to its staff and subcontractors who have access to departmental information.
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3. All provider employees who have access to departmental infonnation shall comply with, and be provided a copy of CFOP 50-2, and shall sign the DCF
Security Agreement fonn CF 0114 annually. A copy ofCF 0114 may be obtained from the contract manager.
4. The provider shall make every effort to protect and avoid unauthorized release of any personal or confidential information by ensuring both data and
storage devices are encrypted as prescribed in CFOP 50-2. If encryption of these devices is not possible, then the provider shall assure that unencrypted
personal and confidential departmental data will not be stored on unencrypted storage devices. The provider shall require the same of all subcontractors.
5. The provider agrees to notify the contract manager as soon as possible, but no later than five (5) business days following the determination of any breach
or potential breach of personal and confidential departmental data. The provider shall require the same notification requirements of all subcontractors.
6. The provider shall provide notice to affected parties no later than 45 days following the determination of any potential breach of personal or confidential
departmental data provided in section 817.5681, F.S. The provider shall require the same notification requirements of all subcontractors.
x. Accreditation
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 the department's providers will either be accredited, have a
plan to meet national accreditation standards, or will initiate a plan within a reasonable period of time.
Y. Provider Employment Opportunities
I. Agency for Workforce Innovation and Workforce Florida: The provider 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.
2. Transitioning Young Adults: The provider understands the department's Operation Full Employment initiative to assist young adults aging out of the
dependency system. The department encourages provider participation with the local Community-Based Care Lead Agency Independent Living Program
to offer gainful employment to youth in foster care and young adults transitioning from the foster care system.
Z. Health Insurance Portability and Accountability Act
The provider shall, where applicable, comply with the Health Insurance Portability and Accountability Act (42 U. S. C. 1320d.) as well as all regulations
promulgated thereunder (45 CFR Parts 160,162, and 164).
AA. Emergency Preparedness
1. If the tasks to be performed pursuant to this contract include the physical care or supervision 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 records protection, alternative
accommodations for clients in substitute care, supplies, and a recovery plan that will allow the provider to continue functioning in compliance with the
executed contract in the event of an actual emergency. For the purpose of disaster planning, the term supervision includes the responsibility of the
department, or its contracted agents to ensure the safety, permanency and well-being of a child who is under the jurisdiction of a dependency court.
Children may remain in their homes, be placed in a non-licensed relative/non-relative home, or be placed in a licensed foster care setting.
2. 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.
3. An updated emergency preparedness plan shall be submitted by the provider no later than 12 months following the acceptance of an original plan or
acceptance of an updated plan. The department agrees to respond in writing within 30 days of receipt of the updated plan, accepting, rejecting, or
requesting modification to the plan.
BB. PUR (Purchasing) 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 deparbnent'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 are required by any section of the Florida Statutes~ the terms or conditions contained in the PUR 1000 Form shall
take precedence.
cc. Notification of Legal Action
The provider shall notify the department of legal actions taken against them or potential actions such as lawsuits, related to services provided through this
contract or that may impact the provider's ability to deliver the contractual services, or adversely impact the department. The department's contract manager will be
notified within 10 days of provider becoming aware of such actions or from the day of the legal filing, whichever comes first.
DO. Whistleblower's Act Requirements
In accordance with subsection 112.3187(2)~ F.S., the provider and its subcontractors shall not retaliate against an employee for reporting violations of law, rule,
or regulation that creates substantial and specific danger to the public~s health, safety, or welfare to an appropriate agency. Furthermore, agencies or independent
contractors shall not retaliate against any person who discloses information to an appropriate agency alleging improper use of governmental office, gross waste of funds,
or any other abuse or gross neglect of duty on the part of an agency, public officer, or employee. The provider and any subcontractor shall inform its employees that they
and other persons may tile a complaint with the Office of Chief Inspector General, Agency Inspector General, the Florida Commission on Human Relations or the
Whistle-blower's Hotline number at 1-800-543-5353.
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EE. Proprietary or Trade Secret Information
I. Unless exempted by law, all public records are subject to public inspection and copying under Florida's Public Records Law, Chapter 119, F.S. Any claim
by provider of proprietary or trade secret confidentiality for any information contained in provider's documents (reports, deliverables or workpapers, etc.,
in paper or electronic form) submitted in connection with this contract will be waived, unless the claimed confidential infonnation is submitted in
accordance with paragraph 2 below.
2. The provider must clearly label any portion of the documents, data or records submitted that it considers exempt from public inspection or disclosure
pursuant to Florida" s Public Records Law as proprietary or trade secret. The labeling will include a justification citing specific statutes and facts that
authorize exemption of the information from public disclosure. If different exemptions are claimed to be applicable to different portions of the protected
information, the provider shall include infonnation correlating the nature of the claims to the particular protected information.
3. The department., when required to comply with a public records request including documents submitted by the provider, may require the provider to
expeditiously submit redacted copies of documents marked as confidential or trade secret in accordance with paragraph 2 above. Accompanying the
submission shall be an updated version of the justification under paragraph 2, correlated specifically to redacted information. The redacted copy must
exclude or obliterate only those exact portions that are claimed to be proprietary or trade secret. If the provider fails to promptly submit a redacted copy
and updated justification in accordance with this paragraph, the department is authorized to produce the records sought without any redaction of
proprietary or trade secret information.
4. The department is not obligated to agree with the provider's claim of exemption on the basis of proprietary or trade secret confidentiality and the provider
shall be responsible for defending its claim that each and every portion of the redactions of proprietary or trade secret information are exempt from
inspection and copying under Florida's Public Records Law.
FF. Support to the Deaf or Hard-of-Hearing
The provider and its subcontractors, where direct services are provided, shall comply with section 504 of the Rehabilitation Act of 1973, 29 V.S.C. 794, as
implemented by 45 C.F.R. Part 84 (hereinafter referred to as Section 504), the Americans with Disabilities Act of 1990, 42 V.S.C. 12131, as implemented by
28 C.F.R. Part 35 (hereinafter referred to as ADA), and the Children and Families Operating Instruction (CFOP) 60-10, Chapter 4, entitled "Auxiliary Aids and
Services For The Deaf and Hard-of-Hearing."
I. If the provider or any of its subcontractors employs 15 or more employees, the provider shall designate a Single-Point-of-Contact (one per rum) to ensure
effective communication with deaf or hard-of-hearing customers or companions in accordance with Section 504, the ADA, and CFOP 60-10, Chapter 4.
The name and contact information for the provider's Single-Point-of-Contact shall be furnished to the department's Grant or Contract Manager within 14
calendar days of the effective date of this requirement.
2. The provider shall, within 30 days of the effective date of this requirement, contractually require that its subcontractors comply with section 504, the
ADA, and CFOP 60-10, Chapter 4. A Single-Point-of-Contact shall be required for each subcontractor that employs 15 or more employees. This Single-
Point-of-Contact will ensure effective communication with deaf or hard-of-hearing customers or companions in accordance with Section 504 and the ADA
and coordinate activities and reports with the provider's Single-Point-of-Contact.
3. The Single-Point-of-Contact shall ensure that employees are aware of the requirements, roles & responsibilities, and contact points associated with
compliance with Section 504, the ADA, and CFOP 60-10, Chapter 4. Further, employees of providers and its subcontractors with 15 or more employees
shall attest in writing that they are familiar with the requirements of Section 504, the ADA, and CFOP 60-10, Chapter 4. This attestation shall be
maintained in the employee's personnel file.
4. The provider's Single-Point-of-Contact will ensure that conspicuous Notices which provide information about the availability of appropriate auxiliary aids
and services at no-cost to the deaf or hard-of-hearing customers or companions are posted near where people enter or are admitted within the agent
locations. Such Notices must be posted immediately by providers and subcontractors. The approved Notice can be downloaded through the Internet at:
http://www.dcf.state.fl.us/adminliglci vilrights.shtml
5. The provider and its subcontractors shall document the customer's or companion's preferred method of communication and any requested auxiliary
aids/services provided in the customer's record. Documentation, with supporting justification, must also be made if any request was not honored. The
provider shall submit compliance reports monthly, not later than the 15th day of each month, to the department's Grant or Contract Manager. The
provider shall distribute Customer Feedback forms to customers or companions, and provide assistance in completing the forms as requested by the
customer or companion.
6. If customers or companions are referred to other agencies, the provider must ensure that the receiving agency is notified of the customer's or companion's
preferred method of communication and any auxiliary aids/service needs.
II. THE DEPARTMENT AGREES:
A. Contract Amount
The department shall pay for contracted services according to the terms and conditions of this contract of an amount not to exceed $81,733.00 or the rate
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.
B. 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 Chief Financial Officer pursuant to section 55.03, F.S., will be due and payable in addition to the invoice
amount. 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 detennined. Financial penalties will be calculated at the daily interest rate of .033330/0. Invoices returned to a provider due to preparation errors will result
in a non-interest bearing payment delay. Interest penalties less than one (I) dollar will not be paid unless the provider requests payment.
CF Standard Contract OS/20 I 0
6
Contract # KG065
c. Vendor Ombudsman
A Vendor Ombudsman has been established within the Department of Financial Services. The duties of this office are found in section 215.422, F.S., which
include disseminating information relative to prompt payment 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 shall be sent to the representative of the provider responsible for administration of the program, to the designated address
contained in this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall begin on July I. 20 10, 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. 20 II.
B. Financial Penalties for Failures to Comply with Requirement for Corrective Actions
I. In accordance with the provisions of section 402. 73( I), F.S., and Rule 65-29.00 I, F.A.C., 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, shall be based upon the
severity of the noncompliance, nonperformance, or unacceptable performance that generated the need for corrective action plan. The penalty, ifimposed,
shall 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 performance of administrative tasks shall result in the imposition of a two percent (20/0) penalty.
4. The deadline for payment shall be as stated in the Order imposing the fmancial 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 tenninated 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 tenninated 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-I.006(3), F.A.C. The department's failure to demand performance of any
provision of this contract shall not be deemed a waiver of such performance. The department's waiver of anyone breach of any provision of this contract
shall not be deemed to be a waiver of any other breach and neither event shall 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 perfonned 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: (I) previously failed to satisfactorily perform in a contract with
the department, been notified by the department of the unsatisfactory performance, 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 this contract 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 level 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.
CF Standard Contract OS/20 I 0
7
Contract # KG06S
E. Official Plyee and RepreseJltatives (Names, Add~, Telephone Numbers, and e--maU addresses):
1. The provider name. as shown on page 1 of this con1ract, and mailing
address of the official payee to whom the payment shall'be made is:
Name: Monroe Countv
Address: 1100 Simonton Street
3. The name. address. telephone number and 'e-mail address of the' contract manager
{or the department for this contract is:
Name: Theresa Phelan
Address: 11 I J 12Ul Street
City: Key'West State:FL Zip Code:33040
Phone: 305-2924510
ext:
City: Key West. State: FL Zip Code: 33040
Phone; 305-292-6810
ext:
e-mail: trixiephe1an@dcf.state.fl.us
4. The name. address, telephone number and e-mail of the representative of the
provider responsible for administration of the progmD under this contract is:
Name: Sh~l~
Address: ] 100 Simonton Street
2. The name of the contact person and Street address where financial and
administrative records are maintained is:
Name: Shety] Graham
Address: 1100 Simonton Street
City: Key West State:FL Zip Code:33040
Phone: 305-292-4510
ext:
e-mail: graham-sheryl@nnonroecounty-tl.gov
City: Key West State:FL Zip Code:33040
Phone: 305-2924510
ext:
e..mail:graham-sheryl@monroecounty-fl.gov
5. Upon change of representatives (names, addresses. telephone numbers and e-mail addresses) by either party, notice shall be provided in writing to the other party and
the notification attached to the originals of tbis contract.
F. All Terms and Conditions Included
This contract and its attachmmts, I II and exhibits A. B. C. D & E and any exhibits referenced in said attachments. togetlw with any documents incorporated by
reference, contain aU 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, eitber verbal or wrinen between the parties. If any term or provision of this
contract is legally determined unlawful or unenforceable. the remainder of the contract shaD remain in full force and effect and such term or provision shaD be stri.cken.
By signing this CODtract, th . rties a~ that they have read and agree to the entire contract, al deseribed. 18 Parqraph In. F. above.
IN WITNESS. THEREO, e parti 0 lui caused this 40 page contract to be executed by their undersigned officials as duly authorized.
PROVIDER: . MON U FLORIDA DEPARTMENT O.F CHILDREN AND FAMILIES
Signature:
Printlfype
Name:
~L/~ f;/~
Gilda P. Ferradaz
Signature:
Printlfyp,e
Name:
Title:
TIde:
arcutt Administrator
eo! eS-IICJ
,Date:
JUN 1 6 2010
Date:
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal Tax In ~..~O~~~,~1:~,~49 Pro~der FIscal Year Ending Date: ~.
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CF Standard Contract OS/2010
8
Contract # ~
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
ATTACHl\'IENT I
A. Services to be Provided.
1. Definition of Terms
3. Contract Terms
Contract terms used in this document can be found in the Florida Department
of Children and Families Operating Procedure (CFOP) 75-2, Glossary of
Terms, which is incorporated herein by reference and can be obtained from
the contract manager.
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) Client. Any person ages 18 through 59 having one (1) or more permanent
physical or mental limitations that restrict the person's ability to perform
normal activities of daily living, and impede the person's capacity to live
independently or with relatives or friends without the provision of
community-based services.
(3) Medicaid Institutional Care Program (MICP). A program designs to
provide primary, acute, and long-term care services at capitated federally
matched rates to Medicaid recipients who are determined eligible for a
nursing home level of care.
(4) Nursing home. Any facility that provides nursing services as defined in
Chapter 464, Florida Statutes, and which is licensed in accordance with
Chapter 400, Florida Statutes.
(5) Outcomes - Quantitative indicators that can be used by the department to
objectively measure a provider's performance toward a stated goal.
(6) Outputs - Process measures of the quantity of services delivered, clients
served, or similar units completed.
(7) Performance Measures - Quantitative indicators, outcomes and outputs,
that can be used by the department to objectively measure a provider's
performance.
(8) Service Providers. Private, for-profit, nonprofit or local government
agencies designated to provide coordination of care for eligible clients.
Monroe County
9
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
Service Providers can be case management providers, direct service
providers, or both.
2. General Description
a. General Statement. 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.
b. Authority. Sections 410.601-410.606, Florida Statutes, 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. Under this contract, the CCDA program provides link
to community-based services that are designed to prevent inappropriate
institutionalization of disabled adults.
3. Clients to be Served.
8. General Description
Adults with disabilities, age eighteen (18) through fifty-nine (59), who are no
longer eligible to receive children's services, and are too young to qualify for
community and home-based services for the elderly, may be served under the
provisions of this contract.
b. Client Eligibility
(1) Applicants must have one or more permanent physical or mental
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 follo\ving manners:
(a) An applicant may present a check, award 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, licensed nurse practitioner, or mental health professional,
:\'Ionroe County
10
PSMAI # GA07
KG065
07/01/2008
\1 onroe County
Community Care for Disabled Adults/Fixed Price
Adult Services Program
which meets the Region'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 department case management staff, in accordance with
subsection 410.604 (2), Florida Statutes.
(2) The department will make the final determination of client eligibility.
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 Regional area.
(2) Clients must not be receiving comparable services from any other 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) To the extent that funds are available, the provider will receive referrals
for clients on whom the Human Service counselors have completed an
Adult Services Screening for Consideration for Community Based
Programs, Exhibit A.
11
PSMAI # GA07
KG06S
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
B. Manner of Service Provision
1. Service Tasks
a. Task List
(1) Service providers will ensure that appropriate community-based services
are provided to clients in a manner designed to meet the client's changing
needs, to assist the client in avoiding or reducing unnecessary dependence
on the delivered service(s), and to increase the client's self-reliance.
(2) The following tasks shall be performed under this contract:
DAdult Day Care X Case DEmergency Alert
Management Response
X Personal Care DHome Health DGroup Activity
Aide Therapy
X Homemaker DHome Nursing X Home Delivered Meals
DInterpreter DTransportation DMedical Therapeutic
Services
DChore DRespite DPhysical and
Exams
DEscort DAdult Day Health
Care
(3) Details of services to be provided under this contract and the negotiated
parameters of those services include: Case Management to be performed
by provider staff; Personal Care and Homemaker services to be performed
by subcontracted vendor. Home Delivered Meals to be purchased through
subcontract and then delivered by provider staff.
(4) Each Regional CCDA program must include case management services
and at least one other community service.
b. Task Limits
The following task limits apply only to the services specified above.
(1) Respite Care services may be provided for up to two hundred forty (240)
hours per client 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 an immediate
supervisor. Documentation of approval must be evident in the case
narrative section of the case manager's file.
~Ionroe County
12
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(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.
(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 referral from the case
manager;
(b) accept gifts from clients;
(c) lend or borrow money or articles 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) Region task limits, which exceed those in CFOP 140-8, Community Care
for Disabled Adults Operating Procedures, and are distinctive to this
contract, are listed here: None.
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
J\ilonroe County
13
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
provide the required quality or quantity of service due to stafftumovers or
shortages.
b. Professional Qualifications
The provider will ensure that staff meets the professional qualifications for
each service, as specified in CFOP 140-8, Community Care for Disabled
Adults Operating Procedures.
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 service delivery, as
stipulated in 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 allows the provider to subcontract for the provision of the
following services under this contract: Personal Care, Homemaker and
Home Delivered Meals. The provider may not subcontract services not
listed. All subcontracting is subject to the provisions of Section 1.1. of the
Standard Contract.
3. Service Location and Equipment
Monroe County
a. Service Delivery Location and Times
(1) Services for this contract will be delivered at the following locations and
times:
SERVICE LOCA TION TIMES
Case Management Client's Home As Needed
Personal Care Client's Home As Needed
Homemaker Client's Home As Needed
Home Delivered Meals Client's Home As Needed
(2) CCDA services may be delivered in the client's home or on-site at a
facility, as negotiated by the department and the provider.
(3) Facilities delivering on-site services to clients shall pass an annual
inspection by the local environmental health and fire authorities.
14
PSMAI # GA07
KG06S
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(4) Service providers will meet the minimum service location and time
requirements as specified in CFOP 140-8, Community Care for Disabled
Adults Operating Procedures.
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, ten
( 1 0) 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 Region'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) If equipment is applicable to a specific provider's contract, the provider
must submit an equipment listing (Exhibit N/ A) to the department which
lists the equipment. The equipment required to perform the contracted
services must be negotiated by the department and the provider. To
ensure uniformity, safety, and quality of service to clients, any requests for
equipment change must be presented in writing to the contract manager
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 list 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 N/ A), as
applicable to the provider's contract for specitic services.
4. Deliverables
"'onroe County
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 and costs, are listed in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures.
15
PSMAI # GA07
KG065
07/01/2008 Community Care for Disabled Adults/Fixed Price
Adult Services Program
b. Records and Documentation
(1) Client Records (all clients)
Providers shall 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 of service provision and delivery;
(d) information documenting the client's need to receive services;
(e) the number of service units provided; and
(t) all other forms or records necessary for program operation and
reporting, as set forth by the department.
(2) Case Management Client records.
Case management agency individual client files shall contain the
following:
(a) a completed client assessment (no more than one (1) year old);
(b) a care plan (no more than one (1) year old);
(c) a release of information form;
(d) a copy ofa completed Adult Services Information System (ASIS)
form;
(e) documentation of the client's age, disability, and income;
(t) a completed and scored copy of the Adult Services Screening for
Consideration for Community Based Services; and
(g) a case narrative.
(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.
"lonroe County
16
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(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
Report Title Reporting Report Date Number DCF Office addresses
Frequency Due of copies to receive report
due
Monthly Monthly The 15th of two Contract
Cumulative month Manager
Summary immediately &
Report following the Program
report period Office
Reporting requirements for this contract include:
(1) Exhibit B, Monthly Cumulative Summary Report. Regions will negotiate
with the provider on specific submission requirement criteria for these
reports.
(2) 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.
(3) Acceptance of Reports. Where the contract requires the delivery of
reports to the department, mere receipt by the department shall not be
construed to mean or imply acceptance of those reports. It is specifically
intended by the parties that acceptance in writing of required reports shall
constitute a separate act. The department reserves the right to reject
reports as incomplete, inadequate, or unacceptable according to the
parameters set forth in the contract. The department, at its option, may
allow additional time within which the provider may remedy the
objections noted by the department or the opportunity to complete, make
adequate, or acceptable, or declare the resulting contract to be in default.
5. Performance Specifications
a. Performance Measures
(1) Ninety eight percent (98%) of adults with disabilities receiving services
will not be placed in a nursing home.
'-'I on roe County
17
PSMAI # GA07
KG065
07/01/2008
.\tlonroe County
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(2) 25: # of qualified disabled adults (ages 18-59) provided case management.
(3) 3: # of qualified disabled adults (ages 18-59) in 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
Measuring Outcomes. The department will measure the outcomes found in
paragraph B.5.a. above as follows:
(1) The outcome measurement contained in paragraph B.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.
(2) The outcome measurement contained in paragraph B.5.a. (2) above will be
calculated by the total number of clients actively receiving case
management from the Community Care for Disabled Adults, Home Care
for Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs.
(3) The outcome measurement contained in paragraph B.5.a (3) above will be
calculated by the total number of clients actively receiving daily living
services from the Community Care for Disabled Adults and the Medicaid
waIver programs.
d. 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 will 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 up to six months for the provider to achieve compliance with the
standards. If the department affords the provider an opportunity to achieve
compliance and the provider fails to achieve compliance within the specified
time frame, the department must cancel the contract in the absence of any
extenuating or mitigating circumstances. The determination of the
extenuating or mitigating circumstances is the exclusive determination of the
department.
18
PSMAI # GA07
KG065
07/01/2008 Community Care for Disabled Adults/Fixed Price
Adult Services Program
6. Provider Responsibilities
a. All Providers Unique Activities
Health Insurance Portability and Accountability Act. If required by 45
CFR Parts 160, 162, and 164, the following provisions shall apply [45 CFR
164.504( e)(2)(ii)]:
(1) 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 .
(2) 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.
(3) The provider agrees to report to the department any use or disclosure of
the information not provided for by this contract or applicable law.
(4) 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.
(5) The provider agrees to make PHI available in accordance with 45 C.F.R.
164.524.
(6) 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.
(7) The provider agrees to make available the information required to provide
an accounting of disclosures in accordance with 45 C.F .R. 164.528.
(8) 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.
(9) 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
:\tlonroe County
19
PSMAI # GA07
KG065
07/01/2008
\1 onroe County
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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.
(10)A violation or breach of any of these assurances shall constitute a material
breach of this contract.
b. Direct Service Provider Unique Activities
(1) 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 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 case management agency or Adult Services
local office of all service terminations, service increase requests and
monthly expenditure trends with regards to the terms of this contract.
(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 an Adult Services
counselor.
(6) The provider shall provide to individuals requesting services a contact
name and phone number to the nearest Adult Services Region Office.
c. Case Management Provider Unique Activities
(1) The case management provider will accept all referrals through the Adult
Services Regional Program Office.
(2) The case management provider will complete ongoing face-to-face
assessments on all pre-screened individuals referred by the Adult Services
Regional Program Office for service consideration and program
application, using the Adult Services Client Assessment, CF-AA 3019.
20
PSMAI # GA07
KG065
07/01/2008
\'lonroe County
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(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, including all corrected claims and adjustments to
claims for services that were delivered to consumers being served through
this contract.
(5) The CCDA case management agency will notify the local Adult Services
office of all service terminations, service increase requests, Exhibit C, and
monthly expenditure trends with regards to the terms of this contract.
(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.
(7) The case management provider shall provide to individuals requesting
services a contact name and phone number to the nearest Adult Services
Region Office.
d. 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 service delivery continuums.
7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply all 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.
21
PS!\'I AI # GA07
KG06S
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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 Clause
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, 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.
FY 2010-2011 Service Unit Unit Price
Service
Case Management Hour $49.89
Personal Care Hour $25.28
Homemaking Hour $21.79
Home Delivered Meals Meal $ 6.30
d. The provider's dollar match for this contract is as follows:
For Fiscal Year 2010-2011: $9,081.00
e. Cash or in kind resources may be used to meet this match requirement.
Monroe County
22
PSMAI # GA07
KG06S
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
2. Invoice Requirements
The provider shall request payment through submission of a properly completed
Monthly Request for Payment and Expenditure Report, Exhibit D, within 15 days
following the end of the month for which payment is being requested. The provider shall
submit to the contract manager an original Monthly Request for Payment and
Expenditure Report, Exhibit D, 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.
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 \vill 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
Monroe County
23
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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. Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, Florida Statutes,
Part I, Transportation Services, and Chapter 41-2, F .A.C., Commission for the
Transportation Disadvantaged, if public funds provided under this contract will be
used to transport clients.
4. MyFloridaMarketPlace Transaction Fee
This contract is exempt from the MyFloridaMarketPlace Transaction Fee in
accordance with Chapter 60A-l.032(1) (e), Florida Administrative Code.
5. Incident Reporting
The provider is required to document all reportable incidents, as defined in CFOP
215-6, Incident Reporting and Client Risk Prevention, which is incorporated herein
by reference.
For each critical incident occurring during the administration of its program, the
provider must, within 24 hours of the incident, complete and submit an Incident
Report (Exhibit E) to the contract manager for this contract. 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 contract manager.
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 contract
manager 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.
6. Mandatory Reporting Requirements
The provider and any subcontractor must comply with and inform its employees of
the following mandatory reporting requirements. Each employee of the provider, and
of any subcontractor, providing services in connection with this contract who has any
knowledge of a reportable incident shall report such incident as follows: 1) reportable
incidents that may involve an immediate or impending impact on the health or safety
of a client shall be immediately reported to the contract manager; and 2) other
reportable incidents shall be reported to the department's Office of Inspector General
by completing a Notification/Investigation Request (form CF 1934) and emailing the
.\lJonroe County
24
PSMAI # GA07
KG065
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
request to the Office of Inspector General at ig complaints(a1dct~state.tl.us. The
provider and subcontractor may also mail the completed form to the Office of
Inspector General, 1317 Winewood Boulevard, Building 5, 2nd Floor, Tallahassee,
Florida, 32399-0700; or via fax at (850) 488-1428. A reportable incident is defined in
CFOP 180-4, which can be obtained from the contract manager
7. Contract Term
The department and the provider agree that this contract shall be for a one year term,
at the provider's request.
E. List of Exhibits
1. Exhibit A, AS Screening for Consideration for Community-Based Programs
2. Exhibit B, CCDA Monthly Cumulative Summary Report
3. Exhibit C, Request for Approval of CCDA Care Plan Services Increase
4. Exhibit D, Monthly Request for Payment and Expenditure Report
5. Exhibit E, Incident Report
Monroe County
25
PSI\t1 AI # GA07
KG065
Exhibit A
,-1, :..'~;~."..';;~~..-:'~'~
qq:,
PART I
1. Name:
AS Screening for Consideration for Community-Based Programs
A. Date of Referral (Initial Contact):
B. D Walk In D Phone D Other:
C. Referral Source (include phone number):
2. Address:
District/Region:
3. Phone:
D. Relationship to Individual Being Referred:
4. Race:_ Gender:_ Age/DOB:
5. Marital Status:
E. Is Individual Aware of Referral? DYes D No
6. Social Security Number:
7. Primary Language:
8. Medicaid D Number:
9. Medicare 0 Number:
10. Other Insurance:
12. Other Essential Person(s): physician, family member(s), POA, guardian, caregiver
(include address and phone number)
11. Financial: (for Placement
& Supportive Services only)
$
$
$
$
$
(S5DI)
(S51)
(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: D Protective Intervention Placement D Protective Intervention Supportive Services D Short-Term Case Mgmt.
D Information & Referral D CCDA Application D ADA Medicaid Waiver Application D HCDA Application
D CCDA Waiting List - Score _ D ADA Medicaid Waiver Waiting List - Score _ D HCDA Waiting List - Score _
21. Due Process Pamphlet (CF/PI140-43) Given/Mailed by:
Date:
23. Reviewed/Approved by:
By:
Date:
Date:
22. Given to Supervisor for Review by:
24. PART I sent to:
25. Referred to AS Counselor/Case Manager:
CF-AA 1022, PDF 10/2005
Date:
Date:
Page 1 of 4
26
PART II
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26. Check sources of information used for FUNCTIONAL ASSESSMENT Section.
o Individual Requesting Services 0 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 services 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 services 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 Dart of the activity.
Can't do it at all: Individual cannot complete activity without total Dhvsical assistance from another person.
Total Score: Add numbers from "Some help" and UCan't do it at all" 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)
o = No help 2 = Some help 3 = Can't do it at all
Comments/Care Plan Implications:
(Include services, supplies eQuipment, etc.)
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
hair)
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. Toileting (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
help)
33. Bladder/Bowel Control - How well can you control
your bladder or bowel? 0
- Never have accident (0)
- Occasionally have accidents (2) Enter Score
- Often have accidents (3)
- Always have accidents (4)
ADL Total Score
(Total possible score = 19) 0
Page 2 of 4
27
INSTRUMENTAL ACTIVITES OF CAlLY 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, supplies, equipment, etc.)
34. Transportation Ability (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.
o 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
45. Home delivered meals
(Formal only)
46. Any other kind of help
(Specify)
Page 3 of 4
28
PART 111- 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."
For item 7, enter the score for ADLs and IADLs from the screening form. For item 8, subtract 40 points if the individual
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.
I Domain/Question Score I
1. Is individual requesting services a victim and at high risk of abuse,
neglect, or exploitation based on Protective Investigator's report? 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 individual solely responsible for
minor children (under the age of 12) in the home? Yes (1 pt.)
4. Is individual homebound? (See AS Saeening for Consideration
for Community-Based Programs INSTRUCTIONS for definition of Yes (1 pt.)
homebound.)
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? Yes (3 pt.)
7. Functional Assessment: ADLs... ...... ... ... . ... .. .. . ... . .. ... .. .... .... 0 (enter ADL total score)
IA D Ls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 (enter IADL total score)
8. Support for Individual Requesting Services:
Does individual currently receive help/services (formallinformal) in
ADL or IADL deficit areas noted? No help (4 pt.)
Help is available but overall inadequate or
changing, fragile or problematic (2 pt.)
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.") Specify program(s) to
which individual is being referred for eligibility determination and
steps taken to refer individual to other program(s).
Minus 40 pt.
HCDA
o
TOTAL SCORE
(Total Possible Score = -40 to +40)
CCDA
o
ADA MW
o
Page 4 of 4
29
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l
Exhibit C
Request for Approval of CCCA Care Plan Services Increase
Part I ReCipient Information
Name: Last name, first name, middle name or initial
Date of birth:
Social security number:
Medicaid/Medicare Medical assistance number:
Current Address:
Address where services will be received:
County:
County:
Status (Transfer/Existing): Describe reason for service funding increase.
If individual is a transfer, indicate originating district/agency: An Adult Services client reassessment was completed on
by and
respective revised care plan revisions made on
If individual is an existing consumer with your agency,
indicate current monthly authorized units of service by
service type( s):
by , to
reflect that this Recipient is justifiably in need of increased
Service(s) based on (check all situations which apply):
D Failing Support System
D Decrease in Functional Capacity
D Rapidly Deteriorating Health
Medicaid waiver eligibility date:
Provider Information
Agency name: Agency contact person:
Agency address:
Phone:
Fax:
E-mail address:
Part II: Summary of Recipient's Presenting Situation. (Refer to form instructions for details about the type of information
required here. Use the space below or include attachment.)
Part III: Proposed New Service Request. (Please indicate the new care plan services being requested and the corresponding,
anticipated service start dates.)
Service Anticipated start date Service Anticipated start date
31
KG065
Part IV: Specific Description of Proposed New Service(s) As Tailored To Meet Recipient's Need. (Refer to the form
instructions for details about the type of information required here. Use the space below or include attachment.)
Part V: Cost Detail for Proposed New Care Plan Service(s).
A. Attach a Cost Detail page for each service requested in Part III. Each Cost Detail page should reflect the total
annual cost of serving the consumer for that service type.
Part VI: Care Plan Modification of Number of Service Units. The Budget Entity Team will not consider authorization to
increase service unit quantity of an authorized service on a Recipient's care plan for any of the following documented
reasons unless this section is accurately and fully completed.
[To justify unit service rates, please present comparative information: unit rate quotes from a minimum of three other service
agencies providing this same service within a ten mile radius; reasons for choosing this specific vendor; a statement attesting to the
fact that selected vendor is a sole source provider of this service in this geographic area, etc. Attach information as necessary (e.g.,
agency administrative costs, your agency salary scale, etc.). Refer to the form instructions.]
D Failing Support System: List proposed add-on number of monthly service units by service component with annualized
service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
D Decrease in Functional Capacity: List proposed add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
D Rapidly Deteriorating Health: List care plan add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
Part VII. Signatures. (Please note: Final approval of all requests for Care Plan increases rest with the Budget Entity Team.
Providers will receive an Award Letter from the Budget Entity Team (or one of its members) when the plan has been apJ roved.)
Provider Agency: (Signature indicates that the information presented in this Request for Care Plan Services Date:
Increase and attachments are accurate and complete.)
RecipienURepresentative: (Signature indicates that the Recipient/Representative has reviewed the Request for
Care Plan Services Increase and attachments.)
Date:
DistrictJRegional Program Staff: (Signature indicates that the district/regional program staff and provider have
agreed upon the services to be funded.)
Date:
DistrictJRegional Adult Services Program Director: (Signature indicates district/regional approval of the Service
Funding Plan.)
Date:
32
KG065
EXHIBIT D
DEPARTMENT OF CHILDREN AND FAMILIES
ADULT SERVICES OFFICE
MONTHLY REQUEST FOR PAYMENT AND EXPENDITURE REPORT
PROVIDER FED. 10 #
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 DEDUCTIONS
REMAINING MATCH BALANCE
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
*IF THIS INVOICE IS FOR A FIXED PRICE CONTRACT. THE REQUEST FOR PAYMENT WILL BE DETERMINED
BY DIVIDING THE LENGTH OF THE CONTRACT INTO THE CONTRACTED AMOUNT (EX.-$12.000[ALLOCATION] DIVIDED BY
12 MONTHS [THE LENGTH OF THE CONTRACT]=$1.000 PAYMENT REQUEST) ON A COST REIMBURSEMENT CONTRACT
THE PAYMENT REQUEST WILL BE THE MONTHLY REQUEST EXPENSE.
CHILDREN AND FAMILIES USE ONLY
DATE INV. RCD.
APPROVED BY:
DATE
IORG
EO
OBJ
DESC.
AMNT.
IOCA
33
KG065
Exhibit E
Circuit 11 & 18
INCIDENT REPORT
CONFIDENTIAL
WARNING: The information contained in this report is confidential. You are hereby notified that dissemination, distribution, or
copying of this document is strictly prohibited, unless authorized by the Department of Children & Families.
I. IDENTIFYING INFORMATION
Reporting Party Phone #:
Reporting Party Name
Date of Incident _'_'_ Time of Incident
Specific Program: check all that apply
DAMH DAS DASA DCMH DCSA DOA Doc DDD D ESS D FS
Please respond to one of the following as appropriate.
a. Contract Provider Name
b. Foster Home Name c. DS Horn e Name
d. DCF Facility Name e. Other Nam e
Did the incident occur in a licensed facility? DYes D No D Don't know.
Specific location/address where incident occurred:
II. TYPE OF INCIDENT
Check one box only.
1. Altercation:
DClient/client DClient/staff D Staff/staff
2. D Client Death
3. D Client Injury or Illness
4. D Elopement/Runaway
5. D Escape
6. D Sexual Battery
7. D Suicide Attempt
8. D Other Incidents
III. PARTICIPANT(S) I WITNESS(ES) (Please check one from each side)
FIRST Name LAST Name SSI Birth Date Race Gender C nent Employee Other Participant Witnes. Other
_1_1- 0 0 0 0 0 0
_1_1- 0 0 0 0 0 0
_1_1- 0 0 0 0 0 0
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KG065
IV. DESCRIPTION OF INCIDENT
Give Detailed Account - (Who, What, When, Where, Why, How) - Add Pages If Necessary
V. CORRECTIVE ACTION AND FOllOW UP
Immediate corrective action taken
Is follow-up action needed? NoD
YEsD
If yes, specify:
35
VI. INDIVIDUALS NOTIFIED
EXTERNAL NOTIFICATION
Agency Notified Person Contacted Status OatelTime Called Copy
Abuse Registry Name Report Accepted
1-800-962-2873 D D
ID# Yes D NoD
Agency for Health Care
Administration Name: N/A D D
Law Enforcement-Department Officer's Name
I I Badge # Case # (if avail) N/A D D
Parent/Guard ianl
Family Member Name Name: N/A D D
Other (Please Specify)
Name: N/A D D
Other (Please Specify)
Name: N/A D D
DCF (for providers only) Name: N/A D D
VII. REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
REPORTING ~~-
EMPLOYEE
SUPERVISOR ~_/-
DCF INTERNAL NOTIFICATION
Individual/Agency Notified Oaterrlme Called Copy Individual/Agency Notified Oatemme Called Copy
D D D D
Client Relations Employee Safety Program
Regional Deputy Director D D H.R. Workers' Compensation D D
Coordinator (employee related incidents only)
D D D D
Program Supervisor Missing Children's Unit
District Legal Counsel D D Contract Manager D D
D D Others (Please specify) D
Public Information Officer D
VIII. DCF REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
Incident Report _/~-
Liaison
QA Review / /
36
INCIDENT DEFINITIONS
The definitions apply to DCF direct or contractual services/employees
1. Altercation. A physical confrontation occurring between a client and employee or two more
clients at the time services are being rendered, or when a client is in the physical custody of
the department, which results in one or more clients or employees receiving medical treatment
by a licensed health care professional.
2. Client Iniurv/lllness. A medical condition of a client requiring medical treatment by a licensed
health care professional sustained or allegedly sustained due to an accident, act of abuse,
neglect or other incident occurring while in the presence of an employee, in a Department of
Children and Families or contracted facility or service center or who is in the physical custody
of the department.
3. Client Death. Any person whose life terminates due to or alleged due to an accident, act of
abuse, neglect or other incident occurring while in the presence of an employee, in a
Department of Children and Families operated or contracted facility or service center, while in
the physical custody of the department; or when a death review is required pursuant to CFOP
175-17,Child Death Review Procedures.
4. Escaoe. The unauthorized absence as defined by statute, departmental operating procedure
or manual of a client committed to, or securely detained in a Department of Children and
Families mental health or developmental services forensic facility covered by Chapters 393,
394 or 916, FS.
5. Sexual Batterv. An allegation of sexual battery by a client on a client, employee on a client, or
client on an employee as evidenced by medical evidence or law enforcement involvement.
6. Suicide Attemot. An act which clearly reflects the physical attempt by a client to cause his or
her own death while in the physical custody of the department or a departmental contracted or
certified provider, which results in bodily injury requiring medical treatment by a licensed health
care professional.
7. Other Incidents. An unusual occurrence or circumstance initiated by something other than
natural causes or out of the ordinary such as a tornado, kidnapping, riot or hostage situation,
which jeopardizes the health, safety and welfare of clients who are in the physical custody of
the department.
37
ATTACHMENT II
The administration of resources awarded by the Department of Children & Families to the provider may be
subject to audits as described in this attachment.
MONITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-133 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 staft: 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 Financial 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-I33, 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 of OMB 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-I33, 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-I33, 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 fmancial 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.
Single Audit Information for Recipients of Recovery Act Funds:
(a) To maximize the transparency and accountability of funds authorized under the American Recovery and
Reinvestment Act of2009 (Pub. L. 111-5) (Recovery Act) as required by Congress and in accordance with
2 CFR 215.21 "Uniform Administrative Requirements for Grants and Agreements" and OMB Circular A-
102 Common Rules provisions, recipients agree to maintain records that identify adequately the source and
application of Recovery Act funds. OMB Circular A-I02 is available at
http://www. whitehouse.gov/omb/circulars/al 02/a 1 02.html.
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KG065
(b) For recipients covered by the Single Audit Act Amendments of 1996 and OMB Circular A-133,
"Audits of States, Local Governments, and Non-Profit Organizations," recipients agree to separately
identify the expenditures for Federal awards under the Recovery Act on the Schedule of Expenditures of
Federal Awards (SEFA) and the Data Collection Form (SF-SAC) required by OMB Circular A-133. OMB
Circular A-133 is available at http://www.whitehouse.gov/omb/circulars/a133/a133.html.This shall be
accomplished by identifying expenditures for Federal awards made under the Recovery Act separately on
the SEFA, and as separate rows under Item 9 of Part III on the SF-SAC by CFDA number, and inclusion of
the prefix "ARRA-" in identifying the name of the Federal program on the SEFA and
as the fITst characters in Item 9d of Part III on the SF-SAC.
(c) Recipients agree to separately identify to each subrecipient, and document at the time of sub award and
at the time of disbursement of funds, the Federal award number, CFDA number, and amount of Recovery
Act funds. When a recipient awards Recovery Act funds for an existing program, the information furnished
to subrecipients shall distinguish the sub awards of incremental Recovery Act funds from
regular sub awards under the existing program.
(d) Recipients agree to require their subrecipients to include on their SEF A information to specifically
identify Recovery Act funding similar to the requirements for the recipient SEF A described above. This
information is needed to allow the recipient to properly monitor subrecipient expenditure of ARRA funds
as well as oversight by the Federal awarding agencies, Offices of Inspector General and the Government
Accountability Office.
PART II: STATE REQUIREMENTS
This part is applicable if the recipient is a nonstate entity as defined 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 fmancial assistance expended during its fiscal year, the recipient shall consider all
sources of state financial assistance, including state fmancial 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 nons tate 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 ofa 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.
39
KG06S
PART 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 of the audit report, whichever occurs first, directly to each of the following
unless otherwise required by Florida Statutes:
A. Contract manager for this contract (2 copies)
B. Department of Children & Families ( 1 electronic copy and management letter, if issued )
Office of the Inspector General
Single Audit Unit
Building 5, Room 237
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
Email address:singleaudit@dcf.state.fl.us
C. Reporting packages for audits conducted in accordance with OMB Circular A-133, as revised, and
required by Part I of this 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
using the Federal Audit Clearinghouse's Internet Data Entry System at:
http://harvester.census.goy/fac/collect/ ddeindex. htm 1
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 II of this agreement shall be submitted by or on behalf
of the recipient directly to the following address:
Auditor General
Local Government Audits/342
Claude Pepper Building, Room 401
111 West Madison Street
Tallahassee, Florida 32399-1450
Email address:flaudgen_Iocalgovt@aud.state.fl.us
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 of the 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 of three years from the date the audit report is issued,
unless extended in writing by the department.
40
KG06S