07/07/1993Contract No. KH441
STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
STANDARD CONTRACT
THIS CONTRACT is entered Into between the State of Florida, Department of Health and Rehabilitative Services,
hereinafter referred to as the "department", and BOARD OF COUNTY COMMISSIONERS COUNTY OF MONROE
hereinafter referred to as the "provider".
THE PARTIES AGREE:
I. THE PROVIDER AGREES:
A. To provide services according to the conditions specified
in Attachment(s) I
B.Federal Laws and Regulations
1. If this contract contains federal funds, the provider
shall comply with the provisions of 45 CFR, Part 74,
and/or 45 CFR, Part 92, and other applicable
regulations as specified in Attachment _L-
2. if this contract contains federal funds and is over
$100,000, the provider shall comply with all applicable
standards, orders, or regulations issued under Section
306 of the Clean Air Act, as amended (42 U.S.C.
1857(h) et seq.), Section 508 of the Clean Water Act,
as amended (33 U.S.C. 1368 et seq.), Executive Order
11738, and Environmental Protection Agency
regulations (40 CFR Part 15). The provider shall report
any violations of the above to the department.
3. If this contract contains federal funding in excess of
$100,000, the provider must, prior to contract
execution, complete the Certification Regarding
Lobbying form, Attachment III . If a Disclosure
of Lobbying Activities form,-S—ta—ndard Form LLL, is
required, it may be obtained from the contract
manager. All disclosure forms as required by the
Certification Regarding Lobbying form must be
completed and returned to the contract manager.
C.Audits and Records
1. To maintain books, records, and documents (including
electronic storage media) in accordance with generally
accepted accounting procedures and practices which
sufficiently and properly reflect all revenues and
expenditures of funds provided by the department
under this contract.
2. To assure that these records shall be subject at all
reasonable times to inspection, review, or audit by
state personnel and other personnel duly authorized
by the department, as well as by federal personnel.
3. To maintain and file with the department such
progress, fiscal and inventory reports as specified in
Attachment I , and other reports as the
department may require within the period of this
contract. Such reporting requirements must be
reasonable given the scope and purpose of this
contract.
4. To provide a financial and compliance audit to the
department as specified in Attachment II and
to ensure that all related party transactions are
disclosed to the auditor. Additional audit requirements
are specified in Attachment I, Special Provisions,
Section D
5. To include these aforementioned audit and record
keeping requirements in all approved subcontracts and
assignments.
D.Retention of Records
1. To retain all client records, financial records,
supporting documents, statistical records, and an
other documents (including electronic storage media
pertinent to this contract for a period of five (5) years
after termination of this contract, or 'if an audit has
been initiated and audit findings have not been
resolved at the end of five (5) years, the records shall
be retained until resolution of the audit findings.
2. Persons duly authorized by the depai'trpent and federal
auditors, pursuant to 45 CFR, Part 92.36(1)q0), shall
have full access to and the right to examine any of said
records and documents during said retentlon geriod or
as long as records are retained, whichever is later.
E. Monitoring -i
1. To provide reports as specified in Attachment
- I _. These reports will be used for monitoring
progress or performance of the contractual services as
Spec ified In Attachment I
2. To permit persons duly authorized by the department
to inspect any records, papers, documents, facilities,
goods and services of the provider which are relevant
to this contract, and/or Interview any clients and
employees of the provider to be assured of satisfactory
Performance of the terms and conditions of this
contract. Following such inspection the department
will deliver to the provider a list of its comments with
regard to the manner in which said goods or services
are being provided. The provider will rectify all noted
deficiencies provided by the department within the
specified period of time set forth in the comments or
provide the department with a reasonable and
acceptable justification for not correcting the noted
Shortcomings. The provider's failure to correct or
justify within a reasonable time as specified by the
department may result in the withholding of payments,
being deemed in breach or default, or termination of
this contract.
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F. endemnification
If the provider is a state agency or subdivision as defined
in section 768.28, Florida Statutes, only No. 2 below is
applicable. Other than state agencies or subdivisions
refer only to No. 1.
1. The provider agrees to be liable for all claims, suits,
judgments, or damages, including court costs and
attorney's fees, arising out of the negligent or
intentional acts or omissions of the provider, and its
agents, subcontractors, and employees, in the course
of the operation of this contract. Further, the provider
agrees to indemnify the department against all claims,
suits, judgments, or damages, including court costs
and attorneys fees, arising out of the negligent or
intentional acts or omissions of the provider, and its
agents, subcontractors, and employees, In the course
of the operation of this contract. Also, the provider
agrees to defend the department, upon receiving
timely written notification from the department, against
all claims, suits, judgments, or damages, including
costs and attorney's fees, arising out of the negligent
or intentional acts or omissions of the provider and its
agents, subcontractors, and employees, In the course
of the operation of this contract. Where the
ovider
and the department commit joint negligent acts, the
Provider shall not be liable for nor have any obligation
to defend the department with respect to that
rt
the joint negligent act committed by the departmentf
In no event shall the provider be liable for or have any
Obligation to defend the department against such
claims, suits, judgements, or damages, including costs
and attorney's fees, arising out of the sole negligent
acts of the department.
2. Any provider who is a state agency or subdivision, as
defined in section 768.28, Florida Statutes, agrees to
be fully responsible for its negligent acts or omissions
or intentional tortious acts which result in claims s
suits against the department, and agrees to be or
for any damages proximately caused by said acts or
omissions. Nothing herein Is intended
waiver of sovereign Immunity by any provider to which
sovereign immunitto serve as a
y applies. Nothing herein shall be
construed as consent by a state agency or subdivision
of the State of Florida to be sued by third parties In any
that matter
r(s an InOut dependent nde of any contract. The provider agrees
pendent contractor of the department
and not an agent or employee.
G.Insurance
1. To provide adequate liability insurance coverage on a
comprehensive basis and to hold such liability
insurance at all times during the existence of this
contract. The provider accepts full responsibility for
identifying and determining the type(s) and extent of
liability insurance necessary to provide reasonable
financial protections for the provider and the clients to
be served under this contract. Upon the execution of
this contract, the provider shall furnish the department
written verification supporting both the determination
and existence of such insurance coverage. Such
PProvgrraameestablisheed abe provided er Operating a self-insurance
er the laws of
the State of Florida. The department reserves thright
to require additional insurance as specified in
Attachment I_ where appropriate.
2. If the provider Is a state agency or subdivision as
defined by section 768.28, Florida Statutes, the
Provider shall furnish the department, upon request,
written verification of liability protection in accordance
with section 768.28. Florida Statutes. Nothing herein
shall be construed to extend any partys liability
beyond that provided In section 768.28, Florida
Statutes.
H.Safeguardinq Information
Not to use or disclose any information concerning a
rclplent of services under this contract for any purpose
not in conformity with the state regulations and federal
regulations (45 CFR, Part 205.50), except upon written
consent of the recipient, or his responsible parent or
guardian when authorized by law.
I. Client Information
To submit Managerhent, program, and client identifiable
data, as1.
specified by the department in Attachment
J. Assignments and Subcontracts
1. To neither assign the responsibility of this contract to
another party nor subcontract for any of the work
contemplated under this contract without prior written
approval of the department. No such approval by the
department of any assignment or subcontract shall be
deemed In any event or in any manner to provide for
the incurrence of any obligation of the department in
addition to the total dollar amount agreed upon in this
Contract All such assignments or subcontracts shall
Section
too them conditions of this contract (except
approval that the departmentph hall deeand to m necessary. of
2• Unless otherwise stated In the contract between the
provider and subcontractor,
working days aftpayments made by the
provider to the subcontractor must be within seven (7)
from the departer receipt of full or
Payments
ment In accordance Pa
section
287.0585, Florida Statutes. Failure to pay within seven
a7lworking days will result in a penalty charged
amount�of Provider and
of id to the subcontractor 9 in
amount dUe, Per day from the expine ration of the rcent of the
allowed herein for payment. Such period
addition to actual Such owed and shall not exceIn
ed
fifteen (15) percent of the outstanding balance due.
rt. r-'inancial Reports
To provide financial reports to the department as
specified In Attachment_
2
L Return of Funds
1. To return to the department any overpayments due to
unearned funds or funds disallowed pursuant to the
terms of this contract that were disbursed to the
provider by the department. The provider shall return
any overpayment to the department within forty (40)
calendar days after either discovery by the provider, or
notification by the department, of the overpayment. In
the event that the provider or its independent auditor
discovers an overpayment has been made, the
provider shall repay said overpayment within forty (40)
calendar days without prior notification from the
department. In the event that the department first
discovers an overpayment has been made, the
department will notify the provider by letter of such a
finding. Should repayment not be made in a time)
manner, the department will charge interest of one (1T
percent per month compounded on the outstanding
balance after forty (40) calendar days after the date of
notification or discovery.
2. For state universities, should repayment not be made
within forty (40) calendar days after the date of
notification, the department will notify the State
Comptroller's Office who will then enact a transfer of
the amounts owed from the state university's account
to the account of HRS.
M. Incident Reporting
1. Client Risk Prevention
If services to clients will be provided under this
contract, the provider and any subcontractors shall, in
accordance with the client risk prevention system,
report those reportable situations listed In
HRSR 215-6, Paragraph 5, in the manner prescribed In
HRSR 215-6 or district operating procedures.
2. Abuse, Neglect and Exploitation Reporting
In compliance with Chapter 415, Florida Statutes, an
employee of the provider who knows, or has
reasonable cause to suspect, that a child, aged person
or disabled adult is or has been abused, neglected, or
exploited, shall immediately report such knowledge or
suspicion to the central abuse registry and tracking
system of the department on the single statewide toll -
free telephone number (1-800-96ABUSE).
4.Transportation Disadvantaged
If clients are to be transported under this contract, the
provider will comply with the provisions of Chapter 427,
Florida Statutes, and Rule Chapter 41-2, Florida
Administrative Code. The provider shall subs* to the
department the reports required pursuant to Volume 10,
Chapter 27, HRS Accounting Procedures Manual.
).Purchasing
I. PRIDE
It is expressly understood and agreed that any articles
which are the subject of, or are required to carry out
this contract shall be purchased from Prison
Rehabilitative Industries and Diversified Enterprises,
Inc. (PRIDE) identified under Chapter 946, Florida
Statutes, in the same manner and under the
procedures set forth in subsections 946.515(2) and (4),
Florida Statutes. For purposes of this contract, the
ierson, firm, or other business entity carrying out the
provisions of this contract shall be deemed to be
substituted for the department insofar as dealings with
PRIDE. This clause Is not applicable to any
subcontractors, unless otherwise required by law. An
abbreviated list of products/services available from
PRIDE may be obtained by contacting PRIDE's
Tallahassee branch office at (904) 487-3774 or
SunCom 277-3774.
2. Procurement of Products or Materials with
Recycled Content
Additionally, it Is expressly understood and agreed that
any products or materials which are the subject of, or
are required to carry out this contract shall be
procured in accordance with the provisions of
section 403.7065, Florida Statutes.
P. Civil Rights Requirements
1. Provider Assurance
The provider assures that it will comply with:
a. Title VI of the Civil Rights Act of 1964, as amended,
42 U.S.C. 2000d et seq., which prohibits
discrimination on the basis of race, color, or national
origin.
b. Section 604 of the Rehaboltation Act of 1973, as
amended, 29 U.S.C. 794, which prohibits
discrimination on the basis of handicap.
C. Title IX of the Education Amendments of 1972, as
amended, 20 U.S.C. 1681 et seq., which prohibits
discriminatlon on the basis of sex.
d. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination
on the basis of age.
a. Section 664 of the Omnibus Budget Reconciliation
Act of 1981, as amended, 42 U.S.C. 9849, which
prohibits discrimination on the basis of race, creed,
color, natkxtal origin, sex, handicap, political
affiliation or beliefs.
f. The Americans with Disabilities Act of 1990, P.L 101-
336, which prohibits discrimination on the basis of
disability and requires reasonable accommodation
for persons with disabilities.
g. All regulations, guidelines, and standards as are now
or may be lawfully adopted under the above
statutes.
The provider agrees that compliance with this
assurance constltutes a condition of continued
receipt of or benefit from funds provided through
this contract, and that it Is binding upon the
Provider, Its successors, transferees, and assignees
for the period dining which services are provided.
The provider further assures that all contractors,
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7/1/93
subcontractors, subgrantees, or others with whom It
arranges to provide services or benefits to
participants or employees In connection with any of
its programs and activities are not discriminating
against those participants or employees In violation
of the above statutes, regulations, guidelines, and
standards.
2. Compliance Questionnaire
In accordance with HRSM 220-2, the provider agrees
to complete the Civil Rights Compliance Questionnaire,
HRS Forms 946 A and B, if services are provided to
clients and if 15 or more people are employed.
O.Requirements of Section 287.058, Florida Statutes
1. To submit bills for fees or other compensation for
services or expenses In sufficient detail for a proper
pre -audit and post -audit thereof.
2. Where applicable, to submit bills for any travel
expenses in accordance with section 112.061, Florida
Statutes. The department may, when specified in
Attachment I , establish rates lower than the
maximum prov in section 112.061, Florida
Statutes.
3. To provide units of deliverables, including reports,
findings, and drafts as specified in
ATTACHMENT I , to be received a6d-
accepted by the contract manager prior to payment.
4. To comply with the criteria and final date by which
such criteria must be met for completion of this
contract as specified in Section III, Paragraph A.2. of
this contract.
5. To allow public access to all documents, papers,
letters, or other materials subject to the provisions of
Chapter 119, Florida Statutes, and made or received
by the provider in conjunction with this contract. It is
expressly understood that substantial evidence of the
provider's refusal to comply with this provision shall
constitute a breach of contract.
R. Withholdings and Other Benefits
1. The provider is responsible for Social Security and
Income Tax withholdings.
2. The provider is not entitled to state retirement or leave
benefits except where the provider is a state agency.
3. Unless justified by the provider and agreed to by the
department In Attachment I, Section D , the
department will not furnish services of support (e.g.,
office space, office supplies, telephone service,
secretarial, or clerical support) normally available to
career service employees.
S. Sponsorship
As required by section 286.25, Florida Statutes, if the
provider is a nongovernmental organization which
sponsors a program financed wholly or in part by state
funds, including any funds obtained through this
contract, it shall, in publicizing, advertising or describing
the sponsorship of the program, state: "Sponsored by
BOARD OF COUNTY COMMISSIONERS COUNTY OF
MONROE
PROVIDER
and the State of Florida, Department of Health and
Rehabilitative Services'. If the sponsorship reference is in
written material, the words "State of Florida, Department
of Health and Rehabilitative Services' shall appear in the
same size letters or type as the name of the organization.
T. Discounted Invoices
To allow a N/A percent discount on selected
Invoices whIc arh a paid in less than �L/ days. The
provider must dearly mark any Invoice witthtthe discount
If it is to be allowed. The provider may submit invoices
with or without the negotiated discount terms. The
department shall comply with subsection 215.422(4),
Florida Statutes, If a discounted Invoice is offered.
U. Final Invoice
The provider must submit the final invoice for payment to
the department no more than 45 days after the
contract ends or is terminated; Me provider fails to do
so, all right to payment is forfeited and the department
will not honor any requests submitted after the aforesaid
time period. Any payment due under the terms of this
contract may be withheld until all reports due from the
provider and necessary adjustments thereto have been
approved by the department.
V. Use Of Funds For Lobbying Prohibited
To comply with the provisions of section 216.347, Florida
Statutes, which prohibits the expenditure of contract
funds for the purpose of lobbying the Legislature or a
state agency.
If. THE DEPARTMENT AGREES:
A. Contract Amount
To pay for contracted services according to the
conditions of Attachment I in an amount not to exceed
$��67 140 , subject to the availability of
tuncls.—The btate of Florida's performance and obligation
to pay under this contract Is contingent upon an annual
appropriation by the Legislature. The costs of services
paid under any other contract or from any other source
are not eligible for reimbursement under this contract.
B. Contract Payment
Pursuant to section 215.422, Florida Statutes, the
voucher authorizing payment of an invoice submitted to
the department shall be filed with the State Comptroller
not later than twenty (20) days from the latter of the date
a proper Invoice Is received or receipt, inspection and
approval of the goods or services, except that in the case
of a bona fide dispute the voucher shall contain a
statement of the dispute and authorize payment only in
the amount not disputed. The date on which an Invoice is
deemed received Is the date on which a proper Invoice is
first received at the place designated by the department.
4
/ 1 /93
nvoices which have to be returned to a vendor because
►f vendor preparation errors will result in a delay in the
)ayment. The invoice payment requirements do not start
intil a properly completed Invoice, as defined in Rule
',hapter 3A-24, Florida Administrative Code, is provided
o the department. Approval and Inspection of goods or
services shall take no longer than five (5) working days
rniess the bid specifications, purchase order or contract
:pecffies otherwise. Such approval is for the purpose of
authorizing payments and does not constitute a final
ipprovai of services purchased under this contract. A
►ayment is deemed to be issued on the first working day
hat payment is available for delivery or mailing to the
)rovider. If a warrant in payment of an invoice is not
3sued within forty (40) days, or thirty-five (35) days for
,ealth care providers as defined in Rule Chapter 3A-24,
.lorida Administrative Code, after the receipt of the
rvoice and receipt, inspection, and approval of the
foods and services, the department shall pay to the
,rovider, in addition to the amount of the invoice, interest
t a rate of one (1) percent per month calculated on a
wily basis on the unpaid balance from the expiration of
uch forty (40) day period, or thirty-five (35) day period
x health care providers as defined in Rule
;hapter 3A-24, Florida Administrative Code, until such
me that the warrant is Issued to the provider. The
;mporary unavailability of funds to make a timely
ayment due for goods or services does not relieve the
epartment from this obligation to pay interest penalties.
endor Ombudsman
Vendor Ombudsman has been established within the
►epartment of Banking and Finance. The duties of this
xfividual include acting as an advocate for vendors who
iay be experiencing problems in obtaining timely
ayment(s) from a state agency. The Vendor
ymbudsman may be contacted at (904) 488-2924 or by
311ing the State Comptroller's Hotline, 1-800-848-3792.
SHE PROVIDER AND DEPARTMENT MUTUALLY
AGREE:
ffective Date
This contract shall begin on J LY 1 . 199
or on the date on which the contract has been signed
by both parties, whichever is later.
This contract shall and on JUNE 30, 1994
ermination
Termination at Will
This contract may be terminated by either parry upon
no less than thirty (30) calendar days notice, without
cause, unless a lesser time is mutually agreed upon by
both parties. Said notice shall be delivered by certified
mail, return receipt requested, or in person with proof
of delivery.
Termination Because of Lack of Funds
In the event funds to finance this contract become
unavailable, the department may terminate the
contract upon no less than twenty-four (24) hours
notice In writing to the provider. Said notice shall be
delivered by certified mail, return receipt requested, or
In person with proof of delivery. The department shall
be the final authority as to the avallabNity of funds.
3. Termination for Breach
Unless the provider's breach is waived by the
department In writing, the department may, by written
notice to the provider, terminate this contract upon no
less than twenty-four (24) hours notice. Said notice
shall be delivered by certified mail, return receipt
requested, or In person with proof of delivery. If
applicable, the department may employ the default
provisions in Chapter 13A-1.006(4), Florida
Administrative Code. Waiver of breach of any
provisions of this contract shall not be deemed to be a
waiver of any other breach and shall not be construed
to be a modification of the terms of this contract. The
provisions herein do not limit the department's right to
remedies at law or to damages.
C.Notice and Contact
1. The name, address and telephone number of the
contract manager for the department for this contract
is:
SEYMOUR BROWN
401 NW 2ND AVENUE, N812
MIAMI. FLORIDA
(305) 377-5029
2. The name, address and telephone number of the
representative of the provider responsible for
administration of the program under this contract is:
MARY BROSKE
5100 COLLEGE ROAD, S.I.
KEYWEST, FLORIDA 33040
(305) 292-4471 OR 292-4474
3.In the event that different representatives are
designated by either party after execution of this
contract, notice of the name and address of the new
representative will be rendered in writing to the other
Party and said notification attached to originals of this
contract.
D.Renegotiation or Modification
1. Modifications of provisions of this contract shall only
be valid when they have been reduced to writing and
duly signed. The parties agree to renegotiate this
contract I federal and/or state revisions of any
applicable laws, or regulations make changes in this
contract necessary.
2. The rate of payment and the total dollar amount may
be adjusted retroactively to reflect price level Increases
and changes in the rate of payment when these have
been established through the appropriations process
and subsequently identified in the department's
operating budget.
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E. Name, Mailing and Street Address of Payee
1. The name (provider name as shown on page 1 of this
contract) and mailing address of the official payee to
whom the payment shall be made:
BOARD OF WLNff QMISSIONERS
CaKFP OF NDMWE
wt,1.I�._
2. The name of the contact person and street address
where financial and administrative records are
maintained:
41:1,1►� :.11
Contract No. l[ H 4 4 I
F. All Terms and Conditions Included
This contract and its attachments as referenced,
( ATTAGMENT I - EXFIIBTIS A-M
ATTAC[ vM II - FINANCIAL & 014LDNM AUDTT
ATFACR4ENr III - CE=CATION RMARDING LOOBYEC
contain all the terms and conditions agreed upon y t )e
parties.
P E AS
A L.
BY
Dale
IN WITNESS THEREOF, the parties hereto have caused this page contract to be executed by their undersigned
officials as duly authorized.
PROVIDER
SIGNED BY:
STATE OF FLORIDA, DEPARTMENT OF
HEALTH AND REHABILITATIVE SERVICES
ANITA M. BOCK
DATE: July 7, 1993 DATE: 7' 3
FEDERAL ID NUMBER (or SS Number for an individual):
VF59-6000749
STATE AGENCY 29 DIGIT SAMAS CODE:
-----------------------------
PROVIDER FISCAL YEAR ENDING DATE:
JUNE 30, 1994
ATTEST: DAMiY L . IML
CONTRACT IS NOT VALID UNTIL SIGNED AND DATED BY
BOTH PARTIES
I.AGE . C=1
IG '+
N.
N.
07/01/93
Alcohol, Drug Abuse and Mental Health services
ATTACHMENT I - STANDARD CONTRACT
A. Services To Be Provided
The provider will ensure the provision of services as
specified in the approved District Plan for Alcohol, Drug
Abuse, and Mental Health Services. The provider is
responsible for the administration and provision of programs
and services in the county(ies) of MQNRnR
B. Manner of Service Provision
1. The provider will comply with Chapters 394 and
397, Florida Statutes, and Chapters 10E-4, 10E-5,
10E-10, 10E-12, 10E-13, 10E-14, 10E-15, and 10E-16, Florida
Administrative Code, as appropriate and the Guide to
Performance Contracting for Alcohol, Drug Abuse and Mental
Health Services.
2. The provider will comply with the ADAMHA
Reorganization Act, P.L. 102-321, Section 201 Part B of
Title XIX of the Public Health Service Act (42 U.S.C. 300x
et seq) as amended July 10, 1992.
3. The provider will comply with all other applicable
state standards, provided they are specified in Florida
Statutes or Administrative Codes established by the
department or made known in writing to the provider with
thirty (30) days advance notice.
4. The provider will comply with the federal and
Florida pharmaceutical rules, regulations, and statutory
requirements as specified in Chapter 465, Florida Statutes,
as appropriate.
5. The provider agrees
outcome measures as delineated
appropriate.
C. Method of Payment
to the program objectives and
in Exhibit D and E as
1. The department will participate in up to 75
percent of approved cost, unless otherwise indicated on
Exhibit B, as determined by Chapter 394 and 397, Florida
Statutes, Chapter 10E-14, Florida Administrative Code,
Chapter 10E-13, Florida Administrative Code, or legislative
proviso. The amount of departmental participation will not
exceed $ 167,140 as detailed in Exhibit B
of this contract.
HCO1
0
07/01/93 ADM Services
ATTACHMENT I - STANDARD CONTRACT (Cont.)
2. The provider will secure, at a minimum, local
match in the amount of $ N/A as identified in the
approved total agency line item operating budget for the
funding sources specified in Exhibit B.
3. The provider will participate in the Title XIX
Florida Medicaid Program as defined in the Community Mental
Health/Alcohol Services Program, Section 1OC-7.525, Florida
Administrative Code, and will:
a. Pursue and submit vouchers on all Medicaid
eligible clients for Medicaid eligible services.
b. Identify and report Medicaid earnings
separate from all other fees. Medicaid earnings are state
funds and cannot be used as local match.
4. If the provider receives federal funds authorized
under the ADAMHA Block Grant Program, which includes the
Community Mental Health Services Block Grant and the
Prevention and Treatment of Substance Abuse Block Grant, the
provider will:
a. Ensure that block grant funds are not used to
fund inpatient services. Inpatient services are defined as
services delivered in a licensed hospital.
b. Ensure that block grant funds are not used to
make cash payments to intended recipients of health
services.
C. Ensure that block grant funds are accounted
for in a manner that permits separate reporting.
d. Ensure that block grant funds are not used to
satisfy any requirement for the expenditure of non-federal
funds as a condition of the receipt of federal funds.
e. Ensure that block grant funds are not used
for the purpose of purchasing or improving land, to
purchase, construct or permanently improve (other than minor
remodeling) any building or other facility, or to purchase
major medical equipment.
f. Ensure that block grant funds are not used to
provide financial assistance to any entity other than a
public or nonprofit private entity.
HC01
07/01/93 ADM Services
ATTACHMENT I - STANDARD CONTRACT (Cont.)
g. Ensure that block grant funds are not used to
pay the salary of an individual, through a grant or other
extramural mechanism, at a rate in excess of $125,000 per
year.
h. Ensure that block grant funds are not
expended to carry out any program of distributing sterile
needles for the hypodermic injection of any illegal drug or
distributing bleach for the purpose of cleansing needles for
such hypodermic injection.
i. Ensure that block grant funds are not
expended to carry out any testing for the etiologic agent
for acquired immune deficiency syndrome unless such testing
is accompanied by appropriate pretest counseling and
appropriate post-test counseling.
j. Ensure that, to the maximum extent
practicable, each individual who requests and is in need of
treatment for intravenous drug abuse is admitted to an
appropriate treatment program within 7 days after making the
request.
5. Payment System
a. The provider may request an advance of the
expected cash needs for each of the initial three months
when supported by appropriate documentation of need.
Subsequent payments will be reimbursed basis by submission
of actual monthly expenditure reports.
b. The department may release less money than
requested for reimbursement when the release of such amounts
would cause the provider to receive an amount in a given
month which exceeded the pro rata share of the total
contracted amount. (Pro rata share is defined as the.
balance of the contract amount divided by the remaining
months in the contract.)
C. The department may, if funds are available,
release more than the monthly pro rata share of the contract
amount only for onetime nonrecurring expenditures, provided
the terms which specify month(s) and amount(s) to be
requested are included as a part of this contract.
d. The department may reduce a request for
advance or withhold payment if a provider is determined to
be out of compliance with the terms of the contract.
e. The department's decision to reduce or
withhold funds shall be in writing and submitted to all
HC01
07/01/93 ADM Services
ATTACHMENT I - STANDARD CONTRACT (Cont.)
involved parties. The written notice will specify the
manner and extent to which the provider has failed to comply
with the terms of the contract. To the extent that the
situation identified as problematic is corrected, payment
shall be reinstated to the provider.
f. The provider will ensure that the unused
amount of advanced funds are temporarily invested in an
interest bearing account. Interest earned on these deposits
will be returned to the department on a monthly basis.
g. The department will support the provider in
the event of state or federal disallowance of any
expenditures which have been made pursuant to written
approval of the department.
D. Special Provisions
1. Financial Reporting System Requirements
a. Each provider will submit service
documentation for clients served within the array of cost
centers that are described in the "Guide to Performance
Contracting For Alcohol. Drug Abuse and Mental Health
Services".
b. The provider will report actual expenditures
in accordance with the standards set forth in the "Guide to
Performance Contracting For Alcohol, Drug Abuse and Mental
Health Services." The provider will not be required to
submit the following reports:
HRS-MH Form 3085, Feb 85.
HRS-MH Form 3086A, Feb 85.
HRS-MH Form 3086B, Feb 85.
HRS-MH Form 3087, Feb 85.
HRS-MH Form 3088, Feb 85.
C. The provider will submit budget detail
reports with budget narrative and a personnel detail report
that reflects the total agency operation by cost center as
specified in Exhibit C.
d. The provider will submit three expenditure
reports: The first is due February 1, which summarizes
actual expenditures, by cost center, up through December 31;
the second is due May 1, which summarizes actual
expenditures through March 31; and the third is due 45 days
after the end of the contract period which summarizes
expenditures for the entire contract period and will serve
as a final report for the contract period.
(b
HCO1
07/01/93 ADM Services
ATTACHMENT I - STANDARD CONTRACT (Cont.)
e. The provider will submit a cost Center
Service Provision Report 30 days after the end of each
quarter to summarize the number of units of service provided
by cost center. The fourth quarter report, due 45 days
after the end of the contract period, will serve as a final
report to summarize the total units of service provided by
cost center for the entire contract period.
f. Although compliance with the implementation
of the new financial reporting system is fully expected, the
implementation of this system will in no way affect the
manner in which providers currently earn state funding. The
Exhibit A is incorporated in this contract to collect
baseline data and is not intended to change the method of
payment and audit guidelines for this contract period.
Payment for this contract is based on a grant-in-aid
reimbursement system as specified in Chapter 394.76, Florida
Statutes and Chapter 10E-14.017, Florida Administrative
Code.
2. Fee Schedule
The provider will develop a sliding discount fee
schedule and fee collection policy which will be used to
determine the amount of payment based on the ability or
inability of a client to pay for publicly subsidized
services received. The discount fee schedule and fee
collection policy shall be approved by the provider's board
of directors and reviewed by the department.
3. Grievance Procedures
The provider will establish procedures through
which applicants for and recipients of services may present
grievances about the operation of the services being
provided under this contract. The provider will advise
persons of their right to appeal a denial or exclusion from
the program, of failure to take account of an individual's
choice of service and of the right to a fair hearing to the
governing authority of the agency.
4. Clinical Records
Chapter 394.459(9), Florida Statutes, exempts
clinical records as public records to protect client
confidentiality.
5. Required Reports
The provider will submit financial and
programmatic reports that are specified in Exhibit C to
the department.
HC01
07/01/93 ADM Services
ATTACHMENT I - STANDARD CONTRACT (Cont.)
6. Block Grant Funding Agreement Program Reports
The provider will submit information, in writing
and in a manner prescribed by the department, regarding the
Community Mental Health Services Block Grant services and
expenditures and the Prevention and Treatment of Substance
Abuse Block Grant services and expenditures. This
information, subject to audit, will be retained by the
department as documentation of compliance with program
requirements.
7. Special Audit Reporting Requirements
The provider will submit an audit report that
includes: (a) a financial statement and a consolidating
schedule; (b) a functional expense statement; (c) a net
income report and (d) a local match report in accordance
with the "Guide to Performance Contracting For Alcohol,, Drug
Abuse and Mental Health Services".
8. Substance Abusing Parents Involved With the
Children and Family Program Protective
Supervision, Health Service Case Management and
Primary Care Services.
The provider agrees to make every effort to obtain
a client's informed consent for release of information
to/from: HRS Children and Family (C&F) Program when the
client/family is under C&F protective supervision; and/or
HRS County Public Health Units when the client/family is
involved with case management and/or primary medical care
services. This will enable the provider to better
coordinate with and communicate to other professionals
intervening with the client and his/her family and better
ensure the health, safety and welfare of the children of
substance abusing/recovering parent(s) or caretaker(s).
9. Performance Objectives and Outcome Measures
Pursuant to Florida Statutes 20.19(18)(c)l., the
provider shall maintain data on the outcome measures
specified in Exhibit D and/or Exhibit E for the types of
services provided under this contract and shall submit such
data to the department upon request.
/,Z
HC01
07/01/93
ATTACHMENT I - STANDARD CONTRACT ( Cont.)
ADM Services
10. The Budget Detail and The Personnel Detail records
will be incorporated in the contract as Exhibit F and F-1,
respectively. The Budget narrative will be retained by the
contract manager.
11. Documentation of Travel Expense
The provider will maintain documentation of travel
expenses on the State of Florida Voucher of Reimbursement of
Travel Expense, Form C676 or a format which is approved by
the office of the Comptroller of the State of Florida. This
information will be retained by the provider agency as
supporting documentation subject to audit.
12. Information Technology Resources
All contract providers must adhere to the departments
procedures and standards when purchasing Information
Technology Resources (ITR) with state funds and if these
resources will revert to the department at the conclusion of
the contract. ITR are data processing hardware, software,
services, supplies and maintenance. The document entitled
"HRS/MS Instructions for Acquisition of Information
Technology Resources", provides procedures which govern ITR
purchases. The department has specified certain hardware and
software as department standards. All acquisitions must be
made in consonance with these standards. Copies of these
materials plus assistance in their use may be obtained from
the Deputy Secretary for Management Systems. Any purchase of
computer hardware and software with departmental funds
requires prior approval of the department.
13. On or before June 30, 1994 providers of Alcohol Drug
Abuse and Mental Health Services will implement a
Comprehensive Service Planning System.
14. Providers of Alcohol, Drug Abuse and Mental Health
Services will apply the self monitoring instruments to their
Programs by September 1, 1993 and submit reports to the
department as indicated in Exhibit C.
/3
MONROE COUNTY GRANTS 3052924477
P.02
a
ALCQHOL DRUG UVSE AND MENTAL HEAI+TH SERVzceS
STATZ ruxDING BY COST CENTER AND
PROGRAM
Doto6/24/93._ ,
EXHIBIT A
n�y,Monroe County Bpard
of Commissioners
RevLsion t
Adult Adult
Child/Adol
Child/Ado,
CAST CENTERS
Mental Sealth substance Abuse
Mentalal H� e_nith
Sslb9t.a1^,g }.�:3g
. A39899ment
g g
S
$
;
g
S
Case management
_167,140S
Crisis stabilization
S
S
Crisis Support/Emetgen
y
$
S
g
S
Day -Night
Drop-In/Self-8alp Centers
Inpatient
1. Intervention
J. Methadone Treatment
10, outpatient
11. outpatient Medical
overlay
13, prevention
14. Prev/Intery - Day
15. Residential petOX
16. Residential Level 1
17. Residential Level 2
18. Residential Level I
18. Residential Level 4
20. Respite Care
21. sheltered Employment
22. supported Employmen'
23. Supported Housing
24. TASC
tat State Funds
S
�
S
S
g
S
5
S
g
S
S
$
S —
S
g_
S
$
S
g
S
$
g
g
S
$
S
S
S
$167,140 - S� $ 1 $- --
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7
W
Alcohol, Drug Abuse and Mental Health Services
Required Reports
Exhibit C
Reports Required for all Contract Providers
Due Copies Sent To
Date
- TASC Statistical Report
10 days
1
Client
after end
Manager
of each
'
month
- Substance Abuse Providers
10 days
1
Client
Waiting List Report
after end
Manager
of each
month
- Case Management Quarterly
30 days
1
Client
Service Provision Report by
after end
Manager
Service Category
of each
quarter
- Wheels / Juvenile Justice
10 days
1
Client
Statistical Reports
after end
Manager
of each
quarter
- Progress Report on Inner
15 days
2
1-Talla
City Grants
after end
1-Client
of each
Manager
Month
- Performance Measure Reports
30 days
1
Client
after end
Manager
of each
quarter
- Monthly Report for Pregnant
10 days
1
Client
Postpartum Women
after end
Manager
of each
quarter
- Alpha / Beta Pre and Post
12/15/93
1
Client
Program Report
06/15/94
Manager
0
Alcohol, Drug Abuse and Mental Health Services
Required Reports
Exhibit C
Reports Required for all Contract Providers
Due Copies
Sent To
Date
- AIDS Report / HIV Counseling
10 days
1 Client
and Testing
after end
Manager
of each
Month
- Juvenile Justice & Wheels Bill
Weekly
1 Client
Beds Report
Manager
Additional Reports Required for
Children's Mental Health Service Providers
- Children's Non Residential Mental
N/A
Health Services Annual Data Report
Annual Audit report which includes:
- Financial Statement and
120 days 3
1-Talla
consolidating schedule
after the
2-Contract
end of
Manager
providers
Fiscal Year
A Functional Expense Statement
A Net Income Report
Local Match Report in accordance with
the "Guide to Performance Contracting
for Alcohol, Drug Abuse and Mental Health
Services."
- Inventory of Property purchased with 05/10/93 1 Contract
State funds Manager
/T
u
Alcohol, Drug Abuse and Mental Health Services
Required Reports
Exhibit C
Reports Required for all Contract Providers
Due Copies Sent To
Date
- Local Match Report 02/01/94 1 Contract
05/01/94 Manager
08/14/94
- Interim Rate Setting Report
Additional Reports Required for
Community Mental Health Providers
02/01/94 1 Contract
05/01/94 Manager
08/14/94
- Community Forensic Program
30 days
2 Client
Quarterly Caseload Status and
after end
Manager
Demographic Report
of each
quarter
- Agency Quarterly Caseload Status
30 days
2 Client
and Demographic Report
after'end
Manager
of each
quarter
- Indigent Program Report
45 days
1 Client
after end
Manager
of F.Y.
- Special Baker Act Facility 30 days 1 Client
Quarterly Caseload Status after end Manager
and Demographic Report of each
quarter
Additional Reports Required for
Substance Abuse Providers
- State Interim Substance Abuse
Reports (SISAR: Admission,
Discharge, and Detox)
30 days 1 Client
after end Manager
of each
Alcohol, Drug Abuse and Mental Health Services
Required Reports
Exhibit C
Reports Required for all Contract Providers
Due Copies Sent To
Date
- Quarterly Service Provision Report.
Due Dates to Contract Managers: 1 Contract
10/31/93; 1/31/94, 4/30/94; As noted Manager
and 8/15/94.
- Response to Monitoring Report 30 days 1 Contract
from date Manager
report is
received
- Block Grant Funding Agreement
Program Reports. Due Dates to 1 Contract
Contract Manager: 1/31/94; As noted Manager
4/30/94; and 7/15/94
- Agency Service Capacity Report 05/10/93 1 Contract
Manager
- Cost Center Personnel Detail 05/10/94 Contract
Report Manager
Cost Center Funding Sources 05/10/93 1 Contract
and Revenue Budget Detail Report Manager
Cost Center Expense Budget Detail 05/10/93 1 Contract
Report Manager
- Cost Center Expenditure Report 02/01/94 1 Contract
05/01/94 Manager
08/14/94
- Monthly Invoice (HRS Form 1005) No later 1 Contract
than the 15th Manager
day of preceding
month
- Local Match Plan
02/01/94
05/01/94
08/14/94
10
Alcohol, Drug Abuse and Mental Health Services
Required Reports
Exhibit C
Reports Required for all Contract Providers
----------------------------------------------------------------
- Monthly Entrant / Refugee Reports by loth of 1 Contract
each month Manager
----------------------------------------------------------------
- Self Monitoring Reports 30 days 1 Contract
after the Manager
end of
each
quarter
----------------------------------------------------------------
5 5)1
07/01/93
Alcohol, Drug Abuse and Mental Health Services
Contract Performance Measures
EXHIBIT D
I. Funding Agreement Requirements:
A. Community Mental Health Funding Agreement
1. Children With A Serious Emotional Disturbance:
To expend mental health block grant funds to
increase funding for the system of integrated
mental health services for children with serious
emotional disturbance.
Required Expenditure Amount
B. Community Substance Abuse Funding Agreements
1. Alcohol and Drug Abuse Services:
a. To expend substance abuse block grant funds for
prevention and treatment activities regarding
alcohol.
Required Expenditure Amount $
b. To expend substance abuse block grant funds for
prevention and treatment activities regarding
other drugs.
Required Expenditure Amount $,A1 -
2. Prevention Services:
To expend substance abuse block grant funds to
provide primary prevention programs for
individuals who do not require treatment for
substance abuse, to educate and council the
individual on -such abuse and provide for
activities to reduce the risk of such abuse by
individuals.
Required Expenditure Amount $A,A'
Alcohol $ /�/y Other Drug $�
M.
HCO1
07/01/93
CONTRACT PERFORMANCE MEASURES
EXHIBIT D (Cont.)
3. Women Services:
ADM Services
To expend substance abuse block grant funds to
increase the availability of substance abuse
treatment services for women. Special emphasis is
placed on the provision of services to pregnant
women and women with dependent children.
Required Expenditure Amounts $ Nn
Alcohol $ /VA Other Drugs $ **VJOV
4. Intravenous Substance Abuse Services:
To expend substance abuse block grant funds to
make available to individuals undergoing substance
abuse treatment early intervention services for
HIV disease. w
Required Expenditure Amount
II. Performance Objectives and Outcome Measures
A. Community Forensic In -Jail Program - 100 percent
of referred detainees will be screened for
determination of need for mental health services.
B. ALPHA Programs Only
1. Eighty percent of students will achieve a
minimum of a six month (for semester programs)or
twelve month (for full school year programs) grade
level increase in reading or will progress to
within grade level, as measured by the Woodcock
Reading Test or similar instrument.
2. Eighty percent of students will achieve a
minimum of a six month (for semester programs) or
twelve month (for full school year programs) grade
level increase in math or will progress within
grade level, as measured by the Key Math Test or
similar instrument.
3. Eighty percent of students identified as
having "significant" or "very significant"
behavior problems will demonstrate improvement on
the Burks Behavior Rating Scale or similar
instrument.
HC01
07/01/93 ADM Services
CONTRACT PERFORMANCE MEASURES
EXHIBIT D (Cont.)
4. Eighty percent of students who complete the
Alpha program will not become involved in
drug/alcohol treatment programs or have an
adjudication for delinquency within one year after
program completion, as evidenced by parental
report and HRS or police records.
C. Children's Mental Health
1. A)X— percent of children served will be
children who have been referred to the provider
and who have been adjudicated dependent or
delinquent and are in the physical custody of the
department.
2. VO- percent of children served will show
improvement in behavior and condition upon program
completion based upon a standardized behavioral
assessment instrument administered at admission
and again at discharge.
D. Adult Mental Health Services
AA percent of all state general revenue
and federal mental health block grant must be
utilized to serve individuals who are seriously
mentally ill. A person who meets the following
criteria can be considered as seriously mentally
ill:
1. A person awaiting admission to, in placement
at, or has been discharged from a state mental
health facility;
2. A person who is at risk of
institutionalization or incarceration for mental
health reasons;
3. A person who has had one or more admissions
to a crisis stabilization unit, short-term
residential facility, or inpatient psychiatric
unit; and/or
4. A person who is experiencing long-term or
serious acute episodes of mental impairment that
may put him/her at risk of requiring more
intensive services.
HCO1
07/01/93
Alcohol, Drug Abuse and Mental Health Services
Special Requirements for Children's Services
EXHIBIT E
A. The provider shall not initiate any publicity involving
clients, including the use of name or identifiable
pictures, without the written consent of the client's
parents or legal guardian.
B. Children and Family Services, and Delinquency Services
clients shall be given priority for alcohol, drug abuse
and mental health services. Children in the physical
custody of the department who are adjudicated dependent
or delinquent shall be given the highest priority for
alcohol, drug abuse and mental health services.
C. The provider shall allow the contract manager and other
agents of the department, including the child's
designated case manager, to conduct.private,
confidential interviews with the child and with
provider staff.
D. The provider shall identify and maintain documentation
of Title IV-E expenditures for each Title IV-E eligible
clients served as specified in HRS Accounting
Procedures Manual, Volume 2, Chapter 9.
E. The provider shall submit documentation of service
provision to Title IV-E eligible clients to the
department in the form and manner specified by the
district.
I
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MONROE COUNTY GRANTS 3052924477
P.02
June 24, 1993
To Whom it May Concern:
The Monroe 4ounty Board of County Commissioners will be
subcontract:kpg with the Life Center Foundation, Inc, for
$ 153,000.00 for the provision of the following:
{ LINE ITEM BUDGET NARRATIVE
SUBCONTRACT WITH THE LIFE CENTER FOUNDATION, INC.
PERSONNEL: 1
Salaries
L58W 1 FTE
$30,000
Case Manager 2 FTE's $25,000)
50,000
Van Driver 1 FTE
20,000
Total. Salaries
100,000
I
Fringe Benefits
i
23,000
Total. Personnel
i
123,000
EXPENSES
Client Transportation
800 miles/wk a $0.20/mi.
i
8,320
Operating Supplies
Office Supplies
800
Telephone, FAX
880
Van Rental & Insurance
20,000
1
Total Expenses
30,000
TOTAL CONTRACTUAL SERVICES
i
153,000
ADMINISTRATION 14,140
The protect Will be administered by the Monroe County Grants
Management Department, as follows:
I;
Cleric4 Support $10,680
Fringe penefits 3,460
Total A�min,istration 14,140
i
I
S. Broske
Director, Gran s Management Department
Monroe County
i
CONTRACT #
ALCOHOL, DRUG
MENTAL HEALTH
EXHIBIT G
ABUSE &
SERVICES
Pursuant to Senate Bill 489, screening for determination of
good moral character is required of those facilities
providing services to children. Failure to do so permits
termination of contract.
An affidavit attesting to completion of fingerprinting
requirements shall be submitted to the department on an
annual basis prior to renewal of the facility license or
facility monitoring.
R
CONTRACT #
ALCOHOL, DRUG ABUSE &
MENTAL HEALTH SERVICES
EXHIBIT H
Logo and Plaque
To affirm the partnership of The Department of Health and
Rehabilitative Services.- Alcohol, Drug Abuse and Mental
Health Program Office with provider agencies, the following
is required:
1. The HRS/Alcohol, Drug Abuse and
Mental Health Logo be placed on the
provider's letterhead;
2. The HRS/Alcohol, Drug Abuse and
Mental Health Logo appear on all
provider agency publications which
advise the public of services funded by
HRS/Alcohol, Drug Abuse and Mental
Health;
3. HRS/Alcohol, Drug Abuse and Mental
Health be mentioned as a funding source
in all electronic and print media news
stories about such funded services;
4. HRS/Alcohol, Drug Abuse and Mental
Health funding be mentioned in all
public presentations about such funded
services; and,
5. An HRS - provided plaque depicting
the HRS/Alcohol, Drug Abuse and Mental
Health Logo be prominently displayed at
the provider's corporate headquarters.
6. No HRS/Alcohol Drug Abuse and Mental
Health Logo shall be placed on the bank
checks of the provider.
30
CONTRACT # ey yV1
ALCOHOL, DRUG ABUSE &
MENTAL HEALTH SERVICES
EXHIBIT I
Two copies of the Annual Operational Plan Service
Operational Criteria are required to be submitted and must
contain the following information:
Table of Organization
Agency Achievements
Agency Sliding Fee Schedule
Board of Directors
Corporate By -Laws
Short -Term goals (for each Program)
Short -Term goals (for each Program)
Bowr/
The Crid..i A, 40r /11d/l *e- has submitted the Agency
Operational Plan Service Operational Criteria (Form B) to
the Alcohol, Drug and Mental Health Program Office.
u
31
SPECIAL REQUEST
EXHIBIT I
CONTRACT # ky oil /
ONE TIME NON -RECURRING EXPENDITURE ADVANCE
Pursuant to Attachment I, Section C, Paragraph 5.0 of
the attached FY 93-94 Contract, we are requesting more
than the monthly pro-rata share of the contract only
for one-time non -recurring expenditures.
This request is for the month of iv 19
in the excess amount of $ o be used
for the purpose of
PROGRAM
SIGNATURE
TITTLE
DATE
.3Z
0
Exhibit K
Nonexpendable Property
Nonexpendable property is defined as tangible personal
property of a nonconsumable nature that has an
acquisition cost of $500 or more per unit and an expected
useful life of at least one year, and hardback bound books
that are not circulated to students or the general public,
the value or cost of which is $100 or more. Hardback books
with a value or cost of $25 or more should be classified
as an OCO expenditure only if they are circulated to
students or to the general public.
All such property purchased under this contract shall be
listed on the property records of the provider. Said
listing shall include a description of the property, model
number, manufacturer's serial number, funding source,
information needed to calculated the federal and / or
state 'share, date of acquisition, unit cost, property
inventory number, and information on the location, use and
condition, transfer, replacement or disposition of the
property.
All such property purchased under this contract shall be
inventoried annually and an inventory report shall be
submitted to the department along with the final
expenditure report. A report of nonexpendable property
shall be submitted to the department along with the
expenditure report for the period in which it was
purchased.
At no time shall the provider dispose of nonexpendable
property purchased under this contract except with the
permission of and in accordance with, instructions from
the department.
33
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Form B
AGENCY OPERATIONAL PLAN
EXHIBIT `.
SERVICE OPERATIONAL CRITERIA
FY 93-94
1.
Agency Name: BOARD OF COUNTY COMMISSIONERS, COUNTY
OF MONROE
(LIFE CENTER FOUNDATION)
2.
Program Service Component: CASE MANAGEMENT
3.
Address: 600 ELIZABETH STREET, KEYWEST, FLORIDA 33040
4.
Director/Coordinator: BILL IRB?
Phone Number: (305) 292-1774' "
5.
Geographic Areas Served: MONROE COUNTY
6.
Days/Hours of Operation: MONDAY THgOUGH FRIDAY 8AM -
'LPM :.
7.
Population Groups Served: ADULT HOMELESS MENTALLY ILL.
-
8.
Staffing Pattern (# ATE): 3FTE
9.
Total Budget, Client Service Capacity and
Utilization gates: Attach Exhibits A & B SEE BUDGET
10.
Comments: SERVICES ARE SUBCONTRACTED TO THE LIFE CENTER
FOUNDATION
i
4 . 113 1 AM
PROVIDER SELF MONITORING
Quarterly, a Provider Self Monitoring Report is to be submitted to DPOADM 11 by
the tenth of the following month. The Provider Self MonitoringReport will include
data on: consumer statistics, waiting lists, Medicaid, crisis services, staff turnover,
board of directors, volunteers, accomplishments, intervention and support services,
status of outstanding corrective actions, and health and safety issues.
36
i
FINANCIAL AND COMPLIANCE AUDITS
ATTACHMENT
This attachment is applicable, if the provider or grantee, hereinafter referred to as provider, is any government entity,
nonprofit organization, or for -profit organization.
PART 1: SINGLE AUDIT
This part is applicable if the provider is a local government entity or nonprofit organization and receives a.total of
$25,000 or more from the department during its fiscal year. The provider has "received" funds when it has obtained cash from
the department or when it has incurred expenses which will be reimbursed by the department.
The provider agrees to have an annual financial and compliance audit performed by independent auditors in accordance with the
current Government Auditing Standards ("Yellow Book") issued by the Comptroller General of the United States. Local
governments shall comply with Office of Management and Budget (OMB) Circular A-128 Audits of State and Local Governments.
Nonprofit providers receiving federal funds passed through the department shall comply with the audit requirements contained
in OMB Circular A-133, Audits of Institutions of Higher Learning and Other Nonprofit institutions, except as modified herein.
Such audits shall cover the entire organization for the organization's fiscal year, not to exceed 12 months. The scope of
the audit performed shalt include the financial audit requirements of the "Yellow Book," and must include reports on internal
control and compliance. The audit report shall include a schedule of financial assistance that discloses each state contract
by number. An audit performed by the Auditor General shall satisfy the requirements of this attachment.
Compliance findings related to contracts with the department shall be based on the contract requirements, including any
rules, regulations, or statutes referenced in the contract. where applicable, the audit report shall include a computation
showing whether or not matching requirements were met. All questioned costs and liabilities due to the department shall be
calculated and fully disclosed in the audit report with reference to the department contract involved. These requirements do
not expand the scope of the audit as prescribed by the "YettowBu k-.,,
If the provider has received any funds from a grants and aids appropriation, the provider will also submit a compliance
report(s) in accordance with the rules of the Auditor General, chapter 10.600, and indicate on the schedule of financial
assistance which contracts are funded from state grants and aids appropriations.
Copies of the financial and compliance audit report, management letter, and all other correspondence, if any, related to
audits performed by independent auditors, other than the Auditor General, shall be submitted within 120 days after the end of
the provider's fiscal year, unless otherwise required by Florida Statutes, to the following:
A. Office of Audit and Quality Control Services
1317 IJinewood Boulevard, Building 5, Room 116
Tallahassee, Florida 32399-0700
B. Contract Manager for the department
C. Submit to this address only those reports prepared in accordance with OMB Circular A-133:
Federal Audit Clearinghouse
U.S. Bureau of the Census
Jeffersonville, Indiana 47132
D. Submit to this address only those reports prepared in accordance with the rules of the
Auditor General, chapter 10.600:
Jim Dwyer
Office of the Auditor General
P. 0. Box 1735
Tallahassee, Florida 32302
The provider shall ensure that audit working papers are made available to the department, or its designee, upon request for a
period of_five years from the date the audit report is issued, unless extended in writing by the department.
•07/01/93
32
140
01,* PART II: GRANTS AND AIDS AUDIT/ATTESTATION
1
This part is applicable if the provider is awarded funds from a grants and aids appropriation, and is either (1) a local
government entity or nonprofit organization receiving a total of less than $25,000 from the department during its fiscal year
or (2) a for -profit organization receiving any amount from the department. The provider has "received" funds when it has
obtained cash from the department or when it has incurred expenses which will be reimbursed by the department.
If the amount received from grants and aids appropriation awards exceeds S100,000, the provider agrees to have an audit
performed by an independent certified public accountant and submit a compliance report(s) in accordance with the rules of the
Auditor General, chapter 10.600. The audit report shall include a schedule of financial assistance that discloses each state
contract by number and indicates which contracts are funded from state grants and aids appropriations.
Compliance findings related to contracts with the department shall be based on the contract requirements, including any
rules, regulations, or statutes referenced in the contract. Where applicable, the audit report shall include a computation
showing whether or not matching requirements were met. All questioned costs and liabilities due to the department shall be
calculated and fully disclosed in the audit report with reference to the department contract involved.
if the amount received from grants and aids appropriation awards exceeds S25,000, but does not exceed $100,000, the provider
may have an audit as described above or have a statement prepared by an independent certified public accountant which attests
that the provider has complied with the provisions of all contracts funded by a grants and aids appropriation.
If the amount received from grants and aids appropriation awards does not exceed $25,000, the provider will have the head of
the entity or organization attest, under penalties of perjury, that the organization has complied with the provisions of all
contracts funded by a grants and aids appropriation.
Copies of the audit report and all other correspondence, if any, related to audits performed by the independent auditor, or
the attestation statement, shall be submitted within 120 days after the provider's fiscal year end to the following:
A. Office of Audit and Quality Control Services
1317 pinewood Boulevard, Building 5, Room 116
Tallahassee, Florida 32399-0700
B. Contract Manager for the department
C. Jim Dwyer
Office of the Auditor General
P. 0. Box 1735
Tallahassee, Florida 32302
The provider shall ensure that audit working papers are made available to the department, or its designee, upon request for a
period of five years from the date the audit report is issued, unless extended in writing by the department.
PART III: NO AUDIT REQUIREMENT
This part is applicable if the provider is not awarded funds from a grants and aids appropriation, and is either (1) a local
government entity or nonprofit organization receiving a total of less than $25,000 from the department during its fiscal year
or (2) a for -profit organization receiving any amount from the department. The provider has "received" funds when it has
obtained cash from the department or when it has incurred expenses which will be reimbursed by the department.
The provider has no audit or attestation statement required by this attachment.
3F
07/01/93
Contract No.
CERTIFICATION REGARDING
DEBARMENT SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION
CONTRACTS/SUBCONTRACTS
This certification is required by the regulations implementing Executive
Order 12549, Debarment and Suspension, signed February 18, 1986. The
guidelines were published in the May 29, 1987 Federal Register (52 Fed.
Reg., pages 20360-20369).
t. Each provider whose contract/subcontract equals or exceeds $25,000 in federal monies must sign this certification
prior to execution of each contract/subcontract. Additionally, providers who audit federal programs must also
• sign, regardless of the contract amount. HRS cannot contract with thesg tomes of providers if they are debarred or
suspended by the federal govemment.
2. This certification is a material representation of fact upon which reliance is placed when this contract/subcontract is
entered into. if it is later determined that the signer knowingly rendered an erroneous certification, the Federal
Government may pursue available remedies, including suspension and/or debarment.
3. The provider shall provide immediate written notice to the contract manager at any time the provider learns that its
certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms "debarred,"suspended,"ineligible,"person,"principal; and 'Voluntarily excluded,' as used in this
certification, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the contract manager for assistance in obtaining a copy of those regulations.
5. The provider agrees by submitting this certification that, it shall not knowingly enter into any subcontract with a
person who Is debarred, suspended, declared ineligible, or voluntarily excluded from participation In this
contract/subcontract unless authorized by the Federal Government.
6. The provider further agrees by submitting this certification that It will require each subcontractor of this
contract/subcontract, whose payment will equal or exceed $25.000 in federar monies, to submit a signed copy of
this certification.
7. The Department of Health and Rehabilitative Services may rely upon a certification of a provider that it Is not
debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it knows that the
certification is erroneous.
8. This signed certification must be kept in the contract managers contract file. Subcontractor's certifications must
be kept at the contractors business location.
CERTIFICATION
(1) The prospective provider certifies, by signing this certification,
that neither he nor his principals is presently debarred, suspended,
proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this contract/subcontract by any federal
department or agency.
(2) Where the prospective provider is unable to certify
statements his certification, such prospective
attach a e lt'orLo this certification.
Signature
Ja&don - Mayor of 1Nbmoe Cotmt:v, Florida.
ATTEST: DANNY L. KOLHAGE, CLERK
3�
to any of the
provider shall
July i i993
Date
PP ED A 7"? ?
LE AL
By _ —
s:;,;,nays Q"ins