Item C08BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: 6-20-2012 Division: —County Administrator
Bulk Item: Yes —X— No — Department: Social Services/In-Home Services_
Staff Contact Person/Phone #: Sheryl Graham/X45 10
AGENDA ITEM WORDING: Approval of the Alzheimer's Disease Initiative (ADI) Contract KZ-
1297 between the Alliance for Aging, Inc. (Area Agency on Aging) and the Monroe County Board of
County Commissioners (Social Services/In-Home Services) for fiscal year 7/1/12 to 6/30/13.
ITEM BACKGROUND: Approval of the ADI Contract will enable Monroe County In -Home
Services to continue providing services to Monroe County's elderly population under the Alzheimer's
Disease Initiative program.
PREVIOUS RELEVANT BOCC ACTION: Prior approval granted to ADI Contract #KZ- 1197 on
5-18-11.
CONTRACT/AGREEMENT CHANGES: none
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $56,746.00 INDIRECT COST: --O--BUDGETED: Yes No
COST TO COUNTY: $5,674.60 10% Cash Match) SOURCE OF FUNDS:
REVENUE PRODUCING: Yes X No — AMOUNT PER MONTH $50.00 Year $600.00 APPROVED BY: County Att/y�x OMB/Purchasing X Risk Management 1 X-
-
DOCUMENTATION:
DISPOSITION:
Revised 1109
Included X Not Required
Contract with: /\|baocc for Aging, Inc. Contract # KZ-l297
Effective Date: July |,2O|2
Expiration Date: June 3O,20|3
Cot \rac1 ofthe Abh6mersDisease Initiative /AIJDContract #KZ-l297will
enable Monroe County In -Home Services to continue providing services to Monroe County's elderly population.
� Contract Manager: Sheryl Graham 4510 Social Services/Stop l
� (Name) (Ext.) (lJepado/cnt/Snnp#)
For BOCC nocctio 6/20/2012 Agenda Deadline: 6/5/2012
CONTRACT COSTS
Total Dollar Value ofContract:
Budgeted? Yes X No Account Codes:
Gnox{:$56,746.0V(Fiscal Year)
Current Year Portion: $_
125 -6853612___-___
- -
' - -
ADDITIONAL COSTS
Estimated Ongoing Costs: For:
(Not included in dollar value above) (eg. Maintenar
- - -
-------------
, janitorial, salarii
ONTRACT REVIEW
Division Director
O.M.B./Purchasing
Date In
Changes
Needed vie
Yes 0 No
Yes 11 No 0
Date Out
t)��
"ivxspormu«eviseaz/z/xmxmnturi;z
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CONTRACT
1 •
Page
ALZHEIMERS' DISEASE INITIATIVE CONTRACT
2012-2013
THIS AGREEMENT is entered into between the Alliance for Aging, Inc., hereinafter
referred to as the "Alliance" and "Monroe County Board of Commissioners.", hereinafter
referred to as the "provider." THIS CONTRACT IS SUBJECT TO FURTHER
MODIFICATION IN ORDER TO INCORPORATE CERTAIN PASS -THROUGH
LANGUAGE REQUIRED BY THE STATE OF FLORIDA DEPARTMENT OF ELDER
AFFAIRS. ALL SUBSEQUENT MODIFICATIONS WILL BE MADE THROUGH
AMENDMENTS TO THIS CONTRACT.
Attachment 1, 11, 111, IV, V, VI, VI1, Vill, IX, X, XI, XII, XIII, XIV, XV and XVI are integral to this
Agreement
Provider Agrees:
A. Services to be Provided:
1. The provider's service provider application for state fiscal year 2012 and any
revisions thereto approved by the Alliance and located in the contract manager's
file, are incorporated by reference in this contract between the Alliance and the
provider, and prescribe the services to be rendered by the provider.
2. Consumers may not be enrolled in a Department of Elder Affairs' state general
revenue funded program, including ADI, who are also enrolled in a Medicaid
capitated long-term care health plan or program. These programs include the
Frail Elder Program operated by United Health Care, the Channeling Program
operated by Miami Jewish Home and Hospital for the Aged, the Long Term Care
Community Diversion Program and the Program of All Inclusive Care for the
Elderly (PACE) program scheduled to begin operation in the Miami -Dade
County area.
B. Manner of Service Provision:
The services will be provided in a manner consistent with and described in the provider's
service provider application for state fiscal year 2012 and the 2011 Department of Elder
Affairs Home and Community Based Services Handbook. In the event the handbook is
revised, such revision will automatically be incorporated into the contract and the
provider will be given a copy of the revisions.
11. The Alliance Agrees:
A. Contract Amount:
To pay for services in an amount not to exceed $56,746, subject to the availability of
funds.
Obligation to Pay:
The Alliance's performance and obligation to pay under this contract is contingent upon
an annual appropriation by the Legislature.
B. Source of Funds:
CONTRACT KZ-1297
The costs of services paid under any other contract or from any other source are not
eligible for reimbursement under this contract. The funds awarded to the provider
pursuant to this contract are in the state grants and aids appropriations.
III. Provider and Alliance Mutually Agree:
A. Effective Date:
1. This contract shall begin on July 1, 2012 or on the date the contract has been
signed by both parties, whichever is later.
2. Delivery of services shall end on June 30, 2013.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed by
their undersigned officials as duly authorized.
SIGNED BY:
NAME:
TITLE:
DATE:
Monroe County Board of
Commissioners.
David Rice
Mayor
6-20-2012
ALLIANCE FOR AGING, INC.
SIGNED BY:
NAME: Max B. Rothman, JD, LL.M.
TITLE: President & CEO
DATE:
81,30
NjA0-UVA1Nnoo-LNVL91SSV
OcIV0813INi ¢
IN0?, 01 SV Cj/',Obd
N01 ' 4nC)o 30OIN
9
CONTRACT KZ-1297 Page 3
ATTACHMENT
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
I. STATEMENT OF PURPOSE
The Alzheimer's Disease Initiative (ADI) Program is focused on caring for persons 18 + with
memory disorders.
II. SERVICES TO BE PROVIDED
A. Services:
1. The provider's service provider application for state fiscal year 2012 and any
revisions thereto approved by the Alliance and located in the contract manager's
file, are incorporated by reference in this contract between the Alliance and the
provider, and prescribe the services to be rendered by the provider.
2. Consumers may not be enrolled in a Department of Elder Affairs' state general
revenue funded program, including ADI, who are also enrolled in a Medicaid
capitated long-term care health plan or program. These programs include the
Frail Elder Program operated by United Health Care, the Channeling Program
operated by Miami Jewish Home and Hospital for the Aged, the Long Term Care
Community Diversion Program operating in Planning and Service Areas 7 and
9, and any other areas that may participate in the Long Term Care Diversion
Program through expansion and the Program of All Inclusive Care for the
Elderly (PACE) program scheduled to begin operation in the Miami -Dade
County area.
B. Manner of Service Provision:
The services will be provided in a manner consistent with and described in the
provider's service provider application for state fiscal year 2012 and the 2011
Department of Elder Affairs Home and Community Based Services Handbook. In
the event the handbook is revised, such revision will automatically be incorporated
into the contract and the provider will be given a copy of the revisions.
91
CONTRACT KZ-1297 Page 4
A. The method of payment in this contract is based on a fixed rate reimbursement for
approved services. The provider must ensure fixed rates include only those costs
that are in accordance with all applicable state and federal statutes and regulations
and are based on audited historical costs in instances where an independent audit is
required. All requests for payment and expenditure reports submitted to support
requests for payment shall be on DOER forms 106Z and 105Z. Duplication or
replication of both forms via data processing equipment is permissible, provided all
data elements are in the same format as included on departmental forms.
B. Invoices must be submitted no later than 90 days after the end of the month on
which the expense was incurred, except that invoices can not be submitted after
close out report date (usually July 15th.) Invoices submitted late will not paid.
Exceptions to this rule are at the discretion of the Alliance, on a case by case basis;
such exceptions must be requested prior to the expiration of the invoicing deadline.
In making a determination of the exception the Alliance will consider whether the
disruption to the billing cycle was beyond the control of the provider, the frequency
with which such exceptions are requested by the provider, and whether the Alliance
can request reimbursement at a late date from DOEA.
C. The provider shall maintain documentation to support payment requests which shall
be available to the Comptroller, the Department of Elder Affairs, or the Alliance upon
request.
D. The provider shall maintain documentation to support payment requests which shall
be available to the Alliance, the Department of Elder Affairs or the Comptroller upon
request.
E. The provider may request a monthly advance for service costs for each of the first
two months of the contract period, based on anticipated cash needs. Detailed
documentation justifying cash needs for advances must be submitted with the signed
contract, approved by the Alliance, and maintained in the contract manager's file. All
payment requests for the third through the twelfth months shall be based on the
submission of monthly actual expenditure reports beginning with the first month of
the contract. The schedule for submission of advance requests is ATTACHMENT II
to this contract. Reconciliation and recouping of advances made under this contract
are to be completed by March and April. All advance payments are subject to the
availability of funds.
F. Advance funds may be temporarily invested by the provider in an insured interest
bearing account. All interest earned on contract fund advances must be returned to
the Alliance within thirty (30) days of the end of the first quarter of the contract
period.
G. The Alliance shall make payment to the provider for provision of services up to
a maximum number of units of service and at the rate(s) stated below
Maximum
Service to be Provided Service Units of Maximum f
Unit Rate Service dollars I
In Home Respite $24.03 2,361 $56 746
51
CONTRACT KZ-1297 Page 5
H. Any payment due by the Alliance under the terms of this contract may be withheld
pending the receipt and approval by the Alliance of complete and accurate financial
and programmatic reports due from the provider and any adjustments thereto,
including any disallowance not resolved.
A. State Laws and Regulations:
The provider agrees to comply with applicable parts of Rule 58D-1, Florida
Administrative Code promulgated for administration of Sections 430.501 through
430.504, Florida Statutes, and the 2009 Department of Elder Affairs Client Home
and Community Based Services Handbook.
B. Assessment and Prioritization for Service Delivery for New Consumers:
The following are the criteria to prioritize new consumers for service delivery. It is
not the intent of the Department of Elder Affairs to remove existing clients from any
program in order to serve new clients being assessed and prioritized for service
delivery.
1. Priority Criteria for Service Delivery:
a. individuals in nursing homes under Medicaid who could be transferred to
the community;
b. individuals in nursing homes whose Medicare coverage is exhausted and
may be diverted to the community;
c. individuals in nursing homes which are closing and can be discharged to
the community; or
d. individuals whose mental or physical health condition has deteriorated to
the degree self care is not possible, there is no capable caregiver and
institutional placement will occur within 72 hours.
2. Priority Criteria for Other Assessed Individuals:
The assessment and provision of services should always consider the most cost effective
means of service delivery. Functional impairment shall be determined through the
department's consumer assessment form administered to each applicant. The most frail
individuals not prioritized in groups one, two or three above, regardless of referral source,
will receive services to the extent funding is available.
...
1. The provider will establish annual co -payment goals. The Alliance also has the
option to withhold a portion of the provider's Request for Payment if goals are
not met according to the Department of Elder Affairs' co -payment guidelines.
R
CONTRACT KZ-1297 Page 6
2.Co-payments include only the amounts assessed consumers O[the amounts
consumers opt k}contribute iOlieu Of8Oassessed CO-p@y[D8Ot. The
contribution must be equal to or greater than the assessed co -payment.
D. Evaluation, Statistics and Reports
The provider agrees tOrespond k}requests for evaluation information and statistical data
concerning its consumers based OOinformation requirements Ofthe Memory Disorder
Clinics and Brain Bank. The provider will ensure Model Day Care Centers supported by
this contract develop innovative therapies and interventions which can be shared with
other Alzheimer's Disease Initiative health and social services personnel via training.
Model Day Care Centers supported by this contract must report to the provider all
training activities provided to health care and social service personnel and caregivers, as
well as Serve as a natural laboratory for service ne|o0ad applied r8S8on:h by Memory
Disorder Clinics. An 8Onuo| Model Day Cora Center Training Raport, ATTACHMENT
UV, is due byJuly 5. 2012.
E. Collaboration with Memory Disorder Clinics:
Memory Disorder Clinics are required to provide four hours of in-service training to all respite and
model day care centers in their designated service areas. The provider agrees to collaborate with
Memory Disorder Clinics to assist in this effort.
F. Service Cost :
The provider will submit semi-annual service cost reports which reflect actual costs of providing each
service bvprogram. This report provides information for planning and negotiatingunit rates.
The provider need to provide the Alliance with 8O expenditure plan byJuly 15D[two weeks after
contract has been signed, a monthly update due on the 21 of each following month.
The expenditure plan and updates must follow the format provided bythe Alliance.
CONTRACT KZ-1297
Page 7
ATTACHMENT It
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
CONTRACT REPORT CALENDAR
Report -. •
Murtber
1 July Advance * ..
2 August Advance *
3 July Expenditure Report ....................................................
4 August Expenditure Report ................................................
5 September Expenditure Report ...........................................
6 October Expenditure Report ...............................................
7 November Expenditure Report ............................................
8 December Expenditure Report ............................................
9 January Expenditure Report / ...............................................
10 February Expenditure Report /July Advance Reconciliation **.....
11 March Expenditure Report /August Advance Reconciliation ** ...
12 April Expenditure Report ....................................................
13 May Expenditure Report ....................................................
14 June Expenditure Report ....................................................
16 Final Expenditure and Closeout Report .................................
Legend: * Advance based on projected cash need.
Submit
to the Alliance
on This Date
July 1
July 1
August 10
September 10
October 10
November 10
December 10
January 10
February 10
March 10
April 10
May 10
June 10
July 10
July 20
** Submission of expenditure reports may or may not generate a payment request.
If final expenditure report reflects funds due back to the Alliance, payment is to
accompany the report.
Note # 1: Report #1 for Advance Basis Contracts cannot be submitted to the Alliance prior to July 1 or
until the contract with the Alliance has been executed. Actual submission of the vouchers to the
Department of Elder Affairs is dependent on the accuracy of the expenditure report.
N
CONTRACT• '.•-
ATTACHMENT III
ANNUAL MODEL DAY CARE CENTER TRAINING REPORT
Model Day Care Center Name:
Printed Name of Person Signature of Person Date Executed
Completing Report Completing Report
The purpose of each model day care program must be to provide service delivery to persons suffering from
Alzheimer's disease or a related memory disorder and training for health care and social service personnel in
the care of persons having Alzheimer's disease or related memory disorders. This report documents the
required training for the State Fiscal Year July 1st through June 30th.
Actual Training Event(s)
Number
Health Care
Professiona
Is Trained
Number
Social
Services
Personne
I
Trained
Total
People
Trained
Training Title:
Date:
Training Summary:
FQ
CONTRACT KZ-1297 Page 9
Under this Contract, the provider agrees to the following:
A. Perform ARC outsourced functions in accordance with policies and procedures developed by
the Alliance for Aging. Refer to the following attachments:
i. Attachment V: Policies and Procedures for Outsourced Function -Screening
ii. Attachment VI: Policies and Procedures for Outsourced Function -Triage
iii. Attachment VII: Policies and Procedures for Activation from Waitlist- Client
Services
iv. Attachment Vlll: Policies and Procedures for Termination from Waitlist- Client
Services
B. Maintain wait lists in CIRTS in accordance with DOEA requirements.
C. Report number of client contacts to the Aging Resource Center.
D. Adhere to prioritization policy as set forth by the Department of Elder Affairs.
E. Update the agency Disaster Plan to incorporate ARC outsourced functions.
F. Ensure against conflicts of interest and inappropriate self -referrals by referring consumers in
need of options counseling or long-term care services beyond the provider's scope of services
to the Aging Resource Center.
G. Ensure that services provided are in the clients' best interest, are the most cost effective, of
high quality, and are responsive and appropriate to the assessed needs.
The Assessed Priority Consumer List (APCL) is maintained when services funded by the department are
not available. Contracted providers of registered services for Alzheimer's Disease Initiative (ADI), Older
American's Act (OAA), and Contracted Services (CS) maintain waiting lists in the CIRTS database for
registered services when funding is not available. Note: OAA3E is an exempt funding source for ARC Wait
List purposes. For services provided through OAA3E, no CIRTS client data entry is required.
Registered Services for the above listed programs are as follows: Adult Day Care (ADC), Adult Day Health
Care (ADHC), Chore (CHO), Escort (ESC), Home Health Aide (HHA), Homemaker (HMK), Model Day Care
(MDC), Personal Care (PECA), Facility -Based Respite (RESF), In -Home Respite (RESP).
N
CONTRACT KZ-1297 Page 10
Attachment V
AGING & DISABILITY RESOURCE CENTER (ADRC) — OUTSOURCED FUNCTIONS
11. If applicable, the provider agrees to the following:
A. Perform ADRC outsourced functions in accordance with the Alliance's policies and
procedures.
i. Policies and Procedures for Outsourced Function -Screening
ii. Policies and Procedures for Outsourced Function -Triage
iii. Policies and Procedures for Activation from Waitlist- Client Services
iv. Policies and Procedures for Termination from Waitlist- Client Services
B. Maintain wait lists in CIRTS in accordance with DOER requirements.
C. Report number of client contacts to the Aging Resource Center.
D. Adhere to prioritization policy as set forth by DOEA on a monthly basis. Reference
DOEA Programs and Services Handbook.
E. Ensure the agency's Disaster Plan reflects ADRC Outsourced Functions, annually or as
needed to incorporate ADRC outsourced functions.
F. Ensure against conflicts of interest and inappropriate self -referrals by referring
consumers in need of options counseling or long-term care services beyond the
provider's scope of services to the Aging and Disability Resource Center.
G. Ensure that services provided are in the clients' best interest, are the most cost
effective, of high quality, and are responsive and appropriate to the assessed needs.
The Assessed Priority Consumer List (APCL) is maintained when services funded by the
department are not available. Contracted providers of registered services for Alzheimer's Disease
Initiative (ADI) and Older American's Act (OAA) maintain waiting lists in the CIRTS database for
registered services when funding is not available.
Registered Services for the above listed programs are as follows: Adult Day Care (ADC), Adult D
Health Care (ADHC), Chore (CHO), Escort (ESC), Home Delivered Meals (HDM), Home Health
•- •memaker (HMK), Model i. i Personal Care (PECA), Facility -Based
•_ • • _ ._ •
W
Page 11
Alliance for Aging,
Aging and Disability Resource Center/Elder Helpline
Policy and Procedure
• • •
*utsourced function!''
Creation Date:
March 5, 2008
Revision Date:
May 2012
Review Date:
May 2011
Objective: To ensure that a comprehensive list of clients in need of services is maintained in CIRTS by
appropriate funding source and that the ADRC is thereby able to effectively gauge the level of elder
service need in Miami -Dade and Monroe Counties.
Policy: To obtain necessary information from clients in order to assist in determining level of need and
eligibility for DOEA funded services
Procedure:
1. ADRC Contracted Providers will collect information from callers and conduct a 701A assessment.
Alternatively, if a 701 B assessment already exists or is provided from another source (i.e. CARES)
the information from the 701 B can be utilized.
2. Based on the information provided via the 701A(B) assessment, the ADRC Contracted Provider will
make a determination as to the services that the caller is in need of receiving .
3. The ARC Contracted Provider will determine the appropriate funding source(s) that provides the
needed services.
4. If the caller is in need of a service(s) that is not provided by the ADRC Contracted Provider, the
ARC Contracted Provider will refer caller to the ADRC Eider Helpline utilizing the ADRC Referral
Form and/or to an ADRC Contracted Provider that provides the needed service.
5. The caller will be provided with general information regarding the ADRC as well as the ADRC Elder
Helpline contact number.
6. The caller will be informed of the services and funding sources that they are being placed on the
wait list for in CIRTS.
needed7. ADRC Contracted Provider will create a client record in CIRTS (if there is no existing record) and
enter the services for the caller by ; i source and i record
in CIRTS, the appropriate fields will be updated].
8. If the ADRC Contracted Provider determines that the caller may qualify for more than one funding
source, ADRC Contracted Provider is encouraged to enter the appropriate information under
multiple funding sources. [if there is an existing client record in CIRTS, the client record in CIRTS
will be updated with appropriate information],
9. ADRC Contracted Provider will inform caller that they will receive a follow-up call (or home visit in
case of active client) to check on their status based on DOEA Wait List Reassessment Standards
and encourage caller to contact the ADRC Elder Helpline with any questions.
is
K 7a t 9,[o9 :tI iF�'>rl
Alliance for Aging, Inc.
Aging and Disability Resource Center/Elder Helpline
Policy and Procedure for
Outsourced function - Triage
Creation Date:
March 5, 2008
Revision Date:
May 2012
Review Date:
May 2011
Objective: To ensure that clients in need of DOEA funded services receive services based on the highest
level of need, first, as funding becomes available.
Policy: To assist clients in obtaining DOEA funded services as funding becomes available, based on
level of need as determined by a CIRTS priority score.
Procedure:
1. ADRC Contracted Provider will conduct periodic follow-up calls (or home visit in case of active client)
to check on client status based on DOEA Wait List Reassessment Standards.
2. Based on the information provided via the 701A(B) assessment, the ADRC Contracted Provider will
update the client information in CIRTS specifically as it pertains to level of need for services by
funding source.
3. The ADRC Contracted Provider will ensure that the CIRTS prioritization score is accurately
maintained, according to DOEA Standards.
4. If the caller is in need of a service(s) that is not provided by the ADRC Contracted Provider, the ADRC
Contracted Provider will refer caller to the ADRC Elder Helpline utilizing the ADRC Referral Form
and/or to an ADRC Contracted Provider that provides the needed service.
5. The caller will be informed of the services and funding sources that they remain on the wait list for
and/or have been removed from the wait list for.
6. ADRC Contracted Provider will advise client of any change in their CIRTS priority score based on the
updated information.
7. ADRC Contracted Provider will remind client of the ADRC Elder Help Line contact number and to
contact the ADRC Elder Help Line with any questions or concerns.
8. As funding becomes available, ADRC Contracted Provider will run CIRTS Prioritization Report and
activate clients according to DOEA Standards (refer to ADRC Client Activation Policies and
Procedures). The Contracted Provider will apply targeting criteria, as appropriate, to prioritized clients
to ensure activations meet programmatic requirements.
IVA
CONTRACT KZ-1297
Page 13
Alliance for Aging, Inc.
Aging and Disability Resource Center/Elder Helpline
Policy and Procedure for
Activation From Wait List — Clients/Services
Creation Date:
March 5, 2008
Revision Date:
May 2012
Review Date:
May 2011
Objective: To ensure that elders in need of DOEA funded services in Miami -Dade and Monroe Counties and
on the CIRTS wait list begin to receive services as funding becomes available.
Policy: ADRC will work with ADRC Contracted Providers to ensure that clients waiting for DOEA
funded services begin to receive those services as funding becomes available.
Procedure:
1. ADRC Contracted Provider will activate clients on CIRTS wait list based on DOEA prioritization
polices and funding availability.
2. ADRC Contracted Provider will update CIRTS status by funding source and service for any services
being activated for the client using appropriate CIRTS codes.
3. Client may be left on wait list of a different funding source than the one being activated if ADRC
Contracted Provider determines that it is appropriate.
4. Client may also be left on wait list in CIRTS if they are being activated by the ADRC Contracted
Provider under a temporary non-DOEA funding source and ADRC Contracted Provider determines
that the clients' need will persist after the temporary funding source is exhausted.
5. ADRC Contracted Provider will inform the client of any services/funding source that they are being
activated for as well as those services and funding sources that they will continue to be wait listed for.
6. ADRC Contracted Provider will inform client to contact the ADRC Elder Helpline if they have any
questions or concerns regarding the status of any of their services.
N
Page 14
Alliance for Aging, Inc.
Aging and Disability Resource Center/Eider Helpline
Policy and Procedure for
Termination From Wait List — Clients/Services
Creation Date:
March 5, 2008
Revision Date:
May 2012
Review Date:
May 2011
Objective: To ensure that the comprehensive list of clients in need of services in CIRTS is appropriately
maintained by funding source and that the ADRC is thereby able to effectively gauge the current
level of elder service need in Miami -Dade and Monroe Counties.
Policy: ADRC will maintain an accurate and current list of clients in need of elder services in Miami -
Dade and Monroe Counties with the assistance of the ADRC Contracted Providers.
Procedure:
1. ADRC Contracted Provider will re -screen clients which the ADRC Contracted Provider initially placed
on the CIRTS wait list for services based on DOEA Reassessment Standards.
2. The re -screening may be in the form of a phone screening or a home visit depending on the clients
status (i.e. active/pending)
3. ADRC Contracted Provider will determine if the client is no longer in need (or eligible) for any of the
services they were wait -listed for.
4. ADRC Contracted Provider will terminate the client from the wait list (entirely or by specific service)
using the appropriate CIRTS termination code for any services or funding source for which the client
is determined to no longer be eligible for or no longer in need of.
5. ADRC Contracted Provider will inform the client of any services/funding source that they are being
removed from the wait list for.
6. ADRC Contracted Provider will inform client of their ability to be re -added to the wait list if their level of
need should change.
7. ADRC Contracted Provider will inform client to contact the ADRC Elder Helpline if they have any
questions or concerns regarding their wait list status.
- i• ' •• a - - M10 B M-• a
w
CONTRACT KZ-1297 page 15
CERTIFICATION REGARDING LOBBYING
CERTIFICATION FOR CONTRACTS, GRANTS,
LOANS AND AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1)No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any state or federal
agency, a member of congress, an officer or employee of congress, an employee of a member of congress,
or an officer or employee of the state legislator, in connection with the awarding of any federal grant, the
making of any federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative
agreement.
(2)If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a member of congress, an
officer or employee of congress, or an employee of a member of congress in connection with this
federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3)The undersigned shall require that the language of this certification be included in the award documents
for all sub -awards at all tiers (including subcontracts, sub -grants, and contracts under grants, loans and
cooperative agreements) and that all subproviders shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than
$100,000.00 for each such failure.
6-20-2012
Signature Date
_David Rice KZ-1297
Name of Authorized Individual Application or Agreement Number
Monroe County Board of County Commissioners 1100 Simonton Street Key West FL 33040
Name and Address of Organization
DOER Form 103 (Revised Nov 2002)
In
CONTRACT KZ-1297 Page 16
FINANCIAL ! COMPLIANCE ALUIU
The administration of resources awarded by the Alliance of Elder Affairs to the provider may be subject to audits
and/or monitoring by the Alliance of Elder Affairs, as described in this section.
In addition to reviews of audits conducted in accordance with OMB Circular A-133, as revised, and Section
215.97, F.S., (see "AUDITS" below), monitoring procedures may include, but not be limited to, on -site visits by the
Alliance staff, limited scope audits as defined by OMB Circular A-133, as revised, and/or other procedures. By
entering into this agreement, the provider agrees to comply and cooperate with any monitoring
procedures/processes deemed appropriate by the Alliance for Aging. In the event the Alliance for Aging
determines that a limited scope audit of the provider is appropriate, the provider agrees to comply with any
additional instructions provided by the Alliance to the provider regarding such audit. The provider further
agrees to comply and cooperate with any inspections, reviews, investigations, or audits deemed necessary by any
level of government.
PART I: FEDERALLY FUNDED
This part is applicable if the provider is a State or local government or a non-profit organization as defined in OMB
Circular A-133, as revised.
hi the event that the provider expends $500,000.00 or more in Federal awards during its fiscal year, the provider
must have a single or program -specific audit conducted in accordance with the provisions of OMB Circular A-
133, as revised. EXHIBIT 1 to this agreement indicates Federal resources awarded through the Alliance of Elder
Affairs by this agreement. In determining the Federal awards expended in its fiscal year, the provider shall
consider all sources of Federal awards, including Federal resources received from the Alliance of Elder Affairs. The
determination of amounts of Federal awards expended should be in accordance with the guidelines established by
OMB Circular A-133, as revised. An audit of the provider conducted by the Auditor General in accordance with the
provisions of OMB Circular A-133, as revised, will meet the requirements of this part.
In connection with the audit requirements addressed in Part I, paragraph 1, the provider shall fulfill the
requirements relative to auditee responsibilities as provided in Subpart C of OMB Circular A-133, as revised.
If the provider expends less than $500,000.00 in Federal awards in its fiscal year, an audit conducted in
accordance with the provisions of OMB Circular A-133, as revised, is not required. In the event that the provider
expends less than $500,000.00 in Federal awards in its fiscal year and elects to have an audit conducted in
accordance with the provisions of OMB Circular A-133, as revised, the cost of the audit must be paid from non -
Federal resources (i.e., the cost of such audit must be paid from provider resources obtained from other than
Federal entities.)
An audit conducted in accordance with this part shall cover the entire organization for the organization's
fiscal year. Compliance findings related to agreements with the Alliance of Elder Affairs shall be based on the
agreement's requirements, including any rules, regulations, or statutes referenced in the agreement. The financial
statements shall disclose whether or not the matching requirement was met for each applicable agreement. All
questioned costs and liabilities due to the Alliance of Elder Affairs shall be fully disclosed in the audit report with
reference to the Alliance of Elder Affairs agreement involved. If not otherwise disclosed as required by Section
.310(b)(2) of OMB Circular A-133, as revised, the schedule of expenditures of Federal awards shall identify
we
CONTRACT KZ-1297 Page 17
expenditures by agreement number for each agreement with the Alliance of Elder Affairs in effect during the
audit period. Financial reporting packages required under this part must be submitted within the earlier of 30 days
after receipt of the audit report or 9 months after the end of the provider's fiscal year end.
As an Alliance requirement the Statement of Functional Expenses need to be part of the Financial and Compliance
Audit Report.
This part is applicable if the provider is a nonstate entity as defined by Section 215.97(2), Florida Statutes.
In the event that the provider expends a total amount of state financial assistance equal to or in excess of
$500,000.00 in any fiscal year of such provider (for fiscal years ending September 30, 2004 or thereafter),
the provider must have a State single or project -specific audit for such fiscal year in accordance with
Section 215.97, Florida Statutes; applicable rules of the Alliance of Financial Services; and Chapters 10.550
(local governmental entities) or 10.650 (nonprofit and for -profit organizations), Rules of the Auditor
General. EXHIBIT I to this agreement indicates state financial assistance awarded through the Alliance of
Elder Affairs by this agreement. In determining the state financial assistance expended in its fiscal year,
the provider shall consider all sources of state financial assistance, including state financial assistance
received from the Alliance of Elder Affairs, 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 Part II, paragraph 1, the provider shall ensure that
the audit complies with the requirements of Section 215.97(8), Florida Statutes. This includes submission of
a financial reporting package as defined by Section 215.97(2), Florida Statutes, and Chapter 10.550 (local
governmental entities) or 10.650 (nonprofit and for -profit organizations), Rules of the Auditor General.
If the provider expends less than $500,000.00 in state financial assistance in its fiscal year (for fiscal years
ending September 30, 2004 or thereafter), an audit conducted in accordance with the provisions of Section
215.97, Florida Statutes, is not required. In the event that the provider expends less than $500,000.00 in
state financial assistance in its fiscal year and elects to have an audit conducted in accordance with the
provisions of Section 215.97, Florida Statutes, the cost of the audit must be paid from the nonstate entity's
resources (i.e., the cost of such an audit must be paid from the provider resources obtained from other than
State entities),
An audit conducted in accordance with this part shall cover the entire organization for the
organization's fiscal year. Compliance findings related to agreements with the Alliance of Elder Affairs
shall be based on the agreement's requirements, including any applicable rules, regulations, or statutes.
The financial statements shall disclose whether or not the matching requirement was met for each
applicable agreement. All questioned costs and liabilities due to the Alliance of Elder Affairs shall be fully
disclosed in the audit report with reference to the Alliance of Elder Affairs agreement involved. If not
otherwise disclosed as required by Rule 691-5.003, Fla. Admin. Code, the schedule of expenditures of state
financial assistance shall identify expenditures by agreement number for each agreement with the Alliance
of Elder Affairs in effect during the audit period. Financial reporting packages required under this part
must be submitted within 45 days after delivery of the audit report, but no later than 12 months after the
provider's fiscal year end for local governmental entities. Non-profit or for -profit organizations are
required to be submitted within 45 days after delivery of the audit report, but no later than 9 months after
17
CONTRACT KZ-1297 Page 18
the provider's fiscal year end. Notwithstanding the applicability of this portion, the Alliance of Elder
Affairs retains all right and obligation to monitor and oversee the performance of this agreement as
outlined throughout this document and pursuant to law.
As an Alliance requirement the Statement of Functional Expenses need to be part of the Financial and Compliance
Audit Report.
PART III: REPORT SUBMISSION
Copies of reporting 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-133, as revised, by or on behalf of the provider directly to each of the following:
The Alliance for Aging, Inc. at the following address:
Alliance for Aging, Inc. Attn: Carlos Lahitte
760 NW 107 th Ave, Suite 214
Miami, FL 33172
MV
CONTRACT KZ-1297 Page 19
ATTACHMENT X
104�11 I �
PART 1: AUDIT RELATIONSHIP DETERMINATION
Providers who receive state or federal resources may or may not be subject to the audit requirements of OMB
Circular A-133, as revised, and/or Section 215.97, Fla. Stat. Providers who are determined to be providers or
subproviders of federal awards and/or state financial assistance may be subject to the audit requirements if the
audit threshold requirements set forth in Part I and/or Part 11 of Exhibit 1 are met. Providers who have been
determined to be vendors are not subject to the audit requirements of OMB Circular A-133, as revised, and/or
Section 215.97, Fla. Stat. Regardless of whether the audit requirements are met, providers who have been
determined to be providers or subproviders of Federal awards and/or state financial assistance, must comply
with applicable programmatic and fiscal compliance requirements.
In accordance with Sec. 210 of OMB Circular A-133 and/or Rule 691-5.006, FAC, provider has been determined to
be:
Vendor or exempt entity and not subject to OMB Circular A-133 and/or Section 215.97, F.S.
X Provider/ subprovider subject to OMB Circular A-133 and/or Section 215.97, F.S.
NOTE: If a provider is determined to be a provider /subprovider of federal and or state financial assistance and
has been approved by the Alliance to subcontract, they must comply with Section 215.97(7), F.S., and Rule 691-
.006(2), FAC [state financial assistance] and Section .400 OMB Circular A-133 [federal awards].
PART 11: FISCAL COMPLIANCE REQUIREMENTS
FEDERAL AWARDS OR STATE MATCHING FUNDS ON FEDERAL AWARDS. Providers who receive
Federal awards or state matching funds on Federal awards and who are determined to be a subprovider, must
comply with the following fiscal laws, rules and regulations:
STATES, LOCAL GOVERNMENTS AND INDIAN TRIBES MUST FOLLOW-
2 CFR Part 225 Cost Principles for State, Local and Indian Tribal Governments (Formerly OMB
Circular A-87)*
OMB Circular A-102 — Administrative Requirements
OMB Circular A-133 — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
NON-PROFIT ORGANIZATIONS MUST FOLLOW:
2 CFR Part 230 Cost Principles for Non -Profit Organizations (Formerly OMB Circular A-122 - Cost
Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-1 10 - Administrative
Requirements)
Requirements)
OMB Circular A-133 - Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
1111r�l itl[111111151 I I J 11 1 ��� I �
In
CONTRACT KZ-1297 Page M
2 CFR Part 220 Cost Principles for Educational Institutions OMB (Formerly Circular A-21 - Cost
Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-1 10 - Administrative
Requirements)
OMB Circular A-133 — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
*Some Federal programs may be exempted from compliance with the Cost Principles Circulars as noted in
the OMB Circular A-133 Compliance Supplement, Appendix 1.
STATE FINANCIAL ASSISTANCE. Providers who receive state financial assistance and who are
determined to be a provider/ subprovider, must comply with the following fiscal laws, rules and regulations:
Section 215.97, Fla. Stat.
Chapter 691-5, Fla. Adniin. Code
State Projects Compliance Supplement
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
NE
CONTRACT KZ-1297 Page 21
ATTACHMENT XI
CERTIFICATION REGARDING DATA INTEGRITY
COMPLIANCE FOR AGREEMENTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENTS
The undersigned, an authorized representative of the provider named in the contract or agreement to
which this form is an attachment, hereby certifies that:
(1)The provider and any sub -providers of services under this contract have financial management
systems capable of providing certain information, including: (1) accurate, current, and complete disclosure
of the financial results of each grant- funded project or program in accordance with the prescribed
reporting requirements; (2) the source and application of funds for all agreement supported activities;
and (3) the comparison of outlays with budgeted amounts for each award. The inability to process
information in accordance with these requirements could result in a return of grant funds that have not
been accounted for properly.
(2)Management Information Systems used by the provider, sub-provider(s), or any outside entity on
which the provider is dependent for data that is to be reported, transmitted or calculated, have been
assessed and verified to be capable of processing data accurately, including year -date dependent
data. For those systems identified to be non -compliant, provider(s) will take immediate action to assure
data integrity.
(3)If this contract includes the provision of hardware, software, firmware, microcode or imbedded
chip technology, the undersigned warrants that these products are capable of processing year -date
dependent data accurately. All versions of these products offered by the provider (represented by the
undersigned) and purchased by the State will be verified for accuracy and integrity of data prior to
transfer.
In the event of any decrease in functionality related to time and date related codes and internal
subroutines that impede the hardware or software programs from operating properly, the provider
agrees to immediately make required corrections to restore hardware and software programs to the
same level of functionality as warranted herein, at no charge to the State, and without interruption to
the ongoing business of the state, time being of the essence.
(4) The provider and any sub-provider(s) of services under this contract warrant their policies and
procedures include a disaster plan to provide for service delivery to continue in case of an
emergency including emergencies arising from data integrity compliance issues.
The provider shall require that the language of this certification be included in all subagreements,
subgrants, and other agreements and that all sub -providers shall certify compliance accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by OMB Circulars A-102 and 2 CFR Part 215 (formerly OMB Circular A-110).
Monroe County Board of County Commissioners 1100 Simonton Street Key Nest FL 33040
Name and Address of Provider
Signature
David Rice
Name of Authorized Signer
May 6-20-2012
Title Date
21
CONTRACT KZ-1297
ATTACHMENT XII
CERTIFICATION REGARDING DEBARMENT, SUSPENSION,
INELIGIBILITY AND VOLUNTARY EXCLUSION FOR LOWER TIER
COVERED TRANSACTIONS
(1)The prospective provider certifies, by signing this certification, neither it nor its principals are
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any federal Alliance or agency.
(2)Where the prospective provider is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this certification.
Signature
Mayor
Title
6-20-2012
OR
_Monroe County BOCC
Agency/Organization
(Certification signature should be same as Contract signature.)
Instructions for Certification
l.The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered
transaction," "person," "primary covered transaction," and "voluntarily excluded," as used herein, have
the meanings set out in the sections of rules implementing Executive Order 12549. (2 CFR 180.5-
180.1020, as supplemented by 2 CFR 376.10-376.995). You may contact the Contract Manager for
assistance in obtaining a copy of those regulations.
2.This certification is a material representation of facts upon which reliance was placed when the
parties entered into this transaction. If it is later determined that the provider knowingly rendered an
erroneous certification, in addition to other remedies available to the federal government, the
Alliance may pursue available remedies, including suspension and/or debarment.
3.The provider will provide immediate written notice to the Contract Manager if at any time the
provider learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances. The provider may decide the method and frequency by which it
determines the eligibility of its principals. Each participant to a lower tier covered transaction
may, but is not required to, check the Excluded Parties List System (EPLS).
4.The provider will include a "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transaction" in all its lower tier covered transactions and in
all solicitations for lower tier covered transactions.
5.The provider agrees that it shall not knowingly enter into any lower tier covered transaction with a
person who is debarred, suspended, determined ineligible or voluntarily excluded from participation,
unless otherwise authorized by the federal government.
6.If the provider knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the federal government, the Alliance may pursue available
remedies, including suspension, and/or debarment.
-.The provider may rely upon a certification of a prospective participant hi a lower tier covered
transaction that it is not debarred, suspended, ineligible, or voluntari , (e Q
,P5
transaction, unless it knows that the certification is erroneous. ,
(Petii_Sed June 2()08)
PEDRVj, MKRPC'Ar-'r1`
22 ASSI&TANT = . N E '
CONTRACT KZ-1297 Page 23
ATTACHMENT XIII
ASSURANCES — NON -CONSTRUCTION PROGRAMS
Public reporting burden for this collection of information is estimated to average 45 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Office of Management and Budget. Paperwork Reduction
Project (0348_0043) , Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions please
contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
I.Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non -Federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
2.Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State,
through any authorized representative, access to and the right to examine all records, books, papers, or
documents related to the award; and will establish a proper accounting system in accordance with generally
accepted accounting standards or agency directives.
3.Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or
presents the appearance of personal or organizational conflict of interest, or personal gain.
4.WM initiate and complete the work within the applicable time frame after receipt of approval of the awarding
agency.
5. Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C.. 4728-4763) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6.Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Title
VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or
national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C.. 1681-1683, and 1685-
1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C..794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act
of 1975, as amended (42 U.S.C.. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism, (g). 523 and 527
of the Public Health Service Act of 1912 (42 U.S.C.. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of
alcohol and drug abuse patient records; (h) Title V111 of the Civil Rights Act of 1968 (42 U.S.C.. 3601 et seq.), as
amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination
provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the
requirements of any other nondiscrimination statute(s) which may apply to the application.
7.Wffl comply, or has already complied, with the requirements of Titles 11 and III of the uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable
treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs.
These requirements apply to all interests in real property acquired for project purposes regardless of Federal
participation in purchases.
8.Wffl comply, as applicable, with the provisions of the Hatch Act (5 U.S.C.. 1501-1508 and 7324-7328), which limit the
political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
9,Will comply, as applicable, with the provisions of the Davis -Bacon Act (40 U.S.C..276a to 276a-7), the Copeland
23
CONTRACT KZ-1297 Page 24
Act (40 U.S.C. 276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333),
regarding labor standards for federally assisted construction subagreements.
10.Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires providers in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000.00 or
more.
I I.Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution
of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of
wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplains in accordance with EO 11988; (e)
assurance of project consistency with the approved State management program developed under the Coastal
Zone Management Act of 1972 (16 U.S.C..1451 et seq.); (0 conformity of Federal actions to State (Clear Air)
Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C..7401 et seq.);
(g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as
amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as
amended, (P.L. 93-205).
12 Will comply with the Wild and Scenic Rivers Act of 1968 components of the national wild and scenic rivers
system. (16 U.S.C.1721 et seq.) related to protecting components or potential
13.Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C.A70), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C..469a-I et seq.).
14.Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development,
and related activities supported by this award of assistance.
15.WiR comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C..2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other
activities supported by this award of assistance.
16.Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C..4801 et seq.), which prohibits the
use of lead- based paint in construction or rehabilitation of residence structures.
17.Wi11 cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Circular No. A-133, Audits of States, Local Governments, and Non -Profit
Organizations.
I SWill comply with all applicable requirements of all other Federal laws, executive orders, regulations and
policies governing this program.
SIGNATURE OF ALTHOR= CERTIFYING OFFICIAL TITLE Mayor
APPLICANT ORGAINIZA-BON Monroe County Board of County j DATE SLTBNIITMD 6-20-2012
Commissioners
A E 0'
Fg#-
-T GO' N,
J
24 4SSiS11AN --,-U
V'
CONTRACT KZ-1297 •.•25
-
[�Il.TlT:
CIVIL RIGHTS COMPLIANCE CHECKLIST
Program/Facility Name A.D.I. Grant
County Monroe
Provider Monroe County BOCC
Address 1100 Simonton Street
Completed By Dotti Albury
City, State, Zip Code Key West, FL 33040
Date 5-2212 1 Telephone 305-2924510
PART 1. READ THE ATTACHED INSTRUCTIONS FOR ILLUSTRATIVE INFORMATION WHICH WILL HELP YOU IN
THE COMPLETION OF THIS FORM.
1. Briefly describe the geographic area served by the program/facility and the type of service provided: The entire Florida
Keys (Monroe County, approximately 120 miles) which are considered rural with some urban characteristics. Services
MCH-IS will provide with this grant is Respite Services.
2. POPULATION OF AREA SERVED. Source of data:
Total#
% White
% Black
% Hispanic
% Other
% Female
73,165
72.3%o
5.7/0
19.6"/o
201/0
460/0
3. STAFF CURRENTLY EMPLOYED. Effective date: 8-15-2011
Total#
% White
1
% Black
% Hispanic
% Other
% Female
% Disabled
20
70.01/t,
30.0"/0
1.00/o
0.01%
80.0"/o
0.011/0
4. CLIENTS CURRENTLY ENROLLED OR REGISTERED Effective
date: 5-22-2012
Total#
% White T
% Black
% Hispanic
% Other
% Female
% Disabled
% Over 40
285
86.8%
1 12.2"/0
16.0)/o
71.0%
72"/0
100"/o
1000/0
5. ADVISORY OR GOVERNING BOARD, IF APPLICABLE.
Total #
°o White
% Black
% Hispanic
10.00%
% Other
% Female
% Disabled
5
100.0"/0
0.0"/0
0.0%
60.0"/o
0.0"/o
PART IL USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE SPACE.
6. Is an Assurance of Compliance on file with the Alliance? If NA or NO explain
NA ❑ YES a No ❑
7. Compare the staff composition to the population. Is staff representative of the population? If NA
or NO, explain.
NA ❑ YES® NO ❑
8.Compare the client composition to the population. Are race and sex characteristics representative of
the Population? If NA or NO, explain.
NA ❑ YES � NCB ❑
W
9.Are eligibility requirements for services applied to clients and applicants without
NAFI YES M)C No F-1
I O.Are all benefits, services and facilities available to applicants and participants in an equally effective
manner regardless of race, sex, color, age, national origin, religion or disability? If NA or NO, explain
NAF-1 YES❑ NO Z
All grants/programs under the AAA that we provide services for are for people 60 and older.
I I.For in -patient services, are room assignments made without regard to race, color, national origin or
disability? If NA or NO, explain.
NARX YES F1 NoF]
We see and provide services to clients in their homes.
12.1s the program/ facility accessible to non-English speaking clients? If NA or NO, explain.
NAF-1 YES NOF-1
13. Are employees arplicants and participants informed of their protection a-ainst
discrimination. I yes, how? Verbalo Written o Postero IfNAorNO,
explain. ❑
14. Give the number and current status of any discrimination complaints
regarding services or employment filed against the program/facility. Zero
M
15. Is the program/facility facility physically accessible to mobility, hearing, and sight -impaired individuals?
C
If NA or 0, explain.
NAF-1 YES MX NO❑
PART 111. THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES
16. Has a self -evaluation been conducted to identify any barriers to serving disabled
individuals, and to make any necessary modifications? If NO, explain
NAF-] YESFX1 No El
17. Is there and established grievance procedure that incorporates due process in
the resolution of complaints? If NO, explain.
NA ❑ YES ZC No 0
18. Has a person been designated to coordinate Section 504 compliance activities? If NO, explain.
NA E1 YES 19 No ❑
19. Do recruitment and notification materials advise applicants, employees and
participants of nondiscrimination on the basis of disability? If NO, explain.
NAE1 YES F)CI No El
19.Are auxiliary aids available to assure accessibility of services to hearing and
sight impaired individuals? If NO, explain.
NA ❑ YES RX NO ❑
M
FE]
M
CONTRACT KZ-1297 Page 28
MW
PART IV. FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF$50,OOOOR
MORE.
21. Do you have a written affirmative action plan? If NO, explain.
NA [—] YES 9 No El
DOEAUSE ONLY
Reviewed By
Incompliance: YES ii NO*
Program Office
*Notice of Corrective Action Sent
Date
Telephone
Response Due
On -Site n Desk Review n
Response Received
DOEA Form 101-A, Revised May 2008 Page 2 of 2
ATTACHMENT XIV
INSTRUCTIONS FOR THE CIVIL RIGHTS COMPLIANCE CHECKLIST
I.Describe the geographic service area such as a district, county, city or other locality. If the
program/ facility serves a specific target population such as adolescents, describe the target
population. Also, define the type of service provided.
2.Enter the percent of the population served by race and sex. The population served includes persons
in the geographical area for which services are provided such as a city, county or other regional area.
Population statistics can be obtained from local chambers of commerce, libraries, or any publication
I
from the 1980 Census containing Florida population statistics. Include the source of your population
statistics. ("Other" races include Asian/ Pacific Islanders and American Indian/Alaskan Natives.)
3.Enter the total number of full-time staff and their percent by race, sex and disability. Include the
effective date of your summary.
4.Enter the total number of clients who are enrolled, registered or currently served by the program or
facility, and list their percent by race, sex and disability. Include the date that enrollment was
counted.
5. Enter the total number of advisory board members and their percent by race, sex, and disability. If
there is no advisory or governing board, leave this section blank.
M
CONTRACT KZ 1297 Page 29
6.Each provider of federal financial assistance must have on file an assurance that the program will be
conducted in compliance with all nondiscriminatory provisions as required in 45 CFR 80. This is
usually a standard part of the contract language for DOEA providers and their sub -grantees, 45 CFR
80.4 (a).
7.1s the race, sex, and national origin of the staff reflective of the general population? For example, if
10% of the population is Hispanic, is there a comparable percentage of Hispanic staff?
S."There there is a significant variation between the race, sex or ethnic composition of the clients and
their
availability in the population, the program/facility has the responsibility to determine the reasons for
such
variation and take whatever action may be necessary to correct any discrimination. Some legitimate
disparities may exist when programs are sanctioned to serve target populations such as elderly or
disabled persons, 45 CFR 80.3 (b) (6).
9. Do eligibility requirements unlawfully exclude persons in protected groups from the provision of
services or employment? Evidence of such may be indicated in staff and client representation
(Questions 3 and 4) and also through on -site record analysis of persons who applied but were denied
services or employment, 45 CFR 80.3 (a) and45CFR80.1 (b) (2).
10.1'articipants or clients must be provided services such as medical, nursing and dental care,
laboratory services, physical and recreational therapies, counseling and social services without
regard to race, sex, color, national origin, religion, age or disability. Courtesy titles, appointment
scheduling and accuracy of record keeping must be applied uniformly and without regard to race,
sex, color, national origin, religion, age or disability. Entrances, waiting rooms, reception areas,
restrooms and other facilities must also be equally available to all clients, 45 CFR 80.3 (b).
I I.For in -patient services, residents must be assigned to rooms, wards, etc., without regard to race,
color, national origin or disability. Also, residents must not be asked whether they are willing to share
accommodations with persons of a different race, color, national origin, or disability, 45 CFR 80.3 (a).
12.Tbe program/facility and all services must be accessible to participants and applicants, including
those persons who may not speak English. hi geographic areas where a significant population of
non-English speaking people live, program accessibility may include the employment of bilingual
staff. In other areas, it is sufficient to have a policy or plan for service, such as a current list of names
and telephone numbers of bilingual individuals who will assist in the provision of services, 45 CFR
80.3 (a).
13.Programs/ facilities must make information regarding the nondiscriminatory provisions of
Title VI available to their participants, beneficiaries or any other interested parties. This
should include information on their right to file a complaint of discrimination with either the
Florida Alliance of Elder Affairs or the U.S. Alliance of HHS. The information may be
supplied verbally or in writing to every individual, or may be supplied through the use of an
equal opportunity policy poster displayed in a public area of the facility, 45 CFR 80.6 (d).
14.Report number of discrimination complaints filed against the program/ facility. Indicate
the basis, e.g., race, color, creed, sex, age, national origin, disability, retaliation; the issues
involved, e.g., services or employment, placement, termination, etc. Indicate the civil rights
law or policy alleged to have been violated along with the name and address of the local,
M
I =.
state or federal agency with whom the complaint has been filed. Indicate the current status,
e.g., settled, no reasonable cause found, failure to conciliate, failure to cooperate, under
review, etc.
15.The program/ facility must be physically accessible to disabled individuals. Physical
accessibility includes designated parking areas, curb cuts or level approaches, ramps and
adequate widths to entrances. The lobby, public telephone, restroom facilities, water
fountains, information and admissions offices should be accessible. Door widths and traffic
areas of administrative offices, cafeterias, restrooms, recreation areas, counters and serving
lines should be observed for accessibility. Elevators should be observed for door width, and
Braille or raised numbers. Switches and controls for light, heat, ventilation, fire alarms, and
other essentials should be
installed at an appropriate height for mobility impaired individuals.
16.Section 504 of the Rehabilitation Act of 1973 requires that a provider of federal financial
assistance conduct a self -evaluation to identify any accessibility barriers. Self -evaluation is a
four step process:
-With the assistance of a disabled individual/ organization, evaluate current practices
and policies which do not comply with Section 504.
-Modify policies and practices that do not meet Section 504 requirements.
-Take remedial steps to eliminate any discrimination that has been identified.
-Maintain self -evaluation on file. (This checklist may be used to satisfy this
requirement if these four steps have been followed.), 45 CFR 84.6.
17.Programs; or facilities that employ 15 or more persons must adopt grievance procedures
that incorporate appropriate due process standards and provide for the prompt and equitable
resolution of complaints alleging any action prohibited by Section 504.45 CFR 84.7 (b).
18.Programs or facilities that employ 15 or more persons must designate at least one person to
coordinate efforts to comply with Section 504.45 CFR 84.7 (a).
19.Continuing steps must be taken to notify employees and the public of the
program/ facility's policy of nondiscrimination on the basis of disability. This includes
recruitment material, notices for hearings, newspaper ads, and other appropriate written
communication, 45 CFR 84.8 (a).
20.Programs/ facilities that employ 15 or more persons must provide appropriate auxiliary
aids to persons with impaired sensory, manual or speaking skills where necessary. Auxiliary
aids may include, but are not limited to, interpreters for hearing impaired individuals, taped
or Braille materials, or any alternative resources that can be used to provide equally effective
services, (45 CFR 84.52 (d)-
21.Programs/ facilities with 50 or more employees and $50,000 in federal contracts must
develop, implement and maintain a written affirmative action compliance program in
accordance with Executive Order 11246. 41 CFR 60 and Title VI of the Civil Rights Act of
1964, as amended.
NN
CONTRACT KZ 1297
ATTACHMENT XV
Verification of Employment Status Certification
As a condition of contracting with the Alliance for Aging, Inc., Monroe County Board of
Commissioners, hereby referred to as contractor, certifies the use of the U.S. Department of
Homeland Security's E-verify system to verify the employment eligibility of all new employees
hired by Contractor during the contract term to perform employment duties pursuant to this
Agreement and (b) that any subcontracts include an express requirement that subcontractors
performing work or providing services pursuant to this Agreement utilize the E-verify system to
verify the employment eligibility of all new employees hired by the subcontractor during the
contract term.
Signature
(Same as contract signature)
Mayor
Title
6-20-2012
Date
_Monroe County Board of County Commissioners
Company Name
m
CONTRACT KZ 1297
ATTACHK8ENTXVI
Alliance for Aging, Inc.
Business Associate Agreement
This Business Associate Agreement isdated bythe Alliance for
Aging, Inc ("Covered Entity") and . ("Business Associate"),
a not -for -profit Florida corporation.
1.0 Background.
11 Covered Entity has entered into one or more contracts or agreements with Business
Associate that involves the use nfProtected Health Information (PHI).
1.2 Covered Entity, recognizes the requirements of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and has indicated its intent to comply in the County's Policies and
Procedures.
13 HIPAA regulations establish specific conditions on when and how covered entities may
share information with contractors who perform functions for the Covered Entity.
14 H|PAArequires the Covered Entity and the Business Associate 0oenter into acontract
oragreement containing specific requirements to protect the confidentiality and security nfpatients' PHI,
as set forth in, but not limited to the Code of Federal Regulations (C.F.R.), specifically 45 C.F.R. §§
164.502(e). 104.504(e). 164.308(b). and 104.314(a-b)(2O18)(as may apply) and contained in this
agreement.
1.5 The Health Information Technology for Economic and Clinical Health Act (2009), the
American Recovery and Reinvestment Act (2009) and Part I — Improved Privacy Provisions and Security
provisions located at42United States Code (U.S.Cj§§17031and 17034(2818)require business
aa000iotmo of covered entities to comply with the H|PAA Security Ru|e, as set forth in, but not limited to 45
C�F.R, §§184.3O8.184.31O.1S4.312.and 1S4.310(28OA) and such sections shall apply toobusiness
associate of a covered entity in the same manner that such sections apply to the covered entity.
The parties therefore agree as follows:
2.0 Definitions. For purposes ofthis agreement, the following definitions apply:
21 Access. The ability orthe means necessary toread, write, modify, orcommunicate
data/information orotherwise use any system resource.
2.2 Administrative Safeguards. The administrative actions, and policies and procedures, t*
manage the selection, development, implementation, and maintenance of security measures to protect
electronic Protected Health Information (ePHI) and to manage the conduct of the covered entity's
workforce in relation to the protection of that information.
2.3 ARRA. The American Recovery and Reinvestment Act (2009)
CONTRACT KZ 1297 Page 33
2.4 Authentication. The corroboration that a person imthe one claimed.
2.5 Availability. The property that data orinformation isaccessible and useable upon
demand byanauthorized person.
2.8 Breach. The unauthorized acquisition, access, use, nrdisclosure ufPHI which
compromises the security orprivacy Vfsuch information.
27 Compromises the Security. Posing osignificant risk nffinancial, reputadnna|.nrother
harm to individuals.
2.8 Confidentiality. The property that data or information is not made available or disclosed
to unauthorized persons or processes.
2.9 Electronic Protected Health |nfmrnnmtimn.(mpH|) Health information aospecified in45
CFR §1 60.103(l)(i) or (1)(ii), limited to the information created or received by Business Associate from or
on behalf nfCovered Entity.
210 HITECH.The Health Information Technology for Economic and Clinical Health Act (2�}8y)
211 Information System. An interconnected set nfinformation resources under the same
direct management control that shares common functionality. Asystem normally includes hardware,
software, information, data, applications, communications, and people.
212 Integrity. The property that data or information have not been altered or destroyed in an
unauthorized manner.
system.
213 Malicious software. Software, for example, avirus, designed todamage nrdisrupts o
214 Pmrti Par I — Improved Privacy Provisions and Security provisions located at 42 United
215 Pmaovxmrd. Confidential authentication information composed of a string of characters.
216 Physical Safeguards. The physical measures, policies, and procedures tnprotect a
covered entity's electronic information systems and related buildings and equipment, from natural and
environmental hazards, and unauthorized intrusion.
2.17 Privacy Rule. The Standards for Privacy nfIndividually Identifiable Health Information at
45CFRPart 18Uand Part 184.subparts Aand E
2.18 Protected Health Information. (PR|) Health information endefined in45CFR
§160.103, limited to the information created or received by Business Associate from or on behalf of
Covered Entity.
2.19 Required By Law. Has the same meaning as the term "required by law" in 45 CFR §
164101
2.20 Secretary. The Secretary of the Department of Health and Human Services or his or her
designee.
2.21 Security incident. The attempted or successful unauthorized access, use, disclosure,
mndifination, or destruction of information orinterference with system operations in an information
system.
2.22 Security or Security measures. All of the administrative, physical, and technical
safeguards |naninformation system.
33
2.23 Security Rule. The Security Standards for the protection of Electronic Protected Health
Information at 45 CFR part 164, subpart C, and amendments thereto.
2.24 Technical Safeguards. The technology and the policy and procedures for its use that
protect electronic protected health information and control access to it.
2.25 Unsecured PHI. Protected health information that is not secured through the use of
technology or methodology specified by the Secretary in guidance issued under 42 U.S.C. section
17932(h)(2).
2.26 All other terms used, but not otherwise defined, in this Agreement shall have the same
meaning as those terms in the Privacy Rule.
3.0. Obligations and Activities of Business Associate.
3.1 Business Associate agrees to not use or disclose PHI other than as permitted or required
by this agreement or as Required by Law.
3.2 Business Associate agrees to:
(a) Implement policies and procedures to prevent, detect, contain and correct
Security violations in accordance with 45 CFR § 164.306;
(b) Prevent use or disclosure of the PHI other than as provided for by this
Agreement or as required by law;
(c) Reasonably and appropriately protect the confidentiality, integrity, and availability
of the ePHI that the Business Associate creates, receives, maintains, or transmits on behalf of the
Covered Entity; and
(d) Comply with the Security Rule requirements including the Administrative
Safeguards, Physical Safeguards, Technical Safeguards, and policies and procedures and
documentation requirements set forth in 45 CFR §§ 164.308, 164.310, 164.312, and 164.316.
3.3 Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is
known to Business Associate of a use or disclosure of PHI by Business Associate in violation of the
requirements of this Agreement.
3.4 Business Associate agrees to promptly report to Covered Entity any use or disclosure of
the PHI not provided for by this Agreement of which it becomes aware. This includes any requests for
inspection, copying or amendment of such information and including any security incident involving PHI.
3.5 Business Associate agrees to notify Covered Entity without unreasonable delay of any
security breach pertaining to:
(a) Identification of any individual whose unsecured PHI has been, or is reasonably
believed by the Business Associate to have been, accessed, acquired, or disclosed during such security
breach; and
(b) All information required for the Notice to the Secretary of HHS of Breach of
Unsecured Protected Health Information.
.i • .i` • i • i i i •
it • ' `# # • '� a 4 # •• #
agrees to the same restrictionsand conditions that apply• # Agreement to Business Associate
respectwith • such information.
3.7 If Business Associate has PHI in a Designated Record Set:
34
CONTRACT KZ 1297
(a) Business Associate agrees to provide access, at the request of Covered Entity
during regular business hours, to PHI in a Designated Record Set, to Covered Entity or, as directed by
Covered Entity, to an individual in order to meet the requirements under 45 CFR §164.524; and
(b) Business Associate agrees to make any amendment(s) to PHI in a Designated
Record Set that the Covered Entity directs or agrees to pursuant to 45 CFR § 164.526 at the request of
Covered Entity or an Individual within 10 business days of receiving the request.
3.8 Business Associate agrees to make internal practices, books, and records, including
policies and procedures and PHI, relating to the use and disclosure of PHI received from, or created or
received by Business Associate on behalf of Covered Entity, available to the Covered Entity or to the
Secretary upon request of either for purposes of determining Covered Entity's compliance with the
Privacy Rule.
3.9 Business Associate agrees to document such disclosures of PHI and information related
to such disclosures as would be required for Covered Entity to respond to a request by an individual for
an accounting of disclosures of PHI in accordance with 45 CFR § 164.528.
3.10 Business Associate agrees to provide to Covered Entity or an individual, upon request,
information collected in accordance with Paragraphs h and i above, to permit Covered Entity to respond
to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 CFR §
164.528 and ARRA § 13404.
3.11 Business Associate specifically agrees to use security measures that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI in electronic or any other form,
that it creates, receives, maintains, or transmits on behalf of the Covered Entity.
3.12 Business Associate agrees to implement security measures to secure passwords used to
access ePHI that it accesses, maintains, or transmits as part of this Agreement from malicious software
and other man-made and natural vulnerabilities to assure the availability, integrity, and confidentiality of
such information.
3.13 Business Associate agrees to implement security measures to safeguard ePHI that it
accesses, maintains, or transmits as part of this agreement from malicious software and other man-made
and natural vulnerabilities to assure the availability, integrity, and confidentiality of such information.
3.14 Business Associate agrees to comply with:
(a) ARRA § 13404 (Application of Knowledge Elements Associated with Contracts);
(b) ARRA § 13405 (Restrictions on Certain Disclosures and Sales of Health
Information); and
(c) ARRA § 13406 (Conditions on Certain Contacts as Part of Health Care
4.0 Permitted Uses and Disclosures by Business Associate. Except as otherwise limited
in this Agreement or any related agreement, Business Associate may use or disclose PHI to perform
functions, activities, or services for, or on behalf of, Covered Entity as specified in any and all contracts
with Covered Entity provided that such use or disclosure would not violate the Privacy Rule if done by
Covered Entity or the minimum necessary policies and procedures of the Covered Entity.
5.0 Specific Use and Disclosure Provisions.
Except5.1 otherwise limited in this agreement or -• agreement,
Associate may use PHI for the proper management and administration of the Business Associate or to
carry out the legal responsibilities of the Business Associate.
5.2 Except as otherwise limited in this agreement or any related agreement, Business
Associate may disclose PHI for the proper management and administration of the Business Associate,
35
provided that disclosures are Required By Law, or Business Associate obtains reasonable assurances
from the person to whom the information is disclosed that it will remain confidential and used or further
disclosed only as Required By Law or for the purpose for which it was disclosed to the person, and the
person notifies the Business Associate of any instances of which it is aware in which the confidentiality of
the information has been breached.
5.3 Business Associate may use PHI to provide data aggregation services to Covered Entity
as permitted by 45 CFR §164.504(e)(2)(i)(B), only when specifically authorized by Covered Entity.
5.4 Business Associate may use PHI to report violations of law to appropriate Federal and
State authorities, consistent with 45 CFR §164.502(j)(1).
6.0 Obligations of Covered Entity.
6.1 Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy
practices of Covered Entity in accordance with 45 CFR § 164.520, to the extent that such limitation may
affect Business Associate's use or disclosure of PHI, by providing a copy of the most current Notice of
Privacy Practices (NPP) to Business Associate as Attachment 1 to this Agreement. Future Notices and/or
modifications to the NPP shall be posted on Covered Entity's website at www.allianceforaging.org.
6.2 Covered Entity shall notify Business Associate of any restriction to the use or disclosure
of PHI that Covered Entity has agreed to in accordance with 45 CFR § 164.522, to the extent that such
restriction may affect Business Associate's use or disclosure of PHI.
7.0 Permissible Requests by Covered Entity. Except for data aggregation or management
and administrative activities of Business Associate, Covered Entity shall not request Business Associate
to use or disclose PHI in any manner that would not be permissible under the Privacy Rule if done by
Covered Entity.
8.0 Effective Date and Termination.
8.1 The Parties hereby agree that this agreement amends, restates and replaces any other
Business Associate Agreement currently in effect between Covered Entity and Business Associate and
that the provisions of this agreement shall be effective as follows:
(a) These Business Associate Agreement provisions, with the exception of the
electronic security provisions and the provisions mandated by ARRA, HITECH and Part I shall be
effective upon the later of April 14, 2003, or the effective date of the earliest contract entered into between
Business Associate and Covered Entity that involves the use of PHI;
(b) The electronic security provisions hereof shall be effective the later of April 21,
2005 or the effective date of the earliest contract entered into between Business Associate and Covered
Entity that involves the use of PHI; and
(c) Provisions hereof mandated by ARRA, HITECH and/or Part I shall be effective
the later of February 17, 2010 or the effective date of the earliest contract entered into between covered
entity and business associate that involves the use of PHI or ePHI.
8.2 Termination for Cause. Upon Covered Entity's knowledge of a material breach by
Business Associate, Covered Entity shall either:
(a) Provide an opportunity for Business Associate to cure the breach or end the
violation and terminate this agreement if Business Associate does not cure the breach or end the violation
within the time specified by Covered Entity;
(b) Immediately terminate this agreement if Business Associate has breached a
material term of this Agreement and cure is not possible: or
(c) If neither termination nor cure is feasible, Covered Entity shall report the violation
to the Secretary.
36
Page 37
8.3 Effect of Termination. Except as provided in subparagraph (b) of this section, upon
termination of this agreement, for any reason, Business Associate shall return all PHI and ePHI received
from Covered Entity, or created or received by Business Associate on behalf of Covered Entity.
(a) This provision shall apply to PHI and ePHI that is in the possession of
subcontractors or agents of Business Associate. Business Associate shall retain no copies of the PHI
and ePHI.
(b) In the event that Business Associate or Covered Entity determines that returning
the PHI or ePHI is infeasible, notification of the conditions that make return of PHI or ePHI infeasible shall
be provided to the other party. Business Associate shall extend the protections of this Agreement to such
retained PHI and ePHI and limit further uses and disclosures of such retained PHI and ePHI, for a
minimum of six years and so long as Business Associate maintains such PHI and ePHI, but no less than
six (6) years after the termination of this agreement.
9.0 Regulatory References. A reference in this agreement to a section in the Privacy Rule
or Security Rule means the section then in effect or as may be amended in the future.
10.0 Amendment. The Parties agree to take such action as is necessary to amend this
agreement from time to time as is necessary for Covered Entity to comply with the requirements of the
Privacy Rule, the Security Rule and the Health Insurance Portability and Accountability Act of 1996, Pub.
L. No. 104-191.
11.0 Survival. Any term, condition, covenant or obligation which requires performance by
either party hereto subsequent to the termination of this agreement shall remain enforceable against such
party subsequent to such termination.
12.0 Interpretation. Any ambiguity in this agreement shall be resolved to permit Covered
Entity to comply with the Privacy Rule and Security Rule.
13.0 Incorporation by reference. Any future new requirement(s), changes or deletion(s)
enacted in federal law which create new or different obligations with respect to HIPAA privacy and/or
security, shall be automatically incorporated by reference to this Business Associate Agreement on the
respective effective date(s).
14.0 Notices. All notices and communications required, necessary or desired to be given
pursuant to this agreement, including a change of address for purposes of such notices and
communications, shall be in writing and delivered personally to the other party or sent by express 24-hour
guaranteed courier or delivery service, or by certified mail of the United States Postal Service, postage
prepaid and return receipt requested, addressed to the other party as follows (or to such other place as
any party may by notice to the others specify):
To Covered Entity: Alliance for Aging, Inc.
Attention: Max Rothman
760 NW 107 Avenue
Miami, Florida 33172
To Business Associate: Monroe County BOCC
Attn: Sheryl Graham, director, Social Services
1100 Simonton Street Rm. 2-257
Key West, FI 33040
Any such notice shall be deemed delivered upon actual receipt,. . `• or
delivery thereof is refused, delivery will be deemed to have occurred on the date such delivery was
attempted.
RE
15.0 Governing Law. The laws of the State ofFlorida, without giving effect toprinciples of
conflict of laws, govern all matters arising under this agreement.
16.0 Severabi!by. Ifany provision inthis agreement isunenforceable tnany extent, the
remainder of this agreement, or application of that provision to any persons or circumstances other than
those as to which it is held unenforceable, will not be affected by that unenforceability and will be
enforceable to the fullest extent permitted by law.
17.0 Successors. Any successor toBusiness Associate (whether bvdirect or indirect or by
purchase, merger, consolidation, or otherwise) is required to assume Business Associate's obligations
under this agreement and agree to perform them in the same manner and to the same extent that
Business Associate would have been required to if that succession had not taken place. This assumption
by the successor of the Business Associate's obligations shall be by written agreement satisfactory to
Covered Entity.
18.8 Entire Agreement. This agreement constitutes the entire agreement ofthe parties
relating to the subject matter of this agreement and supersedes all other oral or written agreements or
policies relating thereto, except that this agreement does not limit the amendment of this agreement in
accordance with section 10.0nfthis agreement.
Covered Entity:
Date:
Business Associate: Monroe County Board of County Commissioners
(signature)
Date: 6-20-2012
BE
Page 1 CONTRACT KZ-1197
ALZHEIMERS' DISEASE INITIATIVE CONTRACT
2011-2012
THIS AGREEMENT is entered into between the Alliance for Aging, Inc., hereinafter
referred to as the "Alliance" and "Monroe County Board of Commisioners.", hereinafter
referred to as the "provider." THIS CONTRACT IS SUBJECT TO FURTHER
MODIFICATION IN ORDER TO INCORPORATE CERTAIN PASS -THROUGH
LANGUAGE REQUIRED BY THE STATE OF FLORIDA DEPARTMENT OF ELDER
AFFAIRS. ALL SUBSEQUENT MODIFICATIONS WILL BE MADE THROUGH
AMENDMENTS TO THIS CONTRACT.
Attachment 1, 11, Ill, IV, V, VI, VII, Viii, IX, X, XI, XII, XIII, and XIV are integral to this
Agreement
I. Provider Agrees:
A. Services to be Provided:
1. The provider's service provider application for state fiscal year 2011 and any
revisions thereto approved by the Alliance and located in the contract manager's
file, are incorporated by reference in this contract between the Alliance and the
provider, and prescribe the services to be rendered by the provider.
2. Consumers may not be enrolled in a Department of Elder Affairs' state general
revenue funded program, including ADI, who are also enrolled in a Medicaid
capitated long-term care health plan or program. These programs include the
Frail Elder Program operated by United Health Care, the Channeling Program
operated by Miami Jewish Home and Hospital for the Aged, the Long Term Care
Community Diversion Program and the Program of All Inclusive Care for the
Elderly (PACE) program scheduled to begin operation in the Miami -Dade
County area.
B. Manner of Service Provision:
The services will be provided in a manner consistent with and described in the provider's
service provider application for state fiscal year 2011 and the 2009 Department of Elder
Affairs Home and Community Based Services Handbook. In the event the handbook is
revised, such revision will automatically be incorporated into the contract and the
provider will be given a copy of the revisions.
11. The Alliance Agrees:
A. Contract Amount:
To pay for services in an amount not to exceed $56,746, subject to the availability of
funds.
Obligation to Pay:
The Alliiance's performance and obligation to pay under this contract is contingent upon
an annual appropriation by the Legislature.
B. Source of Funds:
C 1
r M
i
CONTRACT KZ-119i= Page 2
The costs of services paid under any other contract or from any other source are not
eligible for reimbursement under this contract. The funds awarded to the provider
pursuant to this contract are in the state grants and aids appropriations.
111. Provider and Alliance Mutually Agree:
A. Effective Date:
1. This contract shall begin on July 1, 2011 or on the date the contract has been
signed by both parties, whichever is later.
2. Delivery of services shall end on June 30, 2012.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed by
their undersigned officials as duly authorized.
PROVIDER:
SIGNED BY:
NAME:
TITLE:
DATE:
Mayor
5-18-2011
County Board of
nmisioners.
REDRO J
ASSISTAN�
ALLIANCE FOR AGING, INC.
SIGNED BY:
NAME:
Max B. Rothman, JD, LL.M.
TITLE:
President & CEO
DATE:
AS TO
EY
RNEY V 7
u
2
CONTRACT KZ-1197`,; Page 3
1. STATEMENT OF PURPOSE
The Alzheimer's Disease Initiative (ADI) Program is focused on caring for persons 18 + with
memory disorders.
A. Services:
1. The provider's service provider application for state fiscal year 2011 and any
revisions thereto approved by the Alliance and located in the contract manager's
file, are incorporated by reference in this contract between the Alliance and the
provider, and prescribe the services to be rendered by the provider.
2. Consumers may not be enrolled in a Department of Elder Affairs' state general
revenue funded program, including ADI, who are also enrolled in a Medicaid
capitated long-term care health plan or program. These programs include the
Frail Elder Program operated by United Health Care, the Channeling Program
operated by Miami Jewish Home and Hospital for the Aged, the Long Term Care
Community Diversion Program operating in Planning and Service Areas 7 and
9, and any other areas that may participate in the Long Term Care Diversion
Program through expansion and the Program of All Inclusive Care for the
Elderly (PACE) program scheduled to begin operation in the Miami -Dade
County area.
E. Manner of Service Provision:
The services will be provided in a manner consistent with and described in the
provider's service provider application for state fiscal year 2011 and the 2009
Department of Elder Affairs Home and Community Based Services Handbook. In
the event the handbook is revised, such revision will automatically be incorporated
into the contract and the provider will be given a copy of the revisions.
CONTRACT KZ-11197Page 4
A. The method of payment in this contract is based on a fixed rate reimbursement for
approved services. The provider must ensure fixed rates include only those costs
that are in accordance with all applicable state and federal statutes and regulations
and are based on audited historical costs in instances where an independent audit is
required. All requests for payment and expenditure reports submitted to support
requests for payment shall be on DOEA forms 106Z and 105Z. Duplication or
replication of both forms via data processing equipment is permissible, provided all
data elements are in the same format as included on departmental forms.
B. Invoices must be submitted no later than 90 days after the end of the month on
which the expense was incurred, except that invoices can not be submitted after
close out report date (usually July 15th.) Invoices submitted late will not paid.
Exceptions to this rule are at the discretion of the Alliance, on a case by case basis;
such exceptions must be requested prior to the expiration of the invoicing deadline.
In making a determination of the exception the Alliance will consider whether the
disruption to the billing cycle was beyond the control of the provider, the frequency
with which such exceptions are requested by the provider, and whether the Alliance
can request reimbursement at a late date from DOEA.
C. The provider shall maintain documentation to support payment requests which shall
be available to the Comptroller, the Department of Elder Affairs, or the Alliance upon
request.
D. The provider shall maintain documentation to support payment requests which shall
be available to the Alliance, the Department of Elder Affairs or the Comptroller upon
request.
E. The provider may request a monthly advance for service costs for each of the first
two months of the contract period, based on anticipated cash needs. Detailed
documentation justifying cash needs for advances must be submitted with the signed
contract, approved by the Alliance, and maintained in the contract manager's file. All
payment requests for the third through the twelfth months shall be based on the
submission of monthly actual expenditure reports beginning with the first month of
the contract. The schedule for submission of advance requests is ATTACHMENT 11
to this contract. Reconciliation and recouping of advances made under this contract
are to be completed by March and April. All advance payments are subject to the
availability of funds.
F. Advance funds may be temporarily invested by the provider in an insured interest
bearing account. All interest earned on contract fund advances must be returned to
the Alliance within thirty (30) days of the end of the first quarter of the contract
period.
AllianceG. The payment totheprovider foprovision ofservices up to
a maximum number ofunitsofservice and • belowL
Maximum I
Service to be Provided Service Units of Maximum
Unit Rate Dollars
Service
In Flame respite � Z24,03 2,36$56,746
11
CONTRACT KZ-1197` ,J Page 5
H.
Any payment due by the Alliance under the terms of this contract may be withheld
pending the receipt and approval by the Alliance of complete and accurate financia'
and programmatic reports due from the provider and any adjustments thereto,
including any disallowance it resolved
A. State Laws and Regulations:
The provider agrees to comply with applicable parts of Rule 58D-1, Florida
Administrative Code promulgated for administration of Sections 430.501 through
430.504, Florida Statutes, and the 2009 Department of Elder Affairs Client Home
and Community Based Services Handbook.
B. Assessment and Prioritization for Service Delivery for New Consumers:
The following are the criteria to prioritize new consumers for service delivery. It is
not the intent of the Department of Elder Affairs to remove existing clients from any
program in order to serve new clients being assessed and prioritized for service
delivery.
1. Priority Criteria for Service Delivery:
a. individuals in nursing homes under Medicaid who could be transferred to
the community;
b. individuals in nursing homes whose Medicare coverage is exhausted and
may be diverted to the community;
c. individuals in nursing homes which are closing and can be discharged to
the community; or
d. individuals whose mental or physical health condition has deteriorated to
the degree self care is not possible, there is no capable caregiver and
institutional placement will occur within 72 hours.
2. Priority Criteria for tither Assessed Individuals:
means of service delivery. Functional impairment shall be determined through the
department's consumer assessment form administered to each applicant. The most frail
individuals not prioritized in groups one, two or three above, regardless of referral source,
will receive services to the extent funding is available.
1, The provider will establish annual co -payment goals. The Alliance also has the
option to withhold a portion of the provider's Request for Payment if goals are
not ## i to the Departmentof Affairs'i guidelines,
2. include only the amounts assessed consumers O[the amounts
consumers opt to contribute iDlieu Of8Oassessed CO-p8y[Oert. The
contribution must be equal b]Or greater than the assessed CO-p@y[nenL
The provider agrees kJ respond hOrequests for evaluation information and statistical data
concerning its consumers based on information requirements of the Memory Disorder
Clinics and Brain Bank. The provider will ensure Model Day Care Centers supported by
this contract develop innovative therapies and interventions which can be shared with
other Alzheimer's Disease Initiative health and social services personnel via training,
Model Day Care Centers supported by this contract must report to the provider all
(raining activities provided to health care and social service personnel and caregivers, as
well as oen/a as a natural laboratory for service related applied research by K8arnory
Disorder Clinics. An annual Model Day Cara Center Training RepOrt, ATTACHMENT
IV, iSdue byJuly 5,2O1i.
E. Collaboration with Memory Disorder Clinics:
Memory Disorder Clinics any required to provide four hours of in-service training to all respite and
model day care centers in their designated service areas. The provider agrees to collaborate with
Memory Disorder Clinics to assist in this effort.
F. Service Cost Reports:
The provider will submit semi-annual service cost reports which reflect actual costs of providing each
service by program. This report provides iOhJrnl8dOn for planning and negotiating unit rates.
CONTRACT KZ-1 197
Report SasegLon
Number
1 July Advance * ...............................................................
2 August Advance * .............................. ................ ...........
3 July Expenditure Report ....................................................
4 August Expenditure Report ................................................
5 September Expenditure Report ...........................................
6 October Expenditure Report ...............................................
7 November Expenditure Report ............................................
8 December Expenditure Report ............................................
9 January Expenditure Report / ...............................................
10 February Expenditure Report /July Advance Reconciliation
11 March Expenditure Report /August Advance Reconciliation
12 April Expenditure Report ....................................................
13 May Expenditure Report ....................................................
14 June Expenditure Report ....................................................
16 Final Expenditure and Closeout Report .................................
Legend: Advance based on projected cash need.
ATTACHMENT 11
•V- I" �"'# ft*-Y-Art �
Submit
to the Alliance
on This Date
July 1
July 1
August 10
September 10
October 10
November 10
December 10
January 10
February 10
March 10
April 10
May 10
June 10
July 10
July 20
Submission of expenditure reports may or may not generate a payment request.
If final expenditure report reflects funds due back to the Alliance, payment is to
accompany the report.
Note # 1: Report #1 for Advance Basis Contracts cannot be submitted to the Alliance prior to July 1 or
until the contract with the Alliance has been executed. Actual submission of the vouchers to the
Department of Elder Affairs is dependent on the accuracy of the expenditure report.
N
w CONTRACT KZ-1197 Page 8
Model Day Care Center Name:
Printed Name of Person
Completing Report
Signature of Person
Completing Report
ATTACHMENT III
Date Executed
The purpose of each model day care program must be to provide service delivery to persons suffering from
Alzheimers disease or a related memory disorder and training for health care and social service personnel in
the care of persons having Alzheimer's disease or related memory disorders. This report documents the
required training for the State Fiscal Year July 1st through June 30th.
Actual Training Event(s)
Number
Health Care
Professiona
Is Trained
Number
Social
Services
Personne
I
Trained
Total
People
Trained
Training Title:
Date:
Training Summary:
i
I
3
I
CONTRACTKZ~1 197 Page 9
L Under this Contract, the provider agrees to the following:
A. Perform ARCOUtsOUrCed functions in accordance with policies and procedures developed by
the AJU3DCe for Aging. Refer to the following attachments:
|. Att8ChDl8DtV: Policies and PnOCedUFeS fOr[)utsOU[Ced Function -Screening
|i. Attachment V|: Policies and Procedures fOr[)utSOUrCed Function -Triage
iii. Attachment V||: Policies and P[OC8dUr8S for A[tiV8dOD from VV8iUist- Client
Services
iv. Attachment V|||: Policies and P[OCedUFeS for Termination from VV8iU|st- Client
GarviC8e
B. Maintain wait lists in C|RTG in accordance with D(}EAr8qUirerneOtG.
C. Report number ofclient contacts to the Aging Resource Center.
D. Adhere tOprioritization policy aSset forth bythe Department OfElder Affairs.
E. Update the agency Disaster Plan toincorporate ARC outeourcedfunctions.
F. Ensure against COnOiotS of interest and inappropriate self -referrals by referring consumers in
need of options counseling or long-term care services beyond the provider's scope of services
tothe Aging Resource Center.
G. Ensure that services provided are in the clients' bast interest, are the most cost affactive, of
high quality, and are responsive and appropriate tothe assessed needs.
The Assessed Priority Consumer List (APCL)kSmaintained when services funded bvUladSpa�Dment are
not available. Contracted providers of registered services for/\bchainle�a OiaSaSa Initiative
(AJD|). C}lda[
American's /\ot ({]A4). and Contracted Services (CS) maintain waiting lists in the C|RTS database for
registered services when funding is not available. Note: {}/\A3E is an exempt funding source for ARC Wait
List purposes. For services provided through [)/V\3E. no C/FlTS client data entry is required.
Registered Services for the above listed programs are aefollows: Adult Day Care (AD(�\.Adult OevHa8/th
{�anSA\�HC) Chore Eaco�/E�{�\ Home Homemaker Model ^ ��
, '. ` '. ` '. ` '. r, n'. Day na
CONTRACT KZ~1197 Page 10
Attachment V
Policy and Procedure
Outsourced function - Screening
Objective: To ensure that a comprehensive list of clients in need of services is maintained in CIRTS by
appropriate funding sOW[C8 and that the ARC is Ule[Gh« able to effectively gauge the level of elder
service need iDMiami-Dade and Monroe Counties.
Policy: To obtain necessary iOfO[DlaUnR from clients in order k}assist in determining level of need and
eligibility for DOEA funded services
F»rmoedoma:
1ARC Contracted Providers will collect information from callers and conduct a 701 A assessment.
/Ukyrnativak/. if 701B 8SSSsSrnent already exists or is provided from another source U.S. CARES)
the information from the 701 B can be utilized.
2. Based on the information provided via the 701A(B) assessment, the ARC Contracted Provider will
make a determination as to the services that the caller is in need of receiving (see Contract
ArnandrnantApCL).
3. The ARC Contracted Provider will determine the appropriate funding source(s) that provides the
needed services (see Contract Amendment APCL).
4. If the caller isinneed ofasenice(s)that is not provided by the ARC Contracted Provider, the ARC
Contracted Provider will refer caller to the ARC Elder He/p|ina utilizing the ARC RafSno/ Form
and/or ioanARC Contracted Provider that provides the needed service.
5. The caller will ba provided with general information regarding the ARC aswell aathe ARC Elder
H8|p/iO8contact number.
0. The caller will beinformed of the services and funding sources that they are being placed on the
wait list for in CIRTS.
7. ARC Contracted Provider will create 3 client record in C/RT8 (if there is no existing record) and
enter the services needed for the caller by funding source and service. [If there is an existing record
inC|RT8.the appropriate fields will bSupd3LSd].
O. If the ARC Contracted Provider determines that the caller may qualify for more than one funding
source, ARC Contracted Provider iSencouraged b}enter the appropriate information under multiple
funding sources. [if there is an existing client DgoDrd in C|RT8. the client record in C|RT8 will be
9, ARC Contracted Provider will inform caller that they will receive a follow-up call (or home visit in
case of active client) to check on their status based on DOEA Wait List Reassessment Standards
and encourage caller to contact the ARC Elder Helpline with any questions.
In
CONTRACT KZ-1197 Page 11
Attachment VI
Objective: To ensure that clients in need of DOEA funded services receive services based on the highest
level of need, first, as funding becomes available.
Policy: To assist clients in obtaining DOEA funded services as funding becomes available, based on level
of need as determined by a CIRTS priority score.
Procedure:
1. ARC Contracted Provider will conduct periodic follow-up calls (or home visit in case of active client) to
check on client status based on DOEA Wait List Reassessment Standards.
2. Based on the information provided via the 701 A(B) assessment, the ARC Contracted Provider will
update the client information in CIRTS specifically as it pertains to level of need for services by
funding source
3. The ARC Contracted Provider will ensure that the CIRTS prioritization score is accurately maintained,
according to DOER Standards.
4. if the caller is in need of a service(s) that is not provided by the ARC Contracted Provider, the ARC
Contracted Provider will refer caller to the ARC Elder Helpline utilizing the ARC Referral Form and/or
to an ARC Contracted Provider that provides the needed service.
5. The caller will be informed of the services and funding sources that they remain on the wait list for
and/or have been removed from the wait list for.
6. ARC Contracted Provider will advise client of any change in their CIRTS priority score based on the
updated information.
7. ARC Contracted Provider will remind client of the ARC Eider Help Line contact number and to contact
the ARC Eider Help Line with any questions or concerns.
3. As funding becomes available, ARC Contracted Provider will run CIRTS Prioritization Report and
activate clients according to DOEA Standards (refer to ARC Client Activation Policies and
Procedures). The Contracted Provider will apply targeting criteria, as appropriate, to prioritized clients
to ensure activations meet programmatic requirements.
179
CONTRACT KZ-1197 Page 12
Attachment VII
Alliance for • f !
PolicyiProcedurefor Activation From
Objective: To ensure that elders in need of DOEA funded services in Miami -Dade and Monroe Counties and
on the CIRTS wait list begin to receive services as funding becomes available.
Policy: ARC will work with ARC Contracted Providers to ensure that clients waiting for DOER funded
services begin to receive those services as funding becomes available.
Procedure:
1. ARC Contracted Provider will activate clients on CIRTS wait list based on DOEA prioritization polices
and funding availability.
2. ARC Contracted Provider will update CIRTS status by funding source and service for any services
being activated for the client using appropriate CIRTS codes.
3. Client may be left on wait list of a different funding source than the one being activated if ARC
Contracted Provider determines that it is appropriate.
4. Client may also be left on wait list in CIRTS if they are being activated by the ARC Contracted
Provider under a temporary non -DOER funding source and ARC Contracted Provider determines that
the clients need will persist after the temporary funding source is exhausted.
5. ARC Contracted Provider will inform the client of any services/funding source that they are being
activated for as well as those services and funding sources that they will continue to be wait listed for.
6. ARC Contracted Provider will inform client to contact the ARC Elder Helpline if they have any
questions or concerns regarding the status of any of their services.
Attachment Vlll
in
CONTRACT KZ-1197 Page 13
Policy and Procedure i
Objective: To ensure that the comprehensive list of clients in need of services in CIRTS is appropriately
maintained by funding source and that the ARC is thereby able to effectively gauge the current
level of elder service need in Miami -Dade and Monroe Counties.
Policy: ARC will maintain an accurate and current list of clients in need of elder services in Miami -Dade
and Monroe Counties with the assistance of the ARC Contracted Providers.
Procedure:
1. ARC Contracted Provider will re -screen clients which the ARC Contracted Provider initially placed on
the CIRTS wait list for services based on DOER Reassessment Standards.
2. The re -screening may be in the form of a phone screening or a home visit depending on the clients
status (i.e. active/pending)
3. ARC Contracted Provider will determine if the client is no longer in need (or eligible) for any of the
services they were wait listed for.
4. ARC Contracted Provider will terminate the client from the wait list (entirely or by specific service)
using the appropriate CIRTS termination code for any services or funding source for which the client
is determined to no longer be eligible for or no longer in need of.
5. ARC Contracted Provider will inform the client of any services/funding source that they are being
removed from the wait list for.
6. ARC Contracted Provider will inform client of their ability to be re -added to the wait list if their level of
need should change.
T ARC Contracted Provider will inform client to contact the ARC Elder Helpline if they have any
questions or concerns regarding their wait list status.
8. Reference DOEA Notice of Instruction: Assessed Priority Consumer List#: 062906-1 -I-OVCS as
applicable.
CONTRACT KZ-1197 D Page 14
ATTACHMENT IX
! 4 i
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1)No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any state or federal
agency, a member of congress, an officer or employee of congress, an employee of a member of congress,
or an officer or employee of the state legislator, in connection with the awarding of any federal grant, the
making of any federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative
agreement.
(2)If any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a member of congress, an
officer or employee of congress, or an employee of a member of congress in connection with this
federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit
Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions.
(3)The undersigned shall require that the language of this certification be included in the award documents
for all sub -awards at all tiers (including subcontracts, sub -grants, and contracts under grants, loans and
cooperative agreements) and that all subproviders shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file
the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than
$100,000.00 for each such failure.
Signature
Date
Name of Authorized Individual Application or Agreement Number
Name and Address of Organization
I OFA Form 103 (Revised Nov 2002)
E
CONTRACT KZ-1197 Page 15
ATrACTINIENTX
FINANCIAL i CO i
The administration of resources awarded by the Alliance of Elder Affairs to the provider may be subject to audits
and/or monitoring by the Alliance of Elder Affairs, as described in this section.
MONITORING
In addition to reviews of audits conducted in accordance with OMB Circular A-133, as revised, and Section
215.97, F.S., (see "AUDITS" below), monitoring procedures may include, but not be limited to, on -site visits by the
Alliance staff, limited scope audits as defined by OMB Circular A-133, as revised, and/or other procedures. By
entering into this agreement, the provider agrees to comply and cooperate with any monitoring
procedures/processes deemed appropriate by the Alliance for Aging. In the event the Alliance for Aging
determines that a limited scope audit of the provider is appropriate, the provider agrees to comply with any
additional instructions provided by the Alliance to the provider regarding such audit. The provider further
agrees to comply and cooperate with any inspections, reviews, investigations, or audits deemed necessary by any
level of government
PART I: FEDERALLY FUNDED
This part is applicable if the provider is a State or local government or a non-profit organization as defined in OMB
Circular A-133, as revised.
In the event that the provider expends $500,000,00 or more in Federal awards during its fiscal year, the provider
must have a single or program -specific audit conducted in accordance with the provisions of OMB Circular A-
133, as revised. EXHIBIT 1 to this agreement indicates Federal resources awarded through the Alliance of Elder
Affairs by this agreement. In determining the Federal awards expended in its fiscal year, the provider shall
consider all sources of Federal awards, including Federal resources received from the Alliance of Elder Affairs. The
determination of amounts of Federal awards expended should be in accordance with the guidelines established by
OMB Circular A-133, as revised. An audit of the provider conducted by the Auditor General in accordance with the
provisions of OMB Circular A-133, as revised, will meet the requirements of this part.
In connection with the audit requirements addressed in Part I, paragraph 1, the provider shall fulfill the
requirements relative to auditee responsibilities as provided in Subpart C of OMB Circular A-133, as revised.
If the provider expends less than $500,000.00 in Federal awards in its fiscal year, an audit conducted in
accordance with the provisions of OMB Circular A-133, as revised, is not required. In the event that the provider
expends less than $500,000.00 in Federal awards in its fiscal year and elects to have an audit conducted in
accordance with the provisions of OMB Circular A-133, as revised, the cost of the audit must be paid from non -
Federal resources (i.e., the cost of such audit must be paid from provider resources obtained from other than
Federal entities.)
An audit conducted in accordance with this part shall cover the entire organization for the organizations
fiscal year. Compliance findings related to agreements with the Alliance of Elder Affairs shall be based on the
agreement's requirements, including any rules, regulations, or statutes referenced in the agreement The financial
statements shall disclose whether or not the matching requirement was met for each applicable agreement. All
questioned costs and liabilities due to the Alliance of Elder Affairs shall be fully disclosed in the audit report with
reference to the Alliance of Elder Affairs agreement involved. If not otherwise disclosed as required by Section
310(b)(2) of OMB Circular A-133, as revised, the schedule of expenditures of Federal awards shall identifv
In
CONTRACT KZ-1 197 Page 16
expenditures by agreement number for each agreement with the Alliance of Elder Affairs in effect during the
audit period. Financial reporting packages required under this part must be submitted within the earlier of 30 days
after receipt of the audit report or 9 months after the end of the provider's fiscal year end.
As an Alliance requirement the Statement of Functional Expenses need to be part of the Financial and Compliance
Audit Report.
This part is applicable if the provider is a nonstate entity as defined by Section 215.97(2), Florida Statutes.
In the event that the provider expends a total amount of state financial assistance equal to or in excess of
$500,000.00 in any fiscal year of such provider (for fiscal years ending September 30, 2004 or thereafter),
the provider must have a State single or project -specific audit for such fiscal year in accordance with
Section 215.97, Florida Statutes; applicable rules of the Alliance of Financial Services; and Chapters 10.550
(local governmental entities) or 10.650 (nonprofit and for -profit organizations), Rules of the Auditor
General. EXHIBIT I to this agreement indicates state financial assistance awarded through the Alliance of
Elder Affairs by this agreement. In determining the state financial assistance expended in its fiscal year,
the provider shall consider all sources of state financial assistance, including state financial assistance
received from the Alliance of Elder Affairs, 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 Part 11, paragraph 1, the provider shall ensure that
the audit complies with the requirements of Section 215.97(81), Florida Statutes. This includes submission of
a financial reporting package as defined by Section 215.97(2), Florida Statutes, and Chapter 10.550 (local
governmental entities) or 10.650 (nonprofit and for -profit organizations), Rules of the Auditor General.
If the provider expends less than $500,000.00 in state financial assistance in its fiscal year (for fiscal years
ending September 30, 2004 or thereafter), an audit conducted in accordance with the provisions of Section
215.97, Florida Statutes, is not required. In the event that the provider expends less than $500,000.00 in
state financial assistance in its fiscal year and elects to have an audit conducted in accordance with the
provisions of Section 215.97, Florida Statutes, the cost of the audit must be paid from the nonstate entity's
resources (i.e., the cost of such an audit must be paid from the provider resources obtained from other than
State entities).
An audit conducted in accordance with this part shall cover the entire organization for the
organization's fiscal year. Compliance findings related to agreements with the Alliance of Elder Affairs
shall be based on the agreement's requirements, including any applicable rules, regulations, or statutes.
The financial statements shall disclose whether or not the matching requirement was met for each
applicable agreement. All questioned costs and liabilities due to the Alliance of Elder Affairs shall be fully
disclosed in the audit report with reference to the Alliance of Elder Affairs agreement involved. If not
otherwise disclosed as required by Rule 691-5.0003, Fla. Admin. Code, the schedule of expenditures of state
financial assistance shall identify expenditures by agreement number for each agreement with the Alliance
of Elder Affairs in effect during the audit period. Financial reporting packages required under this part
must be submitted within 45 days after delivery of the audit report, but no later than 12 months after the
provider's fiscal year end for local governmental entities. Non-profit or for -profit organizations are
requir
ed no to be submitted within 45 days after delivery of the audit report, but O later than`9 months after
in
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I CONTRACT KZ-1 197 Page 17
the provider's fiscal year end. Notwithstanding the applicability of this portion, the Alliance of Elder
Affairs retains all right and obligation to monitor and oversee the performance of this agreement as
outlined throughout this document and pursuant to law.
As an Alliance requirement the Statement of Functional Expenses need to be part of the Financial and Compliance
Audit Report.
Iva-64MM
Copies of reporting 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-133, as revised, by or on behalf of the provider directly to each of the following:
The Alliance for Aging, Inc. at the following address:
Alliance for Aging, Inc. Attn: Carlos Lahitte
760 NW 107 th Ave, Suite 214
Miami, FL 33172
M
CONTRACT KZ-1 197 Page 18
ATTACHMENT X
EXI-11131`17-2
PART 1: AUDIT RELATIONSHIP DETERMINATION
Providers who receive state or federal resources may or may not be subject to the audit requirements of OMB
Circular A-133, as revised, and/or Section 215.97, Fla. Stat. Providers who are determined to be providers or
subproviders of federal awards and/or state financial assistance may be subject to the audit requirements if the
audit threshold requirements set forth in Part I and/or Part 11 of Exhibit 1 are met. Providers who have been
determined to be vendors are not subject to the audit requirements of OMB Circular A-133, as revised, and/or
Section 215.97, Fla. Stat. Regardless of whether the audit requirements are met, providers who have been
determined to be providers or subproviders of Federal awards and/or state financial assistance, must comply
with applicable programmatic and fiscal compliance requirements.
In accordance with Sec. 210 of OMB Circular A-133 and/or Rule 691-5.006, FAC, provider has been determined to
be:
- Vendor or exempt entity and not subject to OMB Circular A-133 and/or Section 215.97, F.S.
X Provider/ subprovider subject to OMB Circular A-133 and/or Section 215.97, F.S.
NOTE: If a provider is determined to be a provider /subprovider of federal and or state financial assistance and
has been approved by the Alliance to subcontract, they must comply with Section 215.97(7), F.S., and Rule 691-
.006(2), FAC [state financial assistance] and Section .400 OMB Circular A-133 [federal awards].
PART 11: FISCAL COMPLIANCE REQUIREMENTS
FEDERAL AWARDS OR STATE MATCHING FUNDS ON FEDERAL AWARDS. Providers who receive
Federal awards or state matching funds on Federal awards and who are determined to be a subprovider, must
comply with the following fiscal laws, rules and regulations:
STATES, LOCAL GOVERNMENTS AND INDIAN TRIBES MUST FOLLOW-
2 CFR Part 225 Cost Principles for State, Local and Indian Tribal Governments (Formerly OMB
Circular A-87)*
OMB Circular A-102 — Administrative Requirements
OMB Circular A-133 — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
2 CFR Part 230 Cost Principles for Non -Profit Organizations (Formerly OMB Circular A-1222 - Cost
Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-1 10 - Administrative
Requirements)
Requirements)
OT%413 Circular A-13 )3 - Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
I
EDUCATIONAL INSTITUTIONS (EVEN IF A PART OF A STATE OR LOCAL GOVERNMENT) MUST
FOLLOW -
IN
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CONTRACT KZ-1 197 Page 19
2 CFR Part 220 Cost Principles for Educational Institutions OMB (Formerly Circular A-21 - Cost
Principles)*
2 CFR Part 215 Administrative Requirements (Formerly OMB Circular A-1 10 - Administrative
Requirements)
O'ivfB Circular A-133 — Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
*Some Federal programs may be exempted from compliance with the Cost Principles Circulars as noted in
the OMB Circular A-133 Compliance Supplement, Appendix 1.
STATE FINANCIAL ASSISTANCE. Providers who receive state financial assistance and who are
determined to be a provider/ subprovider, must comply with the following fiscal laws, rules and regulations:
Section 215.97, Fla. Stat.
Chapter 691-5, Fla. Admin. Code
State Projects Compliance Supplement
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
M
CONTRACT KZ-1197
Page 20
ATTACHMENT XI
CERTIFICATION REGARDING DATA INTEGRITY
COMPLIANCE FOR AGREEMENTS, GRANTS, LOANS AND
COOPERATIVE AGREEMENTS
The undersigned, an authorized representative of the provider named in the contract or agreement to
which this form is an attachment, hereby certifies that:
(I)The provider and any sub -providers of services under this contract have financial management
systems capable of providing certain information, including: (1) accurate, current, and complete disclosure
of the financial results of each grant- funded project or program in accordance with the prescribed
reporting requirements; (2) the source and application of funds for all agreement supported activities;
and (3) the comparison of outlays with budgeted amounts for each award. The inability to process
information in accordance with these requirements could result in a return of grant funds that have not
been accounted for properly.
(2)Management Information Systems used by the provider, sub-provider(s), or any outside entity on
which the provider is dependent for data that is to be reported, transmitted or calculated, have been
assessed and verified to be capable of processing data accurately, including year -date dependent
data. For those systems identified to be non -compliant, provider(s) will take immediate action to assure
data integrity.
(3)lf this contract includes the provision of hardware, software, firmware, microcode or imbedded
chip technology, the undersigned warrants that these products are capable of processing year -date
dependent data accurately. All versions of these products offered by the provider (represented by the
undersigned) and purchased by the State will be verified for accuracy and integrity of data prior to
transfer.
In the event of any decrease in functionality related to time and date related codes and internal
subroutines that impede the hardware or software programs from operating properly, the provider
agrees to immediately make required corrections to restore hardware and software programs to the
same level of functionality as warranted herein, at no charge to the State, and without interruption to
the ongoing business of the state, time being of the essence.
(4) The provider and any sub-provider(s) of services under this contract warrant their policies and
procedures include a disaster plan to provide for service delivery to continue in case of an
emergency including emergencies arising from data integrity compliance issues.
The provider shall require that the language of this certification be included in all subagreements,
subgrants, and other agreements and that all sub -providers shall certify compliance accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by OMB Circulars A-102 and 2 CFR Part 215 (formerly- OMB Circular A-1 10).
Name and Address of Provider
Signature Title Date
Name of Authorized Signer
(Revised June 2008)
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CONTRACT KZ-1197 Page 21
• i i : i
i i • • • f
(I)The prospective provider certifies, by signing this certification, neither it nor its principals are
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any federal Alliance or agency.
(21)Where the prospective provider is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this certification.
Signature
Date
Title Agency/Organization
(Certification signature should be same as Contract signature.)
Instructions for Certification
I.The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered
transaction," "person," "primary covered transaction," and "voluntarily excluded," as used herein, have
the meanings set out in the sections of rules implementing Executive Order 12549. (2 CFR 180.5-
180.1020, as supplemented by 2 CFR 376.10-376.995). You may contact the Contract Manager for
assistance in obtaining a copy of those regulations.
2.This certification is a material representation of facts upon which reliance was placed when the
parties entered into this transaction. If it is later determined that the provider knowingly rendered an
erroneous certification, in addition to other remedies available to the federal government, the
Alliance may pursue available remedies, including suspension and/or debarment.
3.The provider will provide immediate written notice to the Contract Manager if at any time the
provider learns that its certification was erroneous when submitted or has become erroneous by
reason of changed circumstances. The provider may decide the method and frequency by which it
determines the eligibility of its principals. Each participant to a lower tier covered transaction
may, but is not required to, check the Excluded Parties List System (EPLS).
4.The provider will include a "Certification Regarding Debarment, Suspension, Ineligibility and
Voluntary Exclusion - Lower Tier Covered Transaction" in all its lower tier covered transactions and in
all solicitations for lower tier covered transactions.
5.The provider agrees that it shall not knowingly enter into anv lower tier covered transaction with a
person who is debarred, suspended, determined ineligible or voluntarily excluded from participation,
unless otherwise authorized by the federal government.
6.If the provider knowingly enters into a lower tier covered transaction with a person who is
suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in
addition to other remedies available to the federal government, the Alliance may pursue available
remedies, including suspension, and/or debarment.
The provider may rely upon a certification of a prospective participant hi a lower tier covered
transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous.
zeevwd June 008)
21
CONTRACT KZ-1 197 Page 22
ATTACHMENT XIII
Public reporting burden for this collection of information is estimated to average 405 minutes per
response, including time for reviewing instructions, searching existing data sources gathering and
maintaining the data needed and completing and reviewing the c6bection of inlormation. Send
comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing burden, to the Office of Management and Budget. Paperwork Reduction
Protect (0348-0043), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
Note: Certain of these assurances may not be applicable to your project or program. If you have questions please
contact the awarding agency. Further, certain Federal awarding agencies may require applicants to certify to
additional assurances. If such is the case, you will be notified.
L Has the legal authority to apply for Federal assistance, and the institutional, managerial and financial capability
(including funds sufficient to pay the non -Federal share of project cost) to ensure proper planning, management, and
completion of the project described in this application.
2.Will give the awarding agency, the Comptroller General of the United States, and if appropriate, the State,
Y.
through any authorized 'representative, access to and the right to examine all records, books, papers, or
documents related to the award; and will establish a proper accounting system in accordance with generally
accepted accounting standards or agency directives.
3.Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or
presents the appearance of personal or organizational conflict of interest, or personal gain.
4.Will initiate and complete the work within the applicable time frame after receipt of approval of the awarding
agency.
5.Will comply with the Intergovernmental Personnel Act of 1970 (42 U.S.C.. 4728-4763) relating to prescribed
standards for merit systems for programs funded under one of the 19 statutes or regulations specified in
Appendix A of OPM's Standards for a Merit System of Personnel Administration (5 C.F.R. 900, Subpart F).
6.Will comply with all Federal statutes relating to nondiscrimination. These include but are not limited to: (a) Tide
VI of the Civil Rights Act of 1964 (P.L. 88-352) which prohibits discrimination on the basis of race, color or
national origin; (b) Tide IX of the Education Amendments of 1972, as amended (20 U.S.C.. 1681-1683, and 1685-
1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C..794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act
of 1975, as amended (42 U.S.C.. 6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970
(P.L. 91-616), as amended, relating to nondiscrintination on the basis of alcohol abuse or alcoholism; (g). 523 and 527
of the Public Health Service Act of 1912 (42 U.S.C.. 290 dd-3 and 290 ee 3), as amended, relating to confidentiality of
alcohol and drug abuse patient records; (h) Tide VIII of the Civil Rights Act of 1968 (42 U.S.C.. 3601 et seq.), as '
amended, relating to nondiscrimination in the sale, rental or financing of housing; (i) any other nondiscrimination
provisions in the specific statute(s) under which application for Federal assistance is being made; and (j) the
requirements of any other nondiscrimination statute(s) which may apply to the application,
7,Wifl comply, or has already complied, with the requirements of Titles 11 and III of the uniform Relocation
Assistance and Real Property Acquisition Policies Act of 1970 (P.L. 91-646) which provide for fair and equitable
treatment of persons displaced or whose property is acquired as a result of Federal or federally assisted programs.
These requirements apply to all interests in real property acquired for project purposes regardless of Federal
participation in purchases.
8,Will comply, as applicable, with the provisions of the Hatch Act (5 U,S.C..1501-1308 and 7/324-7/328), which limit the
political activities of employees whose principal employment activities are funded in whole or in part with Federal
funds.
9,tVill complv, as applicable, with the provisions of the Davis -Bacon Act (40 U,S.C.,276a to 276a-7), the Copeland
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CONTRACT KZ-1 197 Page 23
Act (40 U.S.C. 276c and 18 U.S.C. 874) and the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333),
regarding labor standards for federally assisted construction subagreements.
I O.Will comply, if applicable, with flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234) which requires providers in a special flood hazard area to participate in the
program and to purchase flood insurance if the total cost of insurable construction and acquisition is $10,000.00 or
more.
I I.Will comply with environmental standards which may be prescribed pursuant to the following: (a) institution
of environmental quality control measures under the National Environmental Policy Act of 1969 (P.L. 91-190) and
Executive Order (EO) 11514; (b) notification of violating facilities pursuant to EO 11738; (c) protection of
wetlands pursuant to EO 11990; (d) evaluation of flood hazards in floodplainst in accordance with EO 11988; (e)
assurance of project consistency with the approved State management program developed under the Coastal
Zone Management Act of 1972 (16 U.S.C..1451 et seq.); (f) conformity of Federal actions to State (Clear Air)
Implementation Plans under Section 176(c) of the Clear Air Act of 1955, as amended (42 U.S.C..7401 et seq.);
(g) protection of underground sources of drinking water under the Safe Drinking Water Act of 1974, as
amended, (P.L. 93-523); and (h) protection of endangered species under the Endangered Species Act of 1973, as
amended, (P.L. 93-205),
12 Will comply with the Wild and Scenic Rivers Act of 1968 components of the national wild and scenic rivers
system. (16 U.S.C..1721 et seq.) related to protecting components or potential
13.Will assist the awarding agency in assuring compliance with Section 106 of the National Historic Preservation
Act of 1966, as amended (16 U.S.C.A70), EO 11593 (identification and protection of historic properties), and the
Archaeological and Historic Preservation Act of 1974 (16 U.S.C..469a-I et seq.).
14.Will comply with P.L. 93-348 regarding the protection of human subjects involved in research, development,
and related activities supported by this award of assistance.
15.Will comply with the Laboratory Animal Welfare Act of 1966 (P.L. 89-544, as amended, 7 U.S.C..2131 et seq.)
pertaining to the care, handling, and treatment of warm blooded animals held for research, teaching, or other
activities supported by this award of assistance.
16.Will comply with the Lead -Based Paint Poisoning Prevention Act (42 U.S.C..4801 et seq.), which prohibits the
use of lead- based paint in construction or rehabilitation of residence structures.
17.Will cause to be performed the required financial and compliance audits in accordance with the Single Audit Act
Amendments of 1996 and OMB Circular No. A-133, Audits of States, Local Governments, and Non -Profit
Organizations.
18.Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and
policies governing this program.
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL TITLE
-PPLJCAN`TORG.kN,'tZ-ATION DATE SUBMITTED
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CONTRACT KZ-1 197 Page 24
ATfACfMENTX1V
;W,TATE OF FLORIDA ALLIANCE OF ELDER AFFAIRS
CIVIL RIGHTS COMPLIANCE CHECKLIST
Program Facility Name County lProvider
Address Completed By
City, State, Zip Code Date Telephone
PART I. READ THE ATTACHED INSTRUCTIONS FOR ILLUSTRATIVE INTOWMIATTON WHICH WILL HELP YOU IN
THE COMPLETION OF THIS FORM.
1. Briefly describe the geographic area served by the program/ facility and the type of service provided:
2. POPULATION OF AREA SERVED. Source of data:
Total# % White
% Black j % Hispanic
% Other
% Female
3. STAFF CURRENTLY EMPLOYED. Effective date:
% White
% Black
% Hispanic
% Other
% Female % Disabled
4. CLIENTS CURRENTLY ENROLLED OR REGISTERED Effective date:
% White
% Black
% Hispanic
% Other
% Female
% Disabled %
5. ADVISORY OR GOVERNING BOARD, IF APPLICABLE.
Total # % White
% Black
T I
% Hispanic
I
% Other
I
% Female
% Disabled
I
PART IL USE A SEPARATE SHEET' OF PAPER FOR ANY E)(PLANAT1ONS REQUIRING MORE SPACE.
6. Is an Assurance of Compliance on file with the Alliance? If NA or NO explain
NA YES NO
7. Compare the staff composition to the population. Is staff representative of the population? If NA
or NO, explain.
NA YES NO
8. Compare the client composition to the population. Are race and sex characteristics representative
of the Population? If NA or NO, explain.
NAYES NO
W
9. Are eligibility requirements for services applied to clients and applicants without
regard to race, -c61or, nation origin, sex, age, religion or—d—is-a-bility! It N A or U,
explain.
NA YES NO
10. Are all benefits, services and facilities available to applicants and participants in an equally
effective manner regardless of race, sex, color, age, national origin, religion or disability? If NA or
NO, explain.
NAYES NO
11. For in -patient services are room assignments made without regard to race, color, national origin
or disability? If NA or KO, explain.
NA YES NO
12. Is the program/ facility accessible to non-English speaking clients? If NA or NO, explain.
NA YES NO
13. Are qmplovees, applicants and participants informed of their protection against
discriminatiodiscrimination?I yes, how? Verbal o Written o Poster if NA or NO,
explain.
9
14. Give the number and current status of any discrimination complaints
regarding services or employment filed against the program/ facility.
M
-2t
A r%
_L—Ftaqe-26--
15. Is the proyam/facility physically accessible to mobility, hearing, and sight -impaired individuals?
C
If NA or Q, explain.
NA YES NO
PART 111. THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES
YES NO
16, Has a self -evaluation been conducted to identify any barriers to serving disabled
individuals, and to make any necessary modifications? If NO, explain.
17. Is there and established grievance procedure that incorporates due process in
the resolution of complaints? If NO, explain.
YES NO
18. Has a person been designated to coordinate Section 504 compliance activities? If YES NO
NO, explain. C 0
19, Do recruitment and notification materials advise applicants, employees and
participants of nondiscrimination on the basis of disability? If NO, explain.
Vol
20. Are auxiliary aids available to assure accessibility of services to hearing and
sight impaired individuals? If 1\110, explain,
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CONTRACT KZ-1 197 Page 27
ON
PART IV. FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF $50,000 OR
MORE.
21. Do you have a written affirmative action plan? If NO, explain. YESM
I DOER USE ONLY
[Reviewed By
Incompliance: YES o NO*
�'Notice
Program Office
of Corrective Action Sent
Date
Telephone
Response Due
On -Site n Desk Review n
Response Received
DOEA Form 101-A, Revised May 2008 Page 2 of 2
ATTACHMENT XIV
INSTRUCTIONS FOR THE CIVIL RIGHTS COMPLIANCE
CHECKLIST
L Describe the geographic service area such as a district, county, city or other locality. If the
I
program/facility serves a specific target population such as adolescents, describe the target
population. Also, define the type of service provided.
2.Enter the percent of the population served by race and sex. The population served includes persons
in the geographical area for which services are provided such as a city, county or other regional area.
Population statistics can be obtained from local chambers of commerce, libraries, or any publication
from the 1980 Census containing Florida population statistics. Include the source of your population
statistics. ("Other" races include Asian/ Pacific Islanders and American Indian/ Alaskan Natives.)
3.Enter the total number of full-time staff and their percent by race, sex and disability. Include the
effective date of your summary.
4. Enter the total number of clients who are enrolled, registered or currently served by the program or
facility, and list their percent by race, sex and disability. Include the date that enrollment was
counted,
5,Enter the total number of advisory board members and their percent by race, sex, and disability. If
there is no advisory or governing board, leave this section blank.
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CONTRACT KZ 1097 Page 28
6.Each provider of federal financial assistance must have on file an assurance that the program will be
conducted in compliance with all nondiscriminatory provisions as required in 45 CFR 80. This is
usually a standard part of the contract language for DOER providers and their sub -grantees, 45 CFR
80.4 (a).
7.Is the race, sex, and national origin of the staff reflective of the general population? For example, if
10% of the population is Hispanic, is there a comparable percentage of Hispanic staff?
8.VVhere there is a significant variation between the race, sex or ethnic composition of the clients and
their
availability in the population, the program/facility has the responsibility to determine the reasons for
such
variation and take whatever action may be necessary to correct any discrimination. Some legitimate
disparities may exist when programs are sanctioned to serve target populations such as elderly or
disabled persons, 45 CFR 80.3 (b) (6).
9. Do eligibility requirements unlawfully exclude persons in protected groups from the provision of
services or employment? Evidence of such may be indicated in staff and client representation
(Questions 3 and 4) and also through on -site record analysis of persons who applied but were denied
services or employment, 45 CFR 80.3 (a) and45CFR80.1(b)(2).
1 O.Participants or clients must be provided services such as medical, nursing and dental care,
laboratory services, physical and recreational therapies, counseling and social services without
regard to race, sex, color, national origin, religion, age or disability. Courtesy titles, appointment
scheduling and accuracy of record keeping must be applied uniformly and without regard to race,
sex, color, national origin, religion, age or disability. Entrances, waiting rooms, reception areas,
restrooms and other facilities must also be equally available to all clients, 45 CFR 80.3 (b).
11.For in -patient services, residents must be assigned to rooms, wards, etc., without regard to race,
color, national origin or disability. Also, residents must not be asked whether they are willing to share
accommodations with persons of a different race, color, national origin, or disability, 45 CFR 80.3 (a).
12.The program/facility and all services must be accessible to participants and applicants, including
those persons who may not speak English. In geographic areas where a significant population of
non-English speaking people live, program accessibility may include the employment of bilingual
staff. In other areas, it is sufficient to have a policy or plan for service, such as a current list of names
and telephone numbers of bilingual individuals who will assist in the provision of services, 45 CFR
80.3 (a).
13.Programslfacilities must make information regarding the nondiscriminatory provisions of
Title VI available to their participants, beneficiaries or anv other interested parties. This
should include information on their right to file a complaint of discrimination with either the
Florida Alliance of Elder Affairs or the U.S. Alliance of HHS. The information rnav be
supplied verbally or in writing to every individual, or may be supplied through the use of an
equal opportunity policy poster displayed in a public area of the facility, 45 CFR 80.6 (d).
14.Report number of discrimination complaints filed against the program; facility. Indicate
the basis, e.g., race, color, creed, sex, age, national origin, disability, retaliation, the issues
involved, e.g., services or employment, placement, termination, etc. Indicate the civil rights
law or policy alleged to have been violated along with the name and address of the local,
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CONTRACT KZ 1097 Page 29
state or federal agency with whom the complaint has been filed. Indicate the current status,
e.g., settled, no reasonable cause found, failure to conciliate, failure to cooperate, under
review, etc.
15.The program/ facility must be physically accessible to disabled individuals. Physical
accessibility includes designated parking areas, curb cuts or level approaches, ramps and
adequate widths to entrances. The lobby, public telephone, restroom facilities, water
fountains, information and admissions offices should be accessible. Door widths and traffic
areas of administrative offices, cafeterias, restrooms, recreation areas, counters and serving
lines should be observed for accessibility. Elevators should be observed for door width, and
Braille or raised numbers. Switches and controls for light, heat, ventilation, fire alarms, and
other essentials should be
installed at an appropriate height for mobility impaired individuals.
16.Section 504 of the Rehabilitation Act of 1973 requires that a provider of federal financial
assistance conduct a self -evaluation to identify any accessibility barriers. Self -evaluation is a
four step process:
•With the assistance of a disabled individual/ organization, evaluate current practices
and policies which do not comply with Section 504.
•Modify policies and practices that do not meet Section 504 requirements.
•Take remedial steps to eliminate any discrimination that has been identified.
•Maintain self -evaluation on file. (This checklist may be used to satisfy this
requirement if these four steps have been followed.), 45 CFR 84.6.
17.Programs or facilities that employ 15 or more persons must adopt grievance procedures
that incorporate appropriate due process standards and provide for the prompt and equitable
resolution of complaints alleging any action prohibited by Section 504.45 CFR 84.7 (b).
18.Programs or facilities that employ 15 or more persons must designate at least one person to
coordinate efforts to comply with Section 504.45 CFR 84.7 (a).
19.Continuing steps must be taken to notify employees and the public of the
program/ facility's policy of nondiscrimination on the basis of disability. This includes
recruitment material, notices for hearings, newspaper ads, and other appropriate written
communication, 45 CFR 84.8 (a).
20.Programs/ facilities that employ 15 or more persons must provide appropriate auxiliary
aids to persons with impaired sensory, manual or speaking skills where necessary. Auxiliary
aids may include, but are not limited to, interpreters for hearing impaired individ
uals, duals, taped
or Braille materials, or any alternative resources that can be used to provide equally effective
services, (45 CFR 84.52 (d).
2 I.Fro grams/ facilities with 50 or more employees and $50,000 in federal contracts must
develop, implement and maintain a written affirmative action compliance program in
accordance with Executive Order 11246. 41 CFR 60 and Title VI of the Civil Rights Act of
t964, as amended.
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CONTRACT KZ 1097 Page 30
m