SFY2012 08/18/2011DANNY L. KOLHA GE
CLERK OF THE CIRCUIT COURT
DATE: August 24, 2011
TO: Sheryl Graham, Director
Monroe County Social Services
ATTN: Dottie Albury, In -Home Services Programs
FROM: Isabel C. DeSantis, D.C. tom'"
At the August 18, 2011, Board of County Commissioner's meeting the Board approved
the following:
Item C 1 Home and Community Based Case Management Referral Agreement
between the Florida Department of Children & Families and the Monroe County Board of
County Commissioners (Social Services/In-Home Services Program) for State Fiscal Year (SFY)
July 1, 2011 to June 30, 2012.
Enclosed are six duplicate originals of the above -mentioned executed by Monroe County.
Please be sure that the sets marked Monroe County Clerk's Office Original and Monroe County
Finance Department's Copy are returned to my office as quickly as possible. Should you have
any questions please do not hesitate to contact this office.
cc: County Attorney
Finance
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ADULT PROTECTIVE SERVICES
HOME AND COM'VIUNITY BASED WAIVER
CASE MANAGEMENT REFERRAL AGREEMENT
This Referral Agreement made this day of July, 2011, between the Florida Department of
Children and Families' (DCF) Southern Region Adult Protective Services Program Office, and
Monroe County In -Home Services hereinafter referred to as "case management agency ", details the
responsibilities and the expectations associated with the Medicaid Waiver for State Fiscal Year
(SFY) 2011 -2012. The case management agency is a Medicaid Waiver case management agency.
This Referral Agreement is in effect from the date of signature, through SFY 2011 -2012 for as long
as the Medicaid waiver case management agency remains enrolled with the State of Florida's
Medicaid fiscal agent. Case management agency noncompliance, nonperformance, or unacceptable
performance under this agreement may require a corrective action plan addressing the problems
identified by state agency Quality Assurance Reviews. Failure of case management agencies to
adhere to the Florida Department of Children and Families' guidance on eligibility and referral for
services may result in recoupment of program funds or case management agency dis- enrollment as a
Medicaid Waiver program case management agency.
The purpose of this agreement is to enable eligible disabled adult participants to receive case
management services from qualified case management agencies with oversight of the quality of care
by the Florida Department of Children and Families' Southern Region Adult Protective Services
Program Office and the Medicaid Waiver Specialist employed by the Department of Elder Affairs
(DOER). These services are authorized in order that the participant may remain in the least
restrictive setting and avoid or delay nursing home placement. Services and care are to be furnished
in a way that fosters the independence of each participant and facilitates an increased functional
capacity. All parties agree that routines of care provision and service delivery must be consumer -
driven to the maximum extent possible. All parties agree to and will treat each participant with
dignity and respect.
Objectives
A. To maintain a climate of cooperation and consultation with and between agencies, in order to
achieve maximum efficiency and effectiveness.
B. To participate together by means of shared information in the development and expansion
of services.
C. To promote programs and activities designed to prevent the premature institutionalization
of disabled adults.
D. To provide technical assistance to and consultation between agencies on matters
pertaining to actual service delivery and share appropriate assessment information and
care plans to avoid duplication.
E. To establish an effective working relationship between the case management agency, and the
Florida Department of Children and Families Southern Region Adult Protective Services
Program Office (DCF); the case management agency being responsible for the development
of care plans and authorization of services available under the waiver, the case management
agency being responsible for the direct provision of those services to consumers served under
the waiver program, and the Florida Department of Children and Families being responsible
for management and oversight of the waiver program.
II. Under this Agreement, the DCF Southern Region Adult Protective Services Office agrees to
the following:
A. To provide technical assistance and training to the case management agency.
B. To provide or to assist the Medicaid Waiver Specialist in providing annual on site
monitoring of the case management agency and, when applicable, conduct the same
monitoring of Southern Region DCF staff performing case management activities, using
the approved DOEA Medicaid waiver programmatic monitoring tool.
C. To monitor and project case management agency expenditures.
D. To conduct telephone screenings on all new referrals requesting services through the
ADA -HCBS Medicaid waiver within the timeframes set forth in the Adult Services Wait
List Policy guidelines, and using the Adult Services Screening for Consideration for
Community -Based Programs; CF- AA1022.
E. To accept all Budget Entity Team referrals for face -to face assessments.
F. To complete all initial face -to -face assessments on all pre - screened individuals referred
by the Budget Entity Team for service consideration and program application, using the
Adult Services Client Assessment, CF -AA 3019.
G. To maintain an accurate and current active waiver case list.
H. To notify, on a timely basis, the Adult Protective Services Central Office budget staff of
all waiver service terminations, service increase requests and atypical monthly
expenditure trends with regards to the terms of this Agreement.
III. Under this Agreement, the Case Management Agency agrees to the following:
A. Adhere to the Florida Department of Children and Families' (DCF) guidance on eligibility
and referral for services, as established through the Aged and Disabled Adult (ADA) Waiver
Handbook policy and the ADA Waiver format 1915.
B. Assign qualified case managers in accordance with the Aged and Disabled Adult
Medicaid Waiver Handbook to provide case management under the Medicaid Home and
Community Based Waiver for Aged and Disabled Adults.
C. Explain to each individual requesting consideration for ADA -HCBS Medicaid waiver
services that the Medicaid waiver program maintains a centralized Waiting List on which
the individual will be placed according to his or her score received through the Adult
Services Screening for Consideration for Community Based Services.
D. Supply all new disabled adult referrals (individuals requesting Aged and Disabled Adult
Home and Community Based Waiver services) with the name of a DCF Adult Protective
Services counselor and the phone number to the nearest DCF Adult Protective Services
unit for the individual to pursue service consideration and program screening.
E. Maintain and permit Southern Region Adult Protective Services Program Office access
to:
1. A current and accurate log of all Medicaid waiver claims, activities and payments by
individual consumer;
2. A listing of each Medicaid waiver consumer served by full name, Social Security ID
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and Medicaid ID;
3. Current (within one year) Consumer Care Plans indicating present authorized
service(s) and cost analysis by service on each waiver consumer serviced through this
contract; and,
4. Current log of consumer terminations of service (if applicable) with cost analysis of
the terminated consumer's unexpended care plan budget, date of termination and
reason for termination.
F. Develop and implement the Plan of Care, which must be signed by the consumer, that
specifically outlines:
1. The consumer's health conditions and treatments;
2. Challenges and impediments to the consumer's daily living functionality identified by
the assessment and to be addressed with the Plan of Care;
3. Service(s) authorized;
4. The frequency and intensity of the arranged service interventions;
5. Service gaps;
6. Expected outcomes to be achieved;
7. Cost analysis, by service, of those service units authorized for consumer delivery;
and,
8. The formal and informal support persons (agencies) responsible for delivering both
the DCF funded services authorized by the case manager and all other non -DCF
funded services.
G. Reevaluate the Plan of Care at least every six months.
H. Minimally reassess the client annually or more often if significant changes in the client's
situation warrant, with the Adult Services Client Assessment Instrument and amend the
Plan of Care accordingly. Make the required changes to authorized services and/or
service case management agencies as needed.
I. Adhere to the policies and procedures as outlined in the following manuals published by
the Agency for Health Care Administration: Aged and Disabled Adult Waiver Guidelines
and the Medicaid Case management agency Reimbursement Handbook (Non -
Institutional 081), including any and all attachments or updates.
J. Provide to the Agency for Health Care Administration, by the 15 of each month, a
completed Case management agency Monthly Report Form, CF -AA 1119, which is a
detailed expenditure report showing the number of clients served, defined units and type
of services provided, cost of each service unit, number of units of service provided,
totaled monthly cost of services delivered, and a year to date total cost of services
delivered. This report will also include the number of active clients at the beginning of
the month, the number added and deleted during the month, and the final count at the end
of the month.
K. Refer clients to the qualified direct service case management agency as selected by the client,
whenever reasonable and possible.
L. Issue written service authorizations to subcontracted service case management agencies
with at least 24 hours notice. The authorization will contain at a minimum:
1. Client's name;
2. Client's address (with directions if not easily accessible);
3. Pertinent information regarding client's health or disabilities and living situation; and,
4. Detailed service description including frequency, duration and specific tasks to be
performed.
M. Evaluate quality of services and service documentation by the subcontracted service case
management agency.
N. Hold the Florida Department of Children and Families harmless from financial
responsibility for service claims found out of compliance if they are the result of a failure
by the case management agency to update, renew, or terminate a client care plan or
service authorization. Nothing herein shall extend liability beyond what is established in
Section 768.28, Florida Statutes.
O. Perform semi - annual administrative monitoring of subcontracted service case
management agencies for adherence to authorized care plans and authorized
reimbursement rates.
P. Develop and implement a policy to ensure that its employees, board members, and
management will avoid any conflict of interest or the appearance of a conflict of interest
when disbursing or using the funds described in this agreement or when contracting with
another entity which will be paid by the funds described in this agreement. A conflict of
interest includes, but is not limited to, receiving, or agreeing to receive, a direct or
indirect benefit, or anything of value from a service case management agency, consumer,
vendor, or any person wishing to benefit from the use or disbursement of funds. To avoid
a conflict of interest, the case management agency must ensure that all case management
agency staff, volunteers, and board members bound by this service agreement make a
disclosure to the undersigned case management agency of any relationship which may be
a conflict of interest, within thirty (30) days of original appointment or placement on a
board, or if the individual is serving as an incumbent, within thirty (30) days of the
commencement of the contract.
Q. Follow -up with the undersigned on all billing errors identified by the Agency for Health
Care Administration and/or the DCF Southern Region Adult Protective Services Program
Office to ensure that all void or adjustment claims are submitted no later than 45 days
after each billing error has been identified by either party. Any case management agency
error not adjusted or voided within 45 days may be adjusted or voided by the Agency for
Health Care Administration or Florida Department of Children and Families' Southern
Region Adult Protective Services Program Office. The case management agency's
refusal to adjust or void erroneous claims will result in termination of this agreement.
R. If required by 45 CFR Parts 160, 162, and 164, the following provisions shall apply [45
CFR 164.504(e)(2)(ii)]:
(a) The case management agency hereby agrees not to use or disclose protected
health information (PHI) except as permitted or required by this Agreement, state
or federal law.
(b) The case management agency agrees to use appropriate safeguards to prevent use
or disclosure of PHI other than as provided for by this Agreement or applicable
law.
(c) The case management agency agrees to report to the department any use or
disclosure of the information not provided for by this Agreement or applicable
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law.
(d) The case management agency hereby assures the department that if any PHI
received from the department, or received by the case management agency on the
department's behalf, is furnished to case management agency's subcontractors or
agents in the performance of tasks required by this Agreement, that those
subcontractors or agents must first have agreed to the same restrictions and
conditions that apply to the case management agency with respect to such
information.
(e) The case management agency agrees to make PHI available in accordance with 45
C.F.R. 164.524.
(f) The case management agency agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R. 164.526.
(g) The case management agency agrees to make available the information required
to provide an accounting of disclosures in accordance with 45 C.F.R. 164.528.
(h) The case management agency agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the department or
created or received by the case management agency on behalf of the department
available for purposes of determining the case manager's compliance with these
assurances.
(i) The case management agency agrees that at the termination of this Agreement, if
feasible and where not inconsistent with other provisions of this Agreement
concerning record retention, it will return or destroy all PHI received from the
department or received by the case management agency on behalf of the
department, that the case management agency still maintains regardless of form.
If not feasible, the protections of this Agreement are hereby extended to that PHI
which may then be used only for such purposes as make the return or destruction
infeasible.
(j) A violation or breach of any of these assurances shall constitute a material breach
of this Agreement.
S. Adhere to the Adult Protective Services' Preliminary In -house Procedures for transferring
a Medicaid waiver consumer and the consumer's budget from one circuit to another at the
consumer's request.
IV. Support to the Deaf or Hard -of- Hearing
(a) The case management agency and its partners, subcontractors, and
agents shall comply with section 504 of the Rehabilitation Act of 1973,
29 U.S.C. 794, as implemented by 45 C.F.R. Part 84 (hereinafter
referred to as Section 504) and the Americans with Disabilities Act of
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1990, 42 U.S.C. 12131, as implemented by 28 C.F.R. Part 35
(hereinafter referred to as ADA).
(b) The case management agency shall, if the case management agency
or any of its partners, subcontractors, or agents employs 15 or more
employees, designate a Single- Point -of- Contact (one per firm) to
ensure effective communication with deaf or hard -of- hearing customers
or companions in accordance with Section 504 and the ADA. The name
and contact information for the case management agency's Single -
Point-of- Contact shall be furnished to the department's Southern
Region Adult Protective Services Program Office Administrator within
14 calendar days of the effective date of this requirement.
(c) The case management agency shall, within 30 days of the effective
date of this requirement, contractually require that its partners,
subcontractors and agents comply with section 504 and the ADA. A
Single- Point -of- Contact shall be required for each partner,
subcontractor or agent 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
case management agency's Single- Point -of- Contact.
(d) The Single- Point -of- Contact shall ensure that employees are aware of
the requirements, roles & responsibilities, and contact points
associated compliance with Section 504 and the ADA. Further,
employees of the case management agency, its partners,
subcontractors, and agents with 15 or more employees shall attest in
writing that they are familiar with the requirements of Section 504 and
the ADA. This attestation shall be maintained in the employee's
personnel file.
(e) The case management agency'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, but not later than 30 days after
the signing of the agreement, with respect to the current case
management agency (partners, subcontractors, and agents). The
approved Notice can be downloaded through the Internet at:
hftp://www.dcf.state.fl.us/admin/ig/civilrights.shtml
(f) The case management agency and its partners, subcontractors, and
agents 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 case
management agency shall submit Compliance Reports monthly, not
later than the 15 day of each month, to the department's Southern
Region Adult Protective Services Program Office Administrator. The
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case management agency shall distribute Customer Feedback forms to
customers or companions, and provide assistance in completing the
forms as requested by the customer or companion.
(g) If customers or companions are referred to other agencies, the case
management agency 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.
V. Termination
In the event this agreement is terminated, the case management agency agrees to submit, at the
time notice of intent to terminate is delivered, a plan which identifies procedures to ensure
services to consumers will not be interrupted or suspended by the termination.
A. Termination at Will
This agreement may be terminated by either party upon no less than thirty (30) calendar days
notice, without cause, unless a lesser time is mutually agreed upon by both parties, in writing.
Said notice shall be delivered by certified mail, return receipt requested, or in person with
proof of delivery.
B. Termination for Breach
Unless a breach is waived by the Florida Department of Children and Families in writing or
the parties fail to cure the breach within the time specified by the Florida Department of
Children and Families, the Florida Department of Children and Families may, by written
notice to the parties, terminate the agreement upon no less than twenty -four (24) hours notice.
Said notice shall be delivered by certified mail, return receipt requested, or in person with
proof of delivery.
In witness whereof, the parties have caused this 7 page agreement to be executed by their
undersigned officials as duly authorized.
CD
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Florida Department of Children Monroe County In -Home Services;
and Families Southern Region
Adult Protective Service
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