Item D22
~~
Louis LaTorre, Senior Director
Social Services/tabt
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
MEETING DATE: 6/19-20/02
DIVISION: COMMUNITY SERVICES
BULK ITEM:
YES X
NO
DEPARTMENT: SOCIAL SERVICES
AGENDA ITEM WORDING: Approval of Contract #KG-036 Community Care for Disabled Adults for
Fiscal Year 711102 thru 6/30/03, between the State of Florida, Department of Children & Families and the
Monroe County Board of County Commissioners/Monroe County Social Services (Monroe County In Home
Service Program, The Case Management Agency).
ITEM BACKGROUND: The approval of this contract will ensure the continuation ofIn Home Services to
the consumers that receive services provided by this Grant. This is an on-going grant.
PREVIOUS RELEVANT BOCC ACTION: Approval of Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion Contracts/Subcontracts, required by the State of Florida
before Contract is negotiated.
CONTRACT/AGREEMENT CHANGES: N/A
STAli'.F RECOMMENDATION: Approval
TOTAL COST: $91,713.00 BUDGETED:YES~ NO
COST TO COUNTY: $12,500.00
REVENUE PRODUCING: YES
NO~ AMT.PERMONTH
YEAR
APPROVED BY: COUNTY ATTYl OMB/Purchasing l RISK MANAGEMENT --X
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION:
INCLUDED X
TO FOLLOW NOT REQUIRED_
AGENDAITEM#: {do/~-
DISPOSITION:
Revised 2/27/01
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: State of Florida/Department of
Children & Families
Contract #KG-036
Contract Manager:
Effective Date: July I, 2002
Expiration Date: June 30, 2003
Contract Purpose/Description: Approval of Contract #KG-036 Community Care for Disabled Adults for Fiscal
Year 7/1/02 thru 6/30/03; between the State of Florida/Department of Children & Families and the Monroe
County board of County Commissioners/Monroe County Social Services (Monroe County In Home Service
Program, The Case Management Agency). Approval of this contract will ensure the continuation of In Home
Services to the consumers that receive services provided by this Grant. This is an on-going grant.
Louis La Torre /J y 4573
(Name) f}o" (Ext.)
Social Services/Stop 1
(Department/Stop #)
For BOCC meeting on 6/19-20/02
Agenda Deadline:
6/5/02
CONTRACT COSTS
Total Dollar Value of Contract: $104,213.00 (Fiscal Year)
Budgeted? Yes X No 0 Account Codes:
Grant: $ 91,713,00 (Fiscal Year)
County Match: $ 12,500...00 (Fi~cal Year)
n CIY, Cl (' yt'(tt' Fi-tnC>
Current Year Portion: $
Estimated Ongoing Costs: $
(Not included in dollar value above)
/yr
ADDITIONAL COSTS
For:
(eg. Maintenance, utilities,janitorial, salaries, etc)
CONTRACT REVIEW
Division Director
Changes
Needed
Yes 0 No
Date Out
?P~L
f.o.,~j -C~
~
{1~
Date}n
~ /~/O2-
Risk Management l( - '3- 0,)
O.M.BJPurchasing u,1_~\ 0:;)..
County Attorney (- / cl Ie l7.-
/
Yes 0 No~
Yes 0 NoB/ .ID?
Yes 0 N6
Comments:
OMB Form Revised 2/27/01 MCP #2
03/19/02
CFDAcNo,
Client 0 Non-Client 0
Multi-District 0
FLORIDA DEPARTMENT OF eHILDREN AND FAMILIES
STANDARD CONTRACT
THIS CONTRACT is entered into between the Florida Department of Children and Families, hereinafter referred to as the
"department," and Monroe County (Monroe County In Home Services)
hereinafter referred to as the "provider."
I. THE PROVIDER AGREES:
A, Contract Document
To provide services in accordance with the terms and conditions specified in this contract including all attachments and
exhibits, which constitute the contract document.
B, Requirements of Section 287,058 F,S,
To provide units of deliverables, including reports, findings, and drafts, as specified in this contract, which must be
received and'accepted by the contract manager in writing prior to payment. To submit bills for fees or other compensation
for services or expenses in sufficient detail for a proper pre-audit and post-audit. Where itemized payment for travel
expenses are permitted in this contract, to submit bills for any travel expenses in accordance with section 112.061, F.S. or
at such lower rates as may be provided in this contract. To allow public access to all documents, papers, letters, or other
public records as defined in subsection 119.011 (1), F.S., made or received by the provider in conjunction with this
contract except that public records which are made confidential by law must be protected from disclosure. It is expressly
understood that the provider's failure to comply with this provision shall constitute an immediate breach of contract for
which the department may unilaterally terminate the contract.
C. Governing Law
1, State of Florida Law
That this contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in
all respects in accordance with the Florida law including Florida provisions for conflict of laws.
2, Federal Law
a, That 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.
b. That 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. 7401 et seq.),
section 508 of the Federal Water Pollution Control Act as amended (33 U.S.C. 1251 et seq,), Executive Order 11738 as
amended and where applicable, and Environmental Protection Agency regulations (40 CFR, Part 30). The provider shall
report any violations of the above to the department.
c, That no federal funds received in connection with this contract may be used by the provider, or agent acting for
the provider, to influence legislation or appropriations pending before the Congress or any State legislature. 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 N/A . If a Disclosure of Lobbying Activities form, Standard 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, prior to payment under this contract.
d, That unauthorized aliens shall not be employed. The department shall consider the employment of
unauthorized aliens a violation of section 274A(e) of the Immigration and Nationality Act (8 U.S.C. 1324 a). Such violation
shall be cause for unilateral cancellation of this contract by the department.
e, That if this contract contains $10,000 or more of federal funds, the provider shall comply with Executive Order
11246, Equal Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in
Department of Labor regulation 41 CFR, Part 60 and 45 CFR, Part 92, if applicable.
f, That jf this contract contains federal funds and provides services to children up to age 18, the provider shall
comply with the Pro-Children Act of 1994 (20 U.S.C. 6081). Failure to comply with the provisions of the law may result in
the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative
compliance order on the responsible entity. This clause is applicable to all subcontracts.
D, Audits, Records and Retention
1, To establish and maintain books, records and documents (including electronic storage media) sufficient to reflect all
income and expenditures of funds provided by the department under this contract.
2, To retain all client records, financial records, supporting documents, statistical records, and any other documents
(including electronic storage media) pertinent to this contract for a period of five (5) years after completion of the 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. ofthe audit findings or any litigation which may be based on the terms of this contract, at no
additional cost to the department.
CF Standard Contract, JF 01/2002
CONTRACT # KG036
03/19/02
3, Upon demand, at no additional cost to the department. the provider will facilitate the duplication and transfer of any
records or documents during the required retention period in Subsection I, Paragraph D.2.
4, To assure that these records shall be subject at all reasonable times to inspection, review, copying, or audit by
Federal, State, or other personnel duly authorized by the department.
5. At all reasonable times for as long as records are maintained, persons duly authorized by the department and
Federal auditors, pursuant to 45 CFR, Section 92.36(i) (10), shall be allowed full access to and the right to examine any of
the provider's contracts and related records and documents, regardless of the form in which kept.
6, To provide a financial and compliance audit to the department as specified in this contract and in Attachment ---1L
and to ensure that all related party transactions are disclosed to the auditor.
7, To include the aforementioned audit and record keeping requirements in all subcontracts and assignments.
E, Monitoring by the Department
To permit persons duly authorized by the department to inspect and copy any records, papers, documents, facilities,
goods and services of the provider which are relevant to this contract, and to interview any clients, employees and
subcontractor employees of the provider to assure the department of the satisfactory performance of the terms and
conditions of this contract. Following such review, the department will deliver to the provider a written report of its findings
and request for development, by the provider of a corrective action plan where appropriate. The provider hereby agrees
to timely correct all deficiencies identified in the corrective action plan.
F. Indemnification
NOTE: Paragraphs I.F.1. and 2. are not applicable to contracts executed between state agencies or subdivisions, as
defined in subsection 768.28(2), F.S,
1, To be liable for and indemnify, defend, and hold the department and all of its officers, agents, and employees
harmless from all claims, suits, judgments, or damages, including attorneys' fees and costs, arising out of any act, actions,
neglect, or omissions by the provider, its agents, or employees during the performance or operation of this contract or any
subsequent modifications thereof,
2, That its inability to evaluate its liability or its evaluation of liability shall not excuse the provider's duty to defend and
to indemnify within seven (7) days after notice by the department by certified mail. After the highest appeal taken is
exhausted, only an adjudication or judgment specifically finding the provider not liable shall excuse performance of this
provision, The provider shall pay all costs and fees including attorneys' fees related to these obligations and their
enforcement by the department. The department's failure to notify the provider of a claim shall not release the provider
from these duties. The provider shall not be liable for the sole negligent acts of the department.
G, Insurance
To provide continuous adequate liability insurance coverage during the existence of this contract and any renewal(s) and
extension(s) of it. By execution of this contract, unless it is a state agency or subdivision as defined by subsection
768.28(2), F,S., 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 coverage may be provided by a self-insurance
program established and operating under the laws of the State of Florida. The department reserves the right to require
additional insurance as specified in this contract.
H. Confidentiality of Client Information
Not to use or disclose any information concerning a recipient of services under this contract for any purpose prohibited by
state or federal law or regulations (except with the written consent of a person legally authorized to give that consent or
when authorized by law).
I. Assignments and Subcontracts
1, To neither assign the responsibility for this contract to another party nor subcontract for any of the work
contemplated under this contract without prior written approval of the department which shall not be unreasonably
withheld. Any sublicense, assignment, or transfer otherwise occurring without prior approval of the department shall be
null and void.
2. To be responsible for all work performed and for all commodities produced pursuant to this contract whether
actually furnished by the provider or its subcontractors, Any subcontracts shall be evidenced by a written document. The
provider further agrees that the department shall not be liable to the subcontractor in any way or for any reason. The
provider, at its expense, will defend the department against such claims.
3, To make payments to any subcontractor within seven (7) working days after receipt of full or partial payments from
the department in accordance with section 287.0585, F,S., unless otherwise stated in the contract between the provider
and subcontractor. Failure to pay within seven (7) working days will result in a penalty which shall be charged against the
provider and paid to the subcontractor in the amount of one-half of one percent (.005) of the amount due per day from the
expiration of the period allowed for payment. Such penalty shall be in addition to actual payments owed and shall not
exceed fifteen (15%) percent of the outstanding balance due.
2
CONTRACT # KG036
03/19/02
4, 'That the State of Florida shall at all times be entitled to assign or transfer its rights, duties, or obligations under this
contract to another governmental agency in the State of Florida, upon giving prior written notice to the provider. In the
event the State of Florida approves transfer of the provider's obligations, the provider remains responsible for all work
performed and all expenses incurred in connection with the contract. This contract shall remain binding upon the
successors in interest of either the provider or the department.
J, Return of Funds
To return to the department any overpayments due to unearned funds or funds disallowed pursuant to the terms and
conditions of this contract that were disbursed to the provider by the department. In the event that the provider or its
independent auditor discovers that an overpayment has been made, the provider shall repay said overpayment
immediately without prior notification from the department. In the event that the department first discovers an
overpayment has been made, the contract manager, on behalf of the department, will notify the provider by letter of such
findings. Should repayment not be made forthwith. the provider will be charged at the lawful rate of interest on the
outstanding balance after department notification or provider discovery.
K, Client Risk Prevention and Incident Reporting
1, That if services to clients are to 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 CFOP 215-6 in the manner
prescribed in CFOP 215-6 or district operating procedures,
2, To immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person,
or disabled adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ASUSE), As required
by Chapters 39 and 415, F,S., this provision is binding upon both the provider and its employees.
L. Purchasing
1, To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative
Industries and Diversified Enterprises, Inc., (PRIDE) identified under Chapter 946, F.S., in the same manner and under
the procedures set forth in subsections 946.515(2) and (4), F.S. For purposes of this contract, the provider shall be
deemed to be substituted for the department insofar as dealings with PRIDE. This clause is not applicable to
subcontractors unless otherwise required by law. An abbreviated list of products/services available from PRIDE may
be obtained by contacting PRIDE, (850) 487-3774.
2. To procure any recycled products or materials, which are the subject of or are required to carry out this contract, in
accordance with the provisions of sections 403.7065, and 287.045, F,S.
M. Civil Rights Requirements
1, Not to discriminate against any employee in the performance of this contract or against any applicant for
employment because of age, race, creed, color, disability, national origin, or sex. The provider further assures that all
contractors, 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 because of age, race, creed, color, disability, national origin, or sex. This is binding upon the provider
employing fifteen (15) or more individuals.
2, To complete the Civil Rights Compliance Questionnaire, CF Forms 946 A and S, in accordance with CFOP 60-16,
This is binding upon providers that have fifteen (15) or more employees.
N. Independent Capacity of the Contractor
1, To act in the capacity of an independent contractor and not as an officer, employee of the State of Florida, except
where the provider is a state agency. Neither the provider nor its agents, employees, subcontractors or assignees shall
represent to others that it has the authority to bind the department unless specifically authorized in writing to do so.
2, This contract does not create any right to state retirement, leave benefits or any other benefits of state employees
as a result of performing the duties or obligations of this contract.
3, To take such actions as may be necessary to ensure that each subcontractor of the provider will be deemed to be
an independent contractor and will not be considered or permitted to be an agent, servant, joint venturer, or partner of the
State of Florida.
4, The department will not furnish services of support (e,g., office space, office supplies, telephone service, secretarial
or clerical support) to the provider, or its subcontractor or assignee, unless specifically agreed to by the department in this
contract.
5. All deductions for social security, withholding taxes, income taxes, contributions to unemployment compensation
funds and all necessary insurance for the provider, the provider's officers, employees, agents, subcontractors, or
assignees shall be the sole responsibility of the provider.
0, Sponsorship
As required by section 286.25, F.S" if the provider is a non-governmental 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 (provider's name) and the State of
Florida, Department of Children and Families." If the sponsorship reference is in written material, the words "State of
Florida, Department of Children and Families" shall appear in the same size letters or type as the name of the
organization,
3
CONTRACT # KG036
03/19/02
P. Publicity
Without limitation, the provider and its employees, agents, and representatives will not, without prior departmental written
consent in each instance, use in advertising, publicity or any other promotional endeavor any State mark, the name of the
State's mark, the name of the State or any State affiliate or any officer or employee of the State, or represent, directly or
indirectly, that any product or service provided by the provider has been approved or endorsed by the State, or refer to the
existence of this contract in press releases. advertising or materials distributed to the provider's prospective customers.
Q, Final Invoice
To submit the final invoice for payment to the department no more than ~ days after the contract ends or is
terminated. If the provider fails to do so, all rights to payment are 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.
R. Use of Funds for Lobbying Prohibited
To comply with the provisions of sections 11.062 and 216.347, F.S., which prohibit the expenditure of contract funds for
the purpose of lobbying the Legislature, judicial branch, or a state agency.
S. Public Entity Crime
Pursuant to section 287.133, F.S., the following restrictions are placed on the ability of persons convicted of public entity
crimes to transact business with the department: When a person or affiliate has been placed on the convicted vendor list
following a conviction for a public entity crime, he/she may not submit a bid on a contract to provide any goods or services
to a public entity, may not submit a bid on a contract with a public entity for the construction or the repair of a public
building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform
work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact
business with any public entity in excess of the threshold amount provided in section 287.017, F.S., for CATEGORY TWO
for a period of thirty-six (36) months from the date of being placed on the convicted vendor list.
T. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course of or as a result of work or services performed
under this contract, or in anyway connected herewith, the provider shall refer the discovery or invention to the department
to be referred to the Department of State to determine whether patent protection will be sought in the name of the State of
Florida. Any and all patent rights accruing under or in connection with the performance of this contract are hereby
reserved to the State of Florida.
2, In the event that any books, manuals, films, or other copyrightable materials are produced, the provider shall notify
the Department of State. Any and all copyrights accruing under or in connection with performance under this contract are
hereby reserved to the State of Florida.
3, The provider, if not a state agency, shall indemnify and save the department and its employees harmless from any
liability whatsoever, including costs and expenses, arising out of any copyrighted, patented, or unpatented invention,
process, or article manufactured or used by the provider in the performance of this contract.
4, The department will provide prompt written notification of any claim of copyright or patent infringement. Further, if
such claim is made or is pending, the provider may, at its option and expense, procure for the department, the right to
continue use of, replace, or modify the article to render it non-infringing. If the provider uses any design, device, or
materials covered by letters, patent, or copyright, it is mutually agreed and understood without exception that the
compensation paid pursuant to this contract includes all royalties or costs arising from the use of such design, device, or
materials in any way involved in the work contemplated by this contract.
U, Construction or Renovation of Facilities Using State Funds
That any state funds provided for the purchase of or improvements to real property are contingent upon the provider
granting to the state a security interest in the property at least to the amount of the state funds provided for at least five (5)
years from the date of purchase or the completion of the improvements or as further required by law. As a condition of
receipt of state funding for this purpose, the provider agrees that, if it disposes of the property before the department's
interest is vacated, the provider will refund the proportionate share of the state's initial investment, as adjusted by
depreciation,
V, Information Security Obligations
1. To identify an appropriately skilled individual to function as its Data Security Officer who shall act as the liaison to
the department's Security Staff and who will maintain an appropriate level of data security for the information the provider
is collecting or using in the performance of this contract. An appropriate level of security includes approving and tracking
all provider employees that request system or information access and ensuring that user access has been removed from
all terminated provider employees.
2. To hold the department harmless from any loss or damage incurred by the department as a result of information
technology used, provided or accessed by the provider.
3, To furnish Security Awareness Training to its staff.
4
CONTRACT # KG036
03/19/02
4, To ensure that all provider employees who have access to departmental information are provided a copy of CFOP
50-6 and that they sign the DCF Security Agreement form (CF 114), a copy of which may be obtained from the contract
manager.
W, Accreditation
That the department is committed to ensuring provIsion of the highest quality services to the persons we serve.
Accordingly, the department has expectations that where accreditation is generally accepted nationwide as a clear
indicator of quality service, the majority of our providers will either be accredited, have a plan to meet national
accreditation standards, or will initiate one within a reasonable period of time.
X. Agency for Workforce Innovation and Workforce Florida
That it understands that the department, the Agency for Workforce Innovation, and Workforce Florida, Inc. have jointly
implemented an initiative to empower recipients in the Temporary Assistance to Needy Families Program to enter and
remain in gainful employment. The department encourages provider participation with the Agency for Workforce
Innovation and Workforce Florida.
II. THE DEPARTMENT AGREES:
A, Contract Amount
To pay for contracted services according to the terms and conditions of this contract in an amount not to exceed
$ 91,713,00 , subject to the availability of funds. The State of Florida's performance and obligation to pay under
this contract is contingent upon an annual appropriation by the Legislature. Any costs or services paid for under any other
contract or from any other source are not eligible for payment under this contract.
B. Contract Payment
Pursuant to section 215.422, F.S., the department has five (5) working days to inspect and approve goods and services,
unless the bid specifications, purchase order, or this contract specify otherwise. With the exception of payments to health
care providers for hospital, medical, or other health care services, if payment is not available within forty (40) days,
measured from the latter of the date a properly completed invoice is received by the department or the goods or services
are received, inspected, and approved, a separate interest penalty set by the Comptroller pursuant to section 55.03, F.S.,
will be due and payable in addition to the invoice amount. Payments to health care providers for hospital, medical, or
other health care services, shall be made not more than thirty-five (35) days from the date eligibility for payment is
determined. Financial penalties will be calculated at the daily interest rate of .03333%. Invoices returned to a provider
due to preparation errors will result in a non-interest bearing payment delay. Interest penalties less than one (1) dollar will
not be paid unless the provider requests payment.
C. Vendor Ombudsman
A Vendor Ombudsman has been established within the Department of Banking and Finance. The duties of this office are
found in subsection 215.422 (7), F.S., which include disseminating information relative to the prompt payment of this state
and assisting vendors in receiving their payments in a timely manner from a state agency. The Vendor Ombudsman may
be contacted at (850) 410-9724 or 1-800-848-3792, the State of Florida Comptroller's Hotline.
D. Notice
Any notice, that is required under this contract shall be in writing, and sent by U.S. Postal Service or any expedited
delivery service that provides verification of delivery or by hand delivery. Said notice shall be sent to the representative of
the provider responsible for administration of the program, to the designated address contained in this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall begin on July 1, 2002 , or on the date on which the contract has been signed by the last
party required to sign it, whichever is later. It shall end at midnight, local time in Monroe County , Florida,
on June 30, 2003
B, Termination
1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in
writing to the other party unless a sooner time is mutually agreed upon in writing. Said notice shall be delivered by U.S.
Postal Service or any expedited delivery service that provides verification of delivery or by hand delivery to the contract
manager or the representative of the provider responsible for administration of the program.
2, In the event funds for payment pursuant to this contract become unavailable, the department may terminate this
contract upon no less than twenty-four (24) hours notice in writing to the provider. Said notice shall be sent by U.S. Postal
Service or any expedited delivery service that provides verification of delivery. The department shall be the final authority
as to the availability and adequacy of funds. In the event of termination of this contract, the provider will be compensated
for any work satisfactorily completed.
3, This contract may be terminated for the provider's non-performance upon no less than twenty-four (24) hours notice
in writing to the provider, If applicable, the department may employ the default provisions in Rule 60A-1.006(3), FAC.
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 and conditions of this contract. The provisions herein do not limit the
department's right to remedies at law or in equity.
5
CONTRACT # KG036
03/19/02
4, 'Failure to have performed any contractual obligations with the department in a manner satisfactory to the
department will be a sufficient cause for termination. To be terminated as a provider under this provision, the provider
must have: (1) previously failed to satisfactorily perform in a contract with the department, been notified by the
department of the unsatisfactory performance, and failed to correct the unsatisfactory performance to the satisfaction of
the department; or (2) had a contract terminated by the department for cause.
C, Renegotiations or Modifications
Modifications of provisions of this contract shall be valid only when they have been reduced to writing and duly signed by
both parties. 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.
D, Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
1. The provider name, as shown on page 1 of this 3, The name, address, and telephone number of the
contract, and mailing address of the official payee to contract manager for the department for this contract is:
whom the payment shall be made is:
Monroe County (Monroe County In Home Services)
1100 Simonton Street
Key West, FL 33040
Theresa Phelan
Department of Children and Families
1111 12th Street, #301
Key West, FL 33040
305/292-6810
2, The name of the contact person and street address
where financial and administrative records are maintained
is:
Deloris Simpson
Monroe County In Hone Services
1100 Simonton Street
Key West, FL 33040
4, The name, address, and telephone number of the
representative of the provider responsible for
administration of the program under this contract is:
Deloris Simpson
Monroe County In Home Services
1100 Simonton Street, Key West, FL 33040
305 / 292-4589
5, Upon change of representatives (names, addresses, telephone numbers) by either party, notice shall be provided
in writing to the other party and the notification attached to the originals of this contract.
E. All Terms and Conditions Included
This contract and its attachments, I, exhibits A, B, C, D, E & F and II and
any exhibits referenced in said attachments, together with any documents incorporated by reference, contain all the terms
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
verbal or written between the parties. If any term or provision of this contract is legally determined unlawful or
unenforceable, the remainder of the contract shall remain in full force and effect and such term or provision shall be
stricken.
By signing this contract, the parties agree that they have read and agree to the entire contract, as described in
Paragraph III.E, above.
IN WITNESS THEREOF, the parties hereto have caused this -.JL page contract to be executed by their undersigned
officials as duly authorized,
PROVIDER:
Monroe County (Monroe County In Home Services)
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
SIGNED SIGNED
BY: BY:
NAME: Charles McCoy NAME: Charles M, Auslander
TITLE: Mayor TITLE: District Administrator
DATE: DATE:
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal EID # (or SSN): F596000749029 Provider Fiscal Year Ending Date:
APPROVED AS TO r-ORM
BY
CONTRACT # KG036
, 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
ATTACHMENT I
A. Services to be Provided
1. Definition of Terms
a. Contract Terms
(1) Amendment - A document by which significant changes are
made to the terms of an executed contract. Changes requiring an
amendment include, but are not limited to adjustments in costs,
services, time period, and method of payment. The amendment is
incorporated as part of the original contract.
(2) Contract - A contract, for the purposes of this document, is a
formal written agreement between the department and an
individual or organization for the procurement of services. A
contract consists of the Standard Contract, Program Specific Model
Attachment I (PSMAI)/Attachment I, including special provisions
where appropriate, plus any other attachments or exhibits deemed
necessary. Per Chapter 287, Florida Statutes (F.S.), a contract
must be signed by both parties prior to services being rendered.
(3) Contract Manager - The department's employee responsible for
enforcing the performance of contract terms and conditions. The
contract manager is the department's primary point of contact
through which all contracting information flows between the
department and the provider,
(4) Department - Florida Department of Children and Families,
unless otherwise stated.
(5) District - The Florida Department of Children and Families'
territorial division pertaining to a geographical service area,
including the Suncoast Region.
(6) Exhibit - Information appended to an Attachment I or any other
contract attachment. The use of the word "exhibit" avoids
confusion and allows for clearer referencing. All exhibits to an
Attachment I/PSMAI must be referenced in that Attachment
IIPSMAI.
(7) Federal Fiscal Year - An accounting period of twelve
consecutive months starting on the first day of October and ending
on the last day of September.
04/29/02
7
PSMAI No, GA07
Contract No, KG036
07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(8) Fixed Price - Method of payment used when the service
provided can be broken down into unit cost (e.g., hours, client
days, etc,), or a fixed fee (e.g., payment based on delivery of a
complete service).
(9) Invoice - A completed and timely submitted document used by
the provider to request payment from the department.
(10) Match - It refers to a specified percentage of program or
project costs, cash or in-kind that must be contributed by a grantee
in order to be eligible for funding. This requirement may either be
stated as a specified or minimum percentage of total allowable
costs or a maximum percentage of participation in costs.
(11) Method of Payment - This is the third section of an
Attachment I/PSMAI. It specifies the total or maximum dollar
amount of the contract, the manner in which contract costs will be
displayed on invoices, the frequency with which invoices will be
submitted to the department, and any special conditions pertaining
to payment of contract invoices.
(12) Provider - An organization or individual providing services or
materials to the department in accordance with the terms of the
contract.
(13) Provider Fiscal Year - An accounting period of twelve
consecutive months.
(14) State Fiscal Year - An accounting period of twelve
consecutive months starting on the first day of July and ending on
the last day of June.
(15) Nursing home - Any facility which provides nursing services
as defined in Chapter 464, F,S., which is licensed in accordance
with Chapter 400, F.S.
(16) Outcomes - Quantitative indicators that can be used by the
department to objectively measure a provider's performance toward
a stated goal.
(17) Outputs - Process measures of the quantity(ies) of services
delivered, clients served, or similar units completed.
04/29/02
8
PSMAI No. GA07
Contract No, KG036
f 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(18) Performance Measures - Quantitative indicators, outcomes
and outputs, that can be used by the department to objectively
measure a provider's performance.
b. Program or Service Specific Terms
(1) Activities of Daily Living - Basic activities performed in the
course of daily living, such as dressing, bathing, grooming, eating,
using a commode or urinal, and ambulating around one's own
home.
(2) Client - Any person at least eighteen (18) years through age
fifty-nine (59) who has one (1) or more permanent physical or
mental limitations that restrict the client's ability to perform normal
activities of daily living, and impede the client's capacity to live
independently or with relatives or friends without the provision of
community-based services.
(3) Guide - The Community Care for Disabled Adults Instructional
Guide (Exhibit A) is a publication developed by the department to
better assist department staff and acquaint contract provider staff
with the types of services the department purchases for its
consumers, and the scopes of those services as established by
policy.
(4) Medicaid Institutional Care Program (MICP) - A program that
serves Medicaid recipients who are determined eligible for a
nursing home level of care, which provides primary, acute, and
long-term care services at capitated federally-matched rates.
2. General Description
a. General Statement
(1) The Community Care for Disabled Adults (CCDA) Program is
designed to assist disabled adults, age eighteen (18) through fifty-
nine (59), in utilizing available community and personal resources
to help them remain in their homes, and to prevent them from
premature or inappropriate institutionalization.
(2) Service providers will ensure that appropriate community-
based services (including the duration, frequency, and scope of
care plan) are provided to clients in a manner developed to meet
the client's changing needs.
04/29/02
9
PSMAI No, GA07
Contract No. KG036
07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
b. Authority
Sections 410.601-606, F,S., Chapter 65C-2, Florida Administrative Code
(F,A.C.), and the annual appropriations act, with any proviso language or
instructions to the department, constitute the legal basis for services to be
delivered through the CCDA program.
c. Scope of Service
Servi.ces will be targeted toward eligible adults, age eighteen (18) through
fifty-nine (59), in Monroe County, Florida.
d. Major Program Goal
The community-based services provided under this contract are designed
to prevent inappropriate institutionalization of disabled adults.
3. Clients to be Served
a. General Description
Adults with disabilities, age eighteen (18) through fifty-nine (59), who are
no longer eligible to receive children's services, and are too young to
qualify for community and home-based services for the elderly, may be
served under the provisions of this contract.
b. Client Eligibility
(1) Clients must have one or more permanent physical or mental
limitations, that restrict the ability to perform normal activities of
daily living, as determined through the initial functional assessment
and medical documentation of disability. Determination of a
disability must be established and evidenced in one of the following
manners:
(a) A client may present a check, awards letter, or other
proof showing receipt of Social Security Disability Income, or
some other disability payment (e.g., Worker's
Compensation); or
(b) A client may present a written statement from a licensed
physician, licensed nurse practitioner, or mental health
professional, which meets the district's criteria for evidence
of a disability. This written statement must, at a minimum,
include the client's diagnosis, prognosis, a broad
04/29/02
10
PSMAI No, GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult SelVices Program
explanation of level of functioning, and the interpretation of
need for services based on identified functional barriers
caused by the client's disabling condition.
(2) Clients must have an individual income at or below the
prevailing MICP eligibility standard in order to receive free CCDA
services, Clients with incomes above the standard will be
assessed for a share of the costs, or may be required to provide
volunteer services in lieu of payment.
c. Client Determination
(1) Clients will be assessed for eligibility determination, and
prioritized for services by district or provider case management
staff, in accordance with subsection 410.604 (2), F.S.
(2) The district's program manager will make the final
determination in the event of a dispute regarding client eligibility.
d. Contract Limits
(1) The total annual cost, estimated or actual, for an individual
receiving CCDA services, shall not exceed the average annual
general revenue portion of a Medicaid nursing home bed within the
district area.
(2) Clients must not be receiving comparable services from any
other entity, In order to prevent duplication of services, client files
must contain documentation verifying that all comparable
community services and funding sources have been explored and
exhausted,
(3) The provider shall deliver services only to those persons who
meet program eligibility criteria, and only to the extent that funds
are available,
B. Manner of Service Provision
1. Service Tasks
a. Task List
. (1) This contract will provide the following CCDA services:
(Services are marked accordingly cg]).
04/29/02
11
PSMAI No. GA07
Contract No. KG036
07/01/2002
04/29/02
Community Care for Disabled Adults/Fixed Price
Adult Services Program
DAdult Day Care ~Case Management DEmergency Alert
Response
~Personal Care DHome Health Aide DGroup Activity
Therapy
~Homemaker DHome Nursing ~Home Delivered
Meals
o Interpreter DTransportation DMedical Therapeutic
Services
~Chore DRespite DPhysical and
Exams
DEscort
(2) Details of services to be provided under this contract and the
negotiated parameters of those services are as indicated in the
Guide.
b. Task Limits
The following task limits are only applicable to a specific service(s) that a
provider delivers to the clients:
(1) Each district CCDA program shall include case management
services and at least one other community service.
(2) Personal Care services will not substitute for the care usually
provided by a registered nurse, licensed practical nurse, therapist,
or home health aide. The personal care aide will not change sterile
dressings, irrigate body cavities, administer medications, or perform
other activities prohibited by Chapter S9A-8, F.A.C.
(3) Homemaker service time does not include time spent in transit
to and from the client's place of residence except when providing
shopping assistance, performing errands or other tasks on behalf
of a client.
(4) Several restrictions apply to persons providing Homemaker
service activities. Persons providing services must not:
(a) engage in work that is not specified in the Homemaker
assignment;
(b) accept gifts from clients;
(c) lend or borrow money or articles from clients;
12
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(d) handle client money, unless authorized in writing by a
supervisor or case manager (as evident in the personnel file)
and unless bonded or insured by the employer;
(e) transport clients, unless authorized in writing by a
supervisor or case manager.
(5) The parameters of service delivery, by type of service, are
detailed in the Guide.
(6) District task limits, which exceed those in the Guide, and are
distinctive to this contract, are listed here: N/A
2. Staffing Requirements
a. Staffing levels
(1) The provider will meet the minimum staffing requirements for
each service, as specified in The Community Care for Disabled
Adults Instructional Guide.
(2) The provider will notify the department, in writing, within thirty
(30) days whenever the provider is unable, or expects to be unable
to provide the required quality or quantity of service because of
staff turnovers or shortages.
b. Professional Qualifications
The provider will ensure that staff meets the professional qualifications for
each service, as specified in The Community Care for Disabled Adults
Instructional Guide.
c. Staffing Changes
The provider agrees to notify the department's contract manager within
two (2) working days if a key administrative position (e.g., executive
director) becomes vacant. Planned staffing changes that may affect
service delivery, as stipulated in this contract, must be presented in writing
to the contract manager for approval at least two (2) weeks prior to the
implementation of the change.
04/29/02
13
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
d. Subcontractors
Written requests by the provider to subcontract for the provision of
services under this contract will be routed through the contract manager
for department approval. All subcontracting is subject to the provisions of
Section 1.1. of the Standard Contract.
3. Service location & Equipment
a. Service Delivery location & Times
(1) CCDA services may be delivered in the client's home or on-site
at a facility, as negotiated by the department and the provider.
(2) Facilities delivering on-site services to clients shall pass an
annual inspection by the local environmental health and fire
authorities.
(3) Service providers will meet the minimum service location and
time requirements as specified in The Community Care for
Disabled Adults Instructional Guide.
(4) Services for this contract will be delivered at the following
location(s) and times:
SERVICE lOCA TION TIME(S)
Case Management Client's Home As indicated
Personal Care Client's Home As indicated
Homemaking Client's Home As indicated
Home Delivered Meals Client's Home As indicated
Chore Client's Home As indicated
b. Changes in location
The provider must notify the department of changes in the location of
service delivery. Once the service delivery location is agreed upon, any
proposed change must be presented in writing to the contract manager for
approval, prior to implementation of that proposed change. In the event of
an emergency, temporary changes in location may necessitate waiver of
this designated standard by the district's program office. Such a waiver
will take into consideration the continuity, safety, and welfare of the
department's clients, and is at the department's sole discretion.
04/29/02
14
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
c. Equipment
(1) If equipment is applicable to a specific provider's contract, the
provider must submit an equipment exhibit (Exhibit N/A) to the
department which lists the equipment. The equipment required to
perform the contracted services must be negotiated by the
department and the provider. To ensure uniformity, safety, and
quality of service to clients, any requests for equipment change
must be presented in writing to the contract manager for approval
at least ten (10) days prior to any proposed change.
(2) The provider must inventory all equipment acquired under this
contract annually. The inventory list must be made available within
seven (7) days upon receipt of written request by the contract
manager. The equipment exhibit (Exhibit N/A), if applicable to a
specific provider's contract for specific service(s) provided must list
the items of equipment on the form.
4. Deliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which
may include, but is not limited to, an hour or quarter hour of direct service
delivery; a meal; an episode of travel; or a twenty-four (24) hour period of
Emergency Alert Response maintenance, as defined in The Community
Care for Disabled Adults Instructional Guide. All service units, as well as
their description and costs, are listed in The Community Care for Disabled
Adults Instructional Guide.
b. Records and Documentation
(1) Case Management provider files shall contain the following:
(a) a completed client assessment (not more than one year
old)
(b) a care plan (not more than one (1) year old)
(c) a release of information form
(d) a copy of a completed Client Information System (CIS)
form
(e) documentation of the client's age, disability, and income.
04/29/02
15
PSMAI No. GA07
Contract No. KG036
07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(1) Reporting requirements for this contract include Exhibit B,
Quarterlv Cumulative Summary Reports, if applicable. Districts will
negotiate with the provider on specific submission requirement
criteria for these reports.
(2) Providers of case management services agree to submit
Quarterly Cumulative Summary Reports, which include
management program data (e.g., client identifiable data) to the
department, according to negotiated instructions provided by
the districts. The reports are due according to the following
schedule:
Quarterly Cumulative Summary Due Date
Report
three month October 30
six month February 15
nine month April 30
twelve month August 15
(3) In the event of early termination of this contract, the provider
will submit the final Quarterly Cumulative Summary Report within
forty-five (45) days after the contract is terminated.
5. Performance Specifications
a. Performance Measures
(1) 100 % of adults with disabilities receiving services who are not
placed in a nursing home.
(2) 40 disabled adults provided in-home support.
(3) 95 % of clients will be satisfied with services based upon
responses to the Department Client Satisfaction Survey.
b. Description of Performance Measurement Terms
(1) Clients - Eligible individuals who have met the eligibility criteria
outline in section A.3.b. of this Attachment, and who have
received case management or any of the other services funded
through the CCDA program during the fiscal year evaluated.
04/29/02
17
PSMAI No. GA07
Contract No. KG036
07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(2) Nursing home - Any facility which provides nursing services as
defined in Chapter 464, F.S., which is licensed in accordance
with Chapter 400, F.S.
(3) Placed - Assessment of an individual who is no longer able to
remain in his present place of residence. (To place a client
involves preparation for and follow up of moving a client into a
more restrictive living environment.)
(4) The Department Client Satisfaction survey can be found at the
following website:
http://www5.mvflorida.com/cf web/mvflorida2/healthh uman/pub
I ications/docs/satsu rv /docu ments/qenera I i nstructions2000. htm.
(5) Satisfied - For the purposes of this survey, a satisfied client is a
client that responded "agree" or "strongly agree" to the survey
question: "Overall, I am satisfied with the services that I
received. "
(6) Annual Caseload - is defined as the total number of clients who
reach a point in their service plans once during the year
containing a trigger point.
(7) Trigger Points - the appropriate points in time or service that a
client shall be given the Department Client Satisfaction Survey
to complete, for example at recertification, six months after
admission, case closure, or at some other point. The
department will determine trigger points for each affected client
group, and contract managers will provide the information to
the provider. Providers whose caseloads are less than 150
clients must survey all clients who reach their trigger point, but
are exempt from having to obtain a minimum number of
returns.
(8) Minimum number of returns. The following table identifies the
minimum numbers of clients for which completed surveys are
required in order to report results for the provider's annual
caseload at the ninety percent (90%) confidence level, with a
five percent (5%) error rate:
04/29/02
18
PSMAI No. GA07
Contract No. KG036
, 07/01/2002
04/29/02
Community Care for Disabled Adults/Fixed Price
Adult Services Program
Sample Sizes for Contract Providers
Fiscal Year 2002 - 2003
Number of Clients Served in the Required Minimum
Fiscal Year (Who will hit their trigger Returned
point once during the year)
Less than 150 Must survey all clients
who reach their trigger
point, no minimum
return is required
150 - 200 115
201 - 250 130
251 - 300 143
301 - 350 153
351 - 500 176
501 - 750 199
751 - 1,000 213
1,001 - 1,500 229
1,501 - 2,000 238
2,001 and over 250
c. Performance Evaluation Methodology
(1) Measuring Outcomes. The department will measure the outcomes
found in paragraph B.5.a. above as follows:
(a) The outcome measurement contained in paragraph
B.5.a(1 )above will be measured by taking the number of
active Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid waiver
disabled adults not transferred to a nursing home, divided
the total number of Community Care for Disabled Adults,
Home Care for Disabled Adults, Cystic Fibrosis, and
Medicaid waiver disabled adults.
(b) The outcome measurement contained in paragraph
B.5.a(2)above will be measured by the total number of
Community Care for Disabled Adults, Home Care for
Disabled Adults I Cystic Fibrosis, and Medicaid waiver
disabled adults
(c) The outcome measurement contained in paragraph
B.5.a(3)above will be measured by the following. The
provider will administer the Department's Client Satisfaction
survey to a representative sample of clients in accordance
19
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
with the instructions listed at the following website:
http://www5.mvflorida.com/cf web/mvflorida2/healthh umanl
p ubi ications/docs/satsu rv Idocu ments/qenera I i nstructions2 00
O.htm.
(d) The calculation of the satisfaction rate shall be
determined using the following:
The number of satisfied clients
= Satisfaction Rate
Total number of surveys returned
(2) By execution of this contract the provider hereby acknowledges
and agrees that its performance under the contract must meet the
standards set forth above and will be bound by the conditions set
forth below. If the provider fails to meet these standards, the
department, at its exclusive option, may allow up to six months for
the provider to achieve compliance with the standards. If the
department affords the provider an opportunity to achieve
compliance and the provider fails to achieve compliance within the
specified time frame, the department must cancel the contract in
the absence of any extenuating or mitigating circumstances. The
determination of the extenuating or mitigating circumstances is the
exclusive determination of the department.
6. Provider Responsibilities
a. Provider Unique Activities
The provider will be required to use volunteers to the fullest extent
feasible in the provision of services and program operations. The provider
is required to train, supervise, and appropriately support all volunteers
with insurance coverage.
b. Coordination with Other Providers/Entities
The case management provider must coordinate, as necessary, with The
Developmental Disabilities Program Office of the Department of Children
and Families, the Department of Education, The Department of Health,
and the Florida Statewide Advocacy Council, to serve those clients who
are eligible for services through two (2) or more service delivery
continuums.
04/29/02
20
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply all new providers with a copy of
The Community Care for Disabled Adults Instructional Guide.
(2) The department will provide CCDA technical assistance to the
provider, relative to the negotiated terms of this contract and
instructions for submission of required data.
b. Department Determinations
Should a dispute arise, the department will make the final determination
as to whether or not the contract terms are being fulfilled according to the
contract specifications.
c. Monitoring and Evaluation Methodology
(1) The provider will be monitored in accordance with existing
district procedures (CFOP 75-8, Contract Monitoring).
(2) By execution of this contract, the provider hereby
acknowledges and agrees that its performance under the contract
must meet the standards set forth above and will be bound by the
conditions set forth below. If the provider fails to meet these
standards, the department, at its exclusive option, may allow up to
six months for the provider to achieve compliance with the
standards. If the department affords the provider an opportunity to
achieve compliance, and the provider fails to achieve compliance
wi~hin the specified time frame, the department will terminate the
contract in the absence of any extenuating or mitigating
circumstances. The determination of the extenuating or mitigating
circumstances is the exclusive determination of the department.
(3) The Contract Performance Unit ("CPU") may elect to perform
an on-site administrative and programmatic monitoring during the
contract period. At a minimum, an annual desk monitoring will be
performed which will be accomplished by a combination of the
review(s) of reports or other documentation submitted by the
provider, input from service recipients and others, and visits to the
site of service delivery for programmatic review.
(4) For on-site monitorings, a random discovery sample of open
and closed files will be taken for review. This sample may be
04/29/02
21
PSMAI No. GA07
Contract No. KG036
07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
increased to a random statistical sample depending on the results
of our review. The number of files reviewed will be contingent upon
the population size of services rendered. To facilitate the sampling
process, upon CPU request, the provider shall submit an universal
events listing of all services provided under the contract prior to the
monitoring visit.
(5) A report outlining the department's findings during the on-
site monitoring will be submitted to the provider within 30 days of
concluding field work with an exit conference. The provider agrees
to respond and submit a corrective action plan, if required, within
30 days of receiving the department's report .
C. Method of Payment
1. Payment Clause
a. This is a Fixed Price (Unit Cost) contract. The department shall pay
the provider for the delivery of service units provided in accordance with
the terms of this contract for a total dollar amount not to exceed
$91,713.00, subject to the availability of funds.
b. The department shall make payment to the provider for provision of
services up to the maximum number of units of service at the rates shown
below.
Service Unit Rate Maximum Units
Total/Department to be Delivered
Case Management $20.0862 634
Personal Care $25.7540 645
Homemaking $31.7934 1055
Home Delivered Meals $ 5.6654 4755
Chore $22.4094 84
c. The provider's dollar match for this contract is $10,190.00. Case
management and transportation services may be exempt from match
requirement at the discretion of each district.
2. Invoice Requirements
a. The provider shall request payment through submission of a properly
completed Invoice, Exhibit C, within 10 days following the completion of
all terms and conditions for the delivery of service under this contract. If
04/29/02
22
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
the 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. Payment due under this contract will be withheld until the
department has approved the final product. Replication of the form via
data processing equipment is permissible; replications must include all
data elements included on the departmental form.
b. The provider shall submit to the contract manager an original Invoice,
Exhibit C, along with supporting documentation, for payment on a
monthly basis. The due date for these invoices is the 10th day of the
month following the month being reported.
3. Supporting Documentation
a. It is expressly understood by the provider that any payment due the
provider under the terms of this contract may be withheld pending the
receipt and approval by the department of all financial and program
reports due from the provider as a part of this contract and any
adjustments thereto. Requests for payment, which cannot be
documented with supporting evidence, will be returned to the provider
upon inspection by the department.
b. The provider must maintain records documenting the total number of
recipients and names (or unique identifiers) of recipients to whom services
were provided and the dates the services were provided so that an audit
trail documenting service provision can be maintained.
4. Medicaid Billing
The department and the provider specifically agree and acknowledge that
the Medicaid program is the payor of last resort and:
(1) in no event shall the provider bill the Medicaid program for
services or expenses for Medicaid recipients for which the provider
has already been paid by any other liable third party, and
(2) provider services covered under the Florida Medicaid program
for Medicaid recipients may be billed to the Medicaid program by
the provider, unless the provider is already being paid by any other
liable third party, and
(3) authorized provider services to non-Medicaid recipients, or for
non-Medicaid covered services, may only be billed to the
department or any other non-Medicaid first or third party payor, and
04/29/02
23
PSMAI No. GA07
Contract No. KG036
, 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(4) the provider shall identify and report Medicaid earning separate
from all other fees, and
(5) Medicaid earnings cannot be used as local match, and
(6) the provider will ensure that Medicaid payments are accounted
for in compliance with federal regulations, and
(7) in no event shall both Medicaid and the department be billed
for the same service.
D. Special Provisions
1. Fees
a. The provider will collect fees for services provided according to Rule
65C-2.007, F.A.C.
b. No fees shall be assessed other than those set by the department.
Fees collected in compliance with the department directives will be
disposed of in a manner prescribed by the department.
2. Florida Statewide Advocacy Council
The provider agrees to allow properly identified members of the Florida
Statewide Advocacy Council access to the facility or agency and the right to
communicate with any client being served, as well as staff or volunteers who
serve them in accordance with subsections 402.165(8) (a) & (b), F.S. Members
of the Florida Statewide Advocacy Council shall be free to examine all records
pertaining to any case unless legal prohibition exists to prevent disclosure of
those records.
3. Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, Florida
Statute, Part I, Transportation Services, and Chapter 41-2, Florida Administrative
Code, Commission for the Transportation Disadvantaged, if public funds
provided under this contract will be used to transport clients. The provider
agrees to comply with the provisions of CFOP 40-5 if public funds provided
under this contract will be used to purchase vehicles which will be used to
transport clients.
4. Non-expendable Property.
a. Non-expendable property is defined as tangible personal property of a
non-consumable nature that has an acquisition value or cost of $1,000
04/29/02
24
PSMAI No. GA07
Contract No. KG036
. 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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 $250 or more. Hardback
books with a value or cost of $25 or more should be classified as an
Other Capital Outlay expenditure only if they are circulated to students
or to the general public. The provider will use Exhibit D to report all
capital assets purchased through funding provided by the department
for prior and current year contract.
b. 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 number,
manufacturer's serial number, funding source, information needed to
calculate 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.
c. 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 non-expendable
property shall be submitted to the department along with the
expenditure report for the period in which it was purchased.
d. Title (ownership) to all non-expendable property acquired with funds
from this contract shall be vested in the department upon completion
or termination of the contract.
e. At no time shall the provider dispose of non-expendable property
purchased under this contract except with the permission of, and in
accordance with, instructions from the department.
f. A formal contract amendment is required prior to the purchase of any
item of non-expendable property not specifically listed in the approved
contract budget.
5. Information Technology Resources
All contract providers must adhere to the department's procedures and
standards when purchasing Information Technology Resources (ITRs) as
part of this contract. These resources will revert to the Department at the
conclusion of the contract. ITRs are data processing hardware, software,
service. supplies, maintenance, training, personnel, and facilities. The
provider agrees to secure prior written approval through the contract
manager from the District Management Systems Director for the purchase
of any ITR. The provider will not be reimbursed for any purchase made
prior to this written approval.
04/29/02
25
PSMAI No. GA07
Contract No. KG036
, 07/01/2002
04/29/02
Community Care for Disabled Adults/Fixed Price
Adult Services Program
6.
Provider application is hereby incorporated by reference for programmatic
assurance of service provision. This application will be part of the
contract manager's file.
7.
Morals Clause
The provider understands that performance under this contract involves
the expenditure of public funds from both the state and federal
governments, and that the acceptance of such funds obligates the
provider to perform its services in accordance with the very highest
standards of ethical and moral conduct. Public funds may not be used for
purposes of lobbying, or for political contributions, or for any expense
related to such activities, pursuant to Section I R of the Standard Contract
of this contract. The provider understands that the department is a public
agency which is mandated to conduct business in the sunshine, pursuant
to Florida Law, and that all issues relating to the business of the
department and the provider are public record and subject to full
disclosure. The provider understands that attempting to exercise undue
influence on the department and its employees to allow deviation or
variance from the terms of this contract other than negotiated, publicly
disclosed amendment, is prohibited by the State of Florida, pursuant to
Section III C of the Standard Contract. The provider's conduct is subject
to all state and federal laws governing the conduct of entities engaged in
the business of providing services to government.
8.
Incident Reporting
The provider is required to document all reportable incidents, as defined in
the District 11 Uniform Incident Reporting Protocol for Incident Reporting
and Client Risk Prevention For Critical and Non-Critical Incidents, which is
incorporated herein by reference.
For each incident occurring during the administration of its program, the
provider must, within 24 hours of the incident, complete and submit the
District's approved Incident Report (Exhibit E) to the respective
department program incident report liaison. The liaison for Adult Services
is AI Papa, 401 NW 2nd Avenue, Suite N-812, Miami, FL 33128. It is the
provider's responsibility to use the most current District 11 approved
incident report for this purpose. A copy of the incident report must be
placed in a central file marked "Incident Report" and in each client's file
involved in the incident. Dissemination of the report within the department
will be the responsibility of the department's program incident report
liaison.
26
PSMAI No. GA07
Contract No. KG036
I 07/01/2002
Community Care for Disabled Adults/Fixed Price
Adult Services Program
Incidents that threaten the health, safety or welfare of any person or that
place any person in imminent danger must be reported immediately to the
department by telephonic contact.
The information contained in the incident report is confidential. The
dissemination, distribution or copying of the report is strictly prohibited,
unless authorized by the department.
9. Emergency Plan
The provider shall be responsible for the care, maintenance and, if
necessary, the relocation of clients during any natural disaster or period of
civil unrest. The provider shall submit its emergency plan to the
department for approval at the time of submission of the agency's
proposal and must be updated on a yearly basis. In case of evacuation,
the emergency plan must identify the method of evacuation, the address
of the emergency or shelter facility to be utilized, and the method of
notification of the department of the evacuation.
10. Security Agreement Form
The provider agrees to submit to the Department Contract Manager an
original signed Security Agreement Form CF-114, Exhibit F, for all
required personnel no later than thirty (30) days following the execution of
this contract or thirty (30) days from date of employment. All personnel
who require access to departmental information must sign the Security
Agreement Form prior to receiving access to the information.
11. Financial Penalties
If this is a contract for services, a corrective action plan may be required in
the event of noncompliance, nonperformance or unacceptable
performance. During the period of noncompliance, nonperformance or
unacceptable performance, and absent extenuating circumstances, and
depending upon the nature of the noncompliance, nonperformance or
unacceptable performance, a financial penalty of 10%, 5%, or 2% may be
imposed pursuant to Rule 65-29.001 F.A.C. The deadline for payment
shall be as stated in the Order imposing the financial penalty and in the
event of nonpayment the department may deduct the amount of the
penalty from the invoice(s) submitted by the provider."
04/29/02
27
PSMAI No. GA07
Contract No. KG036
, 7II /200 I
Community Care for Disabled Adults
Adult Services Program
Exhibit A
~
FLORIDA DEPARTMENT OF
CHILDREN
& FAMI LI ES
INSTRUCTIONAL GUIDE
The Instructional Guide defines each of the approved Community Care for Disabled
Adults program services and the requirements associated with the service tasks and
delivery of those services as well as other reporting and billing information necessary
for proper completion of the aforementioned model Attachment I's in a statutorily and
administratively sound fashion.
The CCDA program may be contracted for and financially managed in any of the
three following ways:
FIXED PRICE contracting, using the GAD? PSMA
FIXED PRICE ADVANCE FUNDING contracting, using the GA08 or
COST REIMBURSEMENT contracting, using a district created PSMAI
Each of the 15 districts may enter into anyone, two or three methods of contract
payment with provider agencies serving the CCDA population for any number of
approved CCDA services. All three methods are forms of a formal contract.
The Adult Services Central Office has developed the GAD? and GA08 Program
Specific Model Attachments (PSMAI's) for your convenience and to insure that the
minimum program requirements of the CCDA program are fulfilled and that uniformity
of procurement and delivery of CCDA contractual services is maintained on a
statewide basis.
Both the GAD? and the GA08 PSMAI methods of payment will be addressed in its
own instructional chapter to distinguish its unique reporting and billing requirements
from the other;
Section A - FIXED PRICE or PSMA GAD?
Section B - FIXED PRICE ADVANCE FUNDING or PSMA GA08 and
Section C - A Taxonomy of Services
Revision 6/13/0 I
28
PSMAI No. GA07
Contract No. KG036
. 7/1/200 I
Community Care for Disabled Adults
Adult Services Program
SECTION A
FIXED PRICE
Fixed-price contracts should be used when the service to be provided can be broken
down into standard units (i.e., trips, hours), and a specific rate is paid per unit for a
specific period of time. This formal contract requires a 10% match, either in-kind or
cash. As in the past, case management and/or transportation services may be
exempt from this match requirement at the district's discretion.
Contract providers using the fixed-price method of payment may negotiate monthly
reporting with the district, but are required to submit three, six, nine and twelve
month Cumulative Summary Reports that will be forwarded by the district office to
. the Central Office. A copy of the quarterly Cumulative Summary Form to be used in
this reporting process has been labeled as an Exhibit to this contract.
SECTION B
FIXED PRICE ADVANCE FUNDING
Advance funding may be given only to not-for-profit corporations or government
agencies. Such advances may be made on a monthly basis up to the first two
months of the contract and may not exceed the expected cash needs of the provider.
This formal contract requires a 10% match, either in-kind or cash.
Contract providers using the fixed-price advance funding method of payment may
negotiate monthly reporting with the district, but are required to submit three, six,
nine and twelve month Cumulative Summary Reports that will be forwarded by the
district office to the Central Office. A copy Copies of the quarterly Cumulative
Summary Forms to be used in this reporting process has have been labeled as an
Exhibit to this contract and attached.
Revision 6/13/0 I
29
PSMAI No. GA07
Contract No. KG036
, 7/1I2001
Community Care for Disabled Adults
Adult Services Program
SECTION C
A TAXONOMY OF SERVICES
Adult Day Care
(1) Adult day care means a social program which provides a protective
environment where preventive, remedial, and restorative services are
provided to adults in need of such care.
(2) A unit of service is one hour of actual client attendance at the day care
center, including travel to or from the center if the adult day care center is
providing the transportation with CCDA funds.
Minimum Service Standards
(1) Licensing. This service must be provided in a licensed adult day care
center in accordance with Chapter 400, Part V, Florida Statutes, and Chapter
58A-6, Florida Administrative Code (Regulations).
(2) All adult day care centers, contracted with CCDA funds, must meet the
following additional service standards:
(a) Therapies. Occupational, physical, and speech or language
therapy must be provided if care plans of the enrolled participants
identify the need for such therapies. Arrangements must be made for
clients who need transportation to another location in order to receive
any therapies prescribed by a medical professional.
(b) Transportation. Transportation services consist of conveying
participants from home to the adult day care center and return home. If
the day care center does not provide transportation directly,
arrangements must be made with available transportation providers.
The client's physicallimitation(s) must be considered when planning for
transportation. Wheelchair clients may require an appropriately
equipped vehicle. Provisions must be made to assist persons in
getting on or off the vehicle, if needed.
Revision 6/13/01
30
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
Minimum Staffing Standards
(a) Nursing Staff. A registered or licensed practical nurse, licensed by
the State of Florida, must be on duty at the site during primary hours of
program operation and available at other times. When the position is
filled by a licensed practical nurse, this person must work under the
supervision of a Registered Nurse.
1. Nursing service by a licensed registered nurse or
licensed practical nurse, currently licensed in Florida,
includes, but is not limited to: screening procedures for
chronic diseases (e.g., hypertension, or diabetes);
observation, assessment, and monitoring of clients health
needs and daily functioning levels; administration or
supervision of medications or treatments; counseling for
participant, family or caregiver in matters relating to health
and prevention of illness; and referral to other community
resources with follow-up of suspected physical, mental, or
social problems requiring definitive resolution.
2. The registered or licensed practical nurse must be on
duty at the site during the primary hours of program
operation. If the nurse leaves the site, the administrator
must be on the premises during the center's hours of
operation.
(b) First Aid Certified Staff. At least one staff person, who has had an
approved First Aid course and Cardio-Pulmonary Resuscitation (CPR)
training, and is capable of recognizing symptoms of distress in this
client population must be at the center at all times.
Minimum Training Standards
(1) Training Requirements. Each position must have a pre-service and in-
service training plan. Areas to be covered must be appropriate to job
responsibilities. Suggested topics include: medical record keeping; medical
emergency procedures, monitoring for change (such as medical,
psychological and social, physiological changes with age, chronic diseases);
Adult Day Care (Health) policies and procedures; rehabilitation, and
prescription drugs common to this population, as well as the interaction of
those common drugs.
Revision 6/13/01
31
PSMAI No. GA07
Contract No. KG036
, 7/I/2001
Community Care for Disabled Adults
Adult Services Program
(a) Pre-Service Training. Pre-service training must be documented in
agency records as to content and duration.
(b) In-Service Training. In-service training for staff will be regularly
scheduled. Minimum in-service training must be six hours per year with
content and hours documented in agency and staff records.
Adult Day Health Care
(1) Adult day health care is an organized day program of therapeutic, social
and health activities and services provided to disabled adults for the purpose
of restoring or maintaining optimal capacity for self care.
(2) A unit of service is equal to one hour of actual client attendance at the day
care center, including travel to or from the center if the adult day care center is
providing the transportation with CCDA funds.
Minimum Service Standards
(1) Licensing. Adult day health care center will be licensed by the Agency for
Health Care Administration (AHCA) in accordance with Chapter 400.551, F.S.,
and Chapter 58A-6, F.A.C., the Adult Day Care Rule that can be obtained
from the Department of Elder Affairs.
(2) Licensing Exemptions Adult day care centers exempted from licensure
must adhere to the requirements stated in Chapter 400.553, F.S., and
Chapter 58A-6, F.A.C., the Adult Day Care Rule.
(3) Additional Standards. All day care centers, contracted for adult day health
care services must meet the following service additional standards:
(a) Medical Service. Medical services can be provided by either the
personal physician or advanced registered nurse practitioner of the
client, a staff physician, or both, and must emphasize preventive
treatment, rehabilitation, and continuity of care and also provide for
maintenance of adequate medical records. The health needs of clients
may be supervised by an advanced registered nurse practitioner in
accordance with protocols established in collaboration with the
personal physician of the client or the site staff physician.
Revision 6/I 3/0 I
32
PSMAI No. GA07
Contract No. KG036
7/1/200 I
Revision 6/1 3/0 I
Community Care for Disabled Adults
Adult Services Program
(b) Medical Therapeutic/Rehabilitative Services. Medical
therapeuticlrehabilitative services appropriate to the needs of the client
must be provided by a contractor or by on-site staff.
1. Physical therapy. Progress notes must be written in the
client's medical record, at least quarterly, and signed by the
physical therapist.
2. Occupational therapy as an adjunct to treatment of patients
with physical and mental limitations. Progress notes must be
written in the client's medical record, at least quarterly, and
signed by the occupational therapist.
3. Speech pathology/audiology for clients with speech and
language disorders. Progress notes must be written in the
medical record of the client, at least quarterly, and signed by the
speech therapist.
(c) Social Work Services. Social work services to assist with personal,
family and other problems that interfere with the effectiveness of
treatment must be provided to clients and their families. These
services will be provided by the social work staff employed by the Adult
Day Care Center and are not to be confused with the case
management responsibilities of the CCDA case manager. [The CCDA
case manager will complete the functional assessment of the client, will
counsel in the development of a service plan, will arrange for services,
and will provide ongoing monitoring of the client's situation to ensure
that needed services are received].
(d) Nutritional Services. The administrator must designate a staff
person to be responsible for the daily operation of the food service.
The program must meet the following criteria:
1. Provide a minimum of one meal per day to participants
attending or in transit to the center for four or more hours daily.
Meals are to be of suitable quality and quantity and meet at least
one third of the current Recommended Dietary Allowance (RDA)
established by the Food and Nutrition Board, National Academy
of Sciences, and the National Research Council, adjusted for
age, sex, and activity.
33
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
2. provide dietary and nutritional education for the client and his
family and as adjunct to nutritional services; and
3. ensure that all basic services provided by program aides in
this service area are provided under the direct supervision of the
staff person responsible for the service.
(e) Recreational and Social Activities. Planned recreational and social
activities must be provided by an individual with specialization in
therapeutic recreation. Such services must be suited to the needs of
the clients and designed to encourage physical exercise, to prevent
deterioration, and to stimulate social interaction. All basic services
provided by program aides must be provided under the direct
supervision of the recreation therapist. The registered recreation
therapist may be retained as a consultant.
(f) Transportation Services. Transportation from home to center and
return must be a function of the program. If the center does not provide
transportation directly, arrangements for day care participants needing
transportation must be established. The client's physicallimitation(s)
must be considered when planning for transportation. Wheelchair
clients may require an appropriately equipped vehicle. There must be
an escort on a bus or van to assist persons in getting on and off the
vehicle when needed.
(g) Operational Requirements. Each center must provide services for
a minimum of five hours per day, five days per week.
Minimum Staffing Standards
(1) Staffing Requirements. At least two staff and all staff drivers must have
received training in emergency procedures, CPR by an approved instructor
and basic first aid. At least one staff person who has passed both First Aid
and Cardio-Pulmonary Resuscitation training must be at the site during the
designated daily hours of operation. Minimal staffing must consist of:
(a) Full-Time Professional Staff. A minimum of two full-time (forty
hours per week) professional staff members will be present during all
operational hours. Professionals include the center director, assistant
center director, social worker, registered nurse, and recreational
therapist.
Revision 6/13/0 1
34
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
(b) Staff/Client Ratio. There will be a minimum of one full-time staff
member for every six participants in the center. The owner or operator
may be considered in the count when serving in a dual capacity and
provided the owner or operator provides direct services and is included
in the work schedule for the center. Additional staff will be required as
the client population increases maintaining a one-to-six ratio. Clerical
staff, accountants, cooks and other non-direct care staff (with the
exception of the administrator) will not be considered when calculating
the staff/client ratio.
(c) Center Director. There will be one full-time professional designated
as center director.
(d) Assistant Center Director. There will be one full-time professional
designated as assistant program director to act in the absence of the
center director.
(e) Nursing Staff. A registered nurse (RN) or licensed practical nurse
(LPN) will be on site during the primary hours of program operation and
on call during the hours the center is open. Arrangements will be
formalized for obtaining the services of an LPN or RN in anticipation of
potential absences, planned and unplanned, of the regular nursing
staff.
(f) Additional Staff. Direct care staff members, from a variety of fields,
will be employed in sufficient number to complete a staffing ration of
one full-time staff member for each six clients.
(2) Staff appropriate to the services offered below must be on the premises of
the center during the designated daily hours of operation.
(a) Nursing. Nursing services must include services rendered by
registered nurses (RN) or licensed practical nurses (LPN) that work
under the supervision of a registered nurse. Such nurses must
evaluate quarterly, at a minimum, the particular needs of each client
and provide care and treatment, including medication supervision, as
indicated. Narrative nursing notes must be entered in the client's
medical record at least weekly indicating the individual's progress
toward achieving health goals. More frequent notes are required if
indicated by the client's condition. Narrative nursing notes should
address the client's progress in self care services oriented toward
activities of daily living and personal hygiene, and the extent of
assistance provided by health care professionalss and program aides
in this service area.
Revision 6/1 3/0 1
35
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
(b) Nutritionist. Nutritional services must include dietary and nutritional
education and must be provided under the supervision of a dietitian
who meets licensure and certification as set forth in 58A-6, F.A.C.
(c) Social Worker. Minimum qualifications for this position must meet
licensure and certification as set forth in 58A-6, F.A.C. Services
provided by program aides in this service area must be provided under
the direct supervision of a social worker.
(d) Occupational Therapist. Minimum qualifications for this position
must meet licensure and certification as set forth in 58A-6, F.A.C.
(e) Speech Therapist. Minimum qualifications for this position must
meet licensure and certification as set forth in 58A-6, F.A.C.
(f) Physical Therapist. Minimum qualifications for this position must
meet licensure and certification as set forth in 58A-6.01 (6)(c)1., F.A.C.
(g) Center Director. Minimum qualifications for this position must meet
licensure and certification as set forth in 58A-6, F.A.C.
(3) Additional Major Functions and Duties of the Center Director. Major
Functions and Duties, additional to those outlined in Chapter 58A-6, Florida
Administrative Code:
(a) Recruits, screens and trains staff of facility.
(b) Plans and provides organized programs of pre-service and in-
service training for staff.
(c) Interprets policies and procedures to staff and clientele.
(d) Ensures integration and coordination between program and
appropriate community resources.
(e) Maintains close supervision of staff in the following areas of
operation: secretarial and bookkeeping; housekeeping; maintenance;
transportation; food services; consulting services; and direct services.
(f) Evaluates the performance of each staff member.
Revision 6/13/0 I
36
PSMAI No. GA07
Contract No. KG036
. 7/112001
Community Care for Disabled Adults
Adult Services Program
(g) Assures accurate and timely completion of all records and reports,
including those required for the Client Information System (CIS);
maintains program statistical data and records as required.
(h) Special Requirement. This is an eligible service for clients who are
included within the 2176 Medicaid Waiver Projects (coded 17).
Reporting must comply with the 2176 Medicaid procedures.
Case Management
(1) Case management is a client centered series of activities which
includes planning, arrangement for and coordination of appropriate
community-based services for an eligible Community Care for Disabled Adult
client.
(2) Case management is an approved service, even when delivered in the
absence of other services. Case management includes intake and referral,
comprehensive assessment, development of a service plan, arrangement for
service and monitoring of client's progress to assure the effective delivery of
services and reassessment.
(3) A unit of service is one hour of elapsed time involved in the above
described case management activities.
Recommended Staffing and Caseload Standards
The average caseload should not exceed fifty-five cases per full-time CCDA case
manager, unless approved by the district office. A caseload consists of those clients
determined eligible and receiving case management.
Minimum Qualifications
(1) Contract Service Providers. Case managers must possess a
Bachelor's degree in social work, sociology, psychology, nursing, or related
field. Other directly related job education or experience may be substituted for
all or some of these basic requirements upon approval of the district office.
(2) DCF Staff. DCF case managers must be qualified as described by
departmental job specifications.
Revision 6/1 3/0 I
37
PSMAI No. GA07
Contract No. KG036
7/1I200 I
Community Care for Disabled Adults
Adult Services Program
Training
(1) Contract Service Providers. An in-service training program must be
developed for case management staff. A minimum of six hours per year of in-
service training is required and must be documented in staff records as to
duration and content. The following topics must be included:
(a) An overview of community-based services;
(b) Use of assessment instruments and interviewing techniques;
(c) Record-keeping procedures and the Client Information System;
(d) Overview of DCF services for adults, (across all programs).
(2) DCF Staff. DCF staff must receive training as described by current
department policies.
Chore Service
(1) Chore service means the performance of house or yard tasks such as
seasonal cleaning, yard work, lifting and moving, simple household repairs,
and other tasks not performed by specialized staff for eligible persons who are
unable to do these tasks.
(2) A unit of service is one hour of actual time spent in the performance of
listed or related chore service tasks for one or more clients. If the service is to
be provided to a couple, the unit of service will be assigned to either the
eligible husband or wife, preferably the one who usually performs chore
duties.
Minimum Service Standards
(1) Eligibility to Receive Chore Services.
Client must be unable to perform the chore without assistance.
(2) Service Tasks.
(a) Chore services are usually of short duration performed for a
client on a demand-response basis.
Revision 6/13/0 I
38
PSMAI No. GA07
Contract No. KG036
. 7/1/2001
Community Care for Disabled Adults
Adult Services Program
(b) Tasks to be accomplished will be determined by evaluating the
health and well being of the client, and the capability of chore service
staff.
(c) Specific chore tasks, for example shopping or errands, may be
scheduled at regular intervals, if needed.
(d) Procedures must be developed for chore service workers who
will handle the client's money.
(e) Chore services may include tasks such as those listed in the
service definition, as well as the installation or adjustment of simple
door locks and other basic security devices.
(f) Chore services may be provided by homemaker or other staff,
as long as the worker performing the dual function meets the chore job
description and qualifications. When one employee provides multiple
services, individual tracking documentation must be maintained for
each service. For instance, if a staff person makes a two hour visit to a
client's home and performs an hour of chore and an hour of
homemaker tasks, the time must be recorded as one hour of
homemaker and one hour of chore services rather than two hours of
each service, or two hours of only one or the other.
(3) Training Requirements: Contract Service Providers or Volunteers
(a) Pre-Service Training. Staff or volunteers providing this service
must receive at least three hours of training in the following areas:
1. Safety and home accident prevention;
2. Procedures for handling client's money (if chore-worker
handles money);
3. Client confidentiality;
4. Program policies and procedures;
5. CCDA purpose and philosophy;
6. Emergency procedures in the event of a crisis during the
course of work;
Revision 6/13/01
39
PSMAI No. GAG7
Contract No. KG036
, 7/112001
Community Care for Disabled Adults
Adult Services Program
7. Additional training may include information about disabling
conditions and first aid;
8. If staff or volunteers have received prior equivalent service
training, it may be substituted for part or all of the required hours
of pre-service training. The personnel file of the staff member or
volunteer must include documentation of the prior training. (pre-
service training may include on-the-job training).
(b)' In-Service Training. An annual minimum of six hours of in-
service training must be provided. Content and duration must be
documented in staff and agency records.
(5) Training Requirements: DCF Staff. DCF staff must be qualified as
required by the department for pre-service and in-service training.
Emergency Alert/Response Service
(1) Emergency alert/response service is a system that monitors the safety of
an individual in their own home. The electronic digital equipment of the
system transmits a specially coded signal over existing telephone lines to a
central station offering surveillance services twenty-four hours a day, seven
days a week. Upon receipt of such signal, the central station will alert and
dispatch properly qualified assistance to the subscriber in need.
(2) A unit of service is one day (twenty-four hours) of individual emergency
response unit operation in a client's residence, regardless of actual
emergency use by client. The units are counted by totaling the number of
days the client receives services. (Example: A client who has the unit in
his/her home for the entire month of June has used thirty units (thirty days in
June of emergency alert/response service.)
Minimum Service Standards
(a) It must be determined that the client is especially vulnerable to
medical or other emergency situations which have a likelihood of
developing, given the particular client's profile (mental, physical, social)
and/or living situation.
(b) It must be determined that emergency response service could
prevent such situations from developing or escalating, or could save
the client from a life threatening situation.
Revision 6/13/0 I
40
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
(c) Client must have, or be willing to arrange for, any special provisions
needed for installation, such as private line telephone service.
(d) Client must be mentally and physically able to use the equipment
appropriately.
(3) Service Tasks. The service provides a means of responding to an
emergency situation arising in the home setting involving a disabled adult. It
does not provide emergency services, but rather contacts the appropriate
personnel who will provide emergency services.
(a) Program requires operating a 24-hour, community-based personal
emergency response system designed particularly for functionally
impaired persons living in the community.
(b) Providers will purchase, rent or lease equipment that meets the
attached specifications and arrange for installation, training and
maintenance of the equipment. Batteries and telephone jack installation
fees are costs incurred by the client, unless there is an inability to pay
for these expenses. It is allowable for the provider to purchase batteries
and pay for installation if the client cannot pay.
(c) Providers will designate an emergency response center where
emergency signals are responded to according to a specified operating
protocol.
(d) Providers will ensure that client, signal activity, and service records
are maintained either by the provider or the response center.
(e) Providers will arrange monthly phone calls to each client's home to
test system operation, update records and provide direct client contact.
(f) Operational and technical manuals and training will be provided to
appropriate agency personnel.
(g) The provider or contracting agency will receive detailed manuals
from the emergency response equipment vendor relating to operational
aspects of the system including technical specifications, installation,
testing and field coordination.
(h) The emergency response center will receive detailed manuals
relating to operational aspects of the system including physical
arrangement of equipment, installation of all elements, testing
Revision 6/13/0 I
41
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
procedures, emergency reporting and response procedures and
servicing.
(i) The agency and emergency response center will receive detailed
technical and operations manuals which describe program elements
including equipment functioning; response protocol; record keeping and
reporting procedures; equipment testing; installation in subscriber's
home; user agreement; and suggested forms.
Training Requirements
(a) Pre-Service Training. Contract service providers and/or DCF staff
and emergency response center personnel will receive pre-service
training on location in all operational aspects of the equipment,
subscriber installation, equipment testing, and program implementation.
If staff or volunteers have received prior equivalent service training, this
training can be substituted for part or all of the required hours for pre-
service training.
(b) In Service Training. In-service training for staff providing
emergency alert/response service will be regularly scheduled. Minimum
in-service training will be a total of six hours per year and documented
in staff records as to content and duration.
Escort Service
(1) Escort Service is the personal accompaniment of an individual to,
and/or from service providers or personal assistance to enable clients to
obtain required services needed to implement the service plan.
(2) A unit of escort service is one trip. One trip is defined as one, one-way
trip measured from a point of origin to a destination.
Scope of Service
(a) Escort service should be provided for clients who do not have
anyone in their support system to assist them, or, whose support
system does not yield an individual capable (mentally or physically) of
providing the assistance.
Revision 6/13/0 I
42
PSMAI No. GA07
Contract No. KG036
. 7/1/200 I
Community Care for Disabled Adults
Adult Services Program
(b) The person providing the escort service may not advise the client
on any matter which may constitute conflict of interest.
Training Requirements
(a) Pre-Service Training. A total of six hours per year is required for
contract service providers and DCF staff. The following topics should
be included:
1. Interpersonal relationships;
2. CCDA program and purpose;
3. Confidentiality;
4. Conflict of interest situations;
5. Local service providers and community resources.
Certification or documented training in any of the above subjects may
substitute for the required pre-service training.
(b) In-Service Training. Contract service providers and DCF staff
providing escort services must be scheduled for in-service training to
augment and/or refresh their knowledge. A minimum of six hours per
year is required. Content and duration must be documented in agency
and staff records.
Group Activity Therapy
(1) Group activity therapy is a service provided to three or more CCDA
clients and may include the following activities: physical, recreational, social
interaction, and communication skill building through the use of groups. The
purpose of the service is to prevent social isolation and to enhance social and
interpersonal functioning.
(2) A unit of service is one client receiving group activity therapy for one
daily session.
Eligibility to Receive Group Activity Therapy
Revision 6/13/01
43
PSMAI No. GA07
Contract No. KG036
. 7/1/2001
Revision 6/13/01
Community Care for Disabled Adults
Adult Services Program
(a) Client must need the above described service in order to
achieve a specific goal which will help them to function more
independently.
(b) Client must show measurable improvement in social,
interpersonal, and communication skills through the provision of this
service in order to continue to be eligible to receive the service.
Scope of Service
(a) Group activity therapy may only be provided by a professional
staff person with demonstrated abilities in group dynamics and skill in
conducting the above described group activities.
(b) Group activity therapy should provide an arena in which clients
in need of service can increase their success in social interaction,
communication, and interpersonal functioning.
(c) Group activity therapy is not considered a psychiatric service
where medical treatment in the form of group therapy is provided.
Training Requirements
(a) Pre-Service Training. A total of ten hours per year is required for
contract service providers and DCF staff. The following topics should
be included:
1. CCDA Program and purpose;
2. Local service providers and community resources;
3. Medical and psychological aspects of disability;
4. Group therapy and group dynamics;
5. Communication skill building activities;
6. Recreational activities for the disabled client;
7. Interpersonal and social skill building activities.
44
PSMAI No. GA07
Contract No. KG036
. 7/1/2001
Community Care for Disabled Adults
Adult Services Program
(b) In-Service Training. Staff providing group activity therapy must
be scheduled for in-service training to augment and/or refresh their
knowledge. A minimum of six hours per year will be scheduled for in-
service training. Content, duration, and documentation of attendance
must be on file in the agency and staff records.
Home Delivered Meals
(1) A home delivered meal is a hot or other appropriate, nutritionally sound
meal that meets one-third of the current daily recommended dietary
allowances (RDA) served in the home to a disabled person.
(2) The unit of service is one meal delivered.
Scope of Service
The CCDA service criteria will be met if the meals are provided by a contractor
who is approved to provide home delivered meals that are funded by Older
Americans Act (Title III-C), or Community Care for the Elderly (CCE). The
CCDA program cannot claim commodities or cash-in-lieu of commodities, if
subcontracting with a Title III-C-2 provider.
Training Requirements
(a) Pre-Service. All contract service providers and DCF staff
(volunteers or paid) involved in home-delivered meals service, whether
in meal preparation or delivery, must receive pre-service training.
Training will be appropriate to respective job duties and responsibilities
and must minimally provide instructions for performing assigned tasks.
If staff or volunteers have received prior equivalent service training, this
training can be substituted for part or all of the required hours for pre-
service training.
(b) In-Service. In-service training for all staff involved in home-
delivered meals service will be regularly scheduled. Minimum in-
service training must be six hours per year with attendance, content
and hours documented in agency and staff records.
Special Conditions
Revision 6/13/01
45
PSMAI No. GA07
Contract No. KG036
. 7/11200 1
Community Care for Disabled Adults
Adult Services Program
(1) Food Service Contract Provisions.
Revision 6/13/0 1
(a) Food service contracts are defined as contracts for the purchase
of meals or portions of meals or for food preparation.
(b) All recipients of awards must adhere to the standards set forth in
this manual.
(c) Written specifications for food service contracts must be
approved by the district program office prior to solicitation of bids for
such contracts.
(d) Specifications for bids, and terms and conditions of the
proposed contracts, must establish methods and responsibilities for
each of the following:
1. Delivery.
a. Transportation: trucks, vans.
b. Delivery sites: number and location.
c. Delivery schedule:
(1) Number of days each week;
(2) Hour of delivery for each site.
d. Types of containers for bulk food delivery, if
applicable.
e. Types of containers for individual service.
f. Return of containers:
(1) How and by whom.
(2) Condition (washed, sterilized, etc.).
2. Menus.
a. Written by whom.
b. Approved by whom.
46
PSMAI No. GA07
Contract No. KG036
. 7/1/2001
Revision 6/13/0 I
Community Care for Disabled Adults
Adult Services Program
c. Compliance with required meal pattern and other
standards required herein.
d. CCDA program person responsible for receipt and
review of menus at least 5 weeks in advance of service.
e. Approval of substitutions on menus.
3. Sanitation.
a. Compliance with federal, state and local
regulations.
b. Food preparation facility inspection within previous
6 months.
c. Delivery standards:
(1) Temperature maintenance;
(2) Sanitary conditions.
4. Inspections. Inspection of food preparation, packaging
and storage areas by the department.
5. Food.
a. Number of meals:
(1) Provision for flexibility;
(2) Time limits for ordering amounts of food.
b. Cost schedule.
c. Food purchased by whom.
d. Food provided: entree, vegetable, fruit, milk,
dessert, juice, salad, beverage, cream (or substitute),
condiments, butter or margarine.
e. If foods do not meet proper specifications, the
department will not be required to pay.
47
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
f. If the caterer fails to deliver a meal or any portion
of meals, the department will procure food from other
sources at the caterer's expense.
6. Administration.
a. Sales tax exemption.
b. Caterer's financial records open for audit.
c. Supply information for nutrition reporting on labor
and raw food costs.
d. Insurance coverage.
e. Bonding.
f. Food cost changes.
g. Length of contract.
h. Approval by PDAA.
i. Dates/times of contract payments to contractor.
j. Holidays and other days when meals are not to be
served.
(e) All proposed food service contracts with profit-making
organizations must be submitted for prior approval by the district.
(2) Insurance. It is strongly recommended that food service providers have
adequate liability insurance coverage, including product liability.
Home Health Aide
(1) Home health aide service means health or medically-oriented tasks
furnished to an individual in his or her residence by a trained home health
aide. The home health aide must be employed by a licensed home health
agency and supervised by a licensed health care professional who is an
employee or contractor of the home health agency.
Revision 6/13/01
48
PSMAI No. GA07
Contract No. KG036
711/2001
Community Care for Disabled Adults
Adult Services Program
(2) The unit of service is one hour (or quarter hour portion) of time spent
performing designated home health aide services. It does not include time
spent in transit, but rather is the time spent providing services to the client.
(3) This is a health maintenance service as defined by Section 410.603(4),
F.S. It lists those routine health service(s) necessary to help maintain the
health of a disabled adult.
Eligibility to Receive Home Health Aide Services
The client's medical supervision is under an established plan of treatment. A
plan of treatment means a written instruction provided by the attending
physician for the provision of health care to a disabled adult in his or her
home.
Service Tasks
(a) The home health aide will perform only those activities contained
in a written assignment by a health care professional. (A health care
professional is any person who has completed a course of study in a
field of health care, such as a nurse. The person is usually licensed by
a governmental agency, such as a board of nursing, and becomes
registered or licensed in that health care field. In some instances, the
person is certified by a state regulatory body, such as with a certified
nurses' aide.) Home health aide activities include assisting the patient
with personal hygiene, ambulation, eating, dressing and shaving.
(b) The home health aide may perform other activities as taught by
a health professional employee for a specific patient. These include
and are limited to: assisting with the change of a colostomy, ileostomy
or urestomy bag; a shampoo; the reinforcement of a dressing; assisting
with the use of devices for aid to daily living (i.e. walker, wheelchair);
assisting with prescribed range of motion exercises which the home
health aide and the patient have been taught by a health professional,
assisting with prescribed ice cap or collar; doing simple urine tests for
sugar, acetone or albumin; measuring and preparing special diets;
measuring fluid intake and output; and supervising the self-
administration of medications. This supervision means reminding
clients to take medications, opening bottle caps for clients, reading the
medication label to clients, observing clients while taking medications,
checking the self-administered dosage against the label of the
Revision 6/13/01
49
PSMAI No. GA07
Contract No. KG036
7/\12001
Revision 6/13/01
Community Care for Disabled Adults
Adult Services Program
container and reassuring clients that they have obtained and are taking
the correct dosage.
(c) The home health aide will not: change sterile dressings; irrigate
body cavities, such as an enema; irrigate a colostomy or wound;
perform a gastric lavage or gavage; catheterize a patient; administer
medications; apply heat by any method; care for a tracheotomy tube;
administer eye drops; or any personal health service which has not
been included by the professional nurse in the patient care plan.
(d) The home health aide must keep records of personal health care
activities and the hours spent performing the tasks.
(e) The home health aide will observe appearance and gross
behavior changes in the patient and report any changes to the
professional nurse.
(f) The home health aide patient services must be evaluated by a
health professional staff person at least every two weeks in the home
for the purposes of observing service delivery and the status of the
client.
(g) The agency must maintain a ratio of at least one health
professional employee for every five nonprofessional persons providing
health services. When full-time equivalents are used in the case of
part-time nonprofessional persons providing health services, the actual
number of such persons supervised must not exceed twelve clients.
(h) This service must be provided in compliance with Chapter 59A-
8, F.A.C., Home Health Aide.
Service Criteria
(a) The plan of treatment will be established and reviewed by the
attending physician in consultation with agency staff involved in giving
service to the patient, at such intervals as the severity of the patient's
illness requires, but in any instance, at least every 60 days and shall
include, but not be limited to the following:
1. Diagnosis;
2. Types of services and equipment required;
50
PSMAI No. GA07
Contract No. KG036
7/1/2001
Revision 6/1 3/0 1
Community Care for Disabled Adults
Adult Services Program
3. Specific frequency of visits such as two times a week or
three times a week;
4. Activities permitted;
5. Diet;
6. Medications and treatments;
7. Dated signature of the physician.
(b) Assessment of the need for home health aide services must be
made by the case manager. A service plan must be developed,
specifying frequency and duration of service, and formulated with the
nurse supervisor, physician, licensed physical therapist, or licensed
occupational therapist prior to the delivery of service.
(c) A registered nurse, either paid or volunteer, must be on staff or
under contract as a consultant to make home visits to each client at
least every two weeks. The registered nurse will supervise the home
health aides, assess whether the service plan is being carried out
properly, attend or provide in-service training, review reports and
records, and assist in employee performance evaluations.
(d) The home health aide records services rendered during each
visit, completes time and attendance records, participates in
performance evaluations, prepares incident reports as the need arises,
and attends pre-service and in-service training.
(e) The service provider must develop emergency procedures to be
followed in the event of a crisis during the course of care.
(f) Home health aide care will not substitute for care provided by a
registered or practical nurse, or a licensed therapist.
Training
(a) Pre-Service. The home health aide must have training in
supportive services, which are required to provide and maintain bodily
and emotional comfort, and assist the patient toward independent living
in a safe environment. If the aide receives training through a vocational
school, licensed/certified home health agency, or hospital, the
curriculum will be documented. If training is received through the
51
PSMAI No. GA07
Contract No. KG036
. 7/1/2001
Revision 6/13/01
Community Care for Disabled Adults
Adult Services Program
agency, the curriculum will consist of at least forty-two hours, which
include:
1. Role of the home health aide, differences in families, ethics,
and orientation to the agency (two hours);
2. Physical appearance and personal hygiene (one hour). The
following topics should be included: uniform; hair; hands and
fingernails; cleanliness; teeth; makeup; perfume; jewelry and
smoking;
3. Supervision by a registered nurse, registered physical
therapist, occupational therapist, registered speech therapist
(three hours). The following topics should be included: role of
the supervisor; role of the aide; role of the physician; role of the
patient; plan of care; assignment of tasks; record keeping; and
performance evaluation;
4. Personal care services (twenty-four hours), to include the
following topics; bathing; dressing; toileting; feeding (eating);
bed making; ambulation; body mechanics; transfer techniques;
range of motion and exercises;
5. Nutrition and food management (four hours), to include the
following topics: basic food requirements; purchasing of food;
preparation of food; storage of food; serving of food; and special
diets;
6. Household management (two hours), to include the following
topics: care of bedroom, bathroom, kitchen; care of clothing;
and safety in the home;
7. Emotional aspects of disability, including death and dying (six
hours);
8. If staff or volunteers have received prior equivalent service
training, this training can be substituted for part or all of the
required hours of pre-service training. The personnel file of the
staff member or volunteer must include documentation of the
prior training.
(b) In-Service. In-service training for contract service providers,
DCF staff and home health aides must be regularly scheduled to
augment or refresh the home health aide's knowledge in any of the
52
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
above listed areas. A minimUm of six hours per year is required; staff
records must be documented to indicate training provided.
Homemaker Service
(1) Homemaker service means the performance of or assistance in
accomplishing specific home management duties including housekeeping,
meal planning and preparation, shopping assistance, and routine household
activities by a trained homemaker. With district approval, it may include the
purchase of home and/or cleaning supplies needed for the delivery of
services. Otherwise, clients are responsible for purchasing their own cleaning
supplies.
(2) The unit of service is one hour (or quarter hour portion) of time spent in
the provision of designated homemaker duties by a trained homemaker. It
does not include time in transit to and from the client's place of residence
except when providing shopping assistance, performing errands or other tasks
on behalf of the client. If the service is to be provided to a couple, the unit of
service must be assigned to either the eligible husband or wife, preferably the
one who usually performs homemaking duties.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
U)
Revision 6/13/0 I
Service Tasks
Meal planning and preparation;
Housekeeping;
Laundry;
Clothing repair;
Minor home maintenance. (e.g. changing light bulbs);
Shopping assistance;
Assistance with budgeting and paying bills;
Client transportation, if permitted;
Record keeping as required;
Reporting changes in client condition or behavior, to supervisor;
53
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
(k)
Following established emergency procedures.
*Restrictions on homemaker activities:
1. Must not engage in work that is not specified in the
homemaker assignment;
2. Must not accept gifts from clients;
3. Must not lend or borrow money or articles from clients;
4. Must not perform services requiring a public health nurse,
a home health aid, or personal care worker to perform;
5. Must not handle money unless authorized by supervisor
or case manager and bonded or insured by employer;
6. Must not transport the client unless authorized by
supervisor or case manager.
Service Provision Log. The homemaker is required to fill out a client service
provision log. Any form used must record the following: the date of the visit;
activities performed during the visit, and number of hours spent performing the
activities.
Training Requirements
(a) Pre-Service. A total of twenty hours are required covering the
following: CCDA program and purpose; medical and psychological
aspects of disability; interpersonal relationships; nutrition and meal
preparation; marketing and food storage; use of household equipment
and supplies; planning and organizing household tasks; principles of
cleanliness and safety of the home; record-keeping; agency policies
and procedures; and emergency procedures.
(b) If staff or volunteers have received prior equivalent service
training, this training can be substituted for parts or all of the required
hours of pre-service training. The personnel file of the staff member or
volunteer must include documentation of the prior training.
Revision 6/13/01
54
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
Home Nursing Services
(1) Home nursing service is part-time or intermittent nursing care
administered to an individual by a licensed professional or practical nurse or
advanced registered nurse practitioner, as defined in Chapter 464, F.S., in the
place of residence used as the individuals home, pursuant to a plan of care
approved by a licensed physician.
(2) The unit of service is one hour of client contact by the advanced
registered nurse practitioner or the licensed practical nurse.
(3) This is a health maintenance service as defined by Section 410.603(4),
F.S. It lists those routine health service(s) necessary to help maintain the
health of a disabled adult.
Eligibility to Receive Home Nursing Services
(a) A physician's prescription/plan of treatment is required to obtain
home nursing services. A request for continuation of services, signed
by a physician, is required at sixty-day intervals.
(b) Funding sources inclusive of, but not limited to, Medicare,
Medicaid and third party payment must be exhausted prior to utilization
of CCDA funding for provision of home nursing services.
Service Tasks
(a) Home nursing provides services that assist the client in his/her
efforts to maintain an optimal level of health of body and mind.
(b) Home nursing assists the client to prevent the occurrence or
progression of illness, thus decreasing the frequency of
hospitalizations.
(c) Home nursing can be rendered through a home health agency,
or provided by an independently practicing registered nurse, a
registered nurse employed by a county health unit, or an independently
practicing licensed practical nurse working under the direction of a
registered nurse.
Revision 6/13/01
55
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
(d) Nursing service shall not be rendered in hospitals or skilled or
intermediate care facilities.
(e) Nursing services rendered in the home shall include observation,
assessment, nursing diagnosis, care, health teaching and counseling,
maintenance of health, prevention of illness, administration of
prescribed medications and treatments, and the supervision and
teaching of others in the performance of nursing tasks.
Training Requirements
(a) Pre-Service. A provider of home nursing services must hold a
license, in good standing, to practice professional or practical nursing in
the State of Florida.
(b) In-Service. In-service training requirements can be met through
attendance at professional meetings/conferences and/or completion of
required course work for continuation of registration or licensure status.
A minimum of six hours of meeting attendance, course work or other
training related to the job function must be obtained per year; content
and duration must be documented in staff and agency records.
Interpreter Service
(1) Interpreter service is assisting a client to communicate despite a
hearing or speech impairment or language barrier.
(2) A unit of interpreter service is one hour spent in providing interpreter
service to and/or for a client. It does not include time spent in transit to and
from a client's home or service provider, but rather is the time spent in
interpreting for the client.
Eligibility to Receive Interpreter Services
(a) Client must have communication barrier significant enough to
prevent him or her from effectively and accurately receiving or giving
information.
(b) Client must not be able to secure the service from his or her own
support system.
Revision 6/13/01
56
PSMAI No. GA07
Contract No. KG036
7/112001
Community Care for Disabled Adults
Adult Services Program
Scope of Service
(a) Interpreter service is to be used to free clients from significant
barriers to communication. Barriers: language and deafness.
(b) Interpreter service should be used to assist clients to access
community resources, medical services, or social security, disability, or
other governmental agency resources.
Training Requirements
(a) Interpreters for the deaf must have one of the following
nationally or state recognized certifications: comprehensive skills
certified, interpreting certified, trans-literator certified, or QA screened
level 3.
(b) Language interpreters must be sufficiently proficient in the
languages to be translated.
Medical Equipment/Supplies
(1) The purchase of medical equipment/supplies for use by CCDA clients
is allowable under the CCDA program. Medical equipment/supplies may be
durable, such as walkers, wheelchairs, bedside commodes, etc., or it may be
non-durable, such as Chux bed pads, colostomy supplies, adult diapers, etc.
Durable equipment should be loaned and returned to the program when the
client no longer needs it, so that others may use it. Non-durable
equipment/supplies are not to be reused. Expenditures of more than $100.00
are to be approved by the district before purchase.
(2) There is no measurable "unit" of service for this category. Instead,
providers are requested to maintain documentation regarding the expenditure
of CCDA funds for this service. The following information should be tracked:
(a) Description of the kinds of equipment requested and needed,
and, how many requests were received for each (annually);
(b) Of the requests documented, how many received the needed
equipment (annually);
(c) Itemization of durable equipment purchased: description,
quantity, and price per item (annually);
Revision 6/13/01
57
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
(d) Number of clients utilizing each type of durable equipment
purchased (annually);
(e) Itemization of non-durable equipment purchased: description,
quantity, and price per item (annually);
(f) Number of times non-durable equipment and supplies was given
to CCDA clients.
Scope of Service
(a) The purchase of medical equipment/supplies should be used
only as the last resource to provide the client with needed items.
(b) The purchase of medical equipment/supplies can include both
durable and non-durable equipment. Durable equipment should be
loaned to clients so that more than one person may use the equipment.
Medical Therapeutic Services
(1) Medical Therapeutic Services are those corrective or rehabilitative
services which are prescribed by a physician or nurse practitioner licensed in
the State of Florida, provided by a professionally licensed, registered or
certified professional and are designed to assist the disabled person to
maintain or regain sufficient functional skills to live independently in the least
restrictive environment possible.
(2) Such therapies are necessary services for individuals who have
suffered physical damage or debilitation due to disease or trauma and may
include occupational therapy, physical therapy and services for individuals
with speech, hearing and language disorders.
(3) The unit of service is one hour of client contact by the health
professional in the client's place of residence or facility where the service can
be provided (e.g., hospital outpatient rehab center).
(4) This is a health maintenance service as defined by Section 610.403(4),
F.S. It lists those routine health service(s) necessary to help maintain the
health of a disabled adult.
Revision 6/13/0 I
58
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
Eligibility to Receive Medical Therapeutic Services
(a) A physician or nurse practitioner, or speech, occupational, or
physical therapist, must prescribe the needed services. A request for
continuation of services, signed by one of the professionals named
above is required at sixty day intervals.
(b) A client receiving like services under another program
component will not be regarded as eligible for duplicative medical
therapeutic services, for example, a recipient of physical and
occupational therapy while in an adult day care program will not be
eligible for duplicative services in his/her place of residence or at a
provider facility, unless the frequency of treatment(s) required does not
correspond with the frequency of attendance at day care.
Scope of Service
(a) Services shall include occupational therapy, physical therapy,
speech pathology and audiology. Definitions for these therapies may
be found in the glossary.
(b) Payment for supplies and equipment deemed by the therapist or
physician as reasonable and necessary to the success of the treatment
rendered to the client, will be eligible under this program in accordance
with district program budgets. All resources will be exhausted prior to
the utilization of CCDA funds for the purchase of supplies or equipment
for medical therapeutic services. THE CCDA PROGRAM SHAll BE
THE PROVIDER OF lAST RESORT.
Education and Training Requirements. Any provider of a medical therapeutic
service must hold current registration, certification or license to practice in the
State of Florida in the designated area of the services to be provided.
(a) Pre-Service. None is required.
(b) In-Service. In-service training requirements can be met through
attendance at professional meetings! conferences and/or required
course work for continuation of registration, certification or licensure
status. A minimum of six hours of meeting attendance, course work or
other training related to the job function must be obtained per year;
content and duration must be documented in staff and agency records
holding documentation of the employee's professional qualifications.
Revision 6/1 3/0 I
59
PSMAI No. GA07
Contract No. KG036
, 7/l/200 I
Community Care for Disabled Adults
Adult Services Program
Personal Care
(1) Personal care means services to assist the disabled adult with bathing,
dressing, ambulation, housekeeping, supervision, emotional security, eating,
supervision of self-administered medications and assistance with securing
health care from appropriate sources. Personal care services do not include
medical services.
(2) A unit of service is one hour (or quarter hour) of elapsed time spent in
providing designated personal care services by a qualified personal care aide.
It does not include time spent in transit to and from the client's home.
(3) This is a health maintenance service as defined by Section 410.603(4),
F.S. It lists those routine service(s) necessary to help maintain the health of a
disabled adult.
Service Tasks. The personal care aide will perform such tasks as:
(a) Assisting the client with personal hygiene, dressing, feeding, or
transfer or ambulatory needs, including use of wheelchair, crutches,
walker;
(b) Assisting with toileting and/or use of a bedpan;
(c) Assisting the client with self-administered medications when
ordered by the client's physician, and as prescribed in the personal
care plan. The personal care aide may not administer the medication,
but may bring the medication to the client and remind the client to take
the medication at a specific time;
(d) Assisting with food, nutrition and diet activities including
preparation of meals when essential to good health;
(e) Performing household services such as changing bed linens
when the performance is essential to good health;
(f) Accompanying the client to clinics, physician office visits, or
other trips when health care needs require personal care assistance.
Service Task Restrictions:
(a) A registered nurse, either paid or volunteer, must be on the staff
or under contract to make home visits to supervise personal care aides
Revision 6113/01
60
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
at least every 60 days. The registered nurse will assess whether
activities in the service plan are being carried out properly; attend or
provide in-service training; review reports and records; and conduct or
participate in client staffings. All such activities shall be documented in
the case record. The registered nurse must also participate in the
performance evaluation of the personal care aide.
(b) Personal care will not substitute for the care usually provided by
a registered or practical nurse, therapist, or home health aide. The
personal care aide WILL NOT change sterile dressings, irrigate body
cavities, administer medications, or perform any other activities
prohibited by Chapter 59A-8, F.A.C., Home Health Aide.
(c) Personal care services MUST NOT be confused with services,
which are commonly associated with homemaker and home health aide
services. Services must be required SPECIFICALLY TO ASSIST THE
CLIENT as outlined in the above sections.
Training Requirements. Personal care aides must be trained in those
supportive services, which are required to make the client comfortable and to
assist the client toward independent living in a safe environment. The
personal care staff will receive a minimum of 30 class hours of pre-service
training administered by a registered nurse, or successfully complete and be
certified as a graduate of the Nurse Aide Program administered by a
vocational/technical school, licensed/certified home health agency, or hospital.
(a) Pre-Service Training.
1. Role of the personal care provider and ethics (1 hour).
2. Physical appearance and personal hygiene (1 hour).
3. Supervision by registered nurse (3 hours). This should
include topics such as: role of the supervisor; role of the
personal care aide; role of the physician; role of the client; plan
of care; assignment of tasks; record-keeping; and employee
performance evaluation.
4. Personal care services (18 hours), to include the following
topics: bathing; dressing; toileting; feeding (eating); bed-making;
ambulation; and body mechanics.
Revision 6/13/0 I
61
PSMAI No. GA07
Contract No. KG036
7/1/2001
Community Care for Disabled Adults
Adult Services Program
5. Nutrition and food management (4 hours), to include the
following topics; purchasing food; preparation of food; storage of
food; and serving of food.
6. Household management (2 hours), to include: care of
bedroom, bathroom, kitchen, care of clothing and safety in the
home.
7. Physical, mental, and social aspects of disability; social
aspects of death and dying (2 hours).
(b) If staff or volunteers have received prior equivalent training, it
may be substituted for part or all of the required hours of pre-service
training. The personnel file of the staff member of volunteer must
include documentation of the prior training.
(c) In-Service Training. Staff providing personal care must be
regularly scheduled for a minimum of 6 hours in-service training per
year; training must be documented in staff records.
Physical and/or Mental Examinations
(1) CCDA funds may be used to purchase the services of a physician,
psychologist, psychiatrist, or mental health professional in order for a CCDA
client to receive needed medical or mental health services. (Use the
departments approved fee schedule.)
(2) A unit of service is measured in episodes, with one episode (one unit)
defined as one examination, either physical or mental, made by one
physician, psychologist, or mental health professional.
(3) This is a health maintenance service as defined by Section 410.603(4),
F.S. It lists those routine health service(s) necessary to help maintain the
health of the disabled adult.
THE DPOAA MUST APPROVE EACH EXAMINATION BEFORE SERVICES
ARE RENDERED.
Scope of Service. Physical and mental examinations should be provided for
the purpose of evaluation, rather than extensive treatment provided over time
through numerous examinations.
Training Requirements.
Revision 6/13/0 I
62
PSMAI No. GA07
Contract No. KG036
. 7/\12001
Community Care for Disabled Adults
Adult Services Program
(a) Pre-Service Training. A provider of physical or mental
examinations must hold a license in good standing to practice
medicine, or to conduct psychological examinations, or in the case of
professional mental health counseling, must be certified as a mental
health professional.
(b) In-Service Training. There are no in-service training
requirements.
Respite Care
(1) Respite care means relief or rest for a caregiver from the constant
supervision, companionship, therapeutic and personal care on behalf of the
client for a specified period of time. The purpose of the service is to maintain
the quality of care to the client for a sustained period of time through
temporary, intermittent relief of the primary caregiver.
(2) The unit of service is one hour or quarter hour of elapsed time spent in
the provision of respite care services by a qualified worker.
Scope of Service
(a) Respite care may be provided for up to 240 hours per client per
calendar year depending upon individual need. The service may be
extended up to 360 hours as recommended by the client's case
manager and with documented approval by their immediate supervisor.
The service may be provided during a concentrated period or spaced
throughout the year. Additional hours may be approved by the district
on a case by case basis.
(b) The case manager will determine the level and intensity of care
required by a client. The case manager may obtain consultation from
other service providers, the client's family, caregiver, physician, or
nurse to determine the appropriate level of respite care needed.
(c) Respite care will not be substituted for the care usually
provided by a registered nurse, licensed practical nurse, or
therapist.
(d) In-home respite care may be provided by staff qualified as a
homemaker, home health aide, personal care worker, sitter or
Revision 6/1 3/0 I
63
PSMAI No. GA07
Contract No. KG036
. 7/112001
Revision 6/13/01
Community Care for Disabled Adults
Adult Services Program
companion, a combination of the above, or a trained volunteer,
provided that service standards are met.
(e) Services provided for respite purposes will be classified as such
and not as homemaker, home health aide, personal care services and
the like, even though a homemaker or health aide may render the
servIce.
(f) Respite care staff must be appropriately supervised. A health or
social service professional must be available to supervise and provide
in-service training to workers providing the respite services. If, for
medical reasons, a home health aide must provide all or part of the
respite care services, a registered nurse or health professional must
supervise the aide. As an alternative, an agreement may be developed
with a visiting nurses association, the Red Cross, or a home health
agency, to supervise respite staff.
(g) Respite care staff will be adequately trained to respond to a
crisis, which may occur during the caregiver's absence.
(h) Respite care is to be provided in the client's home in familiar
surroundings, however, when a respite caregiver is not available to go
to the client's home, respite care may be provided by foster homes,
adult congregate living facilities, or nursing homes on a temporary
basis. RESPITE CARE SERVICE MAY NOT BE PROVIDED TO
RESIDENTS RESIDING IN NURSING HOMES OR ASSITED LIVING
FACILITIES.
Training Requirements.
(a) Pre-Service Training. Staff or volunteers providing this service
must receive at least twenty hours of instruction in the following areas:
1. Health problems and care of disabled persons;
2. Basic personal care procedures such as grooming;
3. First aid and handling of emergencies. Formal written
emergency procedures will be developed for the respite staff to
follow should an emergency occur;
4. Food, nutrition, meal preparation, and household
management;
64
PSMAI No. GA07
Contract No. KG036
, 7/1/2001
Community Care for Disabled Adults
Adult Services Program
5. If staff or volunteers have received prior equivalent
service training, the prior training can be substituted for part or
all of the required hours of pre-service training.
(b) In-Service. In-service training for respite care workers will be
scheduled regularly. Minimum in-service training must be provided at
least once per year for a total of six hours. Content and duration must
be documented in staff records.
Training. Training required is dependent upon level of care provided. If
personal care is to be provided, the personal care standards must be met.
Education. Education required is dependent upon level of care provided;
however, the respite worker must have the ability to read, write, and complete
required reports.
Transportation
(1) Transportation service is the transport of a client to and/or from service
providers or community resources. Any transportation essential to the
implementation of the service plan is allowable.
(2) Transportation service is measured in trips: one trip is defined as one,
one-way trip measured from a point of origin to a destination. The following
are two examples of measurement:
Examole #1: Client is taken from home to the doctor's office. 1
trip
Client is taken from the doctor's office to the drug store. 1 trip
Client is taken from the drug store back home. 1 trip
Total # trips this episode: 3
Examole #2: Client is taken from home to rehab therapy. 1 trip
Client is taken from rehab therapy to the grocery store. 1 trip
Client is taken from the grocery store to the drug store. 1 trip
Client is taken from the drug store back to the grocery store
(forgot eggs). 1 trip
Client is taken from the grocery store back home. 1 trip
Total # trips this episode: 5
Revision 6/13/01
65
PSMAI No. GA07
Contract No. KG036
7/l/2001
Community Care for Disabled Adults
Adult Services Program
Scope of Service
(a) Services will be provided on a demand/response basis. Except
for emergencies, clients must request services at least twenty-four
hours in advance to facilitate efficient use of vehicles and staff.
(b) Existing transportation systems and equipment must be utilized
before CCDA funds are used for transportation services.
(c) Services may be provided by ambulance, taxicab, common
carrier, or provider vehicle. The agency or the vehicle owner must
provide excess liability coverage. Transportation services will be
provided only by persons having a valid Florida driver's license. If
volunteers are used, they must have a valid driver's license. Drivers
who transport clients on a regular basis in provider vehicles must have
a valid Florida Chauffeurs license.
(d) When transporting one or two clients, a driver may act as an
escort provided that the case manager determines that the client
cannot be left alone while receiving the services, and the client's needs
will not interfere with the driver's ability to safely control the vehicle. In
such instances, only one or the other may be counted in units of
service; transportation trips or escort hours.
(e) If the client requires supervision while in the vehicle, which the
driver cannot provide, a staff person other than the driver must provide
supervision.
(3) Minimum Service Standards. The following service standards for
transportation must be adhered to:
(a) Provide services in compliance with federal, state and local rules
and regulations issued by the Department.
(b) Document that staff personnel and volunteers are fully trained to
provide the services offered by the transportation program.
(c) CCDA funds may not be used to purchase vehicles.
(d) Document that all drivers who transport clients on a regular
basis in provider vehicles have:
1. A valid State of Florida Chauffeur License;
Revision 6/13/0 I
66
PSMAI No. GA07
Contract No. KG036
7/1/2001
Revision 6/13/01
Community Care for Disabled Adults
Adult Services Program
2. Minimum of one year driving experience with vehicles
similar to those to be operated for the provider;
3. A safe driving record acceptable for insurance coverage;
4. Successfully completed an American Red Cross or similar
program.
(e). Document that volunteers who drive privately owned
automobiles to transport clients meet the minimum requirements set
forth in CFOP 125-1, Community ResourcesNolunteer Management..
(f) Obtain and maintain minimum vehicle insurance coverage on all
provider owned or leased vehicles in accordance with the Division of
Risk Management.
(g) All unusual incidents, accidents or problems must be reported to
proper authorities and investigated by supervisory staff and records
maintained.
Training Requirements.
(a) Pre-Services Training. A total of 10 hours is required for
contract service providers and DCF staff. If staff or volunteers have
received prior equivalent training, it can be substituted for parts or all of
this requirement. The following topics should be included in the
training: interpersonal relationships; operation of vehicle and
equipment; accident and emergency procedures in the event
something may happen to the client while being transported; and
CCDA program and purpose.
(b) In-Service Training. Contract service staff providing medical
transportation must be scheduled regularly for in-service training to
augment or refresh knowledge in any of the above listed areas. A
minimum of six hours must be scheduled per year, content and
duration documented in agency and staff records.
67
PSMAI No. GA07
Contract No. KG036
l~fC'H ILADREN
"" & FAMI LI ES
Exhibit B
Fiscal Year
Community Care for Disabled Adults Quarterly Summary Report
District:
Name of Contract Manager:
Phone Number: SC
Local
Reporting Period:
_3 Month
_6 Month
9 Month
12 Month
I. Expenditures
(1) Total CCDA dollars:
(2) Total expenditures this quarter:
(3) Total expenditures spent to date:
(4) Encumbrances *:
(5) Balance:
II. Report Prepared By:
III. Phone Number:
&IF
DEPARTMENT OF CHILDREN AND FAMILIES Exhibit C
OFFICE OF FAMILY SAFTEY
MONTHLY REQUEST FOR PAYMENT AND EXPENDITURE REPORT
PROVIDER FED. ID #
NAME AND MAILING ADDRESS OF PAYEE:
CONTRACT AM NT.:
REIMBURSEMENT YTD.:_
CONTRACT BALANCE:
DATE:
CONTRACT#:
PERIOD OF SERVICE PROVISION:
NAME OF SERVICE UNITSI AMOUNT PER UNITI TOTAL AMOUNT
OR DESCRIPTION OF MATERIALS QUANTITY EPISODE DUE
TOTAL
TOTAL MATCH REQUIRED PAYMENT
FOR CONTRACT: REQUESTED
THIS MNTH. YTD.
LOCAL CASH MATCH n FLORIDA DEPARTMENT OF
LOCAL IN-KIND ~ CHILDREN
TOTAL DEDUCTIONS
REMAINING MATCH BALANCE -- 'FAMILIES
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
'IF THIS INVOICE IS FOR A FIXED PRICE CONTRACT. THE REQUEST FOR PAYMENT WILL BE DETERMINED
BY DIVIDING THE LENGTH OF THE CONTRACT INTO THE CONTRACTED AMOUNT (EX.-S12.000[ALLOCA TIONI DIVIDED BY
12 MONTHS [THE LENGTH OF THE CONTRACT]=Sl.000 PAYMENT REQUEST) ON A COST REIMBURSEMENT CONTRACT
THE PAYMENT REQUEST WILL BE THE MONTHLY REQUEST EXPENSE.
CHILDREN AND FAMILIES USE ONLY
DATE INV. RCD.
APPROVED BY:
DATE
IORG
EO
OBJ
DESC.
IOCA
AMNT.
(;..r
o (Jl "'" () >-
sg~g; ~
o iri ";!.
~ #.
r
o
)0
~ ~ ~
" s S
"0 ::> ::>
a Iii ii"
"0 <0 <0
~ ~ a
~ ~ ~
0. (i' g.
i'! ~
r1J .g. 2.,
0. ~ D.
~r ~
,r
::>
~
3:0>-OU>"\J r
~~g~~;gQ
c~' ());"'O >
~ "'~8:o!r~ is
rri ~~~.~ z
~ ..
~Z()"'O"'OZ "0
I>>coaac~
i5-;-g-g ~ --
2.~o.~g:-. ~
s=~;~~= 8-
~~.~g.:;~. ~
~'g"C~:::J,~ ~
.g~~~,;-~ -
!o:,;-g~ 0 a
'<()2-_:J0"~, ~
g9:~~~
~~s.sa ~
$!~r~.;~
~a;~~
g~@-g
~ 0 3 ~
~ ~ [ ~
Cl.C:-
.. "
g "~
'" ><
~ ~
o 0
OJ. X
~ b'
"0
~.
....-.----..~ .. .. --------.-------,.--
z
<
~....
~
EXHIBIT D
-
;~
,
"
.'
"
;0
0
"
m
;0
~
-
.
(fl
m
;0
>
r
-
0
m
(fl
(")
;0
=0
~
0
Z
o.
(")
0
(fl
~
..:
..
(")
0
Z
~
~
(")
~
3:
)>
Z
C
;ll
'.-
)>
0
p
0
)>
~
m
(")
"
m
0
~
o.
(fl
~
)>
~
m
~
0
en
"
0
(fl
)>
r:
0
)>
~
m
"-
.-..
z g r
:< ~ m
i ~
"
i>>
B
..
So
'"
~
3
..
,..
:J"
'"
;;;
3
;;;.
0'
c:
OJ
0.
~ ~
a; >!
~ j
- :J.
" '<
~ ~
~ ~.
z '"
.. c-
o;
'"
Q
8
0.
'"'
"
..
".
"
o
Q
" (") (fl 0 ~--
I 0 <c" 0 I
0 Z :J (") )>
Z ~ III C ~
f1:1 $: c s: )>
Cil m r
(") Z r
~ ~ "
Z m ;0
c x ~ 0
s: (1) 0 "
0 m
III S. Z ;0
m
?? <" (") ~
(1) )>
0 Z Z
~. III "
0 m 0
Q " ;0
;0 s:
Q 0 )>
0 < ~
(1) a 0
(II m Z
<c" 0 (")
:J
(1) C 0
~ " Z
0 ~
Z
;0 Z
m m
0 0
C I
m m
(fl ;0
~ !:!l~
" ZZ
;0 Cii3
0
s: ()(1)
~ 03
I ;0=
m ;o~
(") mI
0 (")m
Z ~;o
~ )>m
$: ZIll
0-<
() ~()
~
0 Im
)>;0
?J ~~
,,:;;
:::0-<
0
"
m
;0
~C>
r -C L<3~
~ ...
... 0
~ ~.
3
l/I a. Q"\ ^~
-
-PI :Z::~
~ -Q
....~
- O~
III ::J - ~~
0 - r-
.Q 0 - .... z
~:~ '" Z~
5'r V\
::J -.
0 en
0 -
~-
"C "T1
~ -<
....
c: N
::J 0
... 0
::T N
III I
a N
0
0 0
0
< w
~ Q)
....
0- ::J
0 C-
o
~"'C
n ::::!.
0 0
~ ..,
5' 0
to 0
0 ::J
<
~ ....
..,
.... Q)
N 0
01 ....
0,<
C'D
Q)
..,
(fl
-
ROCHPiLPREN .
." & FAMILIES
District Tracking Number (for CRITICAL incidents)
11 (District)
66 (COL)
59 (SFETC)
YEAR
Sequence Code
Check if CLOSED
Program Code: AS, DA, DD, ESS, FS, MH, SA
DISTRICT 11 INCIDENT REPORT
EXHIBIT E
(Critical incidents must be reported to District Administrator within 24 hours of notification.) CHECK IF CRITICAL 0
CONFIDENTIAL
WARNING: The information contained in this report is confidential. You are hereby notified that dissemination, distribution, or
copying of this document is strictly prohibited, unless authorized by the Department of Children & Families.
I. IDENTIFYING INFORMATION
Reporting Party Phone #:
Reporting Party Name
District Program Area:
Specific Program: check all that apply
OAMH OCMH OASA DCSA ODD OAS OESS OFS 0 DependenlChild 0 DA (all support areas)
Please respond to one of the following as appropriate.
a. Contract Provider Name Specific Program Name
b. Foster Home Name c. DS Home Name
d. DCF Facility Name e. Other Name
Is this a licensed facility? 0 Yes 0 No 0 Don't know.
Specific location/address where incident occurred:
Date of Incident
/
/
Time of Incident
DCF Unit #
II. TYPE OF INCIDENT
Check one box only.
1. 0 Abuse/Neglect/Exploitation
2. 0 AggressionfThreat
3. Altercation:
OClient/client OClient/staff 0 Staff/staff
4. 0 Baker Act
5. 0 Bomb Threat
6. 0 Client Injury
7. 0 Client Death
8. 0 Contraband
9. 0 Criminal Activity
10.0 Damage
11. 0 Drugs
12. 0 Elopement/Runaway
13. 0 Emergency Room Visit
14. 0 Escape
15. 0 Hospital Admission
16. 0 Illness
17.0 Media Coverage
18. 0 Medication Issue
19. 0 Misconduct
20.0 Physical Aggression
21. 0 Self-Injurious Behavior
22.0 Sabotage
23. 0 Sexual Battery
24. 0 Suicide Attempt
25. 0 Suicide IdeationfThreat
26.0 Theft
27. 0 Vandalism
28. 0 Other Incidents
III. PARTICIPANT(S) WITNESS(ES) (if applicable)
FIRST Name LAST Name SS# Birth Date Race Gender Client Employee Participant Witness
_1_1- 0 0 0 0
_1_1- 0 0 0 0
-/-/- 0 0 0 0
'71
CONFIDENTIAL
III. PARTICIPANT(S) WITNESS(ES) (continuation)
-'-'-
-'-'-
-'-'-
o
o
o
o
o
o
o
o
o
o
o
o
IV. DESCRIPTION OF INCIDENT
Give Detailed Account - (Who, What, When, Where, Why, How) - Add Pages If Necessary
V. CORRECTIVE ACTION AND FOllOW UP
Immediate corrective action taken
Is follow-up action needed? NoD
YEsO
If yes, specify:
72-
CONFIDENTIAL
VI. INDIVIDUALS NOTIFIED
EXTERNAL NOTIFICATION
Agency Notified Person Contacted Status DatelTime Called Copy
Abuse Registry Name Report Accepted
1-800-962-2873 D D
10# Yes D NoD
Agency for Health Care
Administration Name: N/A D D
Law Enforcement-Department Officer's Name
II I Badge # Case # (if avail) N/A D D
ParenUGuardian/
Family Member Name Name: N/A D D
Other (Please Specify)
Name: N/A D D
Other (Please Specify)
Name: N/A D D
DCF (for providers only) Name: N/A D 0
VII. REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
REPORTING / /
EMPLOYEE ---
SUPERVISOR / /
---
DCF INTERNAL NOTIFICATION
Individual/Agency DatelTime Called Copy Individual/Agency Notified DatelTime Called Copy
Notified
Client Relations 0 0 Employee Safety Program 0 0
District Administrator 0 0 Florida Local Advocacy Committee 0 0
Division Director/ H.R. Workers' Compensation
Facility Director 0 0 Coordinator (employee relaled Incidents only) 0 0
District Legal Counsel 0 0 Program Office/Risk Manager 0 0
OS Support Coordinator/Case 0 0 Others - (Please specify)
Manager 0 0
EEOC
0 0 Contract Manager 0 0
Public Information Officer 0 0
VIII. DCF REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
I ncident Report _/_/-
Liaison
DIVISION DIRECTOR/
FACILITY DIRECTOR / /
---
f/'7
~lCIH rLDREN
~ & FAMILIES
EXHIBIT F
SECURITY AGREEMENT FORM
The Department of Children and Families has authorized you:
Employee's Name/Organization
to have access to sensitive data through the use of computer-related media (e.g., printed reports,
microfiche, system inquiry, on-line update, or any magnetic media).
Computer crimes are a violation of the department's disciplinary standards and, in addition to
departmental discipline, the commission of computer crimes may result in Federal and/or State
felony criminal charges.
. By my signature, I acknowledge that I have received, read and understand the Computer
Related Crimes Act, Chapter 815, F.S.
. By my signature, I acknowledge that I have received, read and understand Sections 7213,
7213A, and 7431 of the Internal Revenue Code, which provide civil and criminal penalties
for unauthorized inspection or disclosure of Federal tax data.
. By my signature, I acknowledge that it is the policy of the Department of Children and
Families that under no circumstances shall any contract employee be allowed access
to IRS tax information.
I understand that a security violation may result in criminal prosecution according to the provisions
of Federal and State statutes and may also result in disciplinary action against me according to the
provisions in the Employee Handbook. I agree to be bound by the provisions of CFOP 50-6. The
minimum department security requirements are: .
. Personal passwords are not to be disclosed.
. Information is not to be obtained for my own or another person's personal use.
Date
Print Employee's Name
Signature of Employee
Date
Print Supervisor's Name
Signature of Supervisor
CF 114, JF 08/2001
Distribution of Copies: Original - Personnel File/Contract File
Copy - Security File
Copy - Employee
1'1
ATTACHMENT II
The administration of resources awarded by the Department of Children & Families to the provider may be
subject to audits as described in this attachment.
MONITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-133 and Section 215.97,
F.S., as revised, the Department may monitor or conduct oversight reviews to evaluate compliance with
contract, management and programmatic requirements. Such monitoring or other oversight procedures
may include, but not be limited to, on-site visits by Department staff, limited scope audits as defined by
OMB Circular A-133, as revised, or other procedures. By entering into this agreement, the recipient agrees
to comply and cooperate with any monitoring procedures deemed appropriate by the Department. In the
event the Department determines that a limited scope audit of the recipient is appropriate, the recipient
agrees to comply with any additional instructions provided by the Department regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews, investigations, or audits
deemed necessary by the Comptroller or Auditor General.
AUDITS
PART I: FEDERAL REQUIREMENTS
This part is applicable if the recipient is a State or local government or a non-profit organization as defined
in OMB Circular A-133, as revised.
In the event the recipient expends $300,000 or more in Federal awards in its fiscal year, the recipient must
have a single or program-specific audit conducted in accordance with the provisions ofOMB Circular A-
133, as revised. In determining the Federal awards expended in its fiscal year, the recipient shall consider
all sources of Federal awards, including Federal resources received from the Department of Children &
Families. The determination of amounts of Federal awards expended should be in accordance with
guidelines established by OMB Circular A-133, as revised. An audit of the recipient conducted by the
Auditor General in accordance with the provisions of OMB Circular A- I 33, as revised, will meet the
requirements of this part. In connection with the above audit requirements, the recipient shall fulfill the
requirements relative to auditee responsibilities as provided in Subpart C of OMB Circular A-133, as
revised.
PART II: STATE REQUIREMENTS
This part is applicable if the recipient is a nonstate entity as defined by Section 215.97(2)(1), Florida
Statutes.
In the event the recipient expends a total amount of state financial assistance equal to or in excess of
$300,000 in any fiscal year of such recipient, the recipient must have a State single or project-specific audit
for such fiscal year in accordance with Section 215.97, Florida Statutes; applicable rules of the Executive
Office of the Governor and the Comptroller, and Chapters 10.550 (local governmental entities) or 10.650
(nonprofit and for-profit organizations), Rules of the Auditor General. In determining the state financial
07/01/2002
7';
assistance expended in its fiscal year, the recipient shall consider all sources of state financial assistance,
including state financial assistance received from the Department of Children & Families, other state
agencies, and other nonstate entities. State financial assistance does not include Federal direct or pass-
through awards and resources received by a nonstate entity for Federal program matching requirements.
In connection with the audit requirements addressed in the preceding paragraph, the recipient shall ensure
that the audit complies with the requirements of Section 215.97(7), Florida Statutes. This includes
submission of a financial reporting package as defined by Section 2l5.97(2)(d), Florida Statutes, and
Chapters 10.550 or 10.650, Rules of the Auditor General.
PART III: REPORT SUBMISSION
Any reports, management letters, or other information required to be submitted to the Department pursuant
to this agreement shall be submitted within 180 days after the end of the provider's fiscal year or within 30
days of the recipient's receipt of the audit report, whichever occurs first, directlv to each of the following
unless otherwise required by Florida Statutes:
A. Contract manager for this contract
B. District office:
Contract Compliance Unit
Attn: Audit Review Analyst
401 NW 2nd Avenue, Suite N-921
Miami, FL 33128
C. Copies of the reporting packages for audits conducted in accordance with OMS Circular A-133, as
revised, and required by Part I of this agreement shall be submitted, when required by Section .320(d),
OMS Circular A-133, as revised, by or on behalf of the recipient directly to the Federal Audit
Clearinghouse designated in OMS Circular A-133, as revised (the number of copies required by
Sections .320(d)(l) and (2), OMS Circular A-133, as revised, should be submitted to the Federal
Auditing Clearinghouse), at the following address:
Federal Audit Clearinghouse
Bureau of the Census
120 I East lOth Street
Jeffersonville, IN 47132
and other Federal agencies and pass-through entities in accordance with Sections .320(e) and (f),
OMS Circular A-133, as revised.
D. Copies of reporting packages required by Part II of this agreement shall be submitted by or on behalf
of the recipient directly to the following address:
Auditor General's Office
Room 40 I, Pepper Building
III West Madison Street
Tallahassee, Florida 32399-1450
Recipients, when submitting reporting packages to the Department for audits done in accordance with
OMB Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650 (nonprofit or for-profit
organizations), Rules of the Auditor General, should indicate the date the reporting package was delivered
in correspondence accompanying the reporting package.
07/0112002
7h
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the terms of this agreement
for a period of five years from the date the audit report is issued and shall allow the Department or its
designee, Comptroller, or Auditor General access to such records upon request. The recipient shall ensure
that audit working papers are made available to the Department or its designee, Comptroller, or Auditor
General upon request for a period of three years from the date the audit report is issued, unless extended in
writing by the Department.
07/0112002
17