Item C10
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Acting Department Head
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
MEETING DATE: 1-20..2005
DIVISION: COMMUNITY SERVICES
BULK ITEM:
YES _X_
NO
DE~~TMENT: SOCIAL SERVICES
AGENDA ITEM WORDING: Approval of ratification of Contract #KG052 - Community Care for Disabled
Adults (CCDA) Contract between the State of Florida, Department of Children & Families and the Monroe
County Board of County Commissioners (Monroe County Social Services/In-Home Services Program) due to
page 6 of said contract being omitted from review. This contract is for Fiscal Year July 1,2005 through June
30, 2006.
ITEM BACKGROUND: The approval of ratification of Contract #KG052 .- Community Care for Disabled
Adults (CCDA) will enable Monroe County In-Home Services to continue providing services to Monroe
County's disabled adult's ages 18 to 59 under the Community Care for Disabled Adults (CCDA) program_ Due
to timing issues (6-30-05 deadline), County Administrator Mr. Thomas Willi, executed said contract temporary
with retroactive approval by the Board of County Commissioners,
PREVIOUS RELEVANT BOCC ACTION:
March 16,2005.
CONTRACT/AGREEMENT CHAN(;ItS:
N1A
STA.FF RECOMMENDATION: Approval
TOTAL COST: $81,733,00
COST TO COUNTY: $9,081.44 (Required Match)
$16,663.56 (Additional Match)
Total Combined Match $25,745.00
BUDGETEO:YES..lL- NO_
SOURCE OF FUNDS: CCDA
Contract for Fiscal year 712005 thru
6/2006
REVENUE PRODUCING: YES_ NO~ AMT.PER MONTH
YEAR
APPROVED BY: COUNTY ATTYX OMBJPurchasmg-1L RISK MANAGEMENT --X
DIVISION DIRECTOR APPROVAL: ~~t:laq<(
/ JAMES MALLOCH
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DOCUMENTATION:
IN'CLUDED-X- TO FOLLOW_NOT REQtJIRED_
DiSPOSITION:
AGENDA ITEM#:
Rc.l~ed lf03
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MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACrSUMMARY
Contract with: State of Florida/Department of
Children & Families
Contract: #KGOS2
Effective Date: July l, 2005
Expiration Date: June 30, 2006
Contract PurposeJDescription: Approval of ratification of Contract #KG052 - Community Care: for Disabled
Adults (CCDA) Contract between the Alhance for Aging, Inc. and the Monroe County Board ofCo1mty
Commissioners (Monroe County Social Services/In-Home Services Program) due to page 6 of said contract being
omitted from review. This contract is for Fis~ycar July I, 2005 through June 30. 2006.
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Deloris Si~f-/
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For BOCC meetIDjI; on 7120/2005
Contract Manager:
4589
(ExL)
Social Services/Stop 1
(Department/Stop #)
Agenda Deadline:
7/05/2005
CON1RACT COSTS
Total Dollar Value of Contract: $83,599.00
Budgeted? Yes X No Account Codes:
Grant: $ 81,733.00 (Fiscal Year)
County Match: $ 9,081.44 (Fiscal Year) (Required)
$16,663.56 (Additional)
$25,745.00 (fotal Match)
Current Year Portion: $
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Estimated Ongoing Costs: $
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ADDITIONAL COSTS
For:
(c@. Maintenance. utili"';, jani[o,..;al:SnJaf,es. fIe)
CONTRACT REVIEW
Date In
Changes
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Division Director
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Comments:
OMB Form Revised 2127/0] MCP #
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03/01/05
CFDA No.
Client [if Non-Client 0
Multi-District 0
FLORIDA DEPARTMENT OF CHILDREN 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."
l. 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 contain::::
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.
9. 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 if 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.
D. Audits, Inspections, Investigations, 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 six (6) years after completion of the contract or
longer when required bylaw. In the event an audit is required by this contract, records shall be retained for a minimum period of
six (6) years after the audilreport is issued bt until resolution of any audit findings or litigation based on the terms of this
contract, at no additional cost to the department
CF Standard Con1racl, PDF 0312005
CONTRACT # KG052
03101105
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 l. Paragraph 0.2.
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 comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by the
office of The Inspector General (Section 20.055, Florida Statutes).
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: Except to the extent permitted bv s.768.28 , F.S., or other applicable Florida Law, Paragraph I.F.1. and 2. are not
applicable to contracts executed between state agencies or subdivisions, as defined in subsection 76828(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, employees and subcontractors 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 iaw).
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 that 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,
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.
2
CONTRACT # KG052
03/01/05
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 (1-800-96ABUSE). 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, religion, color, disability, national origin, marital status 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, religion, color, disabilily, national origin, marital status 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 B, in accordance with CFOP 60-16. This is
binding upon providers that have fifteen (15) or more employees.
3. Subcontractors who are on the discriminatory vendor list, may not transact business with any public entity, in accordance
with the provisions of section 287.134 F.S.
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.
O. 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.
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
Slate's mark, the name of the State or any State affiliate or any officer or employee of the State, or represent, directly or
indirectJy, that any product or service provjdedbythe 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.
3
CONTRACT # KG052
03/01/05
Q. Final Invoice
To submit the final invoice for payment to the department no more than 45 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.8., 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. Gratuities
The provider agrees that it will not offer to give or give any gift to any department employee. As part of the consideration for this
contract, the parties intend that this provision will survive the contract for a period of two years. In addition to any other remedies
available to the department, any violation of this provision will result in referral of the provider's name and description of the
violation of this term to the Department of Management Services for the potential inclusion of the provider's name on the
suspended vendors list for an appropriate period. The provider will ensure that its subcontractors, if any, comply with these
provisions.
U. 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 seNices performed under this
contract. or in anyway connected herewith, the provider shalf 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 shalf notify the
Department of State. Any and all copyrights accruing under or in connection with performance under this contract are hereby
reseNed 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.
5. All applicable subcontracts shall include a provision that the Federal awarding agency reserves all patent rights with
respect to any discovery or invention that arises or is developed in the course of or under the subcontract.
V. 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.
W. 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 leve! of security includes approving and tracking ali
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. 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,
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CONTRACT # KG052
03/01/05
X, 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.
Y. 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.
Z. Health Insurance Portability and Accountability Act
Where applicable, to comply with the Health Insurance Portability and Accountability Act (42 U. S. C. 1320d.) as well as all
regulations promulgated thereunder (45 CFR Parts 160, 162, and 164).
AA. Emergency Preparedness '
If the tasks to be performed pursuant to this contract include the physical care and control of clients, the provider shall, within 30
days of the execution of this contract, submit to the contract manager an emergency preparedness plan which shall include
provisions for pre.disaster records protection, alternative accommodations for clients in substitute care, supplies, and a recovery
plan that will allow the provider to continue functioning in compliance with the executed contract in the event of an actual
emergency. The department agrees to respond in writing within 30 days of receipt of the plan accepting, rejecting, or requesting
modifications. In the event of an emergency, the department may exercise oversight authority over such provider in order to
assure implementation of agreed emergency relief provisions.
B8. PUR 1000 Form
The PUR 1000 Form is hereby incorporated by reference. In the event of any conflict between the PUR 1000 Form, and any
terms or conditions of this contract (including the department's Standard Contract), the terms or conditions of this contract shall
take precedence over the PUR 1000 Form. However, if the conflicting terms or conditions in the PUR 1000 Form is required by
any section of the Florida Statutes, the terms or conditions contained in the PUR 1000 Form shall take precedence.
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
$ 81,733.00 , or the rate schedule, 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.
8. 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 Financial Services. 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 shalt be sent to the representative of the provider
responsible for administration of the program, to the designated address contained in this contract.
5
CONTRACT # KG052
03/01/05
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall begin on July 1, 2005 , 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 30,2006
B. Financial Penalties for Failures to Comply with Requirement for Corrective Action.
1. In accordance with the provisions of Section 402.73(7), Florida Statutes, and Section 65-29.001, Florida Administrative
Code, corrective action plans may be required for noncompliance, nonperformance, or unacceptable performance under this
contract. Penalties may be imposed for failures to implement or to make acceptable progress on such corrective action plans.
2. The increments of penalty imposition that shall apply, unless the department determines that extenuating circumstances
exist, shall be based upon the severity of the noncompliance, nonperformance, or unacceptable performance that generated the
need for corrective action plan. The penalty, if imposed, shall not exceed ten percent (10%) of the total contract payments
during the period in which the corrective action plan has not been implemented or in which acceptable progress toward
implementation has not been made. Noncompliance that is determined to have a direct effect on client health and safety shall
result in the imposition of a ten percent (10%) penalty of the total contract payments during the period in which the corrective
action plan has not been implemented or in which acceptable progress toward implementation has not been made.
3. Noncompliance involving the provision of service not having a direct effect on client health and safety shall result in the
imposition of a five percent (5%) penalty. Noncompliance as a result of unacceptable performance of administrative tasks shall
result in the imposition of a two percent (2%) penalty.
4. The deadline for payment shall be as stated in the Order imposing the financial penalties. In the event of nonpayment the
department may deduct the amount of the penalty from invoices submitted by the provider.
C. 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.
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.
D. 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.
6
CONTRACT # KG052
03101f05
E. Official Payee and Representatives lNames, 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 whom contract manager for the department for this IXlniract is:
the payment shall be made is:
Monroe County (Monroe County In Home SelVices)
1100 Simonton Street
Key West, FL 33040
2. The name of the contact person and street address
where financial and administrative records are maintained is:
Deloris Simpson
Monroe County In Home Services
1100 Simonton Street
Key West, Fl 33040
Theresa Phelan
Department of Children and Families
1111 12th Street, #308
Key West, FL 33040
305 1292-6810
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 / 292-4588
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
F. All Terms and Conditions Included
This contract and Its attachments, t, II and Exhibits A, B, C & D to Attachment I ,
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 IXlntract shafl supersede all previous communicalions, representations, or agreements, either verbal or written
between the parties. If any term or provision of this contract is legalfy determined unlawful or unenforceable. the remainder of
the IXlntract shall remain in futi 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 lItF. above.
IN WITNESS THEREOF, the parties hereto have caused this
officials as duly authorized.
PROVIDER:
Monroe County
PRINT
NAME:
~k""".,;./ :::r: Mat;.. /'
SIGNED
BY:
--/2
~)
.f
p ;;:;.'...- 1''11. 't. ,,"'-'
'J>. :5 ?e:If.\ IE:
NAME:
Dixie M. Spehar
TITLE:H~Mayor
DATE:
1/4c;f1-
tit ,,~/*.,
STATE AGENCY 29 DIGIT FLAIR CODE:
37
page contract to be executed by their undersigned
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
PRINT
NAME:
SIGNED
BY:
NAME:
Charles M, Hood III
TITLE:
District Administrator
DATE:
Provider Fiscal Year Ending Date; 09/30/05
7 CONTRACT # KG052
--:t-' "
. I ./", ~ j
c,.~J.AA!..W~ 0)-
C <=tl-
03/01/05
E. 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 whom contract manager for the department for this contract is:
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, #308
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:
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
Deloris Simpson
Monroe County In Home Services
1100 Simonton Street
Key West, FL 33040
305 / 292-4588
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.
F. All Terms and Conditions Included
This contract and its attachments, I, II and Exhibits A, S, C & D to Attachment I '
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.F. above.
IN WITNESS THEREOF, the parties hereto have caused this
officials as duly authorized.
37
page contract to be executed by their undersigned
PROVIDER:
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Monroe County
PRINT
NAME:
PRINT
NAME:
SIGNED
BY:
SIGNED
BY:
NAME:
Dixie M. Spehar
NAME:
Charles M. Hood III
TITLE:
Mayor
TITLE:
District Administrator
DATE:
DATE:
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal EID # (or SSN): 596000749 Provider Fiscal Year Ending Date:. 09/30/05
f:\~ONROE C-OUNTY ATTOr1NEY.
7 CONTRACT # KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
ATTACHMENT I
A. Services to be Provided
1. Definition of Terms
a. Contract Terms
(Refer to the Glossary in CFOP 75-2, Contract Management System for Contractual
Services, which is incorporated by reference herein)
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) Case Management Providers - Private, for-profit, or nonprofit or government
agencies designated to provide coordination of care for eligible clients. This
includes assessment of client needs and eligibility, development of care plans,
and the arrangement for appropriate services to meet those needs. Case
management providers integrate all available services through departmentally-
approved direct service providers into a sole program of service delivery uniquely
patterned to meet the client's varying service needs. Case management
providers may choose to deliver only case management services or choose to be
dually responsible as both a direct service provider and a case management
provider.
(3) Client - Any person who is eligible and is at least eighteen (18) years through
age fifty-nine (59), 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.
(4) Direct Service Providers - Private, for-profit, or nonprofit or government
agencies that provide direct service support to eligible clients. Direct services
range from the provision of health services delivered by physicians, nurses,
physiotherapists, occupational therapists, speech therapists, and dietitians, to
services delivered by workers such as homemakers, chore and transportation
worker and personal care aides. The direct service provider may provide one or
more aspects of care. The direct service provider may also choose to deliver
only direct services or choose to be dually responsible as both a case
management provider and a direct service provider.
(5) 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.
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(6) Nursing home - Any facility which provides nursing services as defined in
Chapter 464, Florida Statutes, and which is licensed in accordance with Chapter
400, Florida Statutes.
(7) Outcomes - Quantitative indicators that can be used by the department to
objectively measure a provider's performance toward a stated goaL
(8) Outputs - Process measures of the quantity(ies) of services delivered, clients
served, or similar units completed.
(9) Performance Measures - Quantitative indicators, outcomes and
outputs, that can be used by the department to objectively measure a provider's
performance.
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 enabling them to remain in their own
homes, and preventing their premature or inappropriate institutionalization.
(2) Service providers will ensure that appropriate community-based services are
provided to clients in a manner designed to meet the client's changing needs, to
assist the client in avoiding or reducing unnecessary dependence on the
delivered service(s), and to increase the client's self-reliance.
b. Authority
Sections 410.601-410.606, Florida Statutes, Chapter 65C-2, Florida Administrative Code,
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
Services will be targeted toward eligible adults in Monroe County.
d. Major Program Goal
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.
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
b. Client Eligibility
(1) Applicants 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 permanent disability must be established and evidenced in
one of the following manners:
(a) An applicant may present a check, awards letter, or other proof
showing receipt of Sodal Security Disability Income, or some other
disability payment (e.g., Worker's Compensation); or
(b) An applicant 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 applicant's diagnosis,
prognosis, a broad explanation of level of functioning, and the
interpretation of need for services based on identified functional barriers
caused by the applicant's disabling condition.
(2) Applicants must have an individual income at or below the prevailing MICP
eligibility standard in order to receive free CCDA services.
(3) Applicants with incomes above the standard will be assessed a fee 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), Florida Statutes.
(2) The department will determine client eligibility for this program. The
department will make the final determination of cHent eligibility.
d. Contract Limits
(1) The total annual cost estimated or actual, for an individual receiving CCDA
services, shalf 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 have completed
the Adult Services Screening for Consideration for new Community Based
Services, been scored by that instrument, and were referred to the provider by
the District/Region Program Office, and only to the extent that funds are available.
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
B. Manner of Service Provision
1. Service Tasks
a. Task List
(1) The following tasks will be performed under this contract (check all that
apply [2]).
OAdult Day Care X Case Management OEmergency Alert
Response
X Personal Care OHome Health Aide OGroup Activity
Therapy
X Homemaker OHome Nursing X Home Delivered
Meals
Olnterpreter OTransportation OMedical Therapeutic
Services
DChore ORespite OPhysical and
Exams
DEscort DAdult Day Health
Care
(2) Details of services to be provided under this contract and the negotiated
parameters of those services include: (Descriptions and minimum requirements
for each service listed are listed in "The CFOP 140-8, Community Care for
Disabled Adults Operating Procedures").
(3) Each district CCDA program shall include case management services and at
least one other community service.
b. Task Limits
The following task limits apply only to the services specified above.
(1) Respite Care services may be provided for up to two hundred forty (240)
hours per client per calendar year, depending upon individual need. The service
may be extended to three hundred sixty (360) hours, as recommended by the
case manager and approved by an immediate supervisor. Documentation of
approval must be evident in the case narrative section of the case manager's file.
(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 59A-8,
Florida Administrative Code,
(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:
11
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(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;
(d) handle client money, unless authorized in writing by a supervisor or
case manager (documented 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
CFOP 140-8, Community Care for Disabled Adults Operating Procedures".
(6) District task limits, which exceed those in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures, 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 CFOP 140-8, Community Care for Disabled Adults Operating
Procedures.
(2) The provider wiU notify the department, in writing, within thirty calendar (30)
days whenever the provider is unable, or expects to be unable to provide the
required quality or quantity of service due to staff turnovers or shortages.
b. Professional Qualifications
The provider will ensure that staff meets the professional qualifications for each service,
as specified in CFOP 140-8, Community Care for Disabled Adults Operating Procedures.
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 ten (10) working days
prior to the implementation of the change.
d. Subcontractors
This contract allows the provider to subcontract for the provision of all services under this
contract. All subcontracting is subject to the provisions of Section U. of the Standard
Contract
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
3. Service Location and Equipment
a. Service Delivery Location and 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 CFOP 140-8, Community Care for Disabled Adults
Operating Procedures.
(4) Services for this contract will be delivered at the following location(s) and
times:
SERVICE LOCATION TIMES
Case Manaaement Client's Home As needed
Personal Care Client's Home As needed
Homemakina Client's Home As needed
Home Delivered Meals Client's Home As needed
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, ten (10) working days 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.
c. Equipment
(1) If equipment is applicable to a specific provider's contract, the provider must
submit an equipment listing (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 provider must list the
items of equipment on the equipment listing (Exhibit N/A), as applicable to the
provider's contract for specific services.
4. Oeliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which may include, but
is not limited to, an hour of direct service delivery; a meal; an episode of travel; or a
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Community Care for Disabled Adults/Fixed Price
Adult Services Program
twenty-four (24) hour period of Emergency Alert Response maintenance, as defined in
CFOP 140-8, Community Care for Disabled Adults Operating Procedures. All service
units, as well as their description and costs, are listed in CFOP 140-8, Community Care
for Disabled Adults Operating Procedures,
b. Records and Documentation
(1) Case management agency individual client files shall contain the following:
(a) a completed client assessment (not more than one (1) 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;
(f) a completed and scored copy of the Adult Services Screening for
Consideration for Community Based Services; and
(g) a case narrative.
(2) Providers shaH maintain information on each client served by this contract,
which includes the following:
(a) documentation of the client by name or unique identifier;
(b) current documentation of eligibility for services;
(c) dates of service provision and delivery;
(d) information documenting the client's need to receive services;
(e) the number of service units provided; and
(f) all other forms or records necessary for program operation and
reporting, as set forth by the department
(3) Providers must ensure that all client records accurately match the invoices
submitted for payment. Records must cross reference to each invoice for
payment.
(4) Providers must maintain documentation necessary to facilitate monitoring and
evaluation by the department.
(5) The case management provider must maintain documentation in the client's
file that all comparable community services and funding sources have been
explored and exhausted before using CCDA funding.
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
c. Reports
Report Title Reporting Report Date Number of DCF Office address to receive
Frequency Due copies due report
Monthly Monthly The 10th of 2 Theresa Phelan
Cumulative month Contract Manager
Summary immediately 1111 1ih Street
Reports following the Key West, FL 33040
report period ~
Elizabeth Werner
Program Office
401 NW 2nd Ave, S-526
Miami, FL 33128
(1) Reporting requirements for this contract include, Exhibit A, Monthly
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 Monthly Cumulative
Summary Reports, which include management program data (e.g., client
identifiable data) to the department, according to negotiated instructions provided
by the districts.
(3) In the event of early termination of this contract, the provider wiff submit the
final Monthly 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 will not be placed in a
nursing home.
(2) 21: # of qualified disabled adults (ages 18-59) who will be provided
case management.
(3) 21: # of qualified disabled adults (ages 18-59) actively receiving daily living
services from the CCDA and Aged and Disabled Adults (ADA) Medicaid Waiver
Programs.
b. Description of Performance Measurement Terms
Placed The result of an 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 cHent into a more restrictive alternative living environment).
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult SelVices Program
C. Performance Evaluation Methodology
(1) Measuring Outcomes. The department will measure the outcomes found in
paragraph 8.5.a. above as follows:
(a) The outcome measurement contained in paragraph 8.5.a. (1) above
will be calculated by dividing the total, fiscal year-to-date number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs not
transferred to a nursing home, by the total, fiscal year-to-date number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid wavier programs.
(b) The outcome measurement contained in paragraph 8.5.a. (2) above
will be calculated by the total number clients actively receiving case
management from the Community Care for Disabled Adults, Home Care
for Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs by
the total number of qualified disabled adults eligible to receive such
services.
(c) The outcome measurement contained in paragraph B.5.a(3) above
will be calculated by the total number clients actively receiving daily living
services from the Community Care for Disabled Adults and the Medicaid
waiver programs.
(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 in this contract. 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 Direct Service Provider Unique Activities
(1) 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.
(2) The provider will maintain an accurate and current active case load list.
(3) The provider will maintain a current monthly billing ledger of all
provider claims submitted to the case management agency or Adult
Services local office, including all corrected claims and adjustments
to claims for services that were delivered to consumers being
served through this contract.
(4) The provider will notify the case management agency or Adult
Services local office of all service terminations, service increase
requests (Exhibit B) and monthly expenditure trends with regards
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Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
to the terms of this contract.
(5) The provider will explain to each individual requesting
consideration for CCDA services that the program maintains a
centralized Waiting List on which the individual will be placed
according to his or her score received through an Adult Services
Screening conducted by an Adult Services counselor.
(6) If required by 45 CFR Parts 160, 162, and 164, the following
provisions shall apply [45 CFR 164.504(e)(2)(ii)}:
(a) The provider hereby agrees not to use or disclose protected health
information (PHI) except as permitted or required by this contract, state
or federal law.
(b) The provider agrees to use appropriate safeguards to prevent use or
disclosure of PHI other than as provided for by this contract or applicable
law.
(c) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(e) The provider agrees to make PHI available in accordance with 45
C.F.R. 164.524.
(f) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 CFR.
164.526.
(g) The provider agrees to make available the information required to
provide an accounting of disclosures in accordance with 45 C. F. R.
164.528.
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider on behalf of the
department available for purposes of determining the provider's
compliance with these assurances.
(i) The provider agrees that at the termination of this contract, if feasible
and where not inconsistent with other provisions of this contract
concerning record retention, it wfli return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form. If not feasible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
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07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
m A violation or breach of any of these assurances shall constitute a
material breach of this contract
b. Case Management Provider Unique Activities
(1) The case management provider will accept all Budget Entity Team referrals
through the Adult Services Program Office.
(2) The case management provider will complete all initial face-to-face
assessments on aU pre-screened individuals referred by the Budget Entity Team
for service consideration and program application, using the Adult Services Client
Assessment, CF-AA 3019.
(3) The case management provider will maintain an accurate and current active
caseload list.
(4) The CCDA case management provider will maintain a current monthly billing
ledger of all provider claims submitted to the agency or the local Adult Services
office, including all corrected claims and adjustments to claims for services that
were delivered to consumers being served through this contract.
(5) The case management provider will notify the CCDA case management
agency or the local Adult Services office of all service terminations, service
increase requests (Exhibit B) and monthly expenditure trends with regards to the
terms of this contract
(6) The case management provider will explain to each individual requesting
consideration for CCDA services that the program maintains a centralized
Waiting List on which the individual will be placed according to his or her score
received through an Adult Services Screening.
(7) If required by 45 CFR Parts 160, 162, and 164, the following
provisions shall apply [45 CFR 164.504(e)(2)(ii)]:
(a) The provider hereby agrees not to use or disclose protected health
information (PHI) except as permitted or required by this contract, state
or federal law.
(b) The provider agrees to use appropriate safeguards to prevent use or
disclosure of PHI other than as provided for by this contract or applicable
law.
(c) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(e) The provider agrees to make PHI available in accordance with 45
CFR. 164.524.
18
PSMAI No. GA07
Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(f) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R.
164.526.
(g) The provider agrees to make available the information required to
provide an accounting of disclosures in accordance with 45 C.FR
164.528.
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider on behalf of the
department available for purposes of determining the provider's
compliance with these assurances.
(i) The provider agrees that at the termination of this contract, if feasible
and where not inconsistent with other provisions of this contract
concerning record retention, it wiU return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form. If not feasible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
(j) A violation or breach of any of these assurances shall constitute a
material breach of this contract.
c. Coordination with Other Providers/Entities
The case management provider must coordinate, as necessary, with the Agency for
Persons with Disabilities, 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.
7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply all new providers with a copy of
the Community Care for Disabled Adults Operating Procedures, CFOP 140-8.
(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 the
contract terms are being fulfilled according to the contract specifications.
c. Monitoring Requirements
The provider will be monitored in accordance with existing departmental procedures as
detaHedjn CFOP 75-8, Contract Monitoring.
19
PSMAI No. GA07
Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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 $81,133.00, subject to the availability of funds.
b. The department shall make payments to the provider for the provision of services up
to the maximum number of units of service at the rates shown below.
c. The department agrees to pay for the service units at the unit prices and limits listed
below.
Service Unit Price Maximum # of Units
Case Manaqement $50.78 200
Personal Care $42.38 250
HomemakinCl $34.14 1250
Home Delivered Meals $5.70 3212
c. The provider's dollar match for this contract is $9,081.44. Case management and
transportation services may be exempt from match requirement at the discretion of each
district.
d. Cash or in kind resources may be used to meet this match requirement.
2. Invoice Requirements
The provider shall request payment through submission of a properly completed Invoice, Exhibit
C, within ten days following the end of the month for which payment is being requested. The
provider shall submit to the contract manager an original Invoice, Exhibit C, and N/A copies,
along with supporting documentation. Payment due under this contract will be withheld until the
department has confirmed delivery of negotiated services.
Payments may be authorized only for service units on the invoice which are in accordance with
the above list and other terms and conditions of this contract. The service units for which
payment is requested may not either by themselves, or cumulatively by totaling service units on
previous invoices, exceed the total number of units authorized by this contract.
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, wiU 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
20
PSMAI No. GA07
Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
the services were provided so that an audit trail documenting service provision can be
maintained.
4. MyFloridaMarketPlace
This contract is exempt from the MyFloirdaMarketPlace Transaction Fee in accordance with
Chapter 60A-1.032(1)(e), Florida Administrative Code.
D. Special Provisions
1. Fees
a. The case management provider will collect fees for services provided according to
Rule 65C-2.007, FAC.
b. No fees shall be assessed other than those established by the department. Fees
collected in compliance with the department directives will be reinvested 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), FS 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. MyFloridaMarketPlace Transaction Fee
The State of Florida, through the Department of Management Services, has instituted
MyFloridaMarketPlace, a statewide eProcurement system. Pursuant to subsection 287.057(23),
Florida Statutes (2002), all payments shall be assessed a Transaction Fee of one percent (1.0%),
which the provider shall pay to the State.
For payments within the State accounting system (FLAIR or its successor), the Transaction Fee
shall, when possible, be automatically deducted from payments to the provider. If automatic
deduction is not possible, the provider shall pay the Transaction Fee pursuant to Rule 60A-
1.031(2), Florida Administrative Code. By submission of these reports and corresponding
payments, provider certifies their correctness. All such reports and payments shaH be subject to
audit by the State or its designee.
The provider shall receive a credit of any Transaction Fee paid by the provider for the purchase of
any item(s) if such item(s) are returned to the provider through no fault, act, or omission of the
provider. Notwithstanding the foregoing, a Transaction Fee is non-refundable when an item is
rejected or returned, or declined, due to the provider's failure to perform or comply with
specifications or requirements of the agreement.
Failure to comply with these requirements shall constitute grounds for declaring the provider in
default and recovering procurement costs from the provider in addition to all outstanding fees.
PROVIDERS DELINQUENT IN PAYING TRANSACTION FEES MAY BE EXCLUDED FROM
CONDUCTING FUTURE BUSINESS WITH THE STATE.
4, Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, F.S., Part I, Transportation
Services, and Chapter 41-2, FAC., Commission for the Transportation Disadvantaged, if public
funds provided under this contract will be used to transport clients.
21
PSMAI No. GA07
Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
5. Information Technology Resources.
All contract providers must adhere to the Department's procedures and standards when
purchasing Information Technology Resources (lTRs) 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.
6. 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.
7. Employee Loans
Funds provided by the Department under this contract shall not be used by Not-For-Profit
Corporations to make loans to their employees, officers, directors and/or subcontractors.
Violation of this provision shall be considered a breach of contract, the termination of this contract
shall be in accordance with the Standard Contract, Section 11/, Paragraph B, Subsection 3. A loan
is defined as any advance of money for which the repayment period extends beyond the next
scheduled pay period.
8. 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 annually.
9. 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 critical 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 form
(Exhibit D) to the respective department program incident report liaison. The incident report
liaison for this contract is Al Papa, 401 NW 2nd Avenue, Suite N-1007, 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 also be placed in a central fife marked "Confidential
Incident Report". Dissemination of the report within the department will be the responsibility of the
department's program incident report liaison.
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.
22
PSMAI No. GA07
Contract No. KG052
07/01/2005
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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.
23
PSMAI No. GA07
Contract No. KG052
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EXHIBIT B
~"'HiLDREN
V "FAMILIES Request for Approval of CeCA Care Plan Services Increase
Part I: Recipient Information
Name: Last name, first name, middle name or initial Date of birth:
Soei a I secu rilY number: Medicaid/Medicare Medical assistance number:
Current Address: Address where services will be received:
County: County:
Status (Transfer/Existing): Describe reason for service funding increase.
If individual is a transfer, indicate originating district/agency: An Adult Services client reassessment was completed on
by and
If individual is an existing consumer with your agency, respective revised care plan revisions made on
indicate current monthly authorized units of service by by , to
service type(s): reflect that this Recipient is justifiably in need of increased
Service(s) based on (check all situations which apply):
o Failing Support System
o Decrease in Functional Capacity
o Rapidly Deteriorating Health
Medicaid waiver eligibility date:
Provider Information
Agency name: Agency contacl person:
Agency address:
Phone:
Fax:
E-mail address:
Part II: Summary of Recipient's Presenting Situation. (Refer to form instructions for details about the type of information
required here. Use the space below or include attachment.)
Part III: Proposed New Service Request. (Please indicate the new care plan services being requested and the corresponding,
anticipated service start dates.)
Service
Anticipated start date
Service
Anticipated start date
CF.AA 1121. Mar 2005
Page 1 of 2
1.4
Part IV: Specific Description of Proposed New Service(s) As Tailored To Meet Recipient's Need. (Refer to the form
instructions for details about the type of information required here. Use the space below or include attachment.)
Part V: Cost Detail for Proposed New Care Plan Service(s).
A. Attach a Cost Detail page for each service requested in Part Ill. Each Cost Detail page should reflect the total
annual cost of serving the consumer for that service type.
Part VI: Care Plan Modification of Number of Service Units. The Budget Entity Team will not consider authorization to
increase service unit quantity of an authorized service on a Recipient's care plan for any of the following documented
reasons unless this section is accurately and fully completed.
[To justify unit service rates, please present comparative information: unit rate quotes from a minimum of three other service
agencies providing this same service within a ten mite radius; reasons for choosing this specific vendor; a statement attesting to the
fact that selected vendor is a sole source provider of this service in this geographic area, etc. Attach information as necessary (e.g.,
agency administrative costs, your agency salary scale, etc.). Refer to the form instructions.]
o Failing Support System: List proposed add-on number of monthly service units by service component with annualized
service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Decrease in Functional Capacity: List proposed add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Rapidly Deteriorating Health: List care plan add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
Part VII. Signatures. (Please note: Final approval of all requests for Care Plan increases rest with the Budget Entity Team.
Providers will receive an Award Letter from the Budget Entity Team (or one of its members) when the plan has been approved)
I Provider Agency: (Signature indicates that the information presented in this Request for Care Plan Services Date:
Increase and attachments are accurate and complete.)
RecipienURepresentative: (Signature indicates that the Recipient/Representative has reviewed the Request for Date:
Care Pian Services Increase and attachments.)
District/Regional Program Staff: (Signature indicates that the districllregicnal program staff and provider have Date:
agreed upon the services to be funded.)
DistrictJRegional Adult. Services Program Director: (Signature indicates district/regional approval of the Service Date:
Funding Plan.)
Page 2 of :1
t~
~'C'H rLPRE N
& FAMI LI ES
Request for Service Increase
The CF-AA 1116, Request for Approval of Care Plan Services Increase, will serve as the official
request for increase in service funding by the District/Region Adult Services Office for
Community Care for Disabled Adults (CCDA) consumers requesting an increase in Care Plan
services. This form may be completed manually or electronically, with Parts I, II, IV, and V re-
sized as necessary to accommodate the descriptions and cost information required.
Districts/Zones/Region will complete the Request for Approval of Care Plan Services Increase for
each CCDA consumer who has requested an increase in Care Plan services. After review by the
district coordinator and consumer, this form must be submitted to Central Office for consideration
and approval. Districts/Zones/Region should feel free to consult with Central Office staff as
necessary during the development of any Services Increase request, especially if clarification is
needed.
Provider's adherence to the instructions for completing each section of the Request for Services
Increase will expedite the Districts/Zones/Region evaluation of the request, and will minimize the
need for additional requests for information. Please keep in mind that all parts of the request are
interconnected, and the information you supply in one section should justify and support what
appears in the other sections.
Part I: Consumer and Provider Information
. Complete both the consumer and provider information sections.
· Specific instructions:
. The consumer's SSN, or any other pertinent information about the consumer's medical
assistance status (Medicare, Medically Needy, etc).
Part II: Summary of Consumer's Current Situation
. The infomlation submitted in this section should relate to the other parts of the request,
justifying and supporting the service requests.
. The length of this summary should correlate with the complexity of the service request and
the costs involved. More complex, higher cost plans will require more detailed explanations.
· Specific instructions:
. Include the age of the consumer, diagnosis, disability history and circumstances relative to
the increase in services being requested.
. Provide information about the current caregiver/service provider(s), such as name of primary
caregiver, date of birth of caregiver, caregiver's relationship to consumer, whether or not
there is a legal guardian: service agency presently providing services to the consumer, what
services are being provided and number of service units per service per week, funding source
for those services, and date the services were initiated.
. Describe the current living situation: who lives with/cares for the consumer at the consumer's
place of residence?
· Provide answers to pertinent questions, such as:
. Why are services being requested at this time? What are the impl ications if services
are not provided?
. Who is initiating the present request for service increase?
. Who or which provider agency does the consumer wish to receive the increased
services from?
. Has the above person/agency been contacted to confirm the availability of resourceS
requested by this consumer?
1..1
Part III: Proposed Services Requested
. This section serves as a summary of all the service types requested.
. Identify the anticipated start date for each service type requested.
Part IV: Specific Description of Proposed Service
. Provide a specific description of the services to be provided for each of the service types
requested in Part III. Include references to days and times when services will occur.
. The length ofthis summary should correlate with the complexity of the service Care Plan and
the costs involved. More complex, higher cost Care Plans will require more detailed
exp lanations.
. Include in this section specific information about requests for start-up and other one-time-
only services, as well as supplemental services.
. Specific instructions for preferred service delivery days, and whether morning or afternoon is
preferred.
. Describe specific services requested (e.g. personal care, home delivered meals, case
management, etc.) including:
. The time period/staff ratio for all services (e.g. the specific hours during the day, and
the number of days per week and service units that the consumer requires each day);
. An itemization of any start-up services/articles requested;
Part V: Cost Dctail
. Section A: Attach a Cost Detail page for each service requested in Part III. Each Cost Detail
page should reflect the total annual cost of serving the consumer for that service type. The
charts require a detailed listing of the services to be provided, how costs are computed, and
vendor information if applicable. Indicate the total annual costs in the appropriate boxes.
. Detail hourly rates and should include provider administrative costs, travel costs, and
provider employee fringe benefit costs
. Part V should include a Cost Justification section describing why these costs are appropriate.
Present comparative information, reasons for choosing a specific vendor, the appropriateness
ofthe hourly rate, etc. Attach any information that validates your request for increased unit
rate for the service, or increased units of service for this consumer.
. Round all dollar amounts to the nearest dollar.
Part VI: Modification Request
. Follow the instructions for this section if this is a request to change the level of service for a
consumer currently funded by your District/Zone/Region for that service.
Part VII: Signatures
. The case management provider representative/ resource coordinator (if applicable), and the
consumer/family should sign the Request for Increase before it is forwarded to the
district/regional office.
. Central Office staff may require additional information from the case management provider
(if applicable) or district/regional staff, if deemed necessary, to assist the Budget Entity Team
in determining approval or denial of the request.
March 22, 2005
~~
-',
-.......
EXHIBIT C
DEPARTMENT OF CHILDREN AND FAMILIES
ADULT SERVLCES OFFICE
MONTHLY REQUEST FOR PAYMENT AND EXPENDITURE REPORT
PROVIDER FED. ID #
NAME AND MAILING ADDRESS OF PAYEE:
CONTRACT AMNT.:_
REIMBURSEMENT YTD.:_
CONTRACT BALANCE:_
DATE:
CONTRACT#:
PERIOD OF SERVICE PROVISION:
. NAME OF SERVICE UNITSt AMOUNT PER UNITt 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
TOTAL DEDUCTIONS ~ CHILDREN
REMAINING MATCH BALANCE
...... & FAMILIES
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
~tf rH~S fNVOICE tS FOR A FtXED P-j~jCE CONTRACT> THE REQUEsr FOR PAYMENt Will BE CETERMINEO
flY DIVIDING THE LENGTH OF THE CONTRACT INTO THE CONTRACTED AMOUNT ,EX -S12.000IAllOCA nON! DiVIDED BY
12 MONTKS [THE LENGTH OF THE CONTRACTlcSl ,000 PAYMENT RECUESTl ON A COST REIMBURSEMENT CONtRACT
"'tHE PA vMENT REQUEST WlL BE THE MON'rI-1l Y REQUEST EXPENSE
CHILDREN AND FAMILIES USE ONLY
DATE INV. RCD.
APPROVED BY:
DATE~
EO
OBJ
DESC.
AMNT.
IOCA
J
IORG
21
Florida Department of
CHILDREN
&. FAMILIES
DISTRICT 11 INCIDENT REPORT
District Tracking Number (for CRITICAL incidents)
11 (Di strict)
YEAR Sequence Code
Check if CLOSED _
Program Code: AS, OA, DO, ESS, FS, MH, SA
EXHIBIT D
(Critical incidents must be reported to District Administrator within 24 hours of notification.) CHECK IF CRITICAL l25J
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 OAS DASA OCMH DCSA ODA DoC ODD 0 ESS 0 FS
Please respond to one of the following as appropriate.
a. Contract Provider 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 DClient/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 Inddents
FIRST Name LAST Name SS# Birth Date Race Gender Client Employee Other Participant Witness
_1_1- 0 0 0 0 0 0
_1_1- 0 0 0 0 n 0
L-J
_1_1- 0 0 0 0 0 0
1..0
CONFIDENTIAL
FIRST Name LAST Name SS# Birth Date Race Gender Client Employee other Participant Witness other
_/~- 0 0 0 0 0 0
~_/- 0 0 0 0 0 0
~-'- 0 0 0 0 0 0
. . . .
Give Detailed Account - (Who, What, When, Where, Why, How) - Add Pages If Necessary
Immediate corrective action taken
Is follow-up action needed? NoD
YEsD
If yes, specify:
1>1
CONFIDENTIAL
. . .
EXTERNAL NOTIFICATION
Agency Notified Person Contacted Status DatelTime Called Copy
Abuse Registry Name Report Accepted
1-800-962-2873 0 0
ID# Yes 0 NoD
Agency for Health Care
Administration Name: N/A 0 D
Law Enforcement-Department Officer's Name
Badge # Case # (if avail) N/A 0 0
Parent/Guardianl
Family Member Name Name: N/A 0 0
Other (Please Specify)
Name: N/A 0 0
Other (Please Specify)
Name: N/A 0 0
DCF (for providers only) Name: N/A 0 0
I
NAME SIGNATURE TITLE PHONE # DATE
REPORTING 1 1
EMPLOYEE ---
SUPERVISOR ~_I-
.
Individual/Agency Individual/Agency Notified
Notified
Client Relations Employee Safety Program 0
District Administrator Florida Local Advocacy Committee 0
Division Director/ H.R. Workers' Compensation
Facility Director 0 Coordinator (employes relaled incidents only) 0 0
District Legal Counsel 0 Program Office/Risk Manager 0 0
OS Support Coordinator/Case 0 0 Others - (Please specify) 0 0
Manager
EEOC 0 0 Contract Manager 0 0
Public Information Officer 0 0 Missing Children's Unit 0 0
NAME
SIGNATURE
TITLE
PHONE #
DATE
Incident Report
Liaison
Senior Supervisor
_1_1-
1 1
'32--
CONFIDENTIAL
The definitions apply to DCF direct or contractual services/employees
1. Abuse/NeQlecUExploitation. A reportable event where a client/employee is the subject of abuse, neglect, or
exploitation.
2. AaaressionlThreat. The client engages in verbal threats to harm or aggression towards another person.
3. Altercation. A physical confrontation occurring between a client and employee or two more clients at the time
services are being rendered, or when a client is in the physical custody of the department, which results in one or
more clients or employees receiving medical treatment by a licensed health care professional.
4. Baker Act. Client is placed into a facility under the Baker Act.
5. Bomb Threat. Any threat of harm to property or persons involving an explosive device that is received verbally, in
writing, electronically or otherwise.
6. Client Iniurv/lllness. A medical condition of a client requiring medical treatment by a licensed health care
professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring
while in the presence of an employee, in a Department of Children and Families or contracted facility or service
center or who is in the physical custody of the department.
7. Client Death. Any person whose life terminates due to or alleged due to an accident, act of abuse, neglect or
other incident occurring while in the presence of an employee, in a Department of Children and Families operated
or contracted facility or service center, while in the physical custody of the department; or when a death review is
required pursuant to CFOP 175-17,Child Death Review Procedures.
8. Contraband/Druas (or non-authorized material) Discovery of contraband. Employee/client found with contraband
which includes intoxicating beverage, controlled substance. weapon or device designed to be used as a weapon
or explosive substance, and/or, anything specifically prohibited in writing by the Department (Ref. CFOP 70-12).
9. Misconduct/Criminal Activity. Action resulting in potential liability. Conduct resulting in a law violation.
Falsification of State or client records by an employee.
10. ContrabandJDruQs (or non-authorized material) Discovery of contraband. Employee/client found with contraband
which includes intoxicating beverage, controlled substance, weapon or device designed to be used as a weapon
or explosive substance, and/or, anything specifically prohibited in writing by the Department (Ref. CFOP 70-12).
11. TheftNandalism/Damaqe/Sabotaae. Loss of state or private property of significant value or importance.
12. Elopement/Runaway. The unauthorized absence beyond eight hours, or other time frames as defined by a
specific program operating procedure or manual, of a child or adult who is in the physical custody of the
department.
13. EmerQencv Room Visit. The client is taken to an emergency medical facility for assessment and/or treatment.
14. Escape. The unauthorized absence as defined by statute, departmental operating procedure or manual of a client
committed to, or securely detained in a Department of Children and Families mental health or developmental
services forensic facility covered by Chapters 393, 394 or 916, FS.
15. Hospital Admission. The client is admitted to the hospital for surgery or scheduled medical procedures.
16. Client IniurvJlllness. A medical condition of a client requiring medical treatment by a licensed health care
professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring
while in the presence of an employee, in a Department of Children and Families or contracted facility or service
center or who is in the physical custody of the department.
17. Media Coverage Media coverage that may have an adverse impact of the Department's ability to protect and
serve its clients.
17
CONFIDENTIAL
18. Medications Issue. The client is prescribed psychotropic medication requiring consent of parent and/or court
order and issue not resolved. Issue of incorrect medication or wrong dosage of correct medication. Dosage of
prescribed medication is omitted, or the client has an adverse reaction to medication. This would not include
suicide attempts by intentional overdose, which are Suicidal Attempts.
19. Misconduct/Criminal Activity. Action resulting in potential liability. Conduct resulting in a law violation.
Falsification of State or client records by an employee.
20. Physical Aaaression. The client engages in physical aggressive behavior that is threatening towards persons or
destructive to property or animals, e.g. overturning furniture, throwing objects, striking walls, etc.
21. Self-Iniurious Behavior. The client inflicted upon him/herself or subject self to potential danger (cutting oneself,
walking into traffic).
22. TheftNandallsmfDamaae/Sabotaae. Loss of state or private property of significant value or importance
23. Sexual Battery. An allegation of sexual battery by a client on a client, employee on a client, or client on an
employee as evidenced by medical evidence or law enforcement involvement.
24. Suicide Attempt. An act which clearly reflects the physical attempt by a client to cause his or her own death while
in the physical custody of the department or a departmental contracted or certified provider, which results in bodily
injury requiring medical treatment by a licensed health care professional.
25. SuicidalldeationlThreat. The client talks about killing him/herself or verbally suggests the possibility of killing
him/herself.
26. TheftNandalismfDamaQeJSabotaQe. Loss of state or private property of significant value or importance.
27. TheftNandalismJDamaae/SabotaQe. Loss of state or private property of significant value or importance.
28. pther Incidents. An unusual occurrence or circumstance initiated by something other than natural causes or out of
the ordinary such as a tornado, kidnapping, riot or hostage situation, which jeopardizes the health, safety and
welfare of clients who are in the physical custody of the department.
F/groups/resplan/incidentslform7101 Rev. 2/25/02
,'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 ofthe 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 department's inspector general, the state's Chief Financial Officer or the Auditor
GeneraL
AUDITS
P ART 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 $500,000 or more in Federal awards during 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 detennining the Federal awards expended during 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-133, as revised, will meet the
requirements ofthis 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.I33, as
revised.
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during the audit period. The financial statements should disclose whether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due the
department shall be fully disclosed in the audit report package with reference to the specific contract
number.
04/01/05
KG052
~{
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 $500,000 or more in state financial assistance during its fiscal year, the
recipient must have a State single or project-specific audit conducted in accordance with Section 215.97,
Florida Statutes; applicable rules of the Executive Office of the Governor, the Chief Financial Officer 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 assistance expended during 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 215.97(2)(d), Florida Statutes, and
Chapters 10.550 or 10.650, Rules of the Auditor General.
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during the audit period. The financial statements should disclose whether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due the
department shall be fully disclosed in the audit report package with reference to the specific contract
number.
P ART 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 ofthe audit report, whichever occurs first, directly to each of the following
unless otherwise required by Florida Statutes:
A. Contract manager for this contract (2 copies)
B. Department of Children & Families
ASFMI
Building 2, Room 301
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
C. Copies of the rcporting packages for audits conducted in accordance with OMB Circular A-133, as
revised, and required by Part I of this agreement shall be submitted, when required by Section .320(d),
OMB Circular A-I33, as revised, by or on behalf of the recipient directly to the Federal Audit
Clearinghouse designated in OMB Circular A-133, as revised (the number of copies required by
Sections320(d)(l)and(2), OMB Circular A-133, as revised, should be submitted to the Federal
Auditing Clearinghouse), at the following address:
KG052
04/01105
.-;~
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10tb Street
Jeffersonville, IN 47132
and other Federal agencies and pass-through entities in accordance with Sections .320(e) and (f),
OMB Circular A- 133, as revised.
D. Copies of reporting packages required by Part II ofthis agreement shall be submitted by or on behalf
of the recipient directly to the following address:
Auditor General's Office
Local Government Audits/342
Claude Pepper Building, Room 401
1 I I West Madison Street
Tallahassee, Florida 32399-1450
Providers, when submitting audit report 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 include, when available, correspondence from the
auditor indicating the date the audit report package was delivered to them. When such correspondence is
not available, the date that the audit report package was delivered by the auditor to the provider must be
indicated in correspondence submitted to the department in accordance with Chapter 10.558(3) or Chapter
10.657(2) Rules of the Auditor General.
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the terms of this agreement
for a period of six years from the date the audit report is issued and shall allow the department or its
designee, Chief Financial Officer 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, Chief Financial
Officer 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.
~
~
./
04J01/05
KG052
'J1
CONTRACT #KG051
AMENDMENT #0001
THIS AMENDMENT, 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", amends contract KG051.
1. Standard Contract, Section II, Paragraph A is hereby amended to read:
To pay for contracted services according to the terms and conditions of this contract in an
amount not to exceed $81,773.00, 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 for
from any other source are not eligible for payment under this contract.
2. Attachment I, Section C, Paragraphs l.a., l.b and I.e. are hereby amended to read:
1. Payment Clause
a. This is a Fixed Price contract. The department shall pay the provider for the delivery
of service units provided in accordance with the terms and conditions of this contract for
a total dollar amount not to exceed $81,733.00, subject to the availability of funds.
b. The department shall make payments to the provider for provision of services up to
the maximum number of units of service at the rates shown below.
Service Units Unit Price Maximum # of
Units
Case Management $ 47.73 228
Homemaking $ 27.11 1517
Home Delivered Meals $ 5.10 4000
Personal Care $ 5Lll 183
c. The provider's dollar match for this contract is $9,085.89. Case management and
transportation services may be exempt from match requirement at the discretion of each
district.
4. This amendment shall begin on March 1, 2005, or the date on which the amendment has been
signed by both parties, whichever is later.
5. All provisions in the contract and any attachments thereto in conflict with this amendment
shall be and are hereby changed to conform with the amendment.
AMENDMENT# 0001
KG051
6. All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the contract.
7. This amendment and all its attachments are hereby made a part of this contract.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by
their officials thereunto duly authorized.
PROVIDER: MONROE COUNTY
(Monroe County In Home Services)
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
~I~NED '/tfh J7;. ~4dJ
NAME: Dixie M. Spehar
SIGNED/~ ~ it . i; ';::r, , I ... ..li..-r! ~
BY: LiHCV,,/lty [/!7. /::ta P;, LiL:S'p')-
NAME: Charles M. Hood III
TITLE:
Mayor
TITLE:
District Administrator
DATE
March 16, 2005
."'< IjCh. ~
DATE C/cr-l 0-
590600074902
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