Item C14M
C ounty of f Monroe
ELj » °o
�
BOARD OF COUNTY COMMISSIONERS
/� r i � ��
Mayor George Neugent, District 2
The Florida. Ke Se
y
I
Mayor Pro Tern David Rice, District 4
Danny L. Kolhage, District I
Heather Carruthers, District 3
Sylvia J. Murphy, District 5
County Commission Meeting
July 19, 2017
Agenda Item Number: C.14
Agenda Item Summary #3164
BULK ITEM: Yes DEPARTMENT: Social Services
TIME APPROXIMATE: STAFF CONTACT: Sheryl Graham (305) 292 -4510
N/A
AGENDA ITEM WORDING: Approval of Alzheimer's Disease Initiative Program (ADI)
Contract KZ -1797 between the Alliance for Aging, Inc., and Monroe County Board of County
Commissioners/Monroe County Social Services In -Home Services for the contract year 2017 -2018
(07/01/2017- 06/30/2018) in the amount of $164,647.80.
ITEM BACKGROUND: Approval of the ADI contract will enable Monroe County Social
Services In -Home Services Program to continue providing personal services to Monroe County's
elderly population under the Alzheimer's Disease Initiative Program.
PREVIOUS RELEVANT BOCC ACTION: BOCC approval on 07/19/2017 of ADI Amendment
#002 to Contract KZ -1697 between the AAA and Monroe County BOCC.
CONTRACT /AGREEMENT CHANGES:
None
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
ADI Contract 07 -03 -17
ADI Contract BACKUP 07 -03 -2017
FINANCIAL IMPACT:
Effective Date: 07/01/2017
Expiration Date: 06/30/2018
Total Dollar Value of Contract: $164,647.80
Total Cost to County: 10% Cash Match
Current Year Portion:
Budgeted:
Source of Funds: Grant
CPI:
Indirect Costs:
Estimated Ongoing Costs Not Included in above dollar amounts:
Revenue Producing: Yes If yes, amount: $8,000.00
Grant: Yes
County Match: 10% Cash Match
Insurance Required: No
Additional Details: Revenue produced is from client co- payments.
07/19/17 NEW COST CENTER ADDED
125- 6153617
$164,647.80
REVIEWED BY:
Sheryl Graham
Completed
06/29/2017 1:54 PM
Pedro Mercado
Completed
06/30/2017 1:47 PM
Budget and Finance
Completed
06/30/2017 3:59 PM
Maria Slavik
Completed
07/01/2017 7:46 PM
Kathy Peters
Completed
07/03/2017 1:36 PM
Board of County Commissioners
Pending
07/19/2017 9:00 AM
(LWICOILO PWWOO IaV : IME) Lb PWWOO IaV WOMM44V
1q Pttra�ose of orttraet
The purpose of this contract is to provide services in accordance with the terms and conditions specified in
this contract including all attachments and exhibits, which constiftne the contract document.
2. Ls lttain tlac o]lMtE!
The contract will incorporate attachments, proposabs), state plan(s)a grant agreements, relevant Department
of Elder Affairs handbooks, manuals or desk books, as an integral part of the contract, except to the extent
[list the contract explicitly provides to the contrary. In the event of conflict in language among any of the
documents referenced above. the specific provisions and requirements of the contract doctiment(s) shall
prevail over inconsistent provisions in the proposal(s) or other general materials not specific to this contract
document and identified attachments.
3. Term of Contract
Effective Date:
This contract shall begin on July 1 2017 or on the date the contract has been signed by both parties,
whichever is later.
Delivery ofservices shall end at 11:59 PM, local time in Miami, FL on June 30, 200 The Alliance will
not reimburse the provider for services pro ided alter this date. I looc% er. the parties recogni/e that they
will need to perform continued activities relating to reporting. invoicing and paNinent in JUIN of 2017 to
facilitate payment for services rendered b y the provider Linder this contract,
4.0 Contract Amount
The Alliance agrees to pay for contracted services according to the terms and conditions ol'this contract in
an amount not to exceed $164,647.80 funds her 27 clients, or the rate schedule, subject to the availability of
funds. Any costs or services paid for under any other contract or finern any other source are not eligible for
payment under this contract.
(LWICOIL0 4 IaV : IME) Lb 4 IaV WOMM44V
M
M
11
10
M
M
Obligation to Pay
The Alliance's performance and obligation to pay under this contract is contingent upon an annual
appropriation by the Legislature to the Department and funding received by the Alliance under its contract
with the Department,
Source of Funds
The costs of services paid tinder any other contract or from any other source are not eligible for
reimbursement Linder this contract. The funds awarded to the provider pursuant to this contract are in the
state grants and aids appropriations and consists or the following:
Program Title Year Funding Source CSFA# Fund Amounts
dear F a
Alzheimer Disease 2017- General Reventic 65004 $164,647,80
a
Initiativ 2018
_ i,7 7 an
TOTAL FUNDS CONTAINED IN THIS CONTDACT: $164,64.80
The parties shall re-evaluate the contract's reimbursement rates on an annual basis pursuant to DOEA's
Notice or Policy Clarification: Service Cost Reports Notice #092815 -1 -PC- BS dated September 28
2015 and the approved Alliance's Reimbursement Rate Review Policy.
In the event that contracts cannot be overtired prior to the July lit start date, the Alliance may, at its
discretion. extend this Agreement upon written notice for LIP to 120 days to ensure continuity of service.
Services provided tinder this extension at ill be paid liar out of the succeedina aureernent amount
`Phis contract is executed and entered into in the State or Florida. and shall be construed, performed and
enforced in all respects in accordance with the Florida law, including Florida provisions for conflict of laws.
The Provider shall comply with requirements of s. 287,058, F.S. as amended.
6.2.4 The Provider shall allow public access to all documents, papers, letters, or other public records as defined in
subsection 11 9,011(12), F. S,, made or received by the Provider in conjunction with this contract except for
(LWICOILO 4:)eJ4uO:D IaV : IME) Lb 4:)eJ4uO:D IaV WOMM44V
The Provider shall enSUre that the reqUirements of s. 430,040- and Chapter 435, F,S., as amended, are inct
regarding baeUround screening for all personr o he meet the der ot'a direct service provider and who
are riot exempt from the Department*s level 2 background screening pursuant to s. 4 R& The
(LWICOILO 4:)eJ4uO:D IaV : V9W Lb 4:)eJ4uO:D IaV :4UGWt4
complaint on a complaint log.
9. Public Records anti Retention-
9.1 The Provider, subject to the terms of section 28?.058( 1 )(c). Florida Statutes, and any other applicable legal
and equitable remedies, shall:
a) Keep and maintain public records that ordinarily and nece-,scarily would be required by the public agency
in order to perform the services.
M Provide the public with access to public records on the same terms and conditions that the
Department would provide the records and at a cost that does not exceed the cost provided in Chapter
119, Florida Statutes, or as otherwise provided by law.
c) Ensure that public records that are exempt or confidential and exempt frorn public records disclosure
requirements are not disclosed except as authorized by la %4,
d) Meet all requirements for retaining public records and transfer. at no cost, to the Alliance and the
Department of Elder Afidirs; all public records in possession of the Provider upon termination or expiration
this contract and destroy any duplicate public records that are exempt or confidential and exempt From public
records disclosure requirernentq. All record, stored electronically 1T1U;t be provided to the Department in a
format that is compatible with the inilormation technology system of the Department,
10.2 The Provider shall retain all client records, financial records, supporting docu ments, statistical records. and
any other documents (including electronic storage media) pertinent to this contract for at period of six (6)
years after completion of the contract or longer when required by lao. In the event an audit is rewired by
this contract. records shall be retained for as rrammurn period of six (6J years after the audit report is issued or
until resolution of any audit findings or litigation based on the terms orthis contract. at no additional cost to
the Alliance,
10.3 Upon dernand, at no additional cost to the Alliance. the Provider shall facilitate the duplication and transfer
I
(LW/£0 /LO 4:MWOO IaV : IME) Lb 4:MWOO IaV WOMM44V
as the Alliance may require within the period of this contract.
10.9 The provider shall submit management, program, and client identifiable data, as specified by the Department
of Elder Affairs and / or the Alliance. The provider must record and submit program specific data in
accordance with Elie Department's Client Inficti Registration and Tracking System (CIRTS) Policy
Guidelines,
10.10 The Alliance for Aging, Inc. may unilaterally cancel this Contract. and any contract or agreement
incorporating this Contract by reference. notwithstanding any other provisions of this Contract, for refusal
by the Provider to comply with Section 9 of this Contract by not allowing public access to all clocurrients,
papers, letters, or other material made or received by the Provider in conjunction with the contract or
agreement incorporating this Contract by reference, unless the records are exempt from Section 24(a) of
Article I of the State Constitution and Section 119,07(1 ), Florida Statutes.
(LW/£0 /LO;:)ea;uoa IaV : IME) Lb-£0-LO ;:)ea;uoa IaV : ;uauay 444
15. Indemnification
(LWICOILO 4:MWOO IaV : IME) Lb 4:MWOO IaV WOMM44V
17� Confidentiality of Information
The Provider shall not use or disclose any information concerning a recipient of services tinder this contract
ror any purpose prohibited by state or tederal law or regulations e%cepi vith the written consent of a person
legally authorized to 9 ive that consent or when authorized by kov,
20. RBaannkKrERR(icKvIJNofifica Notification
N
(LW/£0 /LO;:)ea;uoa IaV : IME) Lb-£0-LO ;:)ea;uoa IaV : ;uauay 444
22. AalkaMMLs
(LWICOILO 4:)eJ4uO:D IaV : IME) Lb 4:)eJ4uO:D IaV WOMM44V
25. Fundine ObliLations:
2 &1 The Alliance for Aging, Inc. acknowledges its obligation to pay Inc Provider for tire perfonmante of the
I
(LWICOILO 4:)eJ4uO:D IaV : V9W Lb 4:)eJ4uO:D IaV :4UGwt4
27.3 The Provider and Sub-providers shall provide Units or deliverables, including reports, findings. and drafts as
specified in this contract to be received and accepted by the Contract Manager prior to payment,
28. Return of Funds
29, Data Int acity and So Lmardi a Information
X
31. Conflict or interest
(LW/£0 /LO 4 IaV : IME) Lb 4 IaV WOMM44V
32. Public Entiry Crime
33. Parch '
iMMUMM
Procurement of ProdUCtS or Materials with Recycled Content:
Reusable materials and products shall be used where economically technically feasible.
34. Paten(s, Col Rovalties
Ifthis contract is awarded state funding and ifany discovery. invention or copyrightable material is developed
produced or for which ownership was purchased in the course or or its a result of work or services performed
tinder this contract, the Provider shall refer the discovery, invention or material to the Alliance to be referred to
the Department of State. Any and all patent rights or copyriiflits accrUin" Linder this contract are hereby
reserved to the State of Florida in accordance with Chapter 286, F.S.
35. s
(LWIC0 IL0 4:)e4U IaV : IV9W Lb 4:)e4U IaV :4UGWt4
37. PUR 1000 Form:
3& Use of State Funds to Purchase or ftonrove Real Pr operty
Any state funds provided for the purchase ofor improvements to real property are contingent upon the Provider
or political subdivision granting to the state a security interest in the property at least to the amount OF state
funds provided for at least 5 years from the date Or purchase or the completion of the improvements or as
Further required by law.
39. Dianute -Resolution
Any dispute concerning performance of the contract shall be decided by the Contract Manager, who shall
redLICC the decision to writing and serve a cop), on the Provider,
40. Corrective Action Plan
a) Provider she'd] ensure 100% offlic deliverables identified in ATTACHMENT 1. Section 11 MANNER
OF SERVICE PROVISION are perfortned pur-Riant to contract requirements.
c) In the eventt. Provider bills to correct an identified deficiency v6ithin the approved time period specified
in the CAR the Alliance shall deduct. from the payment for the im,oice of the ibliou ing month. 1 11 0 of
the monthly value or the monthly invoiced funds in the contract for each dm the deficiency is not
corrected. The Alliance shall also deduct. firorn the payment for the invoice of the (rillooino month,
I% of the monthly value ofthe invoiced funds in the contract for each day the Provider fails to firriely
submit a CAP.
d) If Provider fails to timely submit a CAP, the Alliance shall deduct 1% of the monthly value Of the
invoiced rands in the contract for each day the CAP is overdue, beginning the I l"' day after
notification by the Alliance Contract khmager of the deficiency. The deduction will be made from the
payment for the invoice of the following month.
0
(LWICOILO 4:)eJ4uO:D IaV : V9W Lb 4:)eJ4uO:D IaV :4UGWt4
4L Financial Conspauences of Non-Performance
L Delivery of services to eligible clients as referenced in ATTACHMENT
1 Section 1 1.3 Section 11 2.1
of this contract Failure to ensure adherence to established assessment and prioritization criteria as
evidenced in GIFTS reports will result in a reduction of payment eqUal to the percentage of new clients
served who did not meet the criteria, compared to the total number of clients served.
2. Services and units of services as referenced in ATTACHMENT 1, Section 11 2.2 of this contract
Failure to ensure the provision of services in accordance with the current DOEA Programs and Services
Handbook, and ATTACHMENTS V11 and submission of required documentation will result in a 2%
reduction of payment per business day any identified deficiency is not cured or satisfactorily addressed.
3. Performance Specifications as referenced in ATTACHMENT 1, Section 11, 2.6 ofthis contract Failure
to perform the performance specifications and oversight of CCE Program operations will result in a 2°0
reduction of payment per bUsinces day an y identified deficiency in duties is not cured or satisfactorily
addressed in accordance with ATTACHMENT I, Section 11 3. 6.3
4. Exceptions may be granted solely, in writing. by the DOER contract manager.
If any dispute arises out ofthis contract. the venue OrSUCh legal recourse will be Iviianni-Dade County, Florida,
44. Entire Contract
This contract contains all the terms an(] conditions agreed Upon by the Parties,
Z� No oral aureernents or
representations shall be %alid or binding upon the Alliance or the Prop ider unless expressly contained herein or
by a written amendment to this contract signed by both Parties,
45, Force
Em�care
The Parties o,ill not be liable for an\ delays or finhires in performance Ale to circurnstances beyond their
control. rovided the party experiencing the force majeure condition provides immediate written not
P ification to
the other party and takes all reasonable efforts to CUre the condition.
49 Severabillity Clause
The Parties agree that if a Court of competent jurisdiction dearns any term or condition herein void or
unenforceable; the other provisions are severable to that void provision and shall remain in full force and
W
U OZICOILO 4:)e4U IaV : V9W Lb 4:)e4U IaV :4UGWt4
47. Condition Precedent in Contract: - - as
The Partiem agree that the Alliance's performance and obligation to pay tinder this contract is contingent upon
an annual appropriation by than LegWaturc In the Department and a corresponding allocation tinder contract
front the Department to the Alliance.
48. Addition/ Deletion
The Parties agree that the Alliance reserves the right to add or to delete any of the services required under this
contract when deemed to be in the State of Florida's best interest and reduced to a written amendment signed
by both Parties. The Parties shall negotiate compensation for any additional services added.
49. Waiver
The delay or failure by the Alliance to exercise or enforce any of its rights under this contract will not
constitute or be deemed a waiver ofthe Alliances right thereafter to enforce those rights, nor will any single or
partial exercise of any Such right preclude any other or further exercise thereof or the exercise of any other
rid it,
50. CLona plia nee
The Provider shall abide by all applicable current federal statutes, laves, rules and regulations Lis well as
applicable current state statutes, laws. rules and regulations. 'File Parties agree that failure of the Provider to
abide b these laws shall be deerned an event ofriefilUlt Of the Provider, and y d Subject the contract to inatiediate,
unilateral cancellation of tire contract at the discretion of the Alliance,
51. Final Invoice
The Provider shall submit the [trial invoice l payment to the Alliance as specified in Paragraphs 3A, 3.4,1 and
.3.4.2 (date for Final request for payment) of ATTACHMENT 1. If the Provider fails to submit final request
for payment by the deadline, then all rights to payment may be forfeited and the Alliance may not honor any
requests submitted after the aforesaid time period, Any payment due under the terms of this ' contract may 1%
withheld until all reports due from the Provider and necessary adjustments thereto have been approved by the
Alliance.
524 Modifications
g1odifications of than Provisions of this contract shall be valid only when they have been reduced to
writinc— and duly signed by both parties.
(LW/£0 /LO 4 IaV : IME) Lb 4 IaV WOMM44V
any cancellation charges or lost profits.
54.2 In the event funds for payment pursuant to this contract become unavailable, the Alliance may terminate this
contract upon no less than twenty-lour (24) hours' notice in writing to the Provider. Said notice shall be
delivered by U.S. Postal Service or any expedited delivery service that provides verification of del very or by
hand delivery to the Contract Manager or the representative of the Provider responsible for administration of
the contract. I Alliance will be the final authority as to the availability and adequacy of funds, In the event
of tennination of this contract, the Provider will be compensated for any work satisfactorily completed prior to
the date of termination,
56.1 The Alliance's aLitliori7ation pursuant to this section does not authorize electronic transactions between the
Provider and the Alliance, The Provider is authorized to conduct electronic transactions with the Alliance
only Upon further written consent la} the Alliance.
56.2 I..Jpon request by the Alliance. the Provider shall provide the Alliance or DOEA with non - electronic (paper)
copies of records. Nor - electronic (paper) LOPO pr , Y6:--lCd n% t Il - %'; i,l!! CC Ofau', (10CLIaleat that oaS or i"ina I k
in electronic brow o,ith an electronic sionatore must indicate the person and the person's capacity %flio
electronicalb, signed the document on any non - electronic copy of the document.
57. LSM-ecial _
The Provider agrees to the followincy
provisions:
57.1 Investigation of Criminal Allegations:
Any report that implies criminal intent on the part of the Provider or any sub-providers and referred to a
governmental or investigatory agency must be sent to the Alliance. If the Provider has reason to believe that
R
(LW/£0 /LO 4OWWOO IaV : IME) Lb 4OWWOO IaV WOMM44V
the allegations will be refierred to the State Attorney, a law enforcement agency, the United States Attorney's
office, or other governments] a0ency, the Provider shall notify the contract manager, A copy of all
documents, reports. notes or other written material concerning the 'investigation, whether in the possession of
the Provider or SUb-providers, roust be sent to the Alliance's contract manager with a Rlmmary of the
investigation and allegations.
57.3.2 In making any determination Under this provision the Alliance rna% rely upon the findings of another state or
federal auency, or other regulatory bod Arr� clainns for darnauve's for breach of warn, contract or a 2 reement
incorporating this Contract by reference are exempt from administrative proccedin',s and shall be brOLIght
before the appropriate entity in the venue OfiVIiarni-Dade COLHIM
57.3.3 in the altemati%e, the -Mliance at :is ;:ile dlS ill acco %kith section 430,04. 1 take
I i - d I ance
immediate measures against the Provider. includin4r: correcti%c action, unannounced special monitoring,
temporary aSSUMPUCIIII 01' the operation of one or more contractual services, placement of the Provider oil
probationary stains, hoposing a moratorium on Pro ides action. imposing financial penalties for
rioi,perfon car other zidministr,iti taw Cliapter 1-
5704 Use of Service Dollars:
The Provider will optimize the use of contract funds by serving the maxiniurn possible number of individuals
R
(LWIC0 IL0 4 IaV : IV9W Lb 4 IaV :4UGWt4
LML 11c i aa IL 2 a n2 Re a n all R (Narnes. Addresses,
and "I Numbers):
Tile name, address, and telephone manber of the representative for the Alliance for this contract is:
Max B. Rothman, JD. LL.VL President
and CEO
760 NW 107"' Ave, Suite 214
M iami. Florida 33 172
(305) 670-65W Ext, 224
The nanie, address. and telephone number of the representative of
the provider responsible for administration of the
program Linder this contract is:
........................................................... U, ....................................................... ..........................
..................................................... ..............................................................
The Provider narne, as shown on pa _a Le I of' this
........................................................................... ......................................................... ...........................
Monroe County Board of County Commissioners, Social
a. contract, and mailing address of the official payee
Serviceonn-Horne Services
to whom the payment shall be made is:
1100 Simonton Street, 2-257
.................... ............. .............................................................
Key West, FL 33040
.............................................. .......... .......................................................... ...............
The name of the contact person and stree addrcx
Slier) I Groaner, Senior Director
b. where financial and administrative recra are
Monroe County Board of County Commissioners, soci
maintained is:
Services/In-Home Services
1100 Simonton Street, 2-2S7
.......... ................................ ............... ...................................................... .................................................... .........................
Key West, Fl. 33040
............. .......................................... ....................... ........................................................ .........................................................
The name. address. and telephone number of the
c. representative of the Prw1der rcK:::"011 ihle =J r
Sher-0 Grainier, Senior Director
Monroe County Board of County Commissioners, Social
achoinistration of the program Under'dik contract
Services/in-Home Services
Is:
1100 Simonton Street, 2-257
................. ......................
.............................................................................. .......... ............................................................ ...................................................... .........................................................
Key West, FL 33040
........................ ................................ .............. ........................................................ .............
The section and location within the AAA Micre
Vice President for Finance
d, Requests for payment and Receipt and
- 60 NW 107th Avenue. SUite214
Expenditure forms are to be mailed i�.,
..................................... ........................... ........................................................... ...................................................... ................ .................................
Miami, Florida 3' 172-' 15
.......................................................... ...................
........................................................... ...................
Contract Monitor
The name, addresw and telephone number of the
Alliance for Aging. Inc,
Contract Manager for the AAA for this contract is.
7 1 60 NW 107th Avenue, Suite 214
...................................................... ............................................................ .............................................................. .................................................................
Nfiarni, Florida 33172 -31
- .................................................... ....................... ................................. ..................................
In the event different representatives are deal noted by either party after exectr
and address of the new representative will be rendered in writing to the other pillf
originals of this contract.
M
UWZIC0 IL0 4 IaV : V9W Lb 4 IaV :4U
59. All Terris and Conditions Included
This contract and its Attachments, I through X. A, B , E, F, G, and 1-1 and anv exhibits referenced in said
attachments, together with any documents incorporated by reference, contain all the to and conditions
agreed upon by the Parties. There are no provisions, terms, conditions, or obligations other than those
contained herein, and this contract shall supersede all previous communications, representations or agreements,
either written or verbal between the Parties.
By signing this contract, the Parties agree that they have read and agree to the entire contract,
IN WITNESS THEREOF, the Parties hereto have concert this 66 pace contract, to be executed by their Undersigned
ol fichus, as duly authorized.
Monroe County Board of County
Provider Commissioners, Social Se mices/In -Home
Services
SIGNED BY: 4�
ALLIANCE FOR AGING, INC.
0
NAME: kez" (=5- a_kct NAME: MAX B. RO'FH1VIAN, JD, LL.M,
T A .
11113: U
DATE:
TITLE: PRESIDENT AND CEO
r ��
is
(LWZ 1£0 1L0 4Oe4u IaV: b9W Lb-£0-LO ;Oe4uOO IaV :4u8wt43e44V
INDEX TO ATTACHMENTS
Attachment I
SERVICE PROVISIONS COMMUNITY CARE FOR THE ELDERLY
Attachment 11
CERTIFICATION REGARDING LOBBYING CERTIFICATION FOR CONTRACTS, GRANTS,
LOANS AND AGREEMENTS
Attachment III
FINANCIAL AND COMPLIANCE AUDIT
Attachment IV
CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR AGREEMENTS,
GRANTS, LOADS AND COOPERATIVE AGREEMENTS
Attachment A
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION FOR LOWER TIER COVERED TRANSACTIONS
Attachment VI
ASSURANCES NON CONSTRUCTION PROGRAMS
Attachment V11
BUDGET SUMMARY
Attachment VIII
INVOICE REPORT SCHEDULE
Attachment IS
REQUEST FOR PAYMENT FORM
Attachment X
RECEIPT AND EXPENDITURE REPORT
Attachment A
DOER HANDBOOK
Attachment R
CIVIL RIGHTS COMPLIANCE CHECKLIST
Attachment C
REFERRAL PROTOCOL AGING AND DISABILITY RESOURCE CENTER (ADRC)
OUTSOURCED FUNCTIONS
Attachment E
BUSINESS ASSOCIATE AGREEMENT
Attachment F
VERIFICATION OF EMPLOYMENT STATUS CERTIFICATION
Attachment A
BACKGROUND SCREENING AFFADAVIT OF COMPLIANCE
Attachment H
CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS
19
(LWICOIL0 4 IaV : IV9W Lb 4 IaV :4U
ATTACHMENT I
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
SECTION 1. SERVICES TO BE PROVIDED
I.L DEFINITIONS OF TERMS AND ACRONYMS
1.1.2 PROGRAM SPECIFIC TERMS
Aging Out Clients: Individuals reaching 60 years of age who are being transitioned from the Department
of Children and Families Services CommUnit) Care for Disabled Adults (CC DA) or 1-lome Care for
Disabled Adults (HCD) services to the Department's community-based services,
Memory Disorder Clinic: Research oriented programs created pursuant to Sections 4 and (2),
FS., to provide diagnostic and referral services, conduct basic and service-related multidisciplinary
research, and develop training materials and educational opportunities for lay and professional care
or individuals %vith AD.
Model Day Care. A program of therapeutic, social and health activities specific to clients with memory
disorders. Services and activities include, but are not limited to, active and quiet games, reminiscence,
validation therapy, pet therapy, water therapy and other failure free activities appropriate to the client's
level of functioning. Model day care centers will also provide training for health care and social service
personnel in the care of persons having AD or related memory disorders,
1.2 GENERAL DESCRIPTION
1.2.1 General Statement
The primary purpose of the ADD program is to provide a continuum of services
0 addressing the special
needs of individLiUlS with AD, their farm lies and caregivers.
E
(LWICOIL0 4 IaV : IV9W Lb 4 IaV :4U
Alzheimer's Disease Initiative Mission Statement
The ADI program ensures that per-sons afflicted With AD and other forms of de nerds are given essential
1.2.2 services to help them age in place in an elder - friendly environment with security, dignity. and purpose.
The program also provides support to family members and caregivers of persons afflicted with AD.
1.2.3 Authority
The relevant authority governing ADI program are:
(1) Rule 58D-1, Florida Administrative Code
(2) Sections 430.501 through 430.504, F.S.
1.2.4
The services to be provided are those described in the provider's service provider application and as
described in this contract and the current DOER Programs and Services Handbook.
103 INDIVIDUALS TO BE SERVED
General Eligibility
The ADI Program addresses the special needs of individual w ith AD and their caregivers.
1.3.2 Individual Eligibility
Those individuals eligible to receive services tinder this contract must meet the following conditions:
(1) Be 18 years of age or older and have a diagnosis of AD or a related disorder. or be Suspected of having
AD or a related disorder; and
(2) Not be enrolled in a Medicaid capitated long-term care pro
1.3-2.1 Targeted Groups
Priority for services provided under this contract shall be given to those eligible persons assessed to be at risk
of placement in an institution.
SECTION 11. MANNER OF SERVICE PROVISION
2.0 Conditions
All Services under this contract will be provided in a manner consistent with the conditions set forth in the
current Florida Department of Elder Affairs Programs and Services Hand book.
e�
Client access to services. assessment and eligibility determination must conform to the protocols listed in
ATTACHMENT C.
2.1 Service Tasks
To achieve the goals of the AD[ program. the Provider shall perform or ensure the performance of its Sub-
Providers, the folloving tasks:
(1) Client Eligibility Determination;
(2) Assessment and Prioritization of Service Delivery for New Clients.
(3) Delivem of Services to Flisible Clients:
241A Client Eligibility Determination
Priority Criteria for Service Delivery
( Individuals in nursing homes under Medicaid who could be transferred to the community;
21
(LWIC0 IL0 4:)e4U IaV : IME) Lb 4:)e4U IaV WOMM44V
2.1.2.1 Priority Criteria for Service Delivery for Other Assessed IndiNkluals
The assessment and provision Of Services should always consider the
most cost effective means ofservice
delivery, Functional impairment will be determined through Elie Department's runctional assessment form
administered to each applicant. The most frail individuals not prioritized as described in this attachment,
Paragraph 2,1.2. will receive services to the event Funding is available,
2.1.3 Delivery of Services to Eligible Clien is:
The Provider shall ensure the provision of' a continuum of services addressing tire diverse needs of
individuals with AD and their caregivers. The Provider shall ensure services are performed in accordance
%%itll tile current Department ref Elder A fKairs Pro.-raull; and Services I hindboo-k. Services catetuiries include:
( I ) Caregiver Trainint'/SLIPPOrt-, ZP
2.1.3-1 Nlenlor� Disorder Clinics
.)I
(LWICOILO 4:)eJ4uO:D IaV : b9 Lb 4:)eJ4uO:D IaV :4UGWt4
2.1.3.2 Model Day Care Programs
2.2 SERVICE TIMES AND LOCATION
2. 2.1 Service Times
The Provider shall ensure the provision of tile services listed in this contract is available at times appropriate
to rneet client service needs at a minithUrn, during nonnal business hOUrs. Normal business hours are defined
as Monday thrOU 9 h Friday, 8:00arn to 5:00prn.
2.3 Service Units
Services will be reported in units as described in the DOEA Handbook,
23
(LWICOILO 4 IaV : IME) Lb 4 IaV WOMM44V
Client Information and Registration Trackin ystern (CIRTS) Reports
The Provider shall ensure timely input ol'ADI specific data into CIRTS, To ensure CIRT data accuracy,
the Provider shall adhere to the Alliance's GIFT'S Data Integrity Policy and use C I Us -generated reports
which include the following:
2.43 The provider shall provide the Alliance with an expenditure plan by July 15 or two weeks after this contract
has been signed; a monthly update is due on the 15th'' day of each _r011o month. The expenditure plan
and updates Must follow Elie format provided by the Alliance.
2.4.4 The provider shal I respond to surplus-detrcit inquiries and v� Hl provide ad-hoc reports as requested by the
Alliance.
2,4 rLECTRONIC RECORDS AND DOCUNIE-NTATION
I he provider will ensure the collection and maintenance ot'client and service inilormation on a monflih, basis
Ref from the Client Information and Reistration Tracking S�y Ltern (C IRTS). 'Maintenance includes valid e . sports
and backups of all data and systems according to Alliance and Department standards.
2. Timely Data Entry
The provider must enter all required Affil data per the Department'; CIRTS Policy Guidelines for consumers
and services in the CURT database. The data must be entered into GIRT S before the provider submits its
request for payment and expenditure reports to the Al Hance as per ATTACHMENT Vill,
2.5.2 Data Accuracy
W
(LWICOIL0 Pe4U IaV : IV9W Lb Pe4U IaV :4UGWt4
The provider will run monthly GIRT S reports and verily client and service data in GIFTS is accurate. This
report must be submitted to the Alliance orith the monthly reqUeit for payment and expenditure report and
must be reviewed by the A] fiance before the provider's request ficr payment and expenditure reports can be
approved by the Alliance,
2.5.3 Failure to Maintain GIFTS Database
Failure to ensure the collection and maintenance of the GIFTS data may result in the Alliance enacting the
- Enforcernent" Clause of this agreement in ATTACHMENT I, Section 2.7, inclodina delaying or
withholding payment until the problem is corrected,
2.5.4 Computer System Backup and Recovery
2.6i Outcomes
(4) Establish procedures for handling complaints concerning " adverse actions such as termination,
suspension. or reduction in services, as per Section of'ofthe Contract,
(5) Conduct client satis fact ion SUrVCVS to evaluate and improve service delivery.
(6) Monitor and evaluate Subcontractors and vendors for programmatic and fiscal compliance,
t6.2 The perforniance of the Pro ider in pro% idmir the wr, ice-, LIC','cribed in thi h contract ;hall be mcaw.kjred by the
current strategies for the 1 criteria:
(1) Percent of elders assessed vvith high or moderate risk environments who improved their envircurnent
score;
(LW/£0 /L0 4:)ea4uoa IaV : IME) Lb-£0-LO;:)ea;uoa IaV : ;uauay 444
249 ALLIANCE FORAGING RESPONSIBILITIES
2. 9,1 Program Guidance and Technical Assistance
'2 6
(LWICOIL0 43W uoa IaV : b9W Lb 43WWoa IaV :4U8wt43e44V
SECTION III. METHOD ) PAYMENT
3 General Statement of Method of Payment
304 Final Request for Payment:
(LW/£0 /LO 4:MWOO IaV : IME) Lb - CO - LO 4:MWOO IaV WOMM44V
1-
CO
1 !
tM
(L
3.6 Remedies for Nonconforming Services
as
The Provider shall ensure that all goods and/or services provided under this contract are delivered timely, completely
M
0.
and commensurate with required standards of quality. Such goods arid/or services will only be delivered to eligible'
I
program participants,
3.6.1 If ' the Provider fails to meet the prescribed quality standards for services, Such services will not be reimbursed under
this contract. In addition, any nonconforming goods (including huge delivered meals) and/or services not meeting
such standards will not be reimbursed under this contract, The Provider's signature on the request for payment form
certifies maintenance of supporting documentation and acknowledgement that the Provider shall solely bear the costs
associated with preparing or providing nonconforming goods and/or services. The Alliance requires ininechate notice
of any significant and/or systemic infractions that compromise the quality, Security or continuity of services to clients.
3.6.2 Financial Consequences of Surplus
Provider shall ensure the provision of services to the projected number of clients in accordance with Alliance's
forecasts and within the contract amount. The Provider shall ensure expenditure of 100% of the contract amount
budgeted for services to clients at the unit rates established in this contract. In the event the Provider has a surplus of
1% or rnore at the end of the contract term, the Alliance will reallocate 1% ofthe budget for the next year contract term
to other lead agencies found to be serving clients to the fullest extent of their allocated budgets,
3> a3 The Alliance reserves the right to adjust the total aoard as well as the contracted unit rate to reflect provider costs and
utilization rates based on active clients enrolled in the program.
The Alliance may withhold payment tinder the terms of this contract, pending the receipt and approval by the Alliance
3.6.4 of complete and ' accurate financial and programmatic reports due from the provider and any adjustments thereto.
including any disallowance not resolved,
(LWICOIL0 Pe4U IaV : IM0 Lb Pe4U IaV WOMM44V
ATTACHMENT Ill
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS, LOANS AND
AGREEMENTS
(3) 'rhe undersigned shall require that the language of this certification be inclUded in the award documents for all SUb-
awards at all tiers (including subcontracts, sub-grants, and contracts Linder grants, loans and cooperative
agreements) and that all sub-providers shall certify and disclose accordingl
This certification is a material representation of lust upon %%hich reliance %4as placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by section 1352, Title 314 US. Code, Any Person Min falls to file the reqUired certification shall be
q1bject to a civil penalty of not less than $10.000 and not more than $ 100,000 for each such failure,
Signature
Date j(a j fa - M I
-�-
Gr 6 f v x
Maine -x-
o A'00rized Individual
Mal
Name and A���ra�
)too 9%tMoW4-oa 6krelek
1
Application or Agyreement Number
5LA-L-1 a - Q51
It.-e-
DO!"A I orm 103
(Rt: % ked Nei 21)0 2)
29
(LWICOILO 4:MWOO IaV : IME) Lb 4:MWOO IaV WOMM44V
FINANCIAL AND COMPLIANCE AUDIT
ATTACHMENT III
The administration of resources awarded by the Alliance for Aging, Inc, to the provider may be subject to audits and -or
monitoring by the Alliance or the Florida Department of Elder Affairs, as described in this section.
PART 1: FEDERALLY FUNDED
This part is applicable if the provider is a State or love] government or a non-profit organization as defined in OMB
Circular A-] 33. as revised.
M
(LWICOIL0 4 IaV : V9W Lb 4 IaV :4UGwt4
PART TI: STATEFUNDED
This part is applicable if the provider i. a non-state entity as del ined by SCCEion 21 Florida StaftaCS,
PART III: REPORT SUBMISSION
copies or reporting packages tlorau&7 condnctLd ill:
zz� wcordance %kith OVIB GrCL1larA-1 13. as re�ked, and reqUired b%
I
PAR1 I ofthis alyreentent shall be submitted. %0 reqUired b% Se�t:on .'2i (d). 011B Ch �-113 as re%ised, b% or
on bellalforthe provider directly to each of the l`oIho,%jlj,,
The Alliance (or Aging, Inc. at each ofthe following addresses:
Alliance for Aging, Inc.
L�
Attn: Fiscal Monitor
760 NW 107"' Ave. Suite 214
Miami, FL. 3317 -3155
a
(L�OZICOILO 4 IaV : IV9W Lb 4 IaV :4U
Alliance for Aging, Inc.
Attn: Fiscal I'vionitor
760 NW 107' Ave. Suite 214
Miami, FL. 33172-3155
The Auditor General's Office at the following address:
State of Florida Auditor General
Claude Pepper Building, Room 574
111 West N—ladison Street
Tallahassee, Florida 32399-1450
as reports, management letter,
or other information required to be SUbmitted to the Alliance for Aging. Inc, punitnint
to this aureement shall be submitted tirneIN in accordance %%ith 0`v1B CircUlar A Horida StatUtCS, and Chapters
10.550 (local governmental entities) or 10,650 (nonprofit and for-profit organizations). RUICS Of the Auditor General. as
applicable,
Providers, When submitting financial reporting packag to the Alliance for Aging. Inc, for audits done in accordance
Aging.
with OMB Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and for - profit
organizations), Roles of the Auditor General should indicate the date that the reporting package wass delivered to the
provider in correspondence accompanying (lie reporting package,
PART IV: RECORD RETENTION
(LWZ1C01L0 4:)e4u IaV : V9W Lb 4:)e4u IaV :4u
ATTACHMENT III
EXHIBIT - 1
I FEDERAL RESOURCES AWARDED TO THE SUB RECIPIENT PURSUANT TO THIS
AGREEMENT CONSIST OF THE FOLLOWING:
PROGRAM TITLE FUNDING SOURCE CFDA AMOUNT
TOTAL FEDERAL AWARD
L - - - - -.- _ _ ._
COMPLIANCE REQUIRE- EVENTS APPLICABLE TO THE FEDERAL RESOURCES AWARDED
PURSUANT TO THIS AGREEMENT ARE AS FOLLOWS:
2, STATE RESOURCES AWARDED TO THE RECIPIENT PURSUANT TO THIS AGREEMENT CONSIST
OF THE FOLLOWING:
MATCHING RESOURCES FOR F711PRAT, PPrtruArue:
TOTAL AWARD
mmomm
COMPLIANCE REQUIREMENTS APPLICA13LE TO STATE RESOURCES AWARDED I'VURSUANJ'TO
THIS AGREEMENT ARE AS FOLLOWS:
State Financial Assistance
Section 215.97 F.S.
Chapter 691-5 Fla. Administrative Code
.13
STATE FINANCIAL ASSISTANCE SUBJECT TO Sec. 20.97, F.S.
. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..... ................................... ... ... ... ... . ... ... ... ... ... .. ... ... ...
................................... "I'll, ...... .
............. *--l- ... ... ... ... ... ... ... ... ... ... ... ... . .......................... I ...............
PROGRAM TITLE
............................... :: AMOUNT
...
.................................... x .... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. . ... ... ... FUNDING SOURCE CSFA
. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .... . . ........................ .........
... ... ... ... ... ... ... ... ... ... ... ... ... ... ..
Alzheirner'.:- Dil,� e a,�e Initiative
. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . x ..................................... General Re %ewlie 65004 $164.647.80
. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . -111111 ... ... ... ... ..
(L WICOILO 40e4u0a IaV : b9 W Lb 40e4u0a IaV :4u8wt43e44V
PART It AUDIT RELATIONSHIP DETERMINATION
NON-PROFIT ORGANIZATIONS NIUST FOLLOW:
TT ACHMENT III
34
(L�OZICOILO 4 IaV : IV9W Lb 4 IaV :4u
EDUCATIONAL INSTITUTIONS (EVEN IF A PART OF A STATE OR LOCAL GOVERNMENT) MUST
FOLLOW:
*Scare federal programs, may be exempted from compliance with the Cost Principles CirCUlars; as noted in the
ONIB Circular A -133 Compliance Supplement, Appendix 1.
STATE FINANCIAL ASSISTANCE. Providers who receive state financial assistance and who are determined to be
a recipient/sub-recipient must comply with the f0howing fiscal laws. mice and regUlations:
Section 2 13.97. Fla. Stat.
Chapter 691-5, Fla. Adrmn, Code
State Projects Compliance Supplement
Reference Guide for State ExpenclitUres
Other fiscal reqUirements set forth in program lays. roles and regulations
THE REST OF THIS PAGE WAS LEFT BLANK INTENTIONALLY
-35
(LWICOIL0 4 IaV : IV9W Lb 4 IaV :4U
ATTACHMENT IV
CERTIFICATION REGARDING DATA INTEGRITY COMPLIANCE FOR AGREEMENTS, GRANTS,
LOANS AND COOPERATIVE AGREEMENTS
The Undersigned, an authorized representative of the Provider named in the contract or agreement to which this forays is
an attachment, hereby certifies that:
(4) The Provider and any SUb-provider(s) of services tinder this contract warrant their policies and procedures include a
disaster plan to provide For service delivery to continue in case of an ernergency including emergencies arising from
data integrity compliance iSSUCS.
The Provider shall rewire that the language ofthis certification be included in all sub-agreernents, sub-grants, and other
agreements and that all sub-providers shall certify compliance accordingly.
This certification is a material representation Of 1',ICt upon vhich reliance was placed when this transaction was made or
entered into. SUbmission of this certification is a prerequisite for ranking or entering into this transaction imposed by
OMB Circulars A-102 and 2 CFR Part 215 (llormerl� 0NlB Cimillar A-1 10),
Monroe County Board Of Canary Commissioner%, Social Services/In-Horne Services
Ac� Qo"� AIlilvd(Li4m4w.
Title
Name of A athoriced Signer
W
(LWZ1C01L0 Pe4u laV : IV9W Lb Pe4u laV :4u
ATTACHMENT V
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND
VOLUNTARY EXCLUSION FOR LOWER TIER COVERED TRANSACTIONS
(LWICOILO 4:)eJ4uO:D IaV : b9 Lb 4:)eJ4uO:D IaV :4uGwt4
ASS UJUNCES—NON-CONSTR UCTION PROGIUMS
m
ATTACHMENT VI
U1,0ZICIDILID 4 312 4 1 - 10 0 IaV : IV91,0 Ll, 4 312 4 1 - 10 0 IaV :4
16, Will Comply with the Lead-Based Paint Poisonim Prevention Act (42 C,S,C. 480 1 et seq.), which prohibits the use of lead-
based paint ill construction or rehabilitation of residence structures,
17, Will cause to be performed the required financial and compliance audits in accordance with the Sin -le Audit Act Amendments
of 1996 and 0bll3 Orcular No. A-[ 33, Audits of States, Local Governments, and Non-Profit Organ izat ions
Z
18, Will comply all applicable requirements of call other federal la%%s, executive orders, regulations and policies governing this
program,
SI(jN %U1 RI Of %t THORI/I D( I RTH N IN6 011 K 111
kPI't IC kN I ORGkN ]I\ I ]ON
Gza.hcl
O
1) X I I St M111 I I D
Monroe Count Board of County Commissioners, Social
SerN ices/in-Home
Seri ices
Gato Building, Board of County Commissioners
(Otaa Izo /�-
-19
(LWIC0 IL0 Pe4U IaV : V9W Lb Pe4U IaV :4U
ATTACHMENT V11
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
BUDGET SUMMIARV
The Alliance shall make pkvinent to the provider for provision of services Lip to a maxinaUrn number of Units ofsmice
and at the rate(s) stated belcov:
...................... .......................... ........................
Service to be Provide d
........................
Service
Maximum
Units of
. ............................
Maximum
............ ...................... .........................
Unit Rate
Service
Dollars
Case Management
. ......................
$50.51
..........................
150
.............. ..............
:$7,576.50
................ ......................... ......................
Respite in facility
.............
$10.70
..........................
10,188
........
..................................
$109,011-30
............................
.......... ........... .................................
Respite In Home
................
$24,03
........... I ............
............. ..........................
2,000
$48,060,00
.......... ..........................
..........................
TOTAL
........... ........................... ............ ..............
............................
...... .....................
.............
............. ..... ........
..........................
.................. .......
..
. ................
$164,647.80
............. .............
40
(LWICOIL0 4 3 W WOO IaV : IME) Lb 4 IaV WOW4
ALZHEIMER'S DISEASE INITIATIVE
ATTACHMENT Vill
INVOICE REPORT SCHEDULE
Submit to Alliance on
this Date
I
July Advance*
2
August Advance*
3
July Expenditure Report
4
August Expenditure Report
5
September Expenditure Report+ IM 0 advance reconciliation
6
October Expenditure Report+ 1110 advance reconciliation
7
November Expenditure Report + I110 advance reconciliation
8
December Expenditure Report + I110 advance reconciliation
9
January Expenditure Report+ 1110 advance reconciliation
10
February Expenditure Report + 1110 advance reconci I lotion
I I
March Expenditure Report + 1110 advance reconciliation
12
April Expenditure Report + 1110 advance reconcil union
13
May Expenditure Report -+- IM 0 advance reconciliation
14
June Expenditure Report+- Ifl 0 advance reconciliation
15
Final Expenditure and closeout
Legend: * Advance based on projected cash need,
July I
July I
August 10
September 10
October 10
November 10
December 10
January 10
February 10
March 10
April 10
May 10
June 10
July 10
July= 10
Note 1: All advance pay assents made to the Provider shall be returned to the Alliance as rollows:
One-tenth of the advance payment received shall be reported as an advance recoupi on each
Request for Payment. starting with report #5. The adjustment shall be recorded in Part C, Line I
zr
ofthe report (Attachment JX).
Note 21 Subrnission co'expenditure reports may or maN not q as payment request, If final
expenditure report reflects funds due back to the Alliance. pay ment is to accompany the report.
(LWIC0 IL0 Pe4u IaV : V9W Lb Pe4u IaV :4u
ATTACHMENT IX
REQU EST FOR PAYMENT
ALZHEIMERS DISEASE INITIATIVE PROGRAM
'ANIE,
RECR3-ff " INJE, ADDRESS, Pf"ICNEft and FEV*
TvPE OF REPORT
The Requed Pened
psA 0
A lo-WellENT RECY-JEST
8 111DETFOE) OF wylvEtfl'
Advance
?a; rneum e nne. 0
D
F tLel l 6
C BRTF C Afl0f l l hege by cemfy In but =rid of mylbooAladge knot ev
;e; t ea t a, onov C l e an d co"t"d and carfarm , t1 e seirre
and the 'r aNasof Vie ableve noricatrit
prpowed by Dale
A -tooved by
to
lb
j 21
IQ:�Aj_
-------------
ed
I Approv CartfactAmourc
0 OC
00
so C
2 lonvviousFuriols lA�cenved far ContraidPonad
-0
so un
7ds
3 Conrad Balance line I minas ime 2)
S oo
em
larow Furies Requested and Not Recovved for Dw
o= Pen
SO 00
SDO
5 Control Bakince (lim- 3 nines 4)
so GO
PAPTE
SO 00
SON
S001
2 flet E' as Lm falarith
IS -a C,
$000
(DOEAForrin 10-,'Z Pon 8, Lire 3'.
". T
J .'CY Al-
so 00
PARTC HE
LvissAdvanceApp4ed
N um
so 0C
0C
C - vV 0 F u od 5 aje H y Re qt i A 'r. y f Pan B re
rvrus Pon C L It
Cl
UtaotSermes / R.alas pirmited - 5K aftac�, =d rapa rt
OOEA C CCINI 1062
Rwavvj e4" I-'
m
(LW/£0 /L0 4:)ea4uoa IaV: b9W Lb-£0-LO ;:)ea;uoa IaV :4u8wt43e44V
RECEIPTAND EXPENDITURE REPORT"
ALZHEIMER ALZHEIMERS DISEASE INITIATIVE PROGRAM
43
(LWICOILO PWWOO IaV : IV9W Lb PWWOO IaV :4uGwt4
ATTACHMENT A
Title: Department of" Elder Afiltairs Programs & Services Handbook
0
Department of Elder Affairs Programs & Services Handbook
1111 ---- (see Providers/Program DoCLIments) or
of instructions)
44
(LWIC0 IL0 Pe4u IaV : IME) Lb Pe4u IaV WOMM444
3, STAITCURRENTLYIENIRL
5�4 While
bars alp.
So Disablod
4- CLI -NTS CURRERTLY EN
its
Dtsab ed
Over 41
ING BOARD, 11 APPLICABLE,
(60
remale
Dusa blvd
C-)
PAR TM USEA SEPARATE SLICE TOF 11 WER FOR M 1 xm kN % des HE.Qj lR1vG 1101?[,, Nj$ %Cl,'.
6, is Sara Assurance ofCompliance on file with D(')EA' IFNA or NO, explain.
N A
YES
NO
7, Compare the staff oomposition to the population, Is staff representative ofthe population?
I f N/A or NO, explainv
N A
YES
NO
8, Compare the client corapendti t the population, -kre race= and sex characteristics representative of
the population? If NIA or NO, cxplain
N A
YES
NO
— — -- - - -- — - — - ...
1:1
M
El
9. Are clig requirements for services applied to clients and appliCants ivithoul rcgard to race, color,
natiotialorigin,s-,% aid C,reli-ioiiordisaLbilitv? IFNA air \O,t-xillain,
N A YES NO
............................
''I'll'' ....... .............................. ............................. . Li El
10, .%real: henct eni:u lof hl: loapp i�-Jnl, 'I J ill all Ili eff'e0k,"
elantlCr rc` llaf ::,!. � .1 t� C\, , A
explak �7 a-Qe, MIN,111li a or * \ k YE S
.................
..............
........................ ......................... .......... 1:3
11, For in-patient services, are room assignments ulade wilhout regard to race, color, n,
or disabili(y? If A or NO, explain, N A YES NO
.. . . . . . ............... ............. . .............. ---- ..................... ---- ........................ uun ..................... . . . . ............ 9 C. 0
Rey see
41
(LWIC0 IL0 Pe4u IaV : IM0 Lb Pe4u IaV WOMM444
12, Is the pro-ram/facility accessible to noll-f
speaking clients? If N A or NO, explain N. A YES NO
El 9 C1
15° Is the prop U fa physically accessible to nicibility, hearing, and sight-impaired individuals? 11'
N!A or NO, explain, N A YES NO
11 1 9 El
PARTI I 1:111EFOLLO'A IN QI I' %1 1 01�R(gAlk %IS l,NI) I tt t % I - I I I c Mt: RE EMPLOIFES,
16, HaS a self-.-valuadon been conducted to idernift any barriers cc) ser%im- disabled individuals, and tc)
make any necessary nusdifications? If NO. expl'
sat, YES NO
$� 10
20. Are auxiliary s a lab
aid vai cc to ns-Sure accu of service4 it) hearing and sightAirnpaired
individuals? JFNOexjflain, YES NO
PUIT IN: FORPROGRANTSORI- Wil ITIES`IIII, oft %1()Rr FNIPU)l 14 k%D I' I• 01
1 -1, Do )ou have a written affirmative action plan IfNO.esplam, YES NO
Revmcd I u Pact'! 0
46
(LW/£0 /L0 4 IaV : IME) Lb-£O-LO ;0e4u0a IaV :; OW43e4W
INSTRUCTIONS 1 COMPLIANCE
CHECKLIST
(LWICOILO PWWOO IaV : IME) Lb PWWOO IaV WOMM44V
19, COutinkling Steps must be taken to notitN ernplo ees and the Public ol'the prograrn/1'scilivy's policy or
u0ndiscrinnination on [lie basis ca' disability, Tfiis inclUdes recruitment material, notices - for hearings,
n n Z�
ewspaper ads, and other appropriate o,ritten COMMLIIIiCalion� -;5 CFR 84.8 (a).
20. Pro grams/tac i I i ties that ernploy [5 or more persons MUSI, provide appropriate auxiliary aids to persons
with impaired sensory, marmai or speaking skills where necessary, Auxiliary aids may inClUde, but are
not limited to, interpreters per hearing impaired individuals. taped or Braille materials, or arty alternative
reSOUrces that can be used to provide equally effective services, 45 CFR 84,52 (d),
UWZIC0 IL0 Pe4u IaV : IME) Lb Pe4u IaV WOMM444
I
1. Prograrns;Tacilities with 50 or more employees and $50,000.00 in f contracts must develop,
implement and maintain a written affirmative action compliance program in accordance with Executive
Order 11246, 41 CFR60and Title VI ol'ilieCivil Rights Act of` 1964, as amended,
DOEA Form R)1 -E3 Re wd '%I L - :11.1 2- 'i .:
TI IE REST OF TI IIS P WAS IATT BLANK INTILN FIONALLY
40
UWZIC0 IL0 4:MWOD IaV : IM0 Lb 4:MWOD IaV :4UGWt4
Al"FACHMENT C
ADRC OUISOURCED FUNC'r10NS
Under this Contract, the provider agrees to the following,
A. Perform ADRC ClUtsourced functions in accordance %vidi policies and procedures developed by
the Alliance for ging, Rcfcr to the
M following attachments.-
Attachment C EXHIBIT 1: Policies and ProccdUreS for OUtSwurced Function-
Screening
Attachment C EXHIBIT 2 Policies and Procedures for 0111SOUrced Function-
Termination firorn Waidist-Client Services
jjiv Attachment C EXHIBIT 3: Policies and Procedures For Triage
iv, Attachment C EXHIBIT 4 Policies and Procedures flor Activation from Waitlist-
Client Services
G. Ensure that services provided are in the clients' best interest, are the most cost ell'ecti% o l'i l i g h
quality. and are responsive and appropriate to the assessed needs,
The Assessed Priority Consumer List (APCL) is maintained w horl set Funded by the department are last
available. Contracted providers of registered services for Alzheimer's Disease Initiative (ADI). Older
American's Act (OAA and Contracted Services (CS) maintain waiting lists in the CIRTS database for
Z:
registered services when Funding is riot a% ailable. Note: OAA3E is an exempt funding SOUrcc for, DRC Wait
List purposes, For services provided through 0AA ) E. no CI RTS cl ient data eran is require(!,
Registered Services for the above l isted pro-rarris are as to] lo" s: Adult DzP Care (ADC). Adult Dav I lealth
Care (ADHC). Chore (CHO). Escort (ESQ�I Health Aide 0111A). Homemaker (IVVIK). Mode'l Da-, Care
(MDC), Personal Care (PECA), Facifit Respire (RESF). m4 Ionic Respite (RESP). I
U11,0ZIC0 IL0 4 IaV : V911,C) L11, 4 IaV :4UGWt4
ATTACHMENTC Exhibit I
Alliance for Aging, Inc.
Aging,
Aging & Disability Resource Center/Ekler Helpline
Policy and Procedure for
Oulsourced function - Screening
Creation Date: March 5. 2008
Revision Date: May 2017
Review Date: April 2014
Objective: 'ro ensure that a comprehensive list ofelients irl need of serv is maintained in CIRTS by
appropriate funding source and that the ADRC i5 thereby able to effectively gauge the level ofelder service need
in Miami-Dade and Monroe Counties.
Policy: To obtain necessary information from clients in order to -assist in determining level of need and eligibility
for rezistered services bladed through ADL OAA, and I -SP pro rams.
Procedure:
I ADRC Contracted Providers will collect information from callers find conduct a 7 10 IS assessmant.
Alternatively. if a 701 A( B) aq�essnwnl alreadN gist, or is pro ided from another Source (i.e. CARES)
the infra rtnabo'n from the 701 IS can be utilized.
Based oil the information provided -, is the 701 A(B) assessment, the ADRC Contracted Provider will
make a determination as to tile services that the caller is in need ofreccivine.
The ADRC Contracted Provider %g ill determine tile appropriate fiunding source(z) that provides the
needed services,
4. ifthe caller is in need of a services) that is not prolided bN the ADRC Contracted Pro%.ider. tile
ADRC Contracted Provider %4 III refer caller to the ADRC Eider 1-felpline utilizing the ADEC Referral
Forin and. or to an ADRC Contracted Pros ides that pro~ ides the needed service,
The caller will be provided with general information regarding the ADRC as well as Elie ADRC I-Ider
Helpline contact number.
I lie caller sill be intbri oftLe er% ces and kinding sources that thc} are being placed oil the -.%cut
list for fit CIRTS. being
non-case managed programs. rarns. the. ADRC Contracted Provider will create a client record in CIRTS
(ifthere is no existin,:, record} Li;id enter the serN cc-; needed for the caller by ftirlding source and
service. [if there is an existing record in CIRTS, the appropriate fields will be updated].
9. If the ADRC Contracted Provider determines that the caller may qualify for more than one program
for which the provider is funded, ADRC Contracted Provider is encouraged to enter the appropriate
information under Multiple funding sources, [if there is an existing client record in CIRTS, the client
record in CIRTS will be updated with appropriate information],
a
UWZICOILO 4:)eJ4uO:D IaV : IME) Lb 4:)eJ4uO:D IaV :4uGwt4
9. ADRC Contracted Provider will info rin caller that they %vi H receive an annual re-assessment based on
DOEA Wait List Reassessment Standards and encOUra caller to contact the ADD C Elder Helpline
with any questions.
� I
(LWIC0 IL0 43W OD IaV : V9W Lb 4 IaV :4UGWt4
ATTACHMENTC Exhibit 2
Alliance far Aging, Inc.
in & Disability Resource Center/Elder Helpline
Policy and Procedure for
Termination From Wait List — CI ien ts/Sery ices
Creation Date: March 5. 2008
Revision Date: February 2013
Review Date: May 2017
Objective: To ensure that the comprehensive list of clients in need of services in CIRTS is appropriately
maintained by funding Source and that the ADRC is thereby able to cfficcjivejy gaL1tYC the Current level of elder
service need in Miami-Dade and Monroe Counties,
Policy: ADRC will maintain an sections, and current fist ol'clients in need ofelder services in Miarni-Dade and
Monroe Counties with the assistance ref f the ADRC Contracted Providers,
Procedure:
I ADRC Contracted Provider will re-screen clients which the ADRC Contracted Provider initially
placed on the CIRTS wait list for services based on DOER Reassessment Standards.
1 The re-screening tatty be in the form of a phone screening or a home visit depending on the clients
status (Le, active /pending)
ADRC Contracted Provider will determine ifthe client is no longer in need (or eligible) for any ofthe
services they were wait listed for.
4 ADRC Contracted Provider v, ill terminate the client front the oait list {entirel by specific service)
rising the appropriate CIRTS termination code for any services or flunding source for which the client
C
is determined to no longer be eligible for or no lori in need of',
ADRC Contracted Provider o ill infisrin the client of'any services. fundin SOUrCe that they are being
removed firron the wait list for 9
6, ADRC Contracted Provider will inform client of their ability to be re-added to the wait list il'their
level of need should change.
AAEC Contracted Provider will inflarin client to contact the ADRC Elder Helpline ifthcy have any
questions or concerns regarding their wait list status.
& Reference DOEA Notice of` Instruction: Assessed Priority Consumer List#:062906-1 -I-OVCS as
applicable.
Ull,OZICOILO 4 IaV : V911,C) L11, 4 IaV :4UGWt4
ATI'ACHMENTC Exhibit 3
Alliance for Aging, Inc,
in & Disability Resource Center/Eider Helpline
Policy and Procedure far
ClUtsourced function - Triage
Creation Date: March 5, 2008
Revision Date: May 2017
Review Date: April 2014
Objective: To ensure that clients in need a' DOEA funded services receive services based on the highest level of'
need. fi rst, as funding becomes available.
Policy: To assist clients in obtaining DOEA funded services as funding becomes available, based oil level, of need
as detenoined by a CiRTs priority score,
Procedure:
I ADRC Contracted Provider %vill Conduct annual reassessments based on DOER Wait List
Reassessment Standards,
2, If there is no Current 70 I t A or B in CIRTS. the provider will conduct the annual reassessment (701 S)
as appropriate. Based on the information provided via the 701 S: (B) assessment, the ADRC
Contracted Provider will update the client information in CiRTS specifically as it pertains to level of
need for services by funding source
Tile ADRC Contracted Provider will ensure that the GIRT S prioritization score isaccuraleiv
maintained, according to DOER Standards. 11'a significant change has occurred prior to the ' annual re-
screening. the Contracted Provider must rc-�creen, Dcflnhionw and cearnples of significaut cha
are documented in tile DOER Prol & Services Manual Cliapter 2,
I f the caller is in need of it ser% ice(s"t that i; not prw, ided b% tile ADRC Contracted Provider, the
ADRC Contracted Provider will refin caller to tile ES C' Elder I lelpline utilizing the ADRC Referral
Form and. or to art ADRC Contracted Provider that pro% ides the needed service.
Tile caller will be informed of the services and funding Sources that tl_ey remain oil tile visit list for nand: or have
been removed from the aait list for,
5, ADRC Contracted Provider I,% Ill rei i iind cl -- :cut ol'the ADRC Elkier I lelp Line contact number and to
contact the ADRC Elder I lelp Line %i, ith an-,
. question or concerns.
As funding It , becomes available. ADRC Contracted Provider o,illt run CIRTs Prioritization Report and
activate clients according to DOF A Standards {refer to ADRC Client Activation Policies and
Procedures). The Contracted Provider will apply targeting criteria, as appropriate, to prioritized clients
to ensure activations meet programmatic requirements.
; 4
UWZIC0 IL0 4 IaV : V9W Lb 4 IaV :4UGWt4
ATTACHMENT C Exhibit 4
Alliance for Aging, Inc.
Aging & Disability Resource Center/Eider Helpline
Policy and Procedure for
Activation From Wait List — Clients/ Services
Creation Date: March 5, 2008
Revision Date: February 20I 3 )
Review Date: Mav 2017
Objective: To ensure that elders in need of DOE A funded services in Mianni-Dade and Monroe Counties and on
the CIRTS wait list begin to receive services as funding becomes available,
0
Policy: ADRC will work with ADRC Contracted Providers to ensure that clients waiting 6or DOEA funded
services begin to receive those services as funding becomes available, --
Procedure:
I ADRC Contracted Provider will activate clients on CIRTS wait list based oil DOEA prioritization
polices and funding availability,
U11,0ZIC0 ILO PWWOO IaV : V911,C) L11, PWWOO IaV :4UGwt4
ATTACHMENT E
Alliance for Aging, Inc.
Business Associate Agreement
This Business Associate Agreement is dated . ......... -- ........... . --' by me Alliance for Aging, Inc.
("Covered Entity") and Monroe County Board of County Commissioners, Social Serviceslin-Home Services,
("Business Associate"), a not-for-profit Florida corporation,
1,0 Background,
E
(LWIC0 IL0 Pe4U IaV : IME) Lb Pe4U IaV WOMM444
2.6 Breach. Tile Unauthorized acquisition. access, use, or disclosure of PH I which compromises the security
or privacy Of Such information.
17 Compromises the Security. Posing
individuals, . a significant risk of' Financial, repUtationale or other harm to
2.13 Malicious software. Software. for e a %i designed to damage or disrupts a systern.
M
(LWICOILO 4 IaV : IME) Lb 4 IaV WOMM44V
2,25 Unsecured PHI. Protected health information that is not secured through the use of technology or
methodology specified by the Secretary in gUiclance issued under 4 LJ,S,C. section I 7932(h)(2).
(a) Implement policies and procedures to prevent, detect, contain and Correct Security violations in
accordance with 45 CVR § 164,306;
(b) Prevent use or disclosure of the 1 other than as provided for by this Agreement or as required
by law;
(c) Reasonably and appropriately protect the confidentiality. integrity, and availability of the ePHI
that the Business Associate creates, receives, mai
mains, or transmits on behall'of the Covered Entity; and
(d) Comply with the SccuritN Rule requirements including the Administrative Sal guards, Physical
�afeguards, Technical Safeguards, and policies and procedures and documentation requirements set Forth
in 45 CFR §§ 164-308, 164,310, 164,131 2, and 164, ) 16,
13 Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to
Business Associate of a use or disclosure of 1 by Business Associate in violation of the requirements
of this Agreement.
(a) Identification of any individual Whose Unsecured P1 [I has been, or is reasonably believed b
Business Associate to have been. accessed, acquired, or disclosed during such security breach, and '
(b) All inforniation required for the Votice to of Bi-each ey Unv,!curetf Proweical
Health hoo'rnzaflon
3,6 Business Associate agrees to ensure that any � agent. includint, a subcontractor, to whom it pro%ides 1
t� Z
received from. or created or received by Business Associate on behalf ofCovered EntitN, agrees to the
same restrictions and conditions that apply through this Agreement to Business Associate ' oith respect to
Such inforrnation. CP
3.7 It'Business Associate has PHI in a Designated Record Set:
(a) Business Associate agrees to provide access at the request of Covered Entity during regular
business hours, to PFIl in a Designated Record Set, to Covered Entity or, as directed by Entity,
to an individual in order to meat le requirements under 4.5 CFR § 164.524; and
M
(LWICOIL0 4 IaV : IM0 Lb 4 IaV WOMM44V
(b) Business Associate agrees to make any amendment(s) to PHI in a Designated Record Set that the
Covered Entity directs or agrees to pursuant to 45 CFI § 164.526 at the request of Covered Entity or an
Individual within 10 business clays of'receiving the request,
18 Business Associate agrees to make internal practices, books. and records, including policies and
procedures and PHI, relating to tile use and disclosure of PHI received fincon, or created or received by
Business Associate on behalf ofCovered Entity, available to the Covered Entity or to the Secretary upon
request of either for purposes of determining Covered Entity's compliance with the Privacy Rule,
3,11 Business Associate specifically agrees to L19C security measures that reasonably and appropriately protect
the confidentiality, integrity, and availability of Pill in electronic or any other form, that it creates,
receives, maintains. or transmits on behalf of the Covered EntiLv.
3,12 Business Associate agrees to implement security measures to secure passwords used to access ePI-II that
it accesses, maintains, or transmits as part of this Aureernent from malicious software and other man-
made and natural vulnerabilities to assure the availability, integrity, and confidentiality of such
information,
3.13 Business Associate agrees to implement ,securi to safeguard cPHI that it accesses. maintains,
or transmits as part of this agreement from malicious software and other man-made and natural
vulnerabilities to assure the availability, integrity, and confidentiality Of SUCII information,
3.14 Business Associate agrees to comply ckith:
(a) ARRA § 13404 (Application ofKnowledL,
,a Elements Associated O,ith Contracts)-,
(b) ARRA § 0405 (Restrictions on Certain DiICIO�Lirc-; and Sales of health IMbrination): and
(c) ARRA § 1 3406 (Conditions on Certain Contacts as part of I lealth Care Operations),
4,0 Permitted Uses and Disclosures by Business Associate, I xcept a otheroise limited in this Agreement
or any related agreement, Business Associate may use or disclose PI 11 to perform functions. activities, or
services for. or on behalf of Covered Entity as specified in any and all contracts %vith Covered Entity
provided that Such use or disclosure would not violate the Privacy Rule ifdone by Covered Entity or the
minim ncce�-ar� politic, .aid
1 11 x;} CI'L!d .1 'I.It".
3.0 Specific Use and Disclosure Provisions.
5,1 Except as otherwise limited in this agreement or an,.
for Elie proper manag m�
ement and admitratmn of
responsibilities of the Business Associate,
related a-mernent. Business Associate rnac use PHI
the Business Associate or to carry Out the legal
5,2 Except as otherwise limited in this agreement or any related agreement, Business Associate may disclose
PHI for the proper management and administration of the Business Associate, provided that disclosures
are Required By Law, or Business Associate obtains reasonable assurances from the person to whom the
information is disclosed that it will remain confidential and used or further disclosed only as Required By
59
(LWIC0 IL0 4 WOO IaV : IME) Lb 4 IaV WOMM44V
Law or for tile purpose far which it was disclosed to tile person. arid the person notifies the Business
Associate of any instances of which it is aware in which [fie confidentiality of the information has been
breached,
&0 Effective Date anti Termination.
The Parties hereby agree that this agreement amends. restates and replaces any other Business Associate
Agreement currently in effect between Covered Entity and Business Associate' and that tile provisions of
this agreement shall be effective as bellows:
(a) 'rhese Business Associate Agreement provisions, with the excepti o f , the electronic Security
L '
provisions and the provisions mandated by ARRA, HITECH and Part I shall be affective upon the later
ol'April 14. 200j, or the effective date ol� the earliest contract entered into betocen Business Associate
and Covered Entity that involves tile use Of PFIL
M The electronic security provisions hereof shall be effective the later of April 21, 200; or the
effective date of the earliest contract entered into between Business Associate arid Covered En that
involves tile use Of PHI: ar
( Provisions hereof mandated ll� ARRA, HffECI I arid or Part I shali be ell'senve ti l o f
FebrUan 17, 20 10 or tile eft ecti% e el ate le ofthe earliest contract entered into betoeen co%ered entity and
business associate that in--volves the use 001 or ePI ll.
K2 Termination for Cause, Upon Catered Enfit%'s knooledge of a material breach by Business Associate,
Covered Entity shall either,
(a) Provide an opportunin, for Business Associate to Care (lie breach or end the violation and
terminate this agreement if Business Associate does riot cure the breach or end the violation within the
time specified by Covered Entit
Y
(b) Immediately terminate this agreement il"business Associate has breached as material term of this
0
Agreement and care is not possible; or
N
UWZICOILO 4 IaV : V9W Lb 4 IaV :4UGWt4
(c) It' neither termination no[ Care is feasible, Covered Entity shall report the violation to the
Secretary,
9.0 Regulatory References, A reference in this agreement to a section in the Privacy Rule or Security Rule
means the section then in effect or as may be amended in the future.
10,0 Amendment. The Parties agree to take such action as is necessary to amend this agreement from time to
time as is necessary for Covered Fnfity to comply with the requirements of the Privacy Rule, the SCCUritv
Rule and the Health Insurance Portability and ACCOUntability ACE 01' 1996, Polls. L No. 1,
11.0 Survival. Any terra, condition, covenant or obligation which requires performance by either party hereto
subsequent to tile termination of this agreement shall riannin enforceable a-ainst such party Subsequent tai
such termination. 0
12.0 Interpretation. Any ambi(7LIitV in this agreement shall be resolved to permit Covered Entity to comply
I I
With tile Privacy Rule and Security RUIC,
13,0 Incorporation by reference, Any future new reqUirementfs), chan as or deletion(s) enacted in federal
a
lav which create new or different obligations with respect to I HPAA privac or security. shall be
automatically incorporated by reference to this Business Associate Agmernent'on the respective effective
date(s).
To Covered Entity:
Alliance bir Aging, Inc.
Attention: f4ax Rothman
760 N W 107 Avenue
Miami, Florida 33172
To Business Associate: Monroe County Board of County Commissioners, Social Services/In-Home
Services
1100 Simonton 2-257
Key West, FL 33040
Is
(LWICOILO PWWOO IaV : V9W Lb PWWOO IaV :4U
Any Such notice shall be deemed delivered upon actual receipt. If any notice cannot be delivered or delivery
thereof is refused, delivery will be deemed to have Occurred on the date such delivery was attempted,
15,O Governing Law. The laws of State offlorida. Without giving effect to principles orconflict of laws,
govern all matters arising tinder this agreement.
16,0 Severability. If any provision in this agreement is unenforceable to any extent, the remainder of this
agreement. or application of that provision to any persons or circumstances other than those as to which
it is held unenforceable, will not be af by that Linen rorceability and will be enforceable to the fullest
extent permitted by law,
17.0 Successors. Any successor to Business Associate (whether by direct or indirect or by purchase, merger,
consolidation, or otherwise) is required to assume Business Associate's obligations Linder this agreement
and agree to perform them in the same manner and to the same extent that Business Associate would
have been required to if that succession had not taken place. This assumption by the successor of the
Business Associate*s obligations shad be by written agreement satisfactory to Covered Entity.
18,0 Entire Agreement. This agreement constitutes the entire movement of the parties relating to tile Subject
matter of this agreement and Supersedes all other oral or written agreements or policies relating thereto,
except that this agreement does not lit the amendment or this agreement in accordance with section
1 0,0 o this agreement.
I
Covered Entity: Alliance for Aging, Inc.
M
M
Business Associate: Monroe County Board of County Commissioners, Social Services/In-Home Services
By:
{simlat
= rin�goviol�mims Foor
Date: W?& jav } 4
61-
(LW/£0 /LO ;yeaWOO IaV: b9W Lb-£0-LO ;yeaWOO IaV :4UGwt43e44V
ATTACHMENT F
Verification Employment tatus Certificatio
. t
Ties j
I U 1
l %OC
0
x�r
r
L 'r
..:,...::......
xr..
0
(LWIC0 IL0 Pe4u IaV : IME) Lb Pe4u IaV :4uGWt4
ATTACIMENT C
HIC 9c 1al 'emaskeyer' mittan ON paq-
, af 't by Lav t- c 3 fackllgn Oferive,
AW bW SO NUM W "a A& n" co ky% a as WOU . as Q Apag am Rywity
Of Fidef-, paliss4ui r4iec pOwItteg.. nargwa Fen �Aiv and any -owl preann In runny v hwh Mar"
Finpictimmscm 0mawn- awl is ante rown lwtpa
a Is'01" .1 is).N'02� F la, ssat
A A Act =Ar pmWV h '4 p-, In a ", q Fa ,,air
am h Me Cleta'S IMnlizOea, lund: Pfn' PIC Of tef nn'QT
OF delld a L BUSE Me k. NWM wa,"afts, as ,etasdad
laciltiv% and wAsea"I a 4 V, Vaq!jyj ; U %a
KIM= I
As
[ h duta autfic, mal faMmile atative cu D r NUA un
occ
t
!ccoled at 110b 9XIC�tJ SY 2-7W) 1027 1 r-4, 1! 2 2 I-A
STAIE'Llf t LOPHDA, COUNIrs'COF
10 Wr Bfin find iubsmbis-1 betoee -,de aaaa 2L' L Of .—TuLie 2 0 if i:.
H ne
y k' �kvn
- ---------- _ ---------
as pmof f dentd�'-a
...... ---------------
A
EM UD
try Pubo
713807
XPAS
I
A
ME
(L WICOILO 40e4u0a IaV : b9 W Lb 40e4u0a IaV :4u8wt43e44V
ATTACHMENT H
CERTIFICATION REGARDING SCRUTINIZED COMPANIES LIST
o
r
s
65
(LW/£0 /LO;:)ea;uoa IaV : IME) Lb-£0-LO ;:)ea;uoa IaV : ;uauay 444
6 G
AMENDMENT 002 — 06NfiRACT KZ -x.697 Page 1
THIS AMENDMENT is entered into between the Alliance of Aging, Inc. hereinafter referred to as the
"Alliance ", and Monroe County Board of County Commissioners, Social Services /In -Rome Services, hereinafter
referred to as the "contractor" and collectively referred to as the "Parties."
The purpose of this amendment is to make the following changes to the existing ADI Contract for fiscal year
July 02, 2026 - June 30, 2017.
Increase Facility Respite Services: 7,050.00
Total Increase 7,050,00
This amendment changes the total ADI contract funding from $ 164,647.80 to $171,697.80
These funds are non - recurring.
Service to be Provided
Service
Unit Rate
Maximum Units of Service
Maximum
Dollars
Prior Units
I ncrease
(Decrease)
Total
Case Management
$ 50.51
120
(0)
120
$ 6,050.53
Respite In- Facility
$ 10.70
9,118
659
9,777
$ 104,610.35
Respite In -Home
$ 24.03
2,540
0
1 2,540
S 61,036.92
Total Contract Amount
171,697.80
All provisions in the contract and any attachments thereto in conflict with this amendment shall be
are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the
level specified in the contract are hereby amended to conform with this amendment.
This amendment and all its attachments are hereby made a part of the contract.
undersigned officials as duly authorized.
Monroe County Board of County
Commissioners, Social Services/
In -Home Services
SIGNED BY:
ALLIANCE FOR AGING, INC.
SIGNED BY / `jam _,`
NAME: SHERYL GRAHAM
TITLE: ACTING COUNTY ADMINISTRATOR
NAME: Max B. Rothman, JD, LL.M.
TITLE: President & CEO
DATE: 6/22/2017 DATE: �GP•
I
Preparetl vn 06 /21/2917 �'
yJ' /r/i r' � � / • �