SFY2013 07/18/2012DANNY L. KOLHA GE
CLERK OF THE CIRCUIT COURT
DA TE: July 26, 2012
TO: Sheryl Graham, Director
Social Services Department
ATTN: Dotti Albury,
In Home Services
FROM: Pamela G. Hanc k D. C.
At the July 18, 2012, Board of County Commissioner's meeting, the Board granted
approval and authorized execution of Item B 12 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, 2012 to June 30, 2013.
Enclosed are five duplicate originals of the above -mentioned, executed on behalf of
Monroe County, for your handling. Please be sure to return two fully executed originals for the
Clerk and the Finance Department. Should you have any questions, please do not hesitate to
contact our office.
cc: County Attorney w/o document
Finance
File
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ADULT PROTECTION
HOME AND COMMUNITY BASED WAIVER E�
CASE MANAGEMENT REFERRAL AGREEMENT o
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This Referral Agreement made this Jee day of July, 2012, between the Florida Department of
Children and Families' (DCF) Southern Region Adult Protection 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) 2012 -2013. The case management agency is a Medicaid Waiver case management agency.
This Referral Agreement is in effect from the date of signature, through SFY 2012 -2013 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' (DCF) Southern Region Adult Protection
Program Office and the Medicaid Waiver Specialist employed by the Department of Elder Affairs
(DOEA). 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' (DCF) Southern Region Adult Protection
Program Office; 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 Protection Program 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 DCF
Southern Region Adult Protection Program 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-AA 1022.
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 DCF Adult Protection 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 Protection
counselor and the phone number to the nearest DCF Adult Protection unit for the individual
to pursue service consideration and program screening.
E. Maintain and permit the DCF Southern Region Adult Protection 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 and
Medicaid ID;
3. Current (within one year) Consumer Care Plans indicating present authorized service(s)
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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 Care Plan, 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 Care Plan;
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
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G. Reevaluate the Care Plan 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 Care
Plan accordingly. Make the required changes to authorized services and /or service case
management agencies as needed.
1. 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 Protection 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
Protection 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 DCF any use or disclosure of the
information not provided for by this Agreement or applicable law.
(d) The case management agency hereby assures the DCF that if any PHI received from
the DCF, 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.
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(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 DCF or created or
received by the case management agency on behalf of the DCF 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 DCF
or received by the case management agency on behalf of the DCF, 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 DCF Southern Region Adult Protection's 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 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 DCF Southern Region Adult Protection 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
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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:
http://www.dcf.state.fl.us/admin/ig/civiIriglits,shtm1
(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 DCF Southern Region Adult Protection Program Office
Administrator. The 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
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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.
Florida Department of Children
and Families Southern Region
Adult Protection Program Office
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