07/11/1986CCNTRACT
THIS CONTRACT entered into on this first day of July 1986,
between the Board of County Commissioners of Monroe County as the
governing body of the County exercising supervision and control
over Monroe County In -Home Services, the Community Care for .the
Elderly (CCE) Lead Agency for Monroe County, hereinafter referred
to as the Lead Agency, and Florida Health Nursing Services, Inc.,
hereinafter referred to as Florida Health, for the provision of
nursing services to qualified individuals within Monroe County in
accordance with the Community Care for the Elderly (CCE) program
guidelines and Local Service Program (LSP) guidelines promulgated
by the State of Florida Department of Health and Rehabilitative
Services.
The Parties agree:
1. Florida Health will do the following:
A. Make home visits to CCE clients for initial and
follow-up review as assigned by the Lead Agency. Such visits
shall be made by and the services provided hereunder shall be
rendered by a Registered Nurse in accordance with HRS manual
140-4, Community Care for the Elderly Program.
B. Complete a CCE Care Plan and/or a CCE
Re -Evaluation Form as indicated by the Lead Agency for each
client visit made.
C. Deliver to the Lead Agency office those forms
completed for client visits. at designated by the Lead Agency, no
later than the 15th and 30th day of each month.
D. Complete accurate monthly mileage reimbursement
request forms for submission to the Lead Agency, no later than
the last work day of the month.
E. Comply with all Federal and State Laws, rules and
regulations including, but not limited to, the following:
1) All applicable standards, criteria, and
guidelines of the Community Care for the
Elderly Program, the Local Services
Program, and any other applicable
guidelines or criteria established by the
Department of Health and Rehabilitative
Services, State of Florida or any other
applicable Federal or State Agency.
2) All applicable statutes, rules, regula-
tions, guidelines and Executive Orders
pertaining to civil rights and equal
employment opportunity.
It is expressly understood that upon receipt of substantial
evidence of any violation of these laws, rules, and regulations,
the Lead Agency shall have the right to terminate this contract
immediately.
F. Provide insurance. Florida Health shall maintain
Professional Liability Insurance or make adequate provision for
coverage through an approved insurance program. Florida Health
shall provide the Lead Agency with written proof of insurance
coverage prior to the commencement of this agreement.
G. Provide indemnification. Florida Health shall be
liable and shall hold the Lead Agency harmless from any and all
liability of any type, nature, or kind for any negligent acts or
inactions taken or that should have been taken in the performance
of the nursing services hereunder, including, but not limited to,
all claims, suits, judgments, damages, court costs, and attorney
fees. Florida -Health agrees to fully indemnify the Lead Agency
for any and all claims, suits, judgments, damages, court costs,
and attorney fees.
H. Safeguard information. Florida Health shall not
use or disclose any information concerning a recipient of services
under this contract for any purpose not in conformity with Federal
and State laws or regulations except on written consent of the re-
cipient or his responsible parent or guardian when authorized by law.
I. Maintain records in accordance with standard and
accepted audit procedures adequate for proper audit or program act-
ivities and'to make the same available to the Lead Agency or its
duly authorized representatives.
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2. The Lead Agency agrees to do the following:
A. Pay Florida Health on a "fee for service" basis the
sum of $15.00 for each initial or annual client visit and $10.00
for each 60 day follow-up visit, during which services are provided
to said client; as assigned by the Lead Agency. No fee will be paid
in the event that a client is not available when Florida Health
visits the home. Payment will be made on a twice monthly basis on
the 15th and the last day of each month and upon validation of the
statement of service on a from prescribed by the Lead Agency.
B. Provide the appropriate CCE forms to be completed by
Florida Health.
C. Provide a weekly assignment sheet listing the clients
to be visited.
D. Reimburse Florida Health for reasonable mileage
traveled in making client visits on the basis of 20o, per mile. Mile-
age reimbursement will be included the the second monthly payment.
No payment for mileage will be made in the event a client is not
available when Florida Health visits the home.
3. Florida Health together with the Lead Agency jointly agree
as follows:
A. This contract shall commence on July 1, 1986, and
shall terminate on June 30th, 1987.
B. --The total number of clients to be served under this
agreement shall not exceed 336 CCE elderly and LSP disabled clients.
The total number of visits to be made by Florida Health pursuant to
this agreement shall not exceed 168 per month. The total amount of
money payable hereunder shall not exceed $1,890.00 per month.
C. The contract provisions herein may be terminated for
the following causes:
1. Suspension for Reasonable Cause. The Lead Agency for
any reasonable cause, including but not limited to, failure to comply
with the reporting requirements provided herein, temporarily suspend
Florida Health pending corrective action or pending decision to ter-
minate this contract. Said Florida Health will not be entitled to
3
payment of any fee for service until it fully complies with all re-
quirements including the reporting requirements provided herein.
The Lead Agency may, for reasonable cause, prohibit Florida Health
from receiving further assignments and from incurring additional
obligation of payments pending corrective action or pending a dec-
ision to terminate this contract.
In order to terminate or suspend this contract, the Lead
Agency must notify Florida Health in writing of the action to be
taken, the reasons for such action, and. the conditions of the sus-
pension or termination. Said notice shall be afforded 10 days prior
to any action being taken pursuant to this provision.
The notification will also indicate what corrective act-
ions are necessary to remove the suspension and will stipulate a
reasonable time period to correct those actions.
2. Termination/Reduction Because of Lack of Funds. In
the event funds to finance this contract become unavailable or are
reduced, the Lead Agency may reduce or terminate the contract upon
no less than 24 hours notice in writing to Florida Health. The final
determination as to the availability of funds is to be made exclusive-
ly by the Lead Agency.
3. Termination for Breach. The Lead Agency and Florida
Health agree that this contract may be terminated upon evidence of
any violation of this agreement, including but not limited to, viol-
ation of any Federal or State law, rule or regulation. Such Termin-
ation shall be effective immediately upon written notice delivered
to Florida Health. A waiver of breach under any provision of this
contract shall not be deemed to be a waiver of any other breach and
shall not be construed to be a modification of the terms of the
contract.
4. Florida Health may give termination of this contract
upon thirty days written notice to Monroe County project director of
the Community Care for the Elderly (CCE) and Community Care for Dis-
abled Adults (CCDA) project.
4
D. In the event of the termination of this contract for
any reason, Florida Health shall furnish to the to Lead Agency such
reports, records, files and audit materials as may be requested
based upon work completed under the provisions of the contract.
E. Clients shall be accepted for provision of services
only by the Lead Agency.
IN WITNESS WHEREOF, the parties hereto have caused this contract
to be executed by the undersigned.
FLORIDA HEALTH NURSING SERVICES, INC.
B Y Cl�--lam
T ped Name
DATE: )
/'o
Attest: ie�n�•r--�
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
L1«%�M,i
NAME: QAt-)
DATE: /
Al ' S7- DANNY L. KOLHAGE, Clerk
BY:
D rector
DATE:
Attest:
5
ATTACHMENT: I
WORK P ROGRAM
The Florida Health Nursing Services, Inc. will provide the in -home
services of Registered Nurses to Monroe County In -Home Services. Nurses
will be provided on an assigned basis in the Lower Keys through the Key
West office and the Key West Case Manager, and in the Middle Keys through
the Marathon office and the Marathon Case Manager, and in the Upper Keys
through the Plantation office and the Plantation Case Manager.. The nurses
will provide in -home assessment of personal care and homemaker services
needs of clients on an initial visit upon the client's entry into the pro-
gram. Thereafter, the nurse will provide 60 day update visits for assess-
ment and supervision of service needs. The Registered Nurse will assess
whether activities in the case plan are being carried out properly; attend
or provide in-service training; review reports and records; have telephone
and personal conferences; and assist in performance evaluations. The Regis-
tered Nurse may also meet with the personal care aide to provide instructions
and demonstrations of care needs, -may make referrals to other public and
private agencies as he/she deems necessary, and may coordinate total care for
a client receiving multiple services.
1) Client assignment sheets may be delivered or mailed to each clinic site
by the area Case Manager on a bi-monthly basis.
2) The nurse returns the assignment sheet to the clinic nurse responsible
who will in turn return them to the area Case Manager as assignments are
completed. All assignments are to be completed within a two week period
after receipt.
3) Client information sheets will be provided to the clinics by the Case
Manager to be retained and updated by the field nurse.
4) On the initial visits, a care plan will be done. One copy is to be affix-
ed to the client's refrigerator, one copy sent to the Case Manager, and
one copy retained by the nurse.
5) 60 day process notes will be completed in duplicate -one copy to be re-
tained by the nurse and one copy for the Case Manager.
6) All paper work, as completed, may be returned to the Case Manager on a
bi-monthly basis.
7) All mileage is also to be submitted on a bi-monthly basis. Mileage and
-70-
WORK PROGRAM (continued)
visit sheets must be verified by the lead nurse in each clinic before
being sent to the Case Manager for approval. After the Case Manager's
approval, the Project Director and Executive Director must approve the
statement before it is forwarded to the Fiscal Department for payment.
The following forms will be used to facilitate the organization of this
system:
FORM 1: Tickler file form to be maintained by Case Managers for use in
tracking R.N. client visits.
FORM 2: R.N. assessment"sheet to be completed at the time of the R.N.'s
initial visit for use as a tool in planning and providing direct
services - to be updated annually.
FORM 3: R.N. follow-up form to be completed by R.N. during all subsequent
visits for use as a supervision and evaluation tool.
FORM 4: Medicaid Waiver letter to be completed by R.N.'s upon request from
Case Managers as mandated by HRS.
FORM 5: Monroe County audit slip used as the face sheet for forms 6 - 8
when requesting R.N. payment for services.
FORM 6: Memo from Florida Health Nursing Services, Inc. to In -Home Services
requesting payment.
FORM 7: Client assessment sheet on which Case Managers list clients and
deliver to R.N. Supervisors. Upon completion of client visits the
form is first submitted to Case Managers for approval and then
attached in the payment statement.
FORM: 8: Voucher reimbursement of traveling expenses to be completed by each
visiting nurse and submitted in the payment statement.
-71-
FORM 1
CLIENT I S NA,%jE:
ADDRESS:
PHONE:
...........................
Services: ft%f
Initiation Date:
PC Termination Date:
RS Initiation Date:
Chore Termination Date:
VOTES:
-NURSI!!G VISITS:
Initial:
By:
04 - . -72-
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G
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FORM 3
PERSONAL CARE NURSING PROGRESS NOTE
Date: To: •
Fran:
PHYSICAL AND rE TAL STATUS:
SERVICES RECEWM:
Sam:rl.E:
MRKER:
FEC-' -MMATICNS : -
ca•.grrrS:
------------------
SIC '%TURE :
MOUROE COUNTY IN -HOME SERVICES
-74-
FORM 4
• r
DEPARTM.EVT OF HEALTH AND REHABILITATIVE SERVICES
HOME AND MIMUNITY-BASED SERVICE WAIVER PROJECT
DATE:
SUBJECT: Services Required by
(Present Location)
(Telephone)
TO: Case ,tanager
Address
Telephone
I have reviewed the HRS-AA Form 3003 for the above referenced client and I understand;
that the Case Manager recommends that the client will remain in the community and
receive the following services:
Direct Services
CCE
Title X:C POS
Case Management
�— Chore
Escort
Counceling
Homemaker
L Homemaker
CJ Health Support
E= Personal Care
Placement Services
Respite Care
for Adults
Transportation
ED Case Management
---
(� Homemaker
�--��
Homemanagement
'•` D Escort
Since the client meets at least
II, described on the back of this
the following level of
for:,
care criteria for Intermediat
and except for
checked services in the community setting, would be
the provision of the above e
at
risk of nursing home Placement:
I CONCUR :•lITH THE RECO:IMENDATICN
i� I DO
IIOT CC::CUR WITH THE
F.EC Q:•L'•1E:1D,�TZ0:1
•
.
Medical Care Consultant
Date
Please return this form to
Case Manager
-75- Address
' MONROE COUNTY
BOARD OF COON r y COMM I SS I ONFR S
AUnI r S1 rN
Monroe County In -Home Services
Vendor:
Account Number Amount
--- -- Purchase Order No.
$
3
Date.
Approved:
Dept. Head or Authorized Rep.
FINANCE USE ONLY
Vendor No. PO No.— Voucher No. —
Date In Gate Due
Receiver
Vendor Invoice No.
Memo
Amount $ +/
Disc Dollars $ Check No.
ACCOUNT NUMBER --------
AM0UNT ACCOUNT No.
AMOUNT— -- _
+/_
$
S_ • --- -- — S - ----
-76-
- --..der..-�_•- •y�•a ---a•' �-•.i ls.ifni::�-,�...�..b.eriiiwr.
MEMORANDUM
TO: GWEN RODRIGUEZ, PROJECT DIRECTOR
MONROE COUNTY IN -HOME SERVICES
PUBLIC SERVICE BUILDING
WING III - STOCK ISLAND
KEY WEST, FLORIDA 33040
FROM: MARY JANE QUINN, DIRECTOR OF NURSING
FLORIDA HEALTH NURSING SERVICES, INC.
1111 12th STREET
KEY WEST, FLORIDA 33040
RE: REQUEST FOR PAYMENT - CONTRACTURAL NURSING SERVICES
DATE:
The attached listing of services rendered and mileage accrued represents a
true and accurate accounting of the assessment services provided to Monroe
County In -Home Services by Florida Health Nursing Services, Inc. nursing
staff during the period to
Please forward payment to: Jobyna Okell, Executive Director
Florida Health Nursing Services, Inc.
1510 Venera Avenue
Coral Gables, Florida 33146
Submitted by:
Mary Jane Quinn; Director of Nursing
Attachments
Approved by:
Gwen Rodriguez, Project Director
Monroe County In -Home Services
Account Number Louis LaTorre, Executive Director
Monroe County Social Services
-77-
MEMORANDUM
TO: GWEN RODRIGUEZ, PROJECT DIRECTOR
MONROE COUNTY IN -HOME SERVICES
PUBLIC SERVICE BUILDING
WING III - STOCK ISLAND
KEY WEST, FLORIDA 33040
FROM: NORMA JEAN MURPHY, DIRECTOR OF NURSING
FLORIDA HEALTH NURSING SERVICES, INC.
ISLAMORADA SUB UNIT
ISLAMORADA, FLORIDA 33036
RE: REQUEST FOR PAYMENT - CONTRACTURAL NURSING SERVICES
DATE:
The attached listing of services rendered and mileage accrued represents a
true and accurate accounting of the assessment services provided to Monroe
County In -Home Services by Florida Health Nursing Services, Inc. nursing
staff during the period to
Please forward payment to: Jobyna Okell, Executive Director
Florida Health Nursing Services, Inc.
1510 Venera Avenue
Coral Gables, Florida 33146
Submitted by:
Norma Jean Murphy, Director of Nursing
Attachments„ Approved by:
Account Number
Gwen Rodriguez, Project Director
Louis LaTorre, Executive Director
Monroe County Social Services
-78--
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ATTACFDIE,1T II - Responsiblities of R.N.'s and Case Managers
Assessment of the need for personal care services must be made by
the Case Manager who writes a case plan detailing the frequency and
duration of service formulated with the Registered Nurse, prior to
the delivery of service. The plan will be revised by the Case Manager
with input from the Registered Nurse, as needed. If a physician orders
personal care, a written statement of the orders should be provided to
the lead agency for the client's file.
11
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