11/12/1997 MONROE COUNTY MONROE COUNTY BOARD
IN -HOME SERVICES OF
COUNTY COMMISSIONERS
HCBS/MEDICAID WAIVER REFERRAL AGREEMENT
This Referral agreement, made this 12th day of November, 1997, shall be in effect for the period from November 1, 1997
to November 31st, 1998, between Monroe County Board of County CommissionerslMonroe County In -Home Services,
the Case Management Agency, and Staff Builders, Inc., the Service Provider Agency. o cn
O r`
The purpose of this agreement is to promote the development of a coordinated service delivery system tepeet n rn n
r+i :r r
the needs of the aged or disabled adults who are at risk of premature institutionalization. C", ry
3
Objectives ,.- o rn
1. To maintain a climate of cooperation and consultation with and between agencies, ordef #o o
achieve maximum efficiency and effectiveness.
2. To participate together by means of shared information in the development of serviees. N
3. To promote programs and activities designed to prevent premature institutionalization of elders and
disabled adults.
4. The parties of the Agreement will provide technical assistance and consultation to each other on
matters pertaining to actual service delivery and share appropriate assessment information and
care plans so duplication may not occur.
5. Both parties of the Agreement may terminate upon no less than thirty days notice without cause;
the Case Management Agency may terminate upon no less than twenty -four hours notice due to lack
of funds; and unless waived by the Case Management Agency, the Agreement may be terminated for
breach upon no less than twenty -four hour notice. All termination notices must be delivered by
certified mail, return receipt requested, or in person with proof of delivery.
II. Under this agreement, the Service Provider Agency agrees to the following:
1. To accept referrals for the Aged /Disabled Home and Community Based Service (HCBS) Medicaid
Waiver from only the Case Management Agency.
2. To provide quality service(s) specified in Section IV for the waiver participant which is subject
to quality monitoring andlor observation by the Case Management Agency.
3. To provide only those service(s) specifically outlined in the Plan of Care or service authorization
submitted by the Case Management Agency.
4. To bill Medicaid at the usual and customary rate for each service.
5. To attach documents regarding provider qualifications to this agreement; and to provide, as
requested, any information, regarding Medicaid Waiver billing, payment, or waiver participant
information, to the Case Management Agency or Area Agency on Aging. Provider rate
increasesldecreases must be forwarded to the Case Management Agency listing the service(s).
The necessary documentation regarding provider qualifications for additional services will be
signed, attached to the agreement and forwarded to the Area Agency on Aging and the Case
Management Agency.
6. To maintain the waiver participant's confidentiality.
7. To immediately report any changes in the waiver participant's condition to the Case Management
Agency.
8. To maintain enrolled provider status by renewing applicable licensure, certification, contract, and
referral agreements.
•
III. Under this Agreement, the Case Management Agency agrees to the following:
1. To provide the Service Provider Agency with any pertinent information and history on the
referred waiver participant.
2. To provide the Service Provider Agency with a copy of the Plan of Care or a service
authorization form specifically outlining the service(s) to be delivered.
3. To be available to the Service Provider Agency for discussing the referred case.
4. To immediately report any changes in the waiver participant's condition to the
Service Provider Agency.
IV. Under this agreement, the following services will be delivered by the Service Provider Agency:
COMPANIONSHIP, HOMEMAKER, ESCORT, PERSONAL CARE, RESPITE CARE
COUNSELING, THERAPIES: PHYSICAL (PT) OCCUPATIONAL (OT) AND SPEECH,
CAREGIVER TRAINING/ SUPPORT (INDIVIDUAL) CAREGIVER TRAINING/ SUPPORT
(GROUP)
V. Under this Agreement, the Case Management Agency is not bound to only refer to the Service
Provider Agency.
STAFF 133.)1knir
CASE MANAGEMENT AGENCY SERVICE PROVIDER AGENCY
w
—
J
•natu�' ��' signature
3-2 c,1E' L p h cL O I'1 SANDRA J. PARSHALL
print name print name Vice President
National Health Cue Operations
MAYOR
title title
' _ 11112/97 1 113 /Q 1
m date date
' (SEAL)
ATTEST DANNY L. KOLHAGE CLERK
of •O—L t. L C. ,[(/,�
DEPUTY c".r7
Services to be provided hereunder will be
APPROVED AS TO FO' M rendered by the Staff Builders, Inc. wholl -own
AND - SUFFICIE
� subsidiary, rg Y ed
y FF 6v << EKS SFr v �c
licensed entity.
�• NNE . TON ,the local
DATE
PLEASE REMIT TO:
STAFF BUILDERS
BOX
PHILADELPHIA, PA 9175 3980
STAFF BUILDERS PUBLISHED RATES
NURSING SOCIAL WORK, NUTRITION, COUNSELING
RATES RATES
HI -TECH RN CAREGIVER SUPPOR1
ASSESSMENT $100.00 * LCSW HOURLY
UP TO 2 HOURS INDMDUAL I $37.00
GROUP (EACH PERSON) I $20.00 •
PICC UNE INSERTION $375.00 •
HI -TECH RN LCSW ,
REVISIT VISIT $100.00 •
$100.00
UP TO 2 HOURS MSW
VISIT 1 $100.00 •
RN
ASSESSMENT I I $100.00 • DIETICIAN
RN VISIT $85.00 •
REVISIT $90.00 *
CNA, HHA,HMK, LIVE -IN
HI -TECH RN HHA $30.00 •
HOURLY $55.00 • VISITS
RN HHA/CNA 1
$15.00 •
HOURLY $48.00 • HOUR (4 HR. MIN.)
I
HI -TECH LPN HHA/CNA 1 $35.00 •
•
REVISIT $75.00 SPECIAL 2 HOUR SHIFT I
UPTO2HOURS
, PERSONAL CARE j $15.00 •
LPN HOURLY j
REVISIT $60.00 •
HOMEMAKER $15.00 •
HI -TECH LPN p $40.00 • HOURLY i
LPN $40.00 • COMPANIONSHIP $15.00 •
HOURLY HOURLY
RESPIT CARE $15.00 •
HOURLY
ESCORT $18.00 •
THERAPIES
LIVE -IN $180.00 *
PT, OT, ST 24 HOURS
VISITS $40.00 •
ASSESMENT
LPTA, COTA
VISIT $80.00 * 1 .
1
*RATE ADJUSTMENT FOR HOLIDAYS & OVERTIME;
TIME PLUS ONE HALF*
PA k\for\Q„3-- Pc .
STAFF BUILDERS MEDICAID WAIVER RATE SUMMARY
THERAPIES COUNSELING / TRAINING
RATES RATES
PT, OT, ST CAREGIVER SUPPORT / TRAINING
VISITS $10.00 *
ASSESMENT INDIVIDUAL $5.00 •
PICC LINE INSERTION GROUP $2.00 •
VISIT $10.00 • (EACH PARTICIPANT)
COUNSELING
$15.00 •
PARAPROFESSIONAL
PERSONAL CARE $3.75 •
HOMEMAKER $3.75 *
COMPANIONSHIP $3.75 •
RESPIT CARE $3.75 •
ESCORT $4.50 •
*BASED ON 1/4 HOUR UNITS*
P46C\ATY1QAt-V.
OCT - 15 - 97 THU 11 04 AM STAFF BUILDERS FAX N0. 516 327 8778 P. 1
CU/lb/1594 86:48 5163278636
sTAFF BUILDS �
PAGE el
UNANIMOUS WRITTEN CONSENT ,
IN LIEU OF MEETING
OF
THE BOARD OF DIRECTORS
'OF
STAFF BUILDERS SERVICES, INC.
The undersigned,
Directors of STAFF d, being all of th e members of
Corporation (the * BUILDERS SERVICES. INC. the board of
Corpora, to the adoption of the followin °Corporation "), hereby consentei York
r in lieu of
RESOLVED, g esoiutlons:
that bavid
of the Corpor or S ndralt$rs ll, Vice President-
Vine President
pQrat,ions, of the Corporation be, Vice President_
O
authorized arat ins And empowered and each of
deliver. contrac ts/agreement s andem wed t make,
b t nt them hereby is,
derther, to ene into, sign, seal and
to renew do all things necessary f of the Corporation, and
or said contract; Y to implement, maintain, amend
oft
FURTHER VD, that THR REgpLE the Secretary oz Assistant Sec
he RTH R , and a each he Secretary
O the Corporation rat io n r of them hereby
resolution; and certifications of the adoption authorized to
it is p ion of this
ETIRTHER RESOLVED, that
C Oration be, and they the proper officers of the
y hereby are, authorized and
exec al any and a d al uch other documents and instrumen empowered to
s and to
cor ann be
take a l uc i on necessary to carry out the intent of the
r ..
Stephen Savita
C
G y he
David Savitsky —
Dated April 4, 2997
•
A 4aC Q , - c,
Attachment N.
MEDICAID WAIVER
PROCEDURE CODE AND
— — -- __ _ _ RATE SUMMARY
SERVICE PROCEDURE
RATE UPPER LIMIT
CODE UNITS
PER DAY
ADULT DAY
HEALTH CARE W9701 $2.50
CASE AIDE 48 �_
W9713 $5.25* 96
CASE MANAGEMENT HRS STAFF 9 6 ( 1
� �
�W9702 $8.00 f
CASE MANAGEMENT NON HRS
W9703 $11.25 96
CAREGIVER T RAINING /SUPPORT I I`
•(INDIVIDUAL) W9714 $9.25* 32
CAREGIVER TRAINING /SUPPORT
(GROUP) W9715 $2.00 ** 32
CHORE GROUP �
W9.704 $4.50 96 1
COMPANIONSHIP
W9726 $5.25* 96
( s
CONSUMABLE
ICAL SUPPLIES W9716 $100.00*** * * I
COUNSELING $100.00 5 /MONTH
W9705 $15 I
EMERGENCY ALERT RESPONSE - .00 32
INSTALLATION W9724 $95:00* ONE TIME
EMERGENCY ALERT RESPONSE - ONLY
MAINTENANCE W9725 $1.30 - 1.
ENVIRONMENTAL MODIFICATIONS per day
W9717 $500.00 ++ 2 /MONTH s
ESCORT
W9706 $5.25 48 I
HEALTH SUPPORT
W9707 $5.25 48
HOME DELIVERED MEALS
W9723 $4.00 /MEAL 2
HOMEMAKER • .. • W9708 $4.50 48
PERSONAL CARE • W970' • $5.00 96
RESPITE
W9711 $4.50 • 96
RISK REDUCTION -
FINANCIAL ASSESSMENT W9719 $8.75* 32
RISK REDUCTION -
FINANCIAL MAINTENANCE W9720 $5.0.0* 32
RISR REDUCTION - NUTRITIONAL
W9721 • $12:00* 32
RISK REDUCTION - PHYSICAL W9718 $6.25*
L xJ9,
$ 6.25 32
THERAPIES' _ W9722 " $10.00*
= —_ —_ 4 8
It Based on 1/4 hour units
Ya ' per individual in the /per unit
~ .. ._
ed _- M ...w :/ P2r : . i ce
+ may be purchased . one timeonly
limited to two units per month /per client