06/22/1995 Agreement f STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
6600 S.W. 57th. Avenue, Miami, Florida 33143
6/29/95
Mrs. Gwen Rodriguez, Director
Monroe County In -Home Services
5100 College Road, Wing III
Stock Island
Key West, Florida 33040
Dear Mrs. Rodriguez:
Attached please find duly executed Contract KG007
between the Department, and Monroe County In -Home
services for the 1995 -1996 State Fiscal Year.
We take this opportunity to thank you for your coope-
ration in providing services to the Disabled Adults
of Monroe County.
Sincerely,
41
Pedro C. Bouza, MSW
Program Specialist
A zir am
4:§ 11
ty
♦i 11 1 �1
DISTRICT ELEVEN
LAWTON CHILES, GOVERNOR
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Contract No. i Client la Non - Client ❑
CFDA No. N A Multi - District ❑
Grants and Aids N /A
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
STANDARD CONTRACT
THIS CONTRACT is entered into between the State of Florida, Department of Health and Rehabilitative
Services, hereinafter referred to as the "department ", and Monroe County In -Home Services
hereinafter referred to as the "provider ".
THE PARTIES AGREE:
I. THE PROVIDER AGREES:
2. To provide a financial and compliance audit to the
A.Requirements of Section 287.058, FS department as specified in Attachment 11 and
To submit bills for fees or other compensation for to ensure that all related party transactions are
services or expenses in sufficient detail for a proper disclosed to the auditor.
pre- audit and post -audit thereof. Where applicable, to
submit bills for any travel expenses in accordance with 3. To include these aforementioned audit and record
section 112.061, FS. The department may when keeping requirements in all approved subcontracts
specified in Attachment I, establish rates lower than the and - assignments.
maximum provided in section 112.061, FS. To provide
units of deliverables, including reports, findings, and 4. To maintain and file with the department such
drafts as specified in Attachment I, . to be received and progress, fiscal and inventory reports as specified in
accepted by the contract mansg_er prior to payment. To Attachment I, and other reports as the department
comply with the criteria and final date by which such may require within the period of this contract. Such
criteria must be met for completion of this contract as reporting requirements must be reasonable given the
specified in Section III, Paragraph A. of this contract. scope and purpose of this contract.
To allow public access to all documents, papers, letters,
or other materials subject to the provisions ot D.Retention of Records
Chapter 119, FS, and made or received by the provider To retain all client records, financial records,
in conjunction with this contract. It is expressly supporting documents, statistical records, and anv
understood that substantial evidence of the provider s other documents (including electronic storage media)
refusal to comply with this provision shall constitute a pertinent to this contract for a period of five (5) years
breach of contract. after termination of the contract, or if an audit has been
initiated and audit findings have not been resolved at
B.Federal Laws and Regulations the end of five (5) years, the records shall be retained
1.If this contract contains federal funds, the provider until resolution of the audit findings. The provider
shall comply with the provisions of 45 CFR, Part will cooperate with the department to facilitate the
74, and /or 45 CFR Part 92, and other applicable duplication and transfer ot any said records or
regulations as specified in Attachment I. documents during the required retention period.
2.If this contract contains federal funds and is over E.Monitoring the provider shall comply with all Persons duly authorized by the department and federal
applicable standards orders, or regulations issued auditors pursuant to 45 CFR Part 92.36(i)(10), shall
under Section 306 o? the Clean Air Act, as amended have full access to and the right to examine any of said
(42 U.S.C. 1857(h) et seq.) Section 508 of the records and documents at all reasonable times during
Clean Water Act, as amended (33 U.S.C. 1368 et said retention period or as long as records are retained,,
seq.), Executive Order 11738, and Environmental whichever is later, including any records, papers,
Protection Agency regulations (40 CFR Part 15). documents, facilities relevant to this contract, and /or
The provider shall report any violations of the above interview any clients and employees of the provider to
to the department. be assured of satisfactory performance of the terms and
conditions of this contract. Following such inspection
3.If this contract contains federal funding in excess of the department will deliver to the provider a list of its
$100,000, the provider must, rior to contract comments with regard to the manner in which said
execution, complete the Certification Regarding goods or services are being provided. The provider
Lobbying. form, Attachment N/A . -If a will rectify all noted deficiencies rovided by the
Disclosure of Lobbying Activities torm, Standard department within the specified period of time set forth
Form LLL, is required, it may be obtained from the in the comments or provide the department with a
contract manager. All disclosure forms as required reasonable and acceptable justification for not
by the Certification Regarding Lobbying form must correcting the noted shortcomings. The provider's
be completed and returned to the contract manager. failure to correct or justify within a reasonable time as
• specified by the department may result in the
C.Audits and Records withholding of payments, being deemed in breach or
1.To maintain books, records, and documents default, or termination ot this contract.
,(including electronic storage media) in accordance
with generally accepted accounting procedures and F.Indemnification
practices which sufficiently and properly reflect all Provider agrees that it will indemnify, defend, and hold
revenues and expenditures of funds provided by the harmless department and all of department's officers,
department under this contract. agents, and employees from any claim, loss, damage,
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7/1/95
cost, charge, or expense arising out of any acts, working days will result in a penalty charged' against
actions, neglect or omission by provider, its agents the provider and paid to the subcontractor in the •
employees, or subcontracts during the performance of amount of one -half of one (1) percent of the amount
the contract, whether direct or indirect, and whether to due, per day from the expiration of the period
any person or property to which department of said allowed herein for payment. Such penalty shall be
parties may be subject, except that neither provider nor in addition to actual payments owed and shall not
any, of its subcontractors will be liable under this exceed fifteen (15) percent of the outstanding balance
section for damages arising out of injury or damage to due.
persons or property directly caused or resulting Trom
the sole negligence of the department or any of its J.Return of Funds
officers, agents, or employees. To return to the department any overpayments due to
unearned funds or funds disallowed pursuant to the
Provider's obligation to indemnify, defend, and ay for terms of this contract that were disbursed to the
the defense or at the department's option, to participate provider by the department. The provider shall return
and associate with the department in the defense and any overpayment to the department within 40 calendar
trial of any claim and any related settlement days after either discovery by the provider, or
negotiations, shall be triggered by the department's notification by the department, ot the overpayment. In
notice of claim for indemnification to provider. the event that the provider or its independent auditor
Provider's inability to evaluate liability or its discovers an overpayment has been made, the provider
evaluation of liability shall not excuse provider's duty shall repay, said overpayment within 40 calendar days
to defend and indemnify within seven days after such without prior notification from the department. In the
notice by the department is given by registered mail. event that the department first discovers an
Only an adjudication or judgment after the highest overpayment has been made, the department will notify
appeal is exhausted specifically finding the department the provider by letter of such a finding. Should
solely negligent shall excuse performance of this repayment not be made in a timely manner, the
provision by providers. Provider shall pay all costs department will charge interest of one (1) percent per
and fees related to this obligation and its enforcement month compounded on the outstanding balance after 40
by the department. Department's failure to notify calendar days after the date of notification or
provider of a claim shall not release provider of the discovery.
above duty to defend.
K.Incident Reporting
G. Insurance 1. Client Risk Prevention
1.To provide adequate liability insurance coverage on If services to clients will be provided under this
a comprehensive basis and y to hold such liability contract, the provider and any, subcontractors shall,
insurance at all times during the existence of this in accordance with the client risk prevention syystem,
contract. The provider accepts full responsibility for report those reportable situations listed in HRSR
identifying and determining the type(s) and extent of 215 -6 Paragraph 5,, in the manner prescribed in
liability insurance necessary to provide reasonable HRSR 215 -6 or district operating procedures.
financial protections for the provider and the clients
to be served under this contract. Upon the execution 2. Abuse, Neglect and Exploitation Reporting
of this contract, the provider shall furnish the In compliance with Chapter 415, FS, an employee of
department written verification supporting • both the the provider who knows, or has reasonable cause to
determination and existence ot such insurance suspect, that a child aged person or disabled adult is
coverage. Such coverage may be provided by a self- or has been abused, neglected, or exploited,. shall
and _o
insurance program established anperating under immediately report such 'knowledge or suspicion to
the laws of the State of Florida. The department the central abuse registry and tracking system of the
reserves the right to require additional insurance as department on the single statewide toll -free telephone
specified in Attachment I where appropriate. number (1- 800- 96ABUSE).
2.If the rovider is a state agency or subdivision as L.Transportation Disadvantaged
defined by s. 768.28, FS, the provider shall furnish If clients are to be transported under this contract, the
the department,. upon request, written verification of provider will comply with the provisions of Chapter
liability protection in accordance with s. 768.28, FS. 427 FS and Rule Chapter 41 -2, FAC. The provider
Nothing herein shall be construed to extend an shall submit to the department the reports required
party's liability beyond that provided in s. 768.28 pursuant to Volume 10, Chapter 27, HRS Accounting
FS. Procedures Manual.
H.Safeguarding Information M.Purchasing
Not l to use or disclose any information concerning a 1.PRIDE
recipient of services under this contract for any It is agreed that any articles which are the subject of,
a purpose not in conformity with the state regulations or are required to carry out this contract shall be
nd federal regulations (45 CFR, Part 205.50 ),except purchased from Prison Rehabilitative Industries and
upon written consent of the recipient, or his Diversified Ente rises Inc. (PRIDE) identified
responsible parent or guardian wheti_authorized by law. under Chapter 946, FS', in the same manner and
under the procedures set forth in subsections
I.Assignments and Subcontracts 946.515(2) and (4). For purposes of this contract,
1.To neither assign the responsibility of this contract to the provider shall be deemed to be substituted for the
another party nor subcontract for any of the work . department insofar as dealings with PRIDE. This
contemplated under this contract without prior clause is not applicable to subcontractors, unless
written approval of the department. . otherwise required by law. An abbreviated list of
products /services available from PRIDE may be
2. Unless otherwise stated in the contract between the obtained by contacting PRIDE, (904) 487 -3774.
provider and subcontractor, payments made by the
provider to the subcontractor must be within seven 2. Procurement of Materials with Recycled Content
(7) working days after receipt of full or partial Additionally, it is expressly understood and agreed
2 payments from the department in accordance with s. that any products or materials which the su
87.0585, FS. Failure to pay within seven (7) of, or are required to carry out this contract shall be
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717/95 " <4 00-7
' procured in accordance with the provisions of II. THE DEPARTMENT AGREES:
s. 403.7065, and 287.045, FS.
A.Contract Amount
N.Civil Rights Requirements To pay for contracted services according to the
1. To comply with all federal state, and local laws and conditions of Attachment I in an amount not to exceed
ordinances applicable to the work or payment for $ 121, 821.00 , subject to availability of
work thereof, including the Americans With funds. The State of Florida's performance and
Disabilities Act, and shall not discriminate on the obligation to pay under this contract is contingent upon
grounds of race, color, religion, sex, age, handicap, an annual appropriation by the Legislature. The costs
national origin political affiliation, or beliefs, in the of services paid under any other contract or from any
performance of this contract. other source are not eligible for reimbursement under
this contract.
The provider agrees that compliance with this
assurance constitutes a condition a continued receipt B.Contract Payment
of or benefit from funds provided through this Pursuant to s. 215.422, FS, provides that the
contract, and that it is binding upon the provider,. its department has five (5) working days to inspect and
succors, transferees, and assignees for the period approve goods and services, unless - bid specifications
during which services are provided. The rovider or the P.O. specifies otherwise. With the exception of
further assures that all contractors, subcontractors, payments to health care providers for hospital, medical,
subgrantees, or others with whom it arranges to or other health care services, if payment is not
provide services or benefits to participants or available within 40 days, measured from the latter of
employees in connection with any of its programs the date the invoice is received or the goods or services
and activities are not discriminating against those are received, inspected and approved, a separate
participants or employees in violation of the above interest_ penalty set by the Comptroller pursuant to s.
statutes, regulations, guidelines, and standards. 55.03, FS, will be due and payable in addition to the
invoice amount. To obtain the applicable interest rate,
2.Compliance Questionnaire please contact the district fiscal office /contract
In accordance with HRSM 220 -2, the provider administrator. Payments to health care providers for
agrees to complete the Civil Rights Compliance hospitals, medical or other health care services, shall
uestionnaire, HRS Forms 946 A and B, if services be made not more than 35 days from the date of
are provided to clients and if 15 or more individuals eligibility for payment is determined, and the monthly
are employed. interest rate is 1 %. Invoices returned to a vendor due
to preparation errors will result in a ayment delay.
O.Withholdings and Other Benefits Invoice payment requirements do not start until a
The provider is responsible for Social Security and properly completed invoice is provided to the
Income Tax withholdings. The provider is not entitled department.
to state retirement or leave benefits except where the
provider is a state agency. Unless justified by the C.Vendor Ombudsman
provider and agreed to by, the department in A Vendor Ombudsman has been established within the
Attachment I, the department will not furnish services Department of Banking and Finance. The duties of this
of support (e.g., office space, office supplies individual include acting as an advocate for vendors
telephone service, secretarial, or clerical support) who may be experiencing problems in obtaining timely
normally available to career service employees. payment(s) from a state agency. The - Vendor
Ombudsman may be contacted at (904) 488 -2924 or
P.Sponsorship 1- 800 - 848 -3792, the State Comptroller's Hotline.
As required by s. 286.25, FS, if the provider is a
nongovernmental organization which sponsors a III. THE PROVIDER AND DEPARTMENT
program financed wholly or in part by, state funds, MUTUALLY AGREE:
including any funds obtained through this contract, it
shall, in publicizing, advertising or describing the A.Effective and Ending Dates, .
sponsorship of the program, state: "Sponsored by This contract shall. begin on
(provider's name) and the State of Florida Department or on. . date: ,On which the contract has been signed
of Health and Rehabilitative Services ; '. If the by both parties, whichever is later, and end on
sponsorship reference is in written material the words 6/30/96 -.
State of Florida, Department of Health and
Rehabilitative Services" shall appear in the same size
type as the name of the or a nization. B . T Ter a t
letters or t i
yP g 1.Ter at Will
This contract may be terminated by either party, upon
Q.Final Invoice
To submit the final invoice for payment to the no less than thirty (30) calendar days notice, without
P cause, unless a lesser time is mutually agreed upon
department no more than 6 days after the by both parties. Said notice shall be delivered by
contract ends or is terminate . the provider fails to certified mail, return receipt requested, or in person
do so, all right to payment is forfeited and the with proof of delivery.
department will not honor any requests submitted after
the aforesaid time period. Any payment due under the 2.Termination Because of Lack of Funds
terms of this contract may be withheld until all reports In the event funds to finance this contract become
due from the provider and necessary adjustments unavailable, the department may terminate the
thereto have been approved by the department. contract upon no less than twenty -four (24) hours
R.Use Of Funds For Lobbying notice in writing to the provider. Said notice shall
y� g Prohibited be delivered by certified mail, return receipt
To comply with the provisions of section 216.347, FS, requested, or in person with proof of delivery. The
which prohibits the expenditure of contract funds for department shall be the final authority as to the
the purpose of lobbying the Legislature, judicial branch availability of funds.
or a state agency.
3
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7/1/95 Contract No.
3.Termination for Breach appropriations process and subsequently identified in
This contract may be terminated for non - the department's operating budget.
performance by the provider upon no less than
twenty four (24) hours notice. If applicable the E.Notice and Contact
department may employ the default provisions in 1.The name, address and telephone number of the
Chapter 60A- 1.1006 ), FAC. Waiver of breach of de contract manager for the department for this contract
any provisions of this contract shall not be deemed g p
to be a waiver of any other breach and shall not be is: Pedro C. Bouza
construed to be a modification of the terms of this 6 6 0 0 S . W . 57 Avenue
contract. The provisions herein do not limit the Miami Florida 33143
department's right to remedies at law or to damages.
Tel:
305) 284-0950
C.Name, Mailing and Street Address of Payee
1.The name (provider name as shown on page 1 of this 2.The name, address and telephone number of the
contract) and mailing address of the official payee to representative of the provider responsible for
whom the payment shall be made is: administration of the program under this contract:
Monroe County In —Home Services Gwen Rodriguez, Director
5100 College Road, Wing III 5100 College Road, Wing III
Key West, Florida 33040 Key West, Florida 33040
Tel: (305) 292 -4589
3.In the event that different representatives are
2.The name of the contact person and street address designated by either party after execution of this
where financial and administrative records are contract, notice of the name and address of the new
maintained: Gwen Rodriguez, Director representative will be rendered in writing to the
other party and said notification attached to ori
5100 College Road,Wing III of this contract.
Key West, Florida 33040 F.All Terms and Conditions Included
This contract and its attachments as referenced,
Attachment I, & II
Exhibits A, E, C, & D.
D.Renegotiation or Modification
Modifications of provisions of this contract shall only ,
be valid when they have been reduced to writing and contain all the terms and conditions agreed upon b
duly signed. The rate of payment and the total dollar g P by the
amount may be adjusted retroactively to reflect price parties.
level increases and changes in the rate of payment
when these have been established through the
IN WITNESS THEREOF the parties hereto have caused this 28 page contract to be executed by their
undersigned officials as duty authorized.
PROVIDER STATE OF FLORIDA, DEPARTMENT OF
MONROE COUNTY IN —HOME SERVICES HEALTH AND REHABILITATIVE SERVICES
•
SIGNED B7-: "P� SIGNED BY �� ‹26-4; --�''
NAME: ij�]E hldii % SHIRLEY FREEMAN NAME: i/
to M. Bock %�
TITLE: Mayor TITLE:' District Administrator
DATE: Jug 2 - 2 -, i g q S DATE: 6— d 7 _q
STATE AGENCY 29 DIGIT SAMAS CODE:
601010003076060040011100603
Federal EID # (or SSN): VF59- 6000749029
Provider Fiscal Year Ending Date: September 30, 19 9 5
ATTEST: DANNY L. KOLHAGE, CLERK
By 4 G .
_ -` �- Deputy Clerk
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07/01/95 Community Care for Disabled
Adults
Aging and Adult Services
Fixed Price
ATTACHMENT I
A. Services to be Provided.
The services to be provided are identified in Section C.2.
of this attachment. The applicable service definitions and
standards are found in HRSM 140 -8. The performance standard,
Exhibit A , will be used during monitoring and quality
assurance visits if the provider determines client eligibility
for services.
B. Manner of Service Provision.
1. The provider will maintain a current record on each
individual in the program including current documentation of
eligibility for services; identifying information about the
recipient and established need to receive the services; service
delivery data; and all other forms or records necessary for
program operation and reporting as determined necessary by the
department.
2. If the services are not provided in the client's home,
the provider will maintain their facilities in which the services
are provided so that at all times the facilities conform to the
standards required by state and local fire and health
authorities, whichever are more stringent.
3. The provider will maintain sufficient staff, facilities
and equipment to deliver the agreed upon services or will notify
the department whenever they are unable or are going to be unable
to provide the required quality or quantity of services.
C. Method of Payment.
1. The department shall make payment to the provider for a
total dollar amount not to exceed $121,821.00 , subject to the
availability of funds.
2. The department shall make payment to the provider for
provision of services up to a maximum number of units of service
and at the rate(s) stated below:
Services to be
Provided Units of Service Unit Rate Maximum Units
Case Management One Hour $34.71022 1,023
Homemaker Services One Hour $20.91125 1,071.5
Home Delivered Meals One Meal $4.485625 7,590
Personal Care One Hour $22.05329 1,354
GA08
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07/01/95 Community Care for Disabled
Adults
3. Rates listed in paragraph C -2 are the department's 90%
share of the gross cost per unit of service. If the contract is
for Adult Day Health Care or Medicaid waiver service(s) for
Medicaid waiver eligible recipients, then no match is required.
4. The provider shall submit to the contract manager an
original and 3 copies of invoices, Exhibit B for payment on a
monthly basis. The due date for these invoices is the 10th day
of the month following the month being reported.
a. The provider agrees to identify Medicaid waiver
eligible clients and direct bill the Medicaid fiscal agent for
services rendered to these clients. Provider further agrees to
furnish the contract manager with a copy of the remittance
voucher from the Medicaid fiscal agent on a monthly basis.
b. Provider agrees to accept the Medicaid
reimbursement as payment in full and not bill a Medicaid
recipient or the department for the cost of the service or any
portion of the cost of the service. The provider agrees to abide
by the provisions of the Medicaid Aged /Disabled Waiver Handbook.
5. The provider expressly understands that any payment due
under the terms of this contract may be withheld pending the re-
ceipt and approval of the department of all financial and program
reports due from the provider as a part of this contract and any
adjustments thereto.
6. A final report will be made to the department within
sixty (60) days after the contract ends or is terminated, on a
form provided by the department, identifying total units of
service and total payment received. In the event of an over-
payment resulting from revised units of service for the contract
period being reported, these monies must be returned to the
department with the final report.
D. Special Provisions.
1. State Laws and Regulations
a. The provider will comply with the applicable
provisions of Chapter 409, Chapter 410 and Section 20.19(2)(b)2f,
Florida Statutes.
b. The provider will comply with the applicable
provisions of Chapter 10A -16, Florida Administrative Code.
c. The provider will comply with the applicable
provisions of HRSM 140 -8, CCDA Program Manual and any other
applicable guidelines or criteria established by the department.
d. The provider, if offering Adult Day Care Services
or Adult.Day Health Care Services, shall be licensed unless
otherwise exempted under Chapter 400, Part V, Florida Statutes.
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07/01/95 Community Care for Disabled
Adults
2. Client Information
a. The provider of case management services agrees to
submit to the department management program data including client
identifiable data in accordance with instructions provided by the
department.
b. The provider must maintain records documenting the
clients, by name or unique identifier, to whom services are pro-
vided, the number of units provided and the dates of service
provision. This must track to each invoice for payment.
Requests for payment which cannot be supported with supporting
document 1 - :'on will be returned to the provider upon inspection by
the department.
3. Service Reports
The provider agrees to submit to the contract manager a
monthly summary report and six, nine and twelve months cumulative
summary reports as described in Chapter 5, HRSM 140 -8.
4. Expenses
Receipts are required for all expenses incurred, (e.g.,
office supplies, printing, long distance telephone calls, etc.).
Receipts are required for all expenses of this nature.
5. Subcontracts
a. Departmental approval of the provider's
application shall constitute approval of the provider sub-
contracts if the subcontracts follow the service and funding
information as identified in the approved provider application.
b. The provider will provide technical assistance to
all subcontractors, as necessary.
c. The provider agrees to conduct monitoring of
subcontract agencies. Copies of reports of such monitoring
visits will be submitted to the department and other appropriate
agents in a format and within the time frames approved by the
department.
6. Suspension
a. The department may, for reasonable cause,
temporarily suspend the use of funds by a provider pending cor-
rective action, or pending a decision to terminate the award.
b. The department may prohibit the provider from
receiving further payments and may prohibit the provider from in-
curring additional obligations of funds. The suspension may
apply to only part, or all of the provider's operation.
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07/01/95 Community Care for Disabled
Adults
c. To suspend operations of the provider, the
department will notify the provider in writing by Certified Mail
of: the action to be taken; the reason(s) for such action; and
the conditions of the suspension. The notification will also:
indicate what corrective action(s) are necessary to remove the
suspension; indicate the provider's right to an administrative
hearing; and provide the provider with the appropriate time
period to request an administrative hearing before the effective
date of the suspension (unless provider's actions warrant an
immediate suspension).
7. Copyrights Clause
Where activities supported by this contract produce
original writing, sound recordings, pictorial reproductions,
drawings or other graphic representation and works of any similar
nature, the department has the right to use, duplicate and dis-
close such materials in whole or in part, in any manner, for any
purpose whatsoever and to have others acting on behalf of the
department to do so. If the materials so developed are subject
to copyright or patent legal title and every right, interest,
claim, or demand of any kind in and to any patent, trademark or
copyright, or application for the same, will vest in the State of
Florida, Department of State, for the exclusive use and benefit
of the state. Pursuant to section 286.021, Florida Statutes
(1987), no person, firm or corporation, including parties to this
contract, shall be entitled to use the copyright, patent or
trademark without the written consent of the Department of State.
8. Grievance and Fair Hearings Procedures
The provider will utilize the department's fair hearing
system outlined in HRSM 195 -1, Chapter 4 by which client served
by the provider under this contract may present a request for a
fair hearing.
9. Fees
No fees shall be imposed other than those set by the
department. Fees collected in compliance with departmental di-
rectives will be disposed of in a manner prescribed by the
department.
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07/01/95 Community Care for Disabled
Adults
10. Project Independence
The department has implemented Project Independence, an
initiative to assist public assistance recipients to enter and
remain in gainful employment. Employment of Project Independence
participants is a mutually beneficial goal for the provider and
the department in that it provides qualified entry level
employees needed by many providers and provides substantial
savings to the citizens of Florida.
The provider or its agent agrees to notify the
department of entry level employment opportunities associated
with this contract that require a high - - olool education or less.
The department will provide information to the provider
identifying Project Independence clients that are referred to the
provider. In the event that the provider or its agent employs a
person who was referred by the department's Project Independence
office, the provider will notify the department.
11. Plan of Care
Providers acknowledge that the Medicaid waiver client's
plan of care is the official document authorizing Medicaid
billing. If the provider serves Medicaid waiver clients, the
provider agrees to provide services in accordance with the
client's plan of care as authorized by the client's case manager.
If the provider provides adult day health care services, the
provider agrees to provide only those service units contained in
the client's plan of care and authorized by the department in
accordance with established review procedures.
12. Human Rights Advocacy Committee Clause
The provider agrees to allow properly identified
members of the HRAC access to the facility and /or agency and the
right to communicate with any client being served, as well as
staff or volunteers who serve them in accordance with Sections
402.165(8)(a)(b), F.S. Members of the committee shall be free to
examine all records pertaining to any case unless legal
prohibition exist to prevent disclosure of those records.
13. Penalty for Late Payment of Invoices
With the exception of payments to health care providers
for hospital, medical, or other health care services, if payment
is not available within 40 days, measured from the latter of the
date the invoice is received or the goods or services are
received, inspected and approved, a separate interest penalty set
by the Comptroller pursuant to Section 55.03, F.S., will be due
and payable in addition to the invoice amount. To obtain the
applicable interest rate, please contact the District Fiscal
Office.
THIS PAGE LEFT BLANK INTENTIONALLY
ib
C)
14. 14. PROVIDER SELF - MONITORING
The Provider agrees to complete a SELF - MONITORING report
each, and every quarter of the contract. The completed form
must be submitted to the Contract Manager by the 15th. day
of the month following the quarter.(Exhibit D)
15. SERVICE PRIORITY
Priority for services will be given to individuals
referred by the Department.
16. IMPACT ZONE PLANNING DATA
The Provider will make available to HRS District 11
Zip Code data on where their service recipients reside
as well as certain other client identifying information
as requested. This information will be used to facilitate
HRS impact zone planning.
17. POSITION REDUCTIONS
If the Provider reduces the number of positions charged
to this contract, the Department reserves the right to reduce
payments accordingly.
18. SUBCONTRACTS
The Provider agrees to disclose the exact amount of
contract funding used to compensate each employee or sub-
contractor to the provider on an individual basis.
The Provider will submit a final report of expenditures
no later than 45 days following the ending date of the contract.
The expenditure report will show the total amount of compen-
sation from the contract (including salaries, wages, fringe
benefits, bonuses, perquisite, etc.) to each employee of the
Provider, by name, position title, and rate of pay.
If the compensation to an employee of the Provider, is
made up, in whole or in part by funds received by the Provi-
der under other Department (HRS) contract (s) the report must
include additional columns in order to indentify those amounts
by HRS Contract Number.
Each subcontractor of the Provider will be considered the
same as en employee for the purposes of this report. Subcon-
tractors are not required to report conpensation paid to each
employee on an individual basis.
/1
19. TERMS AND CONDITIONS
The following, as referenced contain all the terms and
conditions agreed upon by the parties.
Attachment I (Services, and conditions)
Attachment II (Financial and Compliance Audits)
Exhibit A (Quality Assurance)
Exhibit B (Fixed Price Invoice)
Exhibit C (Budget)
Exhibit D (Provider Self Monitoring Form)
Jz
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IS.40 O
CCDA -1
Exhibit A
FY 1995 - 96
COMMUNITY CARE FOR DISABLED ADULTS
QUALITY ASSURANCE STANDARD
STANDARD:
Clients receiving Community Care for Disabled Adults (CCDA)
services meet all eligibility requirements, have been properly
assessed, have received individualized care plans based on
individualized client needs, and case records are complete and
up -to -date. District office files include scheduled semi - annual
monitoring reports (unless district has been granted a waiver by
PDACS), corrective action plans with documentation of
implementation of those plans, district service plans for
disabled adult population, provider monthly summary reports,
provider semi - annual service cost reports, provider six, nine and
twelve month cumulative summary reports, and documentation of
district tracking of fee assessment monies and tracking of
purchased durable medical equipment.
METHODOLOGY:
The program specialist will review selected case records to
determine compliance with the following criteria:
o Client's age is 18 -59;
o Client has a permanent disability
and case plan contains
documentation supporting said
disability as defined in HRSM 140 -8
as a medically determined physical
or mental impairment that has
lasted or is expected to last for
12 months or longer and restricts
the client's ability to perform
normal activities of daily living
as determined through the initial
functional assessment and
documentation of disability;.
o Medicaid Waiver clients must be
assessed at risk of nursing home
placement;
o Client must not be receiving
comparable services from other
entities;
o Client needs a CCDA service and
documentation exists that all
comparable existing community
services and funding sources have
been explored and exhausted;
/3
o Client must have an individual
income at or below the prevailing
Medicaid Institutional Care program
(ICP) eligibility standard in order
to receive non -fee assessed CCDA
services, clients with incomes
above the ICP standard will be
assessed for services;
o Documentation of the client's
income and assessment for fee
collection; if applicable;
o Fee assessments are tracked by the
unit or provider as applicable-
o A copy of the referral /intake form,
DOEA Form 111 A;
o Current (within one year) uniform
client assessment, DOEA Form 111 B
which has been completed, scored,
signed and dated which clearly
indicates the client's
capabilities, problems services
needed;
•
o Current (within six months and
evidenced to have been updated
quarterly or more if necessary)
service plan, HRS -AA 1025 form,
which coincides with client's
current assessment;
o Current (within one year) Medicaid
waiver health professional
statement, HRS -AA Form 1055, for
SSI CCDA clients who receive
Medicaid waiver services; or 3008
for ICP CCDA clients.
o An information release form signed
by the client allowing the case
manager to make arrangements for
the provision of services;
o Current (within on year) Client
Information System (CIS) HRS Form
3012;
o A case narrative with entries which
are reasonable timely, accurate,
and ensure that client - involved
goals and the client's changing
needs are being addressed.
Exhibit A
/y GA08
(1) Notation in case record that CCDA case
manager has viewed a check awards letter
or other indicating evidence that the
client receives SSI, SSDI, or some other
disability payment; or
(2) A written statement from a licensed
physician (M.D. or Doctor of Osteopathic
Medicine, or a mental health
professional). This "statement" must at
a minimum, include the applicant's
diagnosis, prognosis, and the author's
concurrence or nonconcurrence with a
broad statement about the client's level
of functioning and need for assistance
due to his disability.
LOCATION:
Aging and Adult Service unit and /or CCDA provider.
PERIOD OF ASSESSMENT:
Previous twelve months.
AUTHORITY:
Section 410.601, F.S., Chapter 10A -16, F.A.C. HRSM 140 -8.
SAMPLE SIZE:
Three to Five active case records as time allows.
ESTIMATE OF STAFF TIME:
20 minutes per case record, if no other problems exist.
RATING METHODOLOGY:
This standard is in compliance if 100 percent of the elements in
100 percent of the sampled files confirm clients are
eligible and case records are up -to -date. This standard is
considered in partial compliance if at least 90 percent of the
elements in 100 percent of the sampled files confirm that clients
are eligible and /or case records are up -to -date.
Exhibit A
GA08
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61 7o a1 7
EXAMPLE
FIXED PRICE INVOICE
I N V O I C E
for month of , 199
DATE
PROVIDER'S NAME
CONTRACT #
PROVIDER'S ADDRESS
PERIOD OF SERVICE PROVISION
Phase or Service Amount per Phase or Unit Amount Due
Units of Service for which funds are requested
Total Due $
Signature of Provider
Approval Signature of Contract Manager Date Approved
Exhibit F3
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• ,
MONROE COUNTY IN HOME SERVICES
WING 111- PUBLIC SERVICE BUILDING
5100 COLLEGE ROAD
KEY WEST FL 33040 EXHIBIT C
STATE CCDA CONTRACT KG-
FY 1995 -1996
TOTAL UNITS OF SERVICE PROVIDED:
GROSS RATES:
CASE MANAGEMENT 1023 UNITS X $ 38.5669 $39,453.96
HOMEMAKERS 1071.5 UNITS X $ 23.2347 24,896.00
MEALS 7590 UNITS X $ 4.984 37,828.77
PERSONAL CARE 1354 UNITS X $ 24.5037 33,177.94
TOTAL COST $135,356.67
COUNTY MATCH:
CASE MANAGEMENT 1023 UNITS X $ 3.856675 $3,945.40
HOMEMAKERS 1071.5 UNITS X $ 2.323454 2,489.60
MEALS 7590 UNITS X $ 0.498375 3,782.88
PERSONAL CARE 1354 UNITS X $ 2.450413 3,317.79
TOTAL COUNTY COST $13,535.67
NET RATES:
CASE MANAGEMENT 1023 UNITS X $ 34.71022 $35,508.56
HOMEMAKERS 1071.5 UNITS X $ 20.91125 22,406.40
MEALS 7590 UNITS X $ 4.485625 34,045.89
PERSONAL CARE 1354 UNITS X $ 22.05329 29,860.15
TOTAL STATE COST $121,821.00
04/20/95 12:15 PM B12.WK4
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Exhibit D
DISTRICT XI
COMMUNITY CARE FOR DISABLED ADULTS
PROVIDER SELF MONITORING
This form must be completed by the Agency Director each quarter.
Form must be submitted to the contract manager on or before the
15th day of the month after the quarter ends
AGENCY:
FY: QTR:
Total # of clients receiving service:
Total # of new, unduplicated clients during quarter:
Total # of cases closed during quarter:
Total # on waiting list:
# determined eligible:
# pending eligibility determination:
Number of client files reviewed by zupervisors or administrators
during quarter:
Number of clients contacted by supervisors or administrators
during the quarter:
Staff turnover:
o/# Administrators:
o/# Supervisor:
o/# Direct services staff:
o/# Clerical:
The information contained in this report are true and correct to
the best of my knowledge.
Name /Title Date
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r } • C d 6 7
FINANCIAL AND COMPLIANCE AUDITS
ATTACHMENT
This attachment is applicable, if the provider or grantee, hereinafter referred to as
provider, is any local government entity, nonprofit organization, or for - profit
organization.
An audit performed by the Auditor General shall satisfy the requirements of this
attachment.
PART I: FEDERALLY FUNDED
This part is applicable if the provider is a local government entity or nonprofit
organization and receives a total of $25,000 or more in federal funds passed through the
department during its fiscal year. The provider has "received" federal funds when it has
obtained the cash from the department or when it has incurred reimbursable expenses.
Local governments shall comply with the audit requirements contained in Office of
Management and Budget (OMB) Circular A -128, Audits of State and Local Governments.
Nonprofit providers shall comply with OMB Circular A -133, Audits of Institutions of Higher
Learning and Other Nonprofit Institutions, except as modified herein. Such audits shall
cover the entire organization for the organization's fiscal year. The audit report shall
include a schedule of financial assistance that discloses each state contract by number.
Compliance findings related to contracts with the department shall be based on the
contract requirements, including any rules, regulations, or statutes referenced in the
contract. Where applicable, the audit report shall state whether or not matching
requirements were met. All questioned costs and liabilities due to the department shall
be fully disclosed in the audit report with reference to the department contract involved.
If the provider has received any funds from a grants and aids appropriation, the provider
will also submit a compliance report in accordance with the rules of the Auditor General,
chapter 10.600, and indicate on the schedule of financial assistance which contracts are
funded from state grants and aids appropriations.
The provider agrees to submit the required reports as shown in Part IV.
PART II: STATE FUNDED
This part is applicable if the provider is a nonprofit organization that receives a total
of $100,000 or more from the department during its fiscal year, which is not paid on a set
state or area -wide fixed rate for service, and of which less than $25,000 is federally
funded. The provider has "received" funds when it has obtained the cash from the
department or when it has incurred reimbursable expenses.
The provider agrees to have an annual financial audit performed by independent auditors in
accordance with the current Government Auditing Standards issued by the Comptroller
General of the United States. Such audits shall cover the entire organization for the
organization's fiscal year. The scope of the audit performed shall cover the financial
statements and include reports on internal control and compliance. The audit report shall
include a schedule of financial assistance that discloses each state contract by number.
Compliance findings related to contracts with the department shall be based on the
contract requirements, including any rules, regulations, or statutes referenced in the
contract. Where applicable, the audit report shall state whether or not matching
requirements were met. All questioned costs and liabilities due to the department shall
be fully disclosed in the audit report with reference to the department contract involved.
If the provider has received any funds from a grants and aids appropriation, the provider
will also submit a compliance report in accordance with the rules of the Auditor General,
chapter 10.600, and indicate on the schedule of financial assistance which contracts are
funded from state grants and aids appropriations.
The provider agrees to submit the required reports as shown in Part IV.
0 2 4 2--
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KCc
PART III: CHAPTER 10.600, OR NO AUDIT REQUIREMENT
This part is applicable if the provider is either (1) a for - profit organization, (2) a
local government entity receiving less than $25,000 in federal funds from the department
during its fiscal year, (3) a nonprofit organization receiving less than $100,000 from the
department, of which less than $25,000 is federally funded, during its fiscal year, or (4)
a nonprofit organization receiving a total of $100,000 or more from the department based
on a set state or area -wide fixed rate for service, of which less than $25,000 is
federally funded. The provider has "received" funds when it has obtained cash from the
department or when it has incurred reimbursable expenses.
If the provider receives funds from a grants and aids appropriation, the provider shall
have an audit, or submit an attestation statement, in accordance with the rules of the
Auditor General, chapter 10.600. The audit report shall include a schedule of financial
assistance that discloses each state contract by number and indicates which contracts are
funded from state grants and aids appropriations.
The provider agrees to submit the required reportd as shown in Part IV.
Otherwise, if the provider does not recieve funds from a grants and aids appropriation,
the provider has no audit or attestation requirement required by this attachment.
PART IV: SUBMISSION OF REPORTS
Copies of the audit report and any management letter by the independent auditors, or
attestation statement, required by this attachment shall be submitted within 180 days
after the end of the provider's fiscal year, unless otherwise required by Florida
Statutes, to the following:
•
A. Audit and Evaluation
1317 Winewood Boulevard, Building B, Room 492
Tallahassee, Florida 32399 -0700
B. Contract manager for this contract
C. Submit to this address only those reports prepared in
accordance with OMB Circular A -133:
Federal Audit Clearinghouse
P. 0. Box 5000
•
Jeffersonville, Indiana 47199 -5000
D. Submit to this address only those reports prepared in
accordance with the rules of the Auditor General,
chapter 10.600:
Jim Dwyer
Office of the Auditor General
P. O. Box 1735
Tallahassee, Florida 32302
• The provider shall ensure that audit working papers are made available to the department,
or its designee, upon request for a period of five years from the date the audit report is
issued, unless extended in writing by the department.
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