09/16/2015 Agreement AMY NEAVIL IN, CPA
CLERK OF CIRCUIT COURT & COMPTROLLER
_.:_ MONROE COUNTY,FLORIDA
.YI=1 dl/
DATE: September 29, 2015
TO: Jose Tezanos,
Emergency Management Planner
ATTN: John Scott
Senior Emergency Management Planner l/�-�_��.
FROM: Cheryl Robertson Executive Aide to the Clerk of Court& Comptroller (211), t7- �/JO/xe t.504
At the September 16, 2015 Board of County Commissioner's meeting the Board granted approval and
execution of Item C3 Adoption of Memorandum of Agreement with the State of Florida Department of
Health in Monroe and 118 , .,,raivaiescent• i:=., y, for the purpose of utilizing their
rehabilitation center located in Miami-Dade County, to accept and shelter Monroe County's Medically
Managed Clients during an out-of-county evacuation resulting from a declared emergency
cc: County Attorney (Electronic)
Finance(Electronic)
File /
500 Whitehead Street Suite 101,PO Box 1980,Key West,FL 33040 Phone:305-295-3130 Fax:305-295-3663
3117 Overseas Highway,Marathon,FL 33050 Phone:305-289-6027 Fax:305-289-6025
88820 Overseas Highway,Plantation Key,FL 33070 Phone::852-7145 Fax:305-852-7106
MEMORANDUM OF AGREEMENT BY, AND AMONG, MONROE
COUNTY, FLORIDA DEPARTMENT OF HEALTH IN MONROE COUNTY,
AND PINECREST REHABILITATION CENTER
This Memorandum of Agreement ("MOA") is entered into this I L ' day of
s2S'emlw-e , 2015, by and between the Monroe County Board of County Commissioners
(hereinafter referred to as "County"), a political subdivision of the State of Florida, whose
principal business address is 1100 Simonton Street, Key West, Florida 33040; the State of
Florida Department of Health (hereinafter referred to as "FDOH MONROE"), whose principal
business address is 1100 Simonton Street, Key West, Florida 33040, and PINECREST
CONVALESCENT CENTER, LLC, doing business as Pinecrest Rehabilitation Center
("Receiving Facility"), whose principal business address is 13650 NE Third Court, North Miami,
FL 33161.
PURPOSE
WHEREAS, the County maintains a special needs registry for those residents with
specific medical conditions and who would require the use of public shelters during an
evacuation; and
WHEREAS, this need is met by providing special needs shelters and coordinated by a
multi-agency special needs program; and
WHEREAS, some of the special needs clients' needs exceed the capabilities of those
available at the special needs shelters and require a higher level of care facility ("Medically
Managed Evacuees");
NOW THEREFORE, in consideration of the mutual covenants contained herein, the
parties agree to the following:
Purpose: The purpose of this MOA is to establish the general conditions for the
Receiving Facility, located at 13650 NE Third Court, North Miami, FL 33161, to accept and
shelter Monroe County's Medically Managed Evacuees resulting from a declared emergency by
local, state or federal government(collectively referred to herein as an "EVENT"). This MOA will
be effective during all mandatory evacuations of special needs clients, and only if it is
determined by FDOH MONROE that there is a need to place Medically Managed Evacuees at a
higher level care facility.
II. MOA Term: This MOA shall commence on the latest date it is fully executed by the
parties and unless interrupted by mutual written agreement, shall automatically renew on
January 1st of each subsequent year.
III. Monroe County Responsibilities:
1. Act as the lead liaison/agency contact regarding fiscal and legal issues under this
MOA.
2. Serve as the payer of last resort to the Receiving Facility in the event that client
insurance, state or federal repayment funds are not available.
3. Provide, coordinate and manage the transportation of Medically Managed Evacuees
from Monroe County to and from the Receiving Facility.
4. Maintain a current roster of all registered medically managed clients.
1
5. Advise Medically Managed Evacuees of the general items they will need to bring with
them when evacuating and furnish them with a written list upon the client's
successful registration into the program.
6. Participate in an annual readiness meeting (in person or virtual)with all parties, to be
held each year, prior to June 1st, for the life of this agreement.
7. Identify an agency MOA Manager and provide their contact information to all other
parties (see Attachment A). Written notification of any changes will be delivered to all
parties within 30 days.
IV. Florida Department of Health in Monroe County (FDOH MONROE) Responsibilities:
1. Act as the lead liaison/agency for coordinating activities and operational issues under
this MOA.
2. Serve as the subject matter expert to the County for all medical portions of the
program to include the final determination of a client's designation, resources and all
other medically relevant functions.
3. Ensure that each Medically Managed Evacuee client has a completed Medical
Certification for Nursing Facility/Home- and Community-Based Services form (AHCA
MedServ-3008) and that those forms are provided to the Receiving Facility on or
before the client's arrival at said facility.
4. Notify and place on stand-by the Receiving Facility for any threat that may prompt a
mandatory evacuation as soon as it is identified. When possible, a minimum of 72
hours will be provided prior to any evacuation order being implemented.
5. Stay in regular contact with the Receiving Facility throughout the duration of the
EVENT and notify the Receiving Facility immediately should the threat pass.
6. Develop and maintain the "Medically Managed Coordination and Transportation
Standard Operating Guide (SOG)" to structure and guide the execution of this
program.
7. Participate in an annual readiness meeting (in person or virtual) with all parties, to be
held each year, prior to June 1st, for the life of this agreement.
8. Identify an agency MOA Manager and provide his/her contact information to all other
parties (see Attachment A). Written notification of any changes shall be delivered to
all parties within 30 days.
9. In the event that there is no available space at the Receiving Facility, submit a
mission request to the State's Emergency Support Function (ESF) 8 for assistance in
placing clients in alternative identified facilities.
V. Pinecrest Rehabilitation Center Responsibilities:
1. Serve as shelter for Monroe County's Medically Managed Evacuees as available
facility space allows for. Upon arrival, evacuees will remain at the facility until it is
safe to transport them back to Monroe County or an identified alternate facility.
2. Deliver an updated Skilled Nursing Rate Sheet (Attachment C) to FDOH MONROE
and the County on or before June 1 of each year, for the life of this MOA.
3. Provide specialized care as agreed in AHCA MedServ-3008 patient forms
(Attachment B) and billed per the current Skilled Nursing Rate Sheet (Attachment C).
4. Coordinate with FDOH MONROE to resolve any Medically Managed Evacuee
resource, medication or feeding need not provided for by the client.
5. In the event that there is no available space, notify FDOH MONROE so that the
appropriate mission request can be submitted to the State's Emergency Support
Function (ESF) 8 for assistance in placing clients in alternative identified facilities.
6. Provide the County and FDOH MONROE with all appropriate supporting
documentation needed for repayment and work with both parties to resolve any
matters arising from the federal reimbursement process.
2
7. Participate in an annual readiness meeting (in person or virtual) with all parties, to be
held each year, prior to June 1st, for the life of this MOA.
8. Identify an agency MOA Manager and provide that person's contact information to all
other parties (see Attachment A). Written notification of any changes shall be
delivered to all parties within 30 days.
VI. Fee Structure: The Receiving Facility will charge the prevailing actual Medicaid daily rate
per client for services rendered (the established daily Medicaid rate in effect on the day of the
client's arrival at the Receiving Facility). In the event that the Medically Managed Evacuee
requires additional items (missing medications, etc.) or specialized nursing care during his/her
stay, any additional charges will be based on a Specialized Nursing Rate Sheet (see
Attachment C) in this MOA. The Receiving Facility will provide an annually updated rate sheet to
the County and FDOH MONROE on or before June 1, for the life of this MOA.
VII. Payment and Billing: The Receiving Facility will first seek repayment from the individual
Medically Managed Evacuee's health insurance company for services rendered. Should the
client not have health insurance or in the event that the Medically Managed Evacuee's
insurance company deems the costs ineligible, any available funding through state or federal
sources will be utilized for repayment. In the event that those funding sources are available, the
County will serve as the payer of last resort and will ensure that the Receiving Facility is
compensated for all services rendered. Both FDOH MONROE and the County will ensure that
the Receiving Facility is provided with all appropriate repayment paperwork on or before the
client's initial arrival at the facility.
FDOH MONROE and the County acknowledge and understand that they are responsible for
seeking any federal or state funds available for reimbursement of the costs associated with
sheltering Medically Managed Evacuees. The Receiving Facility agrees to provide FDOH
MONROE and the County all appropriate supporting documentation and work with both parties
to resolve any matters arising from the state or federal reimbursement process.
VIII. INDEMNITY AND HOLD HARMLESS: It is the intent of the parties that each party be
responsible for the acts and omissions of its own officers, employees and agents. To the extent
allowed by Section 768.28, Florida Statutes, all parties to this agreement agree to be
responsible for the acts and omissions of their respective officers, employees, and agents,
which occur within the course and scope of their employment and which result in injury.
IX. Termination: This MOA may be terminated at any time upon mutual written consent by
all parties. Notice shall be delivered in accordance with the notices and provisions outlined
below. Additionally, in the event of default by any party under this MOA, the other parties may
terminate this agreement by providing written notice within 48hrs of said default and pursue any
and all rights available at law or in equity if such default is not cured within a reasonable time
period.
X. Miscellaneous Provisions:
1. Notice. If and when notice is required under this MOA, the notice shall be sent by
first-class mail, return receipt requested, Federal Express with evidence of delivery thereof, or
by hand-delivery to the parties at the following addresses or such other address or manner as
the parties may designate in writing from time to time. In the event of an emergency, notice may
be given orally and confirmed in writing no less than twenty-four(24) hours later.
3
For FDOH MONROE: Administrator, Florida Department of Health in Monroe County
1100 Simonton Street
Key West, Florida 33040
Telephone: 305-293-7500
Email: Bob.Eadie@flhealth.gov
With a Copy to:
Public Health and Medical Preparedness Coordinator, Florida
Department of Health in Monroe County
3333 Overseas Hwy
Marathon, Florida 33050
Telephone: (305) 289-2729
E-Mail: Cyna.wright@flhealth.gov
For Monroe County: Monroe County Administrator
1100 Simonton Street, Suite 205
Key West, FL 33040
Telephone: (305) 292-4441
E-Mail: Gastesi-roman@monroecounty-FLgov
With a Copy to:
Monroe County Emergency Director
Monroe County Emergency Management Department
5192 Overseas Highway
Marathon, Florida 33050
Telephone: (305) 289-6018
E-Mail: Toner-Irene@monroecounty-FL.gov
For Receiving Facility: Administrator
Pinecrest Rehabilitation Center
13650 NE Third Court
North Miami, FL 33161.
Telephone: (305) 893-1170
Email: dgold@pinecrest-rehab.com
2. Mutual Cooperation. It is the intent of the parties to aid each other in their
common goal of emergency management preparation. To this end, the parties shall periodically
confer to discuss changes that are required in this MOA or its implementation. Additionally, the
parties agree to cooperate in the investigation of any claim arising from this MOA and to notify
the other parties of any claim or suit which arises out of the obligations of this MOA.
3. Amendments. This MOA may be amended or modified by mutual consent of the
parties, provided any and all such amendments or modifications shall be in writing and signed
by authorized representatives of both parties.
4. Compliance with Laws. Each party shall comply with applicable Laws pertaining
to this MOA.
4
5. Force Maieure. Neither party shall be liable to the other party for any
interruption, failure, inability, or delay to perform hereunder, if such failure, inability, or delay is
due to any cause beyond the reasonable control of the party so failing, including without
limitation, acts of God, acts of any government, war or other hostility, civil disorder, the
elements, fire, explosion, power failure, telecommunications service failure or interruption,
equipment, failure, industrial or labor dispute, or inability to access necessary supplies, and due
diligence is used in curing such cause and in resuming performance.
6. Binding Agreement: This MOA shall be binding upon and shall inure to the
benefit of, the parties and their respective representatives, successors and permitted assigns.
7. Health Insurance Portability and Accountability Act: The parties shall comply
with the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d-8) as
amended; the Health Information Technology for Economic and Clinical Health Act, (HITECH
Act) enacted under Title XIII of the American Recovery and Reinvestment Act of 2009 (Pub. L.
111-5); and all applicable regulations now or hereinafter promulgated thereunder.
8. Sovereign Immunity: Nothing herein is intended to serve as a waiver of
sovereign immunity by any party under this MOA, to the extent applicable. Further, nothing
herein shall be construed as consent by a state agency, a public body corporate of the State of
Florida or political subdivision of the State of Florida to be sued by third parties in any matter
arising under this MOA or other agreement.
9. Monroe County Code Section 2-152: FDOH MONROE and the Receiving
Facility warrant that they have not employed, retained or otherwise had act on their behalf in
order to procure this MOA any former county officer or employee subjection to the prohibition of
Sections 2-149 of the Monroe County Code or any count officer or employee in violation of
Section 2-150 of the Monroe County Code. For breach or violation of this provision the county
may, in its discretion, terminate this contract without liability and may also, in its discretion,
deduct from the contract or purchase price, or otherwise recover, the full amount of any fee,
commission, percentage, gift, or consideration paid to the former county officer or employee or
current county officer or employee.
[The remainder of this page is intentionally left blank.]
5
IN WITNESS WHEREOF, the parties hereto have caused this MOA to be executed by
their undersigned officials as duly authorized.
WITNESSES: Florida Department of Health in Monroe County
BS .
Title: HIt rtment Administrator
Date: yr
Approved as to form and legality:
By:
Title:
Date:
roe County Board of Co y Commissioners
�1,te
At\ HEAVILIN, Clerk By: an Kolhage
Title:Date: 7 Mayor 9/i to// 5
a
\' ff5lb -t'I: I. .! Aorta t a Ap oved a to form pnd,l9gality:
. epu`t ' erk ri4. 7, ,FfztJ'y
By: Cynthia L. Hall
Title: Assistant County Attorney
Date: 6-ate ' Rl C
PINECREST CONVALESCENT CENTER, LLC,
business-es Pin crest Rehabilitation Center
ralo
(��ycQ\,/y�By:
Title:
Date: Z 20) %7
Approved as to form and legality:
By:
Title:
Date:
6
Attachment A
MOA Manager Contact Sheet
MOA Managers: FDOH MONROE, County and Receiving Facility have identified the following
representatives as MOA Managers. These individuals shall be responsible for coordinating
activities and responsibilities under this MOA and shall serve as liaison/agency contacts
regarding issues or other matters arising out of this MOA:
FDOH MONROE Manager: Cyna Wright
Public Health and Medical Preparedness
Coordinator Florida Department of Health in
Monroe County
3333 Overseas Hwy
Marathon, Florida 33050
Telephone: (305) 289-2729
E-Mail: cyna.wright@flhealth.gov
Monroe County Manager: John Scott
Senior Emergency Management Planner
Monroe County Emergency Management
Department
490 63'1 St Ocean, Suite 150
Marathon, Florida 33050
Telephone: (305) 289-6012
E-Mail: scott-john@monroecounty-fl.gov
Receiving Facility Manager: David Gold
Administrator
Pinecrest Rehabilitation Center
13650 NE Third Court
North Miami, FL 33161.
Telephone: (305) 893-1170
Email: dgcld@pinecrest-rehab.com
This page intentionally left blank
Attachment B
Nursing Facility/Home-and Community-Based Services Form
(AHCA MedServ-3008)
rph�2�pL�ey��'� MEDICAL CERTFICATION FOR NURSING FACILITY/NOME-AND COMMUNI Y.SASED SERVICES FORM
E�KID (Repluc.,Patient Transfer and Continuity of Can Form)
(Al FACILITY INFCRIMTON LEI HISTORY B minimal.AND LASS
F
nMy Rom
ptlmession Dale Db[4mge Data I PHYSICAL EXAM(WAep L P"ys cal may be do Ned)
Fa[ y o :J_ 7 Head Ears Eyes Nose a rem al(HHEEND
(B) DEMOGRAPHIC INFORMATION
Mdnld Al,DOB I r Sex Race N.e iosulmon ary
Car
Iutleitluals LW Name Firs1 Name Whao Abdomen
O
Iv dm"ua Ix Meress phone Numbs, Recta'bras
Hearn eeaIfr 1eoT Care Slutlyle Ross Number Rerd leglol
PHYSICIAN LNFORMATON p"'
b l Ye Free from.ammem[able id/sewn QvesfNn
Will you care mrmtividual in Ws =yes DM 2 LABORATORY HNDDIGS{SePebsnuroe Washed)
II no.referred ID - TU WAOY<SONd Dale
PnnripetDianos. ______ ReAIM
Secondary Diagnosis __- Chen X.Pay DYesCNa Date
Ote Margo MagnusI_ _ Re su Xe
(Problem LDS May betntell
Carboy Performed&Dole _ I / RI IMSIXRATIONS LIVEN
Allergy/Dom ScomSAl
Pneuemmcnl Ve¢me Dae
LIE DIW IIDN AND CREAMERY ORDERS Icoplel May be attached} :e euua Ve mere Date /_
m�: m Dmb inavaCCMe Oats —�
zoner vpaarma Dare
(o) PHYSICAL THERAPY(Attach Ordrsl
=.New Referral =Contivatlon of herapy
(C)PREADMBEION SCREENING FOR MENTALILLNEEW.EMAL RETARDATION
(Ca N'Are FA 7dmie775ntoNPnn1A FREQUENCY OF THERAPY
Is de me novhe primaryd,egnosis? Yes CNn INSThU CTIOXS
2 Is then an mdcAon of,or diagnosis of menuhetam.uon IMP).
of I divivalnnrved MR servieesans the'am 2 pars,' =Y x ONO =SbetcNngq Coordivetng Mhedres se bed to vhe.eheir
3 Is m .2011051S of serious menial Illness MI) e h Mere eamnNal apply'mr um niMneun @Cp ®Pm"mightbemng YAelohvo
S[mmonnma _Pans ormn miximy disorder _ might blaring mbu Nrmn
Mood disorder _PmonalMy disorder _
Somaglormdisorder Oih rpsych/A or mental rd er pmgns ere ran one Sensation Impaired all _
IPan rams leading ismmnie mn dYAy 4FFCAUi DNS esriu Aniapy yes
NoB
the4 brad ryldual neery ed Ml arvlez.MMvhe Pa9 two years' Yes nNm _pNne
5 kathe ln&e dual a dangenoaeio/others'(pbw erect exptnmaq O�{ryg _Other
6 is elndmd uvl on any med.nuon br the names/ore serious ADDmOXAL THERAPIES ARE Order)
„whams d hgnnelil
7 II yes n the dMI or psychiatric dug noses con rolled wen motheaten?ons 0sCuchhe Therapy cup espy
D Is being edmmed from a her spill Mer nerving acute Yen BNo Speech Th<npy eONer aN
ICoesem udrF (III TREATMENT AND SOURNESS!REEDS RAS,Orieal
9 orwh,ehoesthy mdrvhe ree,ne nore in geaMAysery mexkn"e mndNon QYv QNo _
pas mNeh ig CareFee Diabetic Cans
IDH laheys
gran p[le uiloyn uLMelis p urn lav tA. QYes One UacsrFng Feeding rube _Momror BH otl S.qa uFr¢q ue n[y
L apso nursing to cAry mesa0 d _Missing Changes _M mi
_OOomy Care ude Feedingu^
C) AOOrIONAL ORDERS(ON maybe htl) VMnndCare -
Teach rI (Seim rem mqq
( — aconmg O �CoN
Gs, mur.e Vmm
IIIsWSPns
ISPECIAL DIET ORDERS(Omen maybe aualietll
Y) TYPE OF CARE RECOM.ENDED MOSTEE COWLS TED ANv 3lOh O)
Checkone Rehab Polenhal(checks/Ye/ QGoad Omar=Po r
Skied rag Eaendn Can Finlay
(ECI).Duben
ce Care:Dur.eon- Adrm an Date to Nnhq rashly - I
es ECF Nursing Pflaky Can lo m be ndm WM he/sheon for he/sheoe"m e rorve dung hospitalisat ion m
CI Ce ymallhrsm ueb dnidsineedofMedicadWamerSernesmlry lnemuvonalplacement
Ptlm Phyallani Neese Meats Den el Medical Condebq___ __--___
Add FM
Photon Merillbtf Fa
Eyed Contact Address FOR ONLINE APPLICANT USE ONLY
R APPLYING ADR MEDICAID.PLEASE INCLUDE 005
r I ACCESS CONFIRMATION NOMBER EELOW
Phyuciont Slgnaure and Cam Rgulred
Aau EORM.m tom cur mAtMmn TVs.trams and CmTYtl LYCRA FOSS m.uRAM CF lemI
—
Attachment B
Nursing Facility/Home-and Community-Based Services Form
(AHCA MedServ-3008)
PLORIOA t NURSING/SOCIAL WORK ASSESSMENT
AIQ- (Page 2 may De completed by a Nurse or Social Worker]
ADLs ARE AT TIME
INDMDUAL'S NAME DOB OF NF ADMISSION
(R)VISION el F —
v —
1 Noanimm• 6equi,ecaannce'
( /isms 5 2 an 4Bn=tl AMBULATION _2 xxb ass-sere device _th aablbep
Setll 3 NM1b eupenlsan 6 Bed bound
HEARING �] Goo: 3vep, =e R50bry zmamm ecnnp
(w/e tl it �+.Fate �e Deaf ENDURANCE —_2 Ns ede r s e Qe ble lolevea
used) _3 Family Inrales sbanantnea
SPEECH s °aa a Goeluurexm sgns TRANSFER
=2 Fair R4 unable n spe —z e e:dbound�ana
—43 p_n, 3'Mb sup:n eon
COMMUNI- _I Marne megesiervs reformat on WHEELCHAIR I No axcmnee eeIs norm
Li-red 2 - u u a
ed ability USE ellnabrea
1 ra lY unable tlAficut tee emg NIA
MENTAL .n .Aggresses 9 SNfty re a detl —1 rvoaauunce Bathroom
AND ]Confused Dneupe.e 11 O e moth sled ne 2 Wth assIre Jenne B-BePsne mmmedn
BEHAVIOR 3 COonemetl Nouexe TOILETING 3 WM supsnmon 0 Bedpan
STATUS of se =nne,z a Pequ„ezaemmIlae
5.Intel aaeAance
niment
SKIN —z madOPA QSns O ague —i norm mlio m - or less
CONDITION — 0P e[eBLADDER —_3Frequenen n�mmn Puplo onu y
_3 Manion�lonP Sage CONTROL
e Open Wound 4 Anal immanence
6 Catheter-mdrelAng
1 the assists.
n ee —I Omlun
t
z SuenaPensioner no^nee a e
DRESSING BOWEL = Fl repenmmnnae-upto arms fay3Bepambe atlere:15:7. CONTROL _a Tote meone e
5 050my
Tub I.Na as9ance In Aspirates
BATHING P'pipwresM119�on a B-Sbmnr FEEDING stelenup only3 Pe assisleore Span➢e Bale 3 Pe upassisassistancees assistance
TEACHING DIET
I Full _3 Pureed
areas B3OafryLeoiyy I MCGaniol Sol 4 Other lm eely)
'(HANDS ON NEEDED)
Comments: —.
SIGNATURE AND TITLE DATE I / __
IL) SOCIAL WORK ASSESSMENT
Prior Living Anangemem— _ --
Long Range Plan/Agency Referrals__
Adjustments to(lines,or Disability
Comments --
µCAuEDSFRv 1ornm lits2019--IleethaesFJ Ratner edCmla„ee.mFtem X Jl :om.naS / OQFACC SSCo.Amati,t -
• . ,
Attachment C
Skilled Nursing Rate Sheet
Other Pinecrest Service Rates:
- Bariatric Care (350 Ibs+) +$75.00/Day
- Tracheotomy Care +$75.00/Day
- HIV Patients on high costs meds (cost of current medication +8% administration fee)
- Complex wound care which would include Stage 4 or greater wound(s) and or wound
vac +$70.00/Day
- Isolation requiring a private room +$200.00/Day
- Rehabilitation to include PT, OT and Speech Therapy +$45.00/per unit of treatment