Item C0211,151 iNou N MEN
Meeting Date
Bulk Item: Yes
H.'552KIM
x No
Division: _County Administrator
Department: Social Services/In-Home Services
Staff Contact Person/Phone 9: %ervI Graham/X4 5 10
AGENDA ITEM WORDING: Approval of Amendment 001 to the Home Care for the Elderly (HCE)
Contract KH-1272 between the Alliance for Aging, Inc. (Area Agency on Aging) and the Monroe
County Board of County Commissioners (Social Services/In-Home Services) for the period of
7/1/2012 to 6/30/2013.
ITEM BACKGROUND: Approval of Amendment 001 to the HCE Contract will increase the amount
available for Special Subsidy by $1,296.00 for a total for the year of $10,800.00
PREVIOUS RELEVANT BOCC ACTION: Prior approval granted for the Home Care for the
Elderly (HCE) Grant Contract #KH-1272 on 6-20-12.
CONTRACT/AGREEMENT CHANGES: Increase of Special Subsidy funds of $1,296.00 for a
contract amount of $9,504.00 to $10,800.00. This plus the $12,694.00 for Case Management will give
a contract total of $23,494.00.
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $23,494.00 INDIRECT COST: --O--BUDGETED: Yes X No
COST TO COUNTY: $0 (No Cash Match Required) SOURCE OF FUNDS: Grant
REVENUE PRODUCING: Yes No AMOUNT PER MONTH Year
APPROVED BY: County AttyE� OMB/Purchasing X Risk Management ' X—
Included X Not Required
III
Revised 1/09
AGENDA ITEM #
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Alliance for Aging, Inc. Contract: Amend, I to HCE Contract #KH-1272
Effective Date: July 1, 2012
Expiration Date: June 30, 201,E
Contract Purpose/Description: Approval of Amendment 001 to the Home Care for the Elderly (HCE)
Contract#KH-1272 will increase the special subsidy funds of $1,296.00 for a total of $10,800.00. This will make
the grand total of the contract $23,494.00
Contract Manager: Sheryl Graham 4510 Social Services/Stop I
(Name) (Ext.) (Department/Stop #)
For BOCC meeting on 8/15/2012 Agenda Deadline: 7/3 1/2012
CONTRACT COSTS
Total Dollar Value of Contract: $23,494.00
Budgeted? Yes X No 0 Account Codes
Grant: $23,494.00 (Fiscal Year)
County Match: $0 (No Cash Match required)
Estimated Ongoing Costs: $ /yr
(Not included in dollar value above)
Current Year Portion: $
125-6153912-
ADDITIONAL COSTS
For:
CONTRACT REVIEW
Datejn
Changes
Date Out
Needed R
2
Division Direct or
1,2—
'�7
Yes 0 No L
Risk Management
I
Yes 7 N6
O.M.B./Purchasing
-Tim 1
Yes 11 No
County Attorney
�'hxj X
Yes Ei N
Comments:
13M 13 t is 111 ill M-
Amendment 001 CONTRACT KH 1272 Page I
THIS AMENDMENT, entered into between the Alliance for Aging, Inc. hereinafter referred
to as the "Alliance", and Monroe County Board of Commissioners.
The purpose of this amendment is to increase the amount available for Special Subsidy •
$1,296.00 for a total for the year of $10,800.00
All provisions in the contract and any attachments thereto in conflict with this amendment
shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the contract are hereby amended to conform with this amendment.
This amendment and all its attachments are hereby made a part of the contract.
IN WITNESS WHEREOF, the parties hereto have caused this 1-page amendment to be executed
by their undersigned officials as duly authorized.
PROVIDER:
Monroe County Board of
Commissioners
David Rice
NAME:
Mayor
TITLE:
8-15-2012
DATE:
SIGNED BY:
NAME:
TITLE:
DATE:
ALLIANCE FOR AGING, INC.
Max B. Rothman, JD, LL.M.
President & CEO
M
Contract Number KH 1272 1 Page 2
The Alliance's performance and obligation to pay under this contract is contingent upon
an annual appropriation by the Legislature.
B. Source of Funds:
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 recipient
pursuant to this contract are in the state grants and aids appropriations.
Program Title
Year
Funding Source
CSFA#
Fund Amounts
Home Care for the
Elderly
2012
General Revenue
65001
$12,694
TOTAL FUNDS CONTAINED IN THIS CONTRACT:
$12,694
111. Recipient and Alliance Mutually Agree:
A. Effective Date:
1. This contract shall begin on Julyll, 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. This contract shall end on July
15,2013.
IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed by
their undersigned officials as duly authorized.
Monroe County Board of
yCommissioners.
SIGNED BY: SIGNED BY:
David Rice
Mayor
TITLE:
6-20-2012
DATE:
ZEAL) G L
,,?-A4V L C
I if r-A ky, I
ALLIANCE FOR AGING, INC.
Max B. Rothman, JD,
TITLE: President & CEO
DATE:
fj
MON", COUNTY 'ATTO EY
OV AS/ 'F
IN
Contract Number KH 1272 Page 3
ATTACHMENT
HOME CARE ` THE ELDERLY PROGRAM
The Home Care for the Elderly (HCE) Program encourages the provision of care in family -
type living arrangements in private homes on a not for profit basis as an alternative to
nursing home or other institutional care.
A. Services:
1. The recipient's July 2011 application, 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 recipient, and prescribe the services to
be rendered by the recipient.
2. Consumers may not be enrolled in a Department of Elder Affairs' state general
revenue funded program, including HCE, 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 any other areas that may participate in the Long Term Care
Community Diversion Program through expansion and the Program of All Inclusive
Care for the Elderly (PACE) program.
B. Manner of Service Provision:
The services will be provided in a manner consistent with and described in the
recipient's July 2011 application and the 2010 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 recipient will be
given a copy of the revisions.
111. METHOD OF PAYMENT
A. The method of payment in this contract is based on a fixed rate reimbursement for
approved services. The recipiente# rates include only icosts
requestsare 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 • payment and expenditure reii submitted to support requestsfor
payment shall be on DOEA forms 106H and 105H. Duplication or replication of both
forms via data processing equipment is permissible, provided all data elements are in
the same format as included on department forms.
Zi. Invoicessubmitted no later than90 days after the end of i on
J'
Contract Number KH 1272 Page 4
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 DOER.
C. The recipient 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 recipient may request a monthly advance for service costs 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 nine 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 June 2012 reports. All advance payments
are subject to the availability of funds.
E. Advance funds may be temporarily invested by the recipient in an insured interest
bearing account. All interest earned on contract fund advances must be returned to the
Alliance at the end of the first quarter of the contract period.
F. Contingent upon the recipient's ability to maintain program expenditures within
the assigned quarterly allocations and the availability of funds, the Alliance shall
make payment to the provider for provision of services at the rate(s) stated
below:
SERVICE TO BE UNIT MAXIMUM MAXIMUM
PROVIDED RATE UNITS DOLLARS
Case Management $50.48 251 $12,694
G. 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 recipient and any adjustments thereto, including any
disallowance not resolved,
IV. REPORTING:
The provider need to provide the Alliance with an expenditure plan by July 15 or two
weeks after contract has been signed, a monthly update due on the 15 of each following
month.
The expenditure plan and updates must follow the format provided by the Alliance.
10
Contract Number KH 1272 Page 5
1. The recipient agrees to comply with applicable parts of Rule Chapter 581-1-1, Florida
Administrative Code promulgated for administration of Sections 430.601 through
430.608, Florida Statutes, and the 2010 Department of Elder Affairs Home and
Community Based Services Handbook.
2. The recipient agrees to comply with the provisions of Sections 07.021 and 97.058.
Florida Statutes, and all rules related thereto in the Florida Administrative Code.
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 03 [G0ovG existing clients from any
program in order to serve new clients being assessed and prioritized for service
1. Priority Criteria for Service Delivery:
a\ Individuals in nursing homes under Medicaid who could be transferred to the
community;
b) Individuals innursing homes whose Medicare coverage }aexhausted and
may be diverted to the QJ0muDih/;
o) 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 /anot possible, there |onocapable caregiver and
institutional placement will occur within 72hours.
2. Priority Criteria for Other Assessed Individuals:
The assessment and provision of services should always consider the most cost effective means
Qfservice delivery. Functional impairment shall b8determined through the department's
consumer assessment form administered k]each applicant. The most frail individuals not
prioritized in groups one, two or three above, regardless of referral GOurne, will receive services to
the extent funding is available,
1. The recipient will ensure the collection and maintenance of Home Care for the Elderly (HCE)
subsidies and case management information on a monthly basis from the Consumer Information,
Registration and Tracking System (CIRTS). Maintenance includes valid exports and backups of
all data and systems according to department standards.
Contract Number KH 1272 Page 6
2. The recipient must ensure all data for HCE subsidies are entered in the CIRTS by the 15th of each
month. HCE subsidy data entered into the CIRTS by the 15th of the month will be for payments
incurred between the 16th of the previous month and the 15th of the current month. Case
management data entered into the CIRTS by the 15th of the month will be for units of service
provided during the previous month from the 16th and up to and including the 15th of the current
month or case management units of service may be entered according to the recipient schedule,
in aggregate on the 31 st or daily, weekly or monthly.
3. The recipient will ensure data entry for HCE subsidies will cease on the 15th of the month and the
CIRTS Monthly Service Utilization Report, by consumer and by worker identification is run.
4. The recipient will ensure the Monthly Utilization Report, by consumer and by worker identification
is verified, corrected, certified no later than the 20th of the month in which the report is generated.
5. The recipient will ensure caregivers determined eligible for the HCE basic subsidy after the 15th of
a month, will be processed to begin eligibility for the HCE basic subsidy on the 1 st day of the next
month.
6. The Alliance will reconcile and verify the CIRTS data prior to payment for HCE basic and special
subsidies and case management.
8. The Alliance will reconcile and verify the CIRTS data prior to payment for HCE basic and special
subsidies and case management.
I
Report Number Based On
ATTACHMENT 11
Submit To The Alliance
On This Date
1
July Advance* ...................................... ...... ..............
July
2
August Advance ^ .'--.....—.'--.—.—.—...--.'—.
July
3
July Expenditure Report ..]/12Advance Reconciliation .......
August 15
4
August Expenditure Report ...1/12Advance Reconciliation .'
September 15
5
September ExpenditureReport 1/12Advance Reconciliation
OctObar15
6
October Expenditure Report ... 1/12Advance Reconciliation
November 15
7
November Expenditure Report ... 1/12Advance Reconciliation
December 15
8
December Expenditure Report ... 1/12Advance Reconciliation
January15
9
January Expenditure Report ... 1/12Advance Reconoi|iaUon...
February 15
10
February Expenditure Raport..1/12Advance Recond|iaUoO...
March 15
11
March Expenditure Rapo/t..1/12Advance Reconciliation ....
April 15
12
April Expenditure Report ... 1/12Advance Reconciliation ....
May 15
13
May Expenditure Report ... 1/12Advance Reconciliation .......
Juna1 5
14
June Expenditure Report ... 1/12Advance Reconciliation ......
July 15
18
Final Expenditure and Closeout Report...........
July 15
Legend * Advance based on projected cash need.
Note # : RGpOrt#1 for Advance B8SkS Contracts C8DD{t be submitted tOthe Alliance prior 83July 1
Oruntil the contract with the Alliance has been executed. Actual submission cf the
vouchers to the Department of Elder Affairs is dependent on the accuracy of the
expenditure report.
0
aontract Number KH 1272 Page 8
ATTACHMENT Ili
Issue: Screening, Triage, and Referral for Activation under the Community Care for the
Elderly/Home Care for the Elderly Programs and for the Aging & Disabled Adults and the
Assisted Living for the Elderly Medicaid Waivers.
Policy: Referrals will be based on availability of funds, in accordance with prioritization requirements.
Purpose: To ensure funding is spent expeditiously and consumers are referred into programs for
appropriate services.
Procedure for Monroe County:
Roles and Responsibilities
A. Alliance for Aging / Aging and Disability Resource Center
Reconciles overall program and Lead Agency specific spending levels on a monthly
basis to ensure the Lead Agency is operating within the funding allocation.
➢ Reviews the number of cases released for activation based on projected funding
available.
y Screens consumers to link with appropriate resources and prioritize for DOER -funded
programs and services.
Recommends potential cases for activation based upon projected funding available by
Lead Agency.
Selects consumers from the waiting list based on their prioritization score.
Refers consumers from the waiting list to the Lead Agency in Monroe County for
activation, based on availability of funds.
Monitors compliance with service standards and outcome measures.
Reviews care plans and files per the File Review Policies and Procedures.
Reviews data in CIRTS.
B. Case Management Agency
y Requests and accepts referrals from the Aging and Disability Resource Center, to serve
an optimal caseload and to avoid surpluses or deficits in accordance with the AAA
CCEIHCE Surplus/Deficit Analysis policy.
Refers inquiries from consumers interested in services to the ADRC for Information and
Referral to community resources, Screening, Triage, and Long -Term Care Options
Counseling, as appropriate.
The functions of Screening and Intake are outsourced to the Lead Agency. Screening
and Intake may also be completed by the ADRC.
Completes comprehensive assessments on new consumers and annual reassessment
on existing consumers and develops care plans and reviews care plans semi-annually.
Authorizes service delivery and enters data into CIRTS.
Screens consumers for Medicaid Waiver eligibility,
y Bills in CIRTS and Medicaid as appropriate.
Monitors care plans in an effort to keep costs down while sustaining the individuals in
8
ntract Number KH 1272 Page 9
the community.
Management Ofthe Assessed Prioritized Consumer List l.
A. Referrals 0Qthe ADRCare routed to the Information and Referral Specialists or |Rb]ke Unit staff
depending OO the buze of referral. Clients are provided information OD CQ0rOUDit« [e3OU[CeG and
pPOg[8Dls available iOC|Qd|Og phV@t8 pay options. FoersOOS are d|nSCt8d to those resources most
capable Ofmeeting the need they have expressed toAORC staff. Cases presenting strong identifiers
that indicate the consumer might benefit from publicly funded long t8nD care services are screened,
entered into C|RTG' triaged and provided options COUASe|iDg. In Monroe County, the functions Of
Screening and Intake are OUtsVunOed to the Lead Agency. Screening and Intake may also be
completed bythe ADRC.
DOEA prioritization requirements will be adhered to by both entities, as follows:
APSHigh Risk Referrals (See section B)
2. Imminent Risk cases will b8prioritized for activation after AP8High Risk
Referrals have been served. If budgetary constraints prevent opening new oasoe.
clients will be p|@D8d On the APCL AORC staff will contact the client on 8 monthly basis
tVdetermine if there has been achange inthe client's situation.
3. All other CARES referrals will be screened and prioritized in accordance with D{]E/\
requirements.
4. Aging Out consumers will be referred by DCF for prioritization
and/or activation in the corresponding aged program managed by the Alliance, as
appropriate (See section IV).
5. Consumers applying for the Community Care for the Elderly (CCE)
and/or Home Care for the Elderly (HCE)programs will becontacted and screened using
the statewide osS8SSm8nt fO[OO developed by the [}gp8rt08Dt Of Elder Affairs for this
purpose (Form 701A). If consumer is being served through aDOEA-hunded agency
which enters their annual assessment into C|RTS. the Priority Score generated by that
assessment will determine their ranking onthe APCL.
6. CODSurn8ns referred for indUs|OD under the Assisted Living for the Elderly
(ALE) Medicaid Waiver APCL will be interviewed and screened using the 701 A form.
7. Consumers referred for inclusion under the Aging and Disabled Adult
/ADA> Medicaid Waiver APCL will be contacted and screened fD||Vvving the same
procedure as the one described under Section 5. Individuals who appear aspotentially
eligible for other types Of public assistance will be referred to the ECOnOnniC Self -
Sufficiency Unit atthe Department QfChildren and Families.
& All other referrals will be waitlisted and prioritized, during which time other communi
resources will be researched, including private pay/fee for services provider
Consumers on the waiting lists will be reassessed according to the 2011 Department
Elder Affairs Programs and Services Handbook, or any revisions made thereafter. I
N
`
2ract Number KH 1272 Page 10
Ui Opening New Cases
A. CCE/ADA/ALE/HCE Clients
The Fiscal Department will monitor Lead Agency specific spending levels oDamonthly
basis tOensure each Lead Agency isoperating within its spending authority. In addition,
the fiscal department will analyze surplus/deficit projections, BOdghGR9theinfV[rnBdon
with the Lead Agency to assist in their determination of slot availability. The Lead
Agency will request referrals directly from the A[)RC. The Fiscal Department will be
notified of the number of new cases being referred to the Lead Agency for activation.
2. Upon receipt of the request for referrals from the Lead Agency, the
ADRC Intake Unit Supervisor will run the PhohdZ8d FUsh Report to identify the
consumers 0Dthe APCLtVbeopened.
3. In r8SpVDS8 to the request for [8f8rn]|S' th8/\DRC |DtGh8 Unit Supervisor will refer wait
listed clients to the Lead Agency for activation, in accordance with prioritization
requirements. The Intake Unit will update the wait list enrollment using the appropriate
code to terminate from the APCL. Upon receipt of referral, the Lead Agency will enter
the APPLenrollment, and subsequent enrollments toreflect client status.
B. AP8Referra|o
APS Low and Intermediate Risk referrals will be screened and prioritized by the /\ORXC
for services as per the [][}E/VAPS Memorandum of Understanding. Low and
Intermediate Risk referrals are also offered information and referral to additional
community resources, including private pay as appropriate.
2. APS High Risk Referrals are not vvaidioted. They are irnrnedio&a|y referred for service
from OCF in Monroe County to the Lead Agency, ARTT referrals will be forwarded
directly the Lead Agency. APScmses are to be served for amaximum of 31calendar
days. |fadditional time is justified, the case management agency will staff the case with
the Alliance tOobtain the extension needed.
3. Upon receipt of the AP8 High Risk referral, the Lead Agency will coordinate services to
begin within the 72hour period mandated bystatute. Acomprehensive assessment will
bedone within 72hours Ofthe referral. Services required under the care plan will
remain in p|@n8 for rnaxirnurn of 31 days, unless an extension has been granted.
4The Lead Agency will enter ACTV enrollment under their provider number in CIRTS. In
addition, service codes will be entered by service date for all services provided. If a
service(s) is not provided as required under the care plan, an NDP code will need to be
entered in CIRTS and the case notes under the client file should document the reason
for non -delivery of such service(s).
A. All "Aging Out" consumers will be referred by DCF to the ADRC for enrollment into the
corresponding aged program managed by the Alliance.
ON
Contract Number KH 1272
age 11
B. Consumers active in the GCDA and HCDA programs that are turning 60 and are eligible
for CCE and/or HCE will be opened in the corresponding aged program managed by the
Alliance if funding is available. If funding is available, these consumers will be made
active. if funding is not available, they will be waitlisted for these programs but will be
given priority for activation once funding is available.
C. Consumers active in the ADA Medicaid Waiver, upon turning age 60, will continue to be
eligible for and receive ADA Medicaid Waiver services.
11
cor, tract Number KH 1272 lPage 12
ATTACHMENT IV
0 * =1
LOANS AND AGREEMENTS
The undersigned certifies, to the best of his or her knowledge and belief, that:
(I)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 S 100,000.00 for each such
failure.
6-20-2012
Signature Date
—David Rice KH 1272
Name of Authorized Individual Application or Agreement Number
Monroe Count v BOCC 1100 Simonton Street Key West, FL 33040
Name and Address of Organization
Mop E COUNTY
PR,oVr A/V
R J ME
_J ASSISTA
12
ontract Number KH 1272 Page 13
ATYACIINIENTV
� i • j
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 motion
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.
1iil ff�.�
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 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 net 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
)10(bl{31 of OMB Circular < -t 33, .s revised, cl, the schedule edt�ie of expenditures of Federal l awards Shall id ntif3
I3
dontract Number KH 1272 Page 14
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.
V U tv -1 811160104121MIDIND
This part is applicable if the provider is a nonstate entity as defined by Section 213.97(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(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 121 months after the
provider's fiscal year end for focal 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
the provider's fiscal 'ear end. Notwithstanding the applicability of this portion, the Alliance of Elder
IE
2ontract Number KH 1272 Page 15
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.
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 107th Ave. Suite 214
Miami, FL 33172-3155
IN
Contract Number KH 1272 Page 16
ATTACHMENT V
W7411111-ft
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 recipients or
subrecipients 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 recipients or subrecipients 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 Recipient/ subrecipient subject to OMB Circular A-133 and/or Section 215.97, F.S.
NOTE: If a provider is determined to be a recipient /subrecipient 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 subrecipient, 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 -I 10 - Administrative
Requirements)
Requirements)
ONVIB Circular A-133 - Audit Requirements
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
EDUCATIONAL INSTITUTIONS (EVEN IF A PART OF A STATE OR LOCAL GOVERNT-NIETN-o MUST
FOLLOW -
In
Contract Number KH 1272 Page 17
2 CER Part 220 Cost Principles for Educational Institutions OMB {Formerly Circular A-21 - Cost
Principles)*
2 CFR Part 2115 Administrative Requirements (Formerly OMB Circular A -I 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 recipient/ subrecipient, must comply with the following fiscal laws, rules and regulations:
Section 213.97, Fla. Stat.
Chapter 6915, Fla. Admin. Code
State Projects Compliance Supplement
Reference Guide for State Expenditures
Other fiscal requirements set forth in program laws, rules and regulations
M
ontract Number KH 1272 Page 18
ATTACHMENT VI
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
I
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)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-1 10).
Monroe County BOCC, 1100 Simonton Street, Kev West. FL 33040
Name and Address of Provider
Mavor - 6-20-2012
Signature %" Title 600; TTORNEY
N f�$'E COUr
'�q 1 �4 � A
David Rice "
A-
Narne of Authorized SigIner ZEAL)
(Revised June 2008)
contract Number KH 1272 Page 19
FNI ICWT41 kT Ilh
(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.
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.
SEAL)
6-20-2012 MR-1 t�. tE-
Signature Date`
_Mayor Monroe County Board of County Commissioners
Title Agency/OrganizalqOAA
(Certification signature should be same as Contract signature.)
Instructions for Certification '"
Date
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 lover 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.
(Revised lure 2i 8)
im
Con'iract Number KH 1272 'JPage 20 ATTACHMENT VIII
Public reportingg burden for this collection of information is estimated to average 45 minutes per
response, inclu in time for reviewing instructions, searching existin,data sources, gathering and
maintaining the data needed and completing and reviewing
the Dlection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducin this burden, to the Office of Management and Budget. Paperwork Reduction
Project (0348-0043) , Was on 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.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.Wil1 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 VIII of the Civil Rights Act of 1968 (42 U.S.C.. ' )601 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.
/.Will 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 (P1. 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.
S.Will comply, as applicable, with the provisions of the Hatch Act (5 US.C_ 1501-1508 and 77324-7328), 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-�, the Copeland
act ( J() U,S.C. 6L and 18 U,S,C, 87/4) an d the Contract Work Hours and Safety Standards Act (40 U.S.C. 327-333),
_27
W
Contract Number KH 1272
regarding labor standards for federally assisted construction subagreements.
10.Wi11 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 recipients 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.
11.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.); (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-1 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.Wi11 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 Mayor
i
I �
z APPUC N"T ORGANIZATION Monroe County Board of County DATES BM 'FED 6-20-2012
Commissioners
l �
f,L'K,�jW.AGECL M, 0Vr /A
I
,VY4y4.
{�
i
.rsTWUNTYICE
21
Atract Number KH 1272 Page 22
ATTACHMENT IX
STATE OF FLORIDA ALLIANCE OF ELDER AFFAIRS STATE OF FLORIDA
ALLIANCE OF ELDER AFFAIRS
CIVIL RIGHTS COMPLIANCE CHECKLIST
P�og—rarn—/Facility —Nam—eH.C—.E. G—rant C-O—Unty—ml•—nroe Provider Monroe County BOCC
— W]
City, State, Zip Code Key West, FL 33040
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
MCIHS will provide with this grant are Basic and Special Subsidy.
2.
0. Other .C� /0
�2 7--
Total# % White % Black 1,1. Hispanic % Other % Female
73,165 72.3)/o 1 5.7/o 9.6"/o ? fto I 46.60/o I
3. STAFF CL-RRENTLY
EMPLOYED.
",V-,--
Effective date:
6-la-MI I
Tot"1#
�7��0.000'/(o
t
% Black
% Other
% Female
% Disabled
20
30.owo/o
1.01/0
off/o
80.00/o
0.91/0
4. CLIENTS CURRENTLY ENROLLED OR REGISTERED Effective date: 5-222012
er�% Female 0Disabled % Over 40
To 11 White BlackF� His7anic% Other
F%
285 86.8"/0 122/16.0�1.0�%o 72/100'/1005.
ADVISORY OR GOVERNING BOARD, IF APPLICABLE.
Total #
%White
I % Black
I %Hispanic
% Oth r
% Female
% Disabled
—1
PARTH. 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
NAF-] YES 0 No F-1
7. Compare the staff composition to the population. Is staff representative of the population? If NA
or NO, explain.
NA 0 YES FX1 NO
S.Compare the client comiosition to the population. Are race and sex characteristics representative of
L
the Population? If NA L 0, explain.
F' YES5
NA -I' No 0
j
W
9,Are eligibility requirements for services applied to
MN
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.
NAM YES F-1 NOZ
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.
NA MX YES[--] NOF-1
We see and provide services to clients in their homes.
12.Is the program/ facility accessible to non-English speaking clients? If NA or NO, explain.
NA❑ YES 9 NOF_�
13. Are employees applicants and participants informed of their protection against
discrimination., If yes, how? Verbal o Written o Poster F-i If NA or NO,
explain. El
14. Give the number and current status of any discrimination complaints
regarding services or employment filed against the program facility. Zero
15. Is the program/facility physically accessible to mobilitv, hearing, and sight -impaired individuals?
If NA or NO, explain.
M
Contract Number KH 1272 Page 24
E570��
PART III. THE FOLLOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES F-1 M
16. Has a setf-evaluation been conducted to identify any barriers to serving disabled
individuals, and to make any necessary modifications? If NO, explain
NA❑ YES FYI- NOF-1
17. Is there and established grievance rocedure that incorporates due process in
the resolution of complaints? if NO, explain.
NAFJ YES nX NO ❑
18. Has a person been designated to coordinate Section 504 compliance activities? If NO, explain.
NAM YESFX1 NO n
19. Do recruitment and nocation materials advise applicants, emplovees and
participants of nondiscrimination on the basis of disability? If NO, explain.
NA 0 YES nX NO 0
19,Are auxiliary aids available to assure accessibility of services to hearing and
sight impaired individuals? If NO, explain.
NA [:1 YES n)C NO FL-
j
Mw
24 0 1:1
C6tract Number KH 1272 Page 25
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.
NA ❑ YES F-"l*- No F-1
DOEAUSE ONLY
Reviewed By
Incompliance: YES o 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 IX
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 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.
i -y. If
.Enter the total number of advisory board members and their percent by race, sex, and disability.
there is no advisory or governing board, leave this section blank.
6, Each recipient of federal financial assistance must have on file ari assurance that the program will be
conducted in compliance with all nondiscriminatory provisions as required in4,5 CFR 80. -n1iS is usually a
standard part of the contract language for DOEA recipients and their sub -grantees, 45 CFR 80,4 (a).
W
0 CONTRACT KH 1272 Page 26
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. 'here 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).
II .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.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, 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
M
CONTRACT KH 1272 Pag
e 27
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 recipient 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).
2 1.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.
M
CONTRACT KH 1272
ATTACHMENT X
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
Monroe County Board of County Commissioners
Company Name
DEEP') I Y CLEPe
6-20-2012
Date
W
CONTRACT KH 1272 Page 29
ATTACHMENT XI
Alliance for Aging, Inc.
Business Associate Agreement
This Business Associate Agreement is dated , by the Alliance for Aging,
Inc ("Covered Entity") and Monroe County Board of County Commissioners, ("Business Associate"), a
not -for -profit Florida corporation.
wmnn�-�-j
1 A Covered Entity has entered into one or more contracts or agreements with Business
Associate that involves the use of Protected 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.
1.3 HIPAA regulations establish specific conditions on when and how covered entities may share
information with contractors who perform functions for the Covered Entity.
1.4 HIPAA requires the Covered Entity and the Business Associate to enter into a contract or
agreement containing specific requirements to protect the confidentiality and security of patients' 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),
164.504(e), 164.308(b), and 164.314(a-b)(2010) (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 at 42 United States Code (U.S.C.) §§ 17931 and 17934 (2010) require business associates
of covered entities to comply with the HIPAA Security Rule, as set forth in, but not limited to 45 C.F.R. §§
164.308, 164.310, 164.312, and 164.316 (2009) and such sections shall apply to a business 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 of this agreement, the following definitions apply:
2.1 Access. The ability or the means necessary to read, write, modify, or communicate
data/information or otherwise use any system resource.
2.2 Administrative Safeguards. The administrative actions, and policies and procedures, to
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.
2.5 Availability. The property that data or information is accessible and useable upon demand
by an authorized person.
2.6 Breach. The unauthorized acquisition, access, use, or disclosure of PHI which compromises
the security or privacy of such information.
2.7 Compromises the Security. Posing a significant risk of financial, reputational, or other harm
to individuals.
W
1,
CONTRACT KH 1272 Page 30
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 Information. (ePH1) Health information as specified in 45 CFR
§160.103(1)(i) or (1)(ii), limited to the information created or received by Business Associate from or on behalf
of Covered Entity,
2.10 HITECH. The Health Information Technology for Economic and Clinical Health Act (2009)
2.11 Information System. An interconnected set of information resources under the same direct
management control that shares common functionality. A system normally includes hardware, software,
information, data, applications, communications, and people.
2.12 Integrity. The property that data or information have not been altered or destroyed in an
unauthorized manner.
2.13 Malicious software. Software, for example, a virus, designed to damage or disrupts a
system
2.14 Part I. Part I — Improved Privacy Provisions and Security provisions located at 42 United
States Code (U.S.C.) §§ 17931 and 17934 (2010).
2.15 Password. Confidential authentication information composed of a string of characters.
2.16 Physical Safeguards. The physical measures, policies, and procedures to protect 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 of Individually Identifiable Health Information at 45
CFR Part 160 and Part 164, subparts A and E.
2.18 Protected Health Information. (PHI) Health information as defined in 45 CFR §160A03,
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 §
164.103.
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,
modification, or destruction of information or interference with system operations in an information system.
2.22 Security or Security measures. All of the administrative, physical, and technical safeguards
in an information system.
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.
we
3] Business Associate agrees to not use or disclose PHI other than as permitted or required by
this agreement oraoRequired byLaw,
12 Business Associate agrees to:
(a) implement policies and procedures to prevent, detect, contain and correct Security
violations inaccordance with 45CFRH104M8;
(b) Prevent use or disclosure of the PHI other than as provided for bythis Agreement or
as required by law;
/o) Reasonably and epprophabayprotect the oonf�endo]hy.i and ave�bU�ycf
the ePH| that the` Business Associate oreateo, remaiveo, mointaino, or transmits on behalf ofthe 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.
33 Business Associate agrees 10 mitigate, 10the extent practicable, any harmful effect that ia
known to Business Associate of a use or disclosure of PHI by Business Associate in violation of the
requirements ofthis Agreement.
34 Business Associate agrees to promptly report to Covered Entity any use or disclosure of the
PHI not puvidedfor bythis Agreement ofwhich itbecomes avvara.This includes any requests for inapeodon.
copying
~ramendment ofsuch 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 HH0ofBreach of
Unsecured Protected Health Information.
36 Business Associate agrees 0oensure that any agent, indudingaauboon��
aob�tuvvhom�
PHI -H|reoeivedhnm.ororeatedorreoeivedbyBuoinoaoAsaooiabsonbehaKofCoveradEntib\aQroeo
to the same restrictions and conditions that apply through this Agreement to Business Associate with respect
tosuch information.
37 IfBusiness Associate has PHI inaDesignated Record Set:
(o) Business Associate agrees to provide uccoea, at the request of Covered Entity during
regular business hours, to PHI |naDesignated Record Set, toCovered Entity or, asdirected byCovered Entity, to an individual in order to meet the requirements under 45 CFR §164.524; and
(b) Business Associate agrees 0omake any amandmanVs)8zPHI inaDesignated
Record Set that the Covered Entity directs oragrees b»pursuant bo45CFR §1G4.528otthe request of
Covered Entity oranIndividual within 1Qbusiness days ofreceiving the request.
38 Business /\ssoc!ateagrees tomake internal preuhcma.books, and records, including policies
and procedures and PH|, relating to the use and disclosure of PH{ 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 either for purposes of determining Covered Entity's compliance with the Privacy Rule,
3,0 Business Associate agrees indocument such disclosures ofPHI and information related to such disclosures mmwmu e|db required for Covered Entity to respond to a request by an individual for an
accounting ofdisclosures ofPHI inaccordance with 4SCFR §164528,
M
3.10 Business Associate agrees to provide to Covered Entity or an individual, upon request,
311 Business Associate specifically agrees to use security measures that reasonably and
appropriately protect the confidentiality, integrity, andoveUabi|itynfPH|ine|ectronicoranyotharform.thxa 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
313 Business Associate agrees toimplement security measures tosafeguard aPH|that h
accesses, maintains, or transmits as part of this agreement from malicious software and other man-made and
natural vulnerabilities tnassure the availability, inbeghh/, and confidentiality ofsuch information.
and
3.14 Business Associate agrees tucomply with:
(a) ARRA § 13404 (Application of Knowledge Elements Associated with Contracts);
(b) ARRA § 13405 (Restrictions on Certain Disclosures and Sales of Health Information);
(c) ARRA § 13406 (Conditions on Certain Contacts as Part of Health Care Operations).
4.0 Permitted Uses and Disclosures byBusiness Associate. Except oootherwise 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 ofthe Covered Entity.
5.0 Specific Use and Disclosure Provisions.
51 Except as otherwise limited in this agreement or any related agreement, Business Associate
may use PHI for the proper management and administration of the Business Associate or to carry out the
legal responsibilities ofthe 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, 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,
5.4 Business Associate may use PHI to report violations of law to appropriate Federal and Stat4
6.0 Obligations of Covered Entity.
61 Covered Entity shall notify Business Associate of any limitation(s) in its notice of privacy
practices of Covered Entity in accordance with 45 CFR § 164520, 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 XI to this Agreement, Future Notices and/or
modifications to the NPP shall be posted on Covered Entity's website atwww,allianceforagingorg.
0
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CONTRACT KH 1272 Page 33
82 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 ordisclosure ofPHI.
TO Permissible Requests bYCovered Entity. Except for data aggregation ormanagement
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 ifdone byCovered
8.0 Effective Date and Termination.
8] 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 ofPHI;
(b) The electronic security provisions hereof shall be effective the later of April21.2005
or the effective date of the earliest contract entered into between Business Associate and Covered Entity that
involves the use ofPHI; and
(o) Provisions hereof mandated byARRA. H|TECH and/or Part | shall be effective the
later ofFebruary 17. 2O1Oorthe effective date of the earliest contract entered into between covered entity
and business associate that involves the use ofPHI orePH|.
82 Termination for Cause. Upon Covered Entity's knowledge ofamaterial breach byBusiness
Aa000iate, 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 orend 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
(o) Kneither termination nor cure is feasible, Covered Entity shall report the violation to
the Secretary.
8.8 Effect ofTermination. Except aaprovided insubparagraph (b)ofthis 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. Areference iothis agreement boasection 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 isnecessary to amend this
IN
rt
CONTRACT KH 1272 Page 34
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 Board of County Commissioners
Social Services/In-Home Services Program
1100 Simonton Street Key West, FL 33040
Any such notice shall be deemed delivered upon actual receipt. If any notice cannot be delivered or delivery
thereof is refused, delivery will be deemed to have occurred on the date such delivery was attempted.
15.0 Governing Law. The laws of the State of Florida, without giving effect to principles of conflict
of laws, govern all matters arising under this agreement.
16.0 Severability. If any provision in this agreement is unenforceable to any extent, the
remainder of this agreement, or application of that provision to any persons or circumstances other than those
as to which it is held unenforceable, will not be affected by that unenforceability and will be enforceable to the
fullest extent permitted by law.
17.0 Successors. Any successor to Business Associate (whether by direct or indirect or by
purchase, merger, consolidation, or otherwise) is required to assume Business Associate's obligations 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. -v
18.0 Entire Agreement. This agreement constitutes the entire agreement of the parties relating
to the subject matter of this agreement and supersedes all other oral or written agreements or po4icies`refatin
thereto, except that this agreement does not limit the amendment of this agreement in accordance with
section 10.0 of this agreement.
Covered Entity:
By: Date:;
(signature) s
i
• i •' t i i. i• i • •
j � date
0y: _ _
(,signature) S S A. Q
L WOMAMSS .r f
17 A
6-20-2012