Item F15
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date:
11-15-2006
Division: Community Services
Bulk Item: Yes l
No
Department: Social Services/In-Home Services
Staff Contact Person: Deloris Simpson
AGENDA ITEM 'WORDING: Approval of Amendment #00 I to the Community Care for Disabled
Adults (CCDA) Contract #KG058 between the Department of Children & Families and the Monroe
County Board of County Commissioners (Social Services/In-Home Services Program).
ITEM BACKGROUND; The approval of this amendment will allow the Department of Children &
Families to request Monroe County to inventory all nonexpcndable property i.e. computers, vehicles,
etc. purchased with CCDA Funds and return said inventory to DCF in the completion or termination of
said contract
PREVIOUS RELEVANT BOCC ACTION: Prior approval granted to the Community Care for
Disabled Adults (CCDA) Contract June 21, 2006.
CONTRACT/AGREEMENT CHANGES: To inventory and report any nonexpendable property to
the Department of Children & Families purchased with CCDA funds. This does not affect the total
amount of the contract as fund amount will not change.
ST AFF RECOMMENDATIONS: Approval
TOTAL COST $81,733.00
COST TO COUNTY: $9,081.44 (Required Match)
$19,97071 (Additional Match)
Total Match: $29,052.15
REVENUE PRODUCING: Yes
BUDGETED: Yes ~ No
SOURCE OF FUNDS: Ad Valorem Taxes
No
Risk Management
/AMOUNT PER MONTH
"'^ ~
Year
APPROVED BY: County Aft;!
DOCUMENTATION:
Included X
Not Required_~~
DISPOSITION:
AGENDA ITEM #.
ReVIsed 8/06
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract Amendment
#1 to Contract #KG058
Effective Date: November 15,2006
Expiration Date: June 30, 2007
Contract Purpose/Description: Approval of Amendment #00 I to Contract #KG058 will allow the Department of
Children & Families to request Monroe County to inventory all nonexpendable property, i.e. computers, vehicles,
etc. purchased with CCDA Funds and return said inventory to DCF in the completion or termination of said
contract. This wiUnot atfect the total amoulJ%fthe contract as fund amount will not change.
, . ,t~/,/J" ".,;;;7
;(J'--' ,/ , ,~,-
Deloris Sim~~:, //'
(Name) L.//'/
Contract with: State of Florida/Department of
Children & Families
Contract Manager:
For BOCC mectmg on 11/15/2006
4589
(EXL)
Social Services/Stop 1
(DepartmenUStop #)
Agenda Deadline:
10/31/2006
CONTR.ACT COSTS
Total Dollar Value of Contract: $110,785.15
Budgeted'! Yes X No Account Codes:
Grant: $ 8L733.00 (Fiscal Year)
County Match: S 9,081.44 CFiscal Year) (Required)
SI9,97(Pl (Additional)
$29.052.15 (Total Match)
Estimated Ongoing Costs: $ ~m..__.j'yT
(Not Included in dollar value ubove)
Current Year Portion: $~_~~_~
ADDITIONAL COSTS
For:
~.~-~-~~~~~-,~~--~
(eg. Mamtenanec, utilities, Janltoriul, salarlCs, lOte)
CONTRi\CT REVIEW
Divlsion Director
Changes
Ncede>i~,
~/ '.
Y es (,'~~~,:~
f!:Y ~ 1-
Yes (N~
"%~,,~-
Yes /No)
~';Y
Risk Management
. ':Ii"
~, ~. . C'h'!:ti
!- " j ~'II;
o.'!\:t':n.;J urcnasmg
lofo
('ounty Attorney
No
J
Yes
Comments:
Date Out
r~~__~~_~~~~~~~__~~
~oooo~___~~'"_~~~~____~~~~~~~~~~~~_~~~~__~~___ ~~~_~~_____~'~~_~~~~~__~~~" ^ ~~__CC"C'C""_~~"__~~"_~_~~~
OMH Form Revised 2/27/01 Mer #2
~~~~~~~~~~~.
O,Yv~lY ~o9.~~~E
\305\ 294-4641
BOARD OF COUNTY COMMISSIONERS
Mayor Charles "Sonny" McCoy, District 3
Mayor Pro Tem Dixie M, Spehar, District 1
George Neugent, District 2
DavId p" Rice, District 4
Glenn Patton, DIstrict 5
MEMORANDUM
TO:
Monroe County Board of County Commissioners
f\ 'I
.,JJj-
FROM:
Dee Simpson, Senior Administrator, In-Horne Services Program
DATE:
10111/2006
RE:
Agenda Item regarding Amendment #001 for Community Care tor Disabled Adults
(CCDA) Contract #KG058
This memorandum is in regards to Amendment #001 for the Community Care for Disabled Adults (CCDA)
Contract #KG058. This Alnendment is between Monroe County Board of County Commissioners (Social
Services/ln - Home Services) and the Department of Children & Families
The approval of this Amendment will approve the following changes:
llardback books with a value or cost of $100.00 or more should be classified as nonexpendable property only if
they are circulated to students or to the general public. All computers, including all desktop and laptop
computers, regardless of the acquisition cost or value are classified as nonexpendab!e property.
When state property will be assigned to a provider for use in performance of a contract, the title for that
property or vehicle shall be immediately transferred to the provider where it shall remain until this contract is
terminated or until other disposition instructions are furnished by the contract manager, When property is
transferred to the provider, the department shaH pay for the title transfeL The provider's responsibility starts
when the fully accounted for property or vehicle is assigned to and accepted by the provider. Business
arrangouents made between the provider and its subcontractors shall not permit the transfer of title or state
property to subcontractors.
Provider shall inventory ail nonexpendable property purchased by CCDA funds including all computers. The
inventory shall include, at a minimum, the identification number; year and/ or model, a description of the
property, its use and condition, current location, the name of the property custodian, class code (use state
standard codes for capital assets), if a group, record the number and description of the components making up
the ,group, make, or manufacturer, serial number(s), if any, and if an automobile, the VIN and certificate
!lUrnbcr\ acquisition date, origmal acquiSItlOn cost, funding source, and information needed to calculate the
federal and lor state share of its cost.
The provider shall furnish a closeout inventory no later than 30 days before the completion or termination of
this contract.
The provider hereby agrees to pay the cost of transferring title to and possession of any property for which
ownership is evidenced by a certificate of title. The provider shall be responsible for repaying to the department
the replacement cost of any property inventoried and not transferred to the department upon completion or
termination of this contract. \Vhen property transfers from the provider to the department, the provider shall be
responsible for paying for the title transfer.
The provider hereby agrees to indemnify the department against any claim or loss arising out of the operation of
any motor vehicle purchased by or transferred to the provider pursuant to this contract
The original Community Care for Disabled Adults (CCDA) #KG058 has been approved by the board on June 21,
2006.
Thank you.
CONTRACT #KG058
AMENDMENT #0001
THIS AMENDMENT, entered into between the Florida Department of Children and
Families; hereinafter referred to as the "department"; and Monroe County (In Home Services),
hereinafter referred to as the "provider", amends contract KG058.
1, Attachment I, Section D, Paragraph 3 is hereby amended to read:
3. Property
a. Nonexpendable property is defined as tangible personal property of a
nonconsumable nature that has an acquisition value or cost of $1 ,000 or more per
unit and an expected useful life of at least one year, and hardback covered bound
books that are not circulated to students or the general public, the value or cost of
which is $250 or more. Hardback books with a value or cost of $1 00 or more
should be classified as nonexpendable property only if they are circulated to
students or to the general public. All computers, including all desktop and laptop
computers, regardless of the acquisition cost or value are classified as
nonexpendable property. Motor vehicles include any automobile, truck; airplane,
boat, or other mobile equipment used for transporting persons or cargo,
b. When state property will be assigned to a provider for use in performance of a
contract, the title for that property or vehicle shall be immediately transferred to
the provider where it shall remain until this contract is terminated or until other
disposition instructions are furnished by the contract manager. When property is
transferred to the provider, the department shall pay for the title transfer. The
provider's responsibility starts when the fully accounted for property or vehicle is
assigned to and accepted by the provider. Business arrangements made between
the provider and its subcontractors shall not permit the transfer of title of state
property to subcontractors. While such business arrangements may provide for
subcontractor participation in the use and maintenance of the property under their
control, the department shaH hold the provider solely responsible for the use and
condition of said property, Provider inventories shall be conducted in accordance
with CFOP 80-2.
c. If any property is purchased by the provider with funds provided by this
contract, the provider shaH inventory all nonexpendable property including
aU computers. A copy of which shall be submitted to the department along
with the expenditure report for the period in which it was purchased. At
least annually the provider shall submit a complete inventory report
(Exhibit B) of all such property to the department whether new purchases
have been made or not.
d. The inventory shaH include, at a minimum, the identification number; year
and/or model,; a description of the property. its use and condition; current
location; the name of the property custodian; class code (use state standard
codes for capital assets); if a group, record the number and description of
the components making up the group; name, make, or manufacturer; serial
number(s), if any, and if an automobile, the VIN and certificate number;
acquisition date; original acquisition cost; funding source; and,
information needed to calculate the federal and/or state share of its cost.
c. The contract manager must provide disposition instructions to the provider
prior to the end of the contract period. The provider cannot dispose of any
property that reverts to the department without the contract manager's
approval. The provider shall furnish a closeout inventory no later than 30
days before the completion or termination of this contract. The closeout
inventory shall include all nonexpendable property including all computers
purchased by the provider. The closeout inventory shall contain, at a
minimum, the same information required by the annual inventory.
f. The provider hereby agrees that all inventories required by this contract
shall be current and accurate and reflect the date of the inventory. If the
original acquisition cost of a property item is not available at the time of
inventory, an estimated value shall be agreed upon by both the provider
and the department and shall be used in place of the original acquisition
cost.
g. Title (ownership) to and possession of all property purchased by the
provider pursuant to this contract shall be vested in the department upon
completion or termination of this contract. During the term of this
contract, the provider is responsible for insuring all property purchased by
or transferred to the provider is in good working order. The provider
hereby agrees to pay the cost of transferring title to and possession of any
property for which ownership is evidenced by a certificate of title. The
provider shall be responsible for repaying to the department the
replacement cost of any property inventoried and not transferred to the
department upon completion or termination of this contract. When
property transfers from the provider to the department, the provider shall
be responsible for paying for the title transfer.
h. If the provider replaces or disposes of property purchased by the provider
pursuant to this contract, the provider is required to provide accurate and
complete information pertaining to replacement or disposition of the
property as required on the pn:rvidcr's annual inventory_
L The provider hereby agrees to indemnify the department against any claim
or loss arising out of the operation of any motor vehicle purchased by or
transferred to the provider pursuant to this contract.
J A formal contract amendment is required prior to the purchase of any
property item not specifically listed in the approved budget
2. This amendment shall begin on October I, 2006, or the date on which the amendment has
been signed by both parties, whichever is IatcL
3. All provisions in the contract and any attachments thereto in conflict with this
amendment shall be and are hereby changed to confonn with the amendment.
4. All provisions not in conflict with this amendment are still in effect and are to be
performed at the level specified in the contract.
5. This amendment and all its attachments are hereby made a part ofth15 contract
IN WITNESS WHEREOF, the parties hereto have caused this 3 page amendment to be executed
by their officials thereunto duly authorized.
PROVIDER: Momoe County
(In Home Services)
FLORIDA DEPARTMENT
OF CHILDREN AND FAMILIES
SIGNED
BY:
SIGNED
BY:
NAME: Charles McCov
NAME:
Gilda P. F erradaz
TITLE: Mavor
TITLE:
District Administrator
DATE
DATE
FEDERAL ID NUMBER: 596000749
04/0; i2006
CFDA No.
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
Client 0 Non-Client 0
Multi-District 0
THIS CONTRACT is entered into between the Florida Department of Children and Families, hereinafter referred to as the
"Department," and Monroe County (Monroe County In Home Services), hereinafter referred to as the "Provider."
I. THE PROVIDER AGREES:
Upon demand, at no additional cost to the Department. the Provider will facHitate the duplication and transfer of any records or
during the required retention period in Subsection I. Paragraph D.2.
4. To assure that these records shall be subject at all reasonable times to inspection, review, copying, or audit by Federal, State.
().f other personnel duly authorized by the Department
A. Contract Document
To orovide services in accordance with the terms and Conditions specified in this contract induding all attachments and exhibits, which
con'stitute the contract document
8. Requirements of Section 287.058 F.S.
To provide units of deliverabtes, including reports, findings, and drafts, as specified In this contract, which must be received and
accepted by the contract manager in writing prior to payment. To submit bills for fees or other compensation for services or expenses
in sufficient detail for a proper pre-audit and post-audit. Where itemized payment for travel expenses are permitted in this contract, to
submit bHts for any travel expenses in accordance with section 112.061, F .S. or at such lower rates as may be provided in this
contract. To allow public access to all documents, papers, letters, or other public records as defined in subsection 119.011 (11 ),F.S"
made or received by the Provider in conjunction With this contract except that public records which are made confidential by law must
be protected from disclosure. It is expressly understood that the Provider's faifure to comply with this provision shaff constitute an
immediate breach of contract for which the Department may unHateraUy terminate the contract.
C. Governing Law
1. State of Florida law
That this contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in all respects
in accordance with the Florida law including Florida provisions for conflict of laws.
2. Federal Law
a. That if this contract contains federal funds the Provider shall comply with the provisions of 45 CFR, Part 74, and/or 45 CFR,
Part 92, and other applicable regulations.
b. That if this contract contains federal funds and is over $100,000, the Provider shall comply with all applicable standards,
orders, or regulations issued under section 306 of the Crean Air Act, as amended (42 U.S,C. 7401 et seq,), section 508 of the Federal
Water Pollution Control Act as amended (33 U.s.C. 1251 et seq.), Executive Order 11738 as amended and where applicable, and
Environmental Protection Agency regulations (40 CFR, Part 30), The Provider shall report any violations of the above to the
Department
c. That no federal funds received in connection with this contract may be used by the Provider, or agent acting for the
Provider, to influence legislation or appropriations pending before the Congress or any State legislature. If this contract contains
federal funding in excess of $100,000, the Provider must. prior to contract execution, complete the Certification Regarding Lobbying
form, Attachment N/A. If a Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may be obtained from the
contract manager. All disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to
the contract manager, prior to payment under this contract.
d. That unauthorized aliens shall not be employed. The Department shall consider the employment of unauthorized aliens a
violation of section 274A(e) of the Immigration and Nationality Act (8 U.S.C. 1324 a). Such violation shall be cause for unilateral
cancellation of this contract by the Department
e. That if this contract contains $10,000 or more offederaJ funds, the Provider shall comply with Executive Order 11246, Equal
Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in Department of Labor regulation
41 CFR, Part 60 and 45 CFR, Part 92, if applicable,
f. That if this contract contains federal funds and provides services to chHdrel1 up to age 18. the Provider shall comply with the
Pro-Children Act of 1994 (20 U,S.C. 6081). Failure to comply with the provisions of the law may result in the imposition of a civil
monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compfiance order on the responsible
entity.
Audits, Inspections, Investigations, Records and Retention
1. To establish and maintain books, records and documents (including electronic storage media) sufficient to reflect aU income
expenditures of funds provided by the Department under this contract
:.t To retain all cHent records, financial records, supporting documents, statistical records, and any other documents (including
storage media) pertinent to this contract for a periOd of six (6) years after completion of the contract or longer when required
law. In the event an audit is required by this contract, records shall be retained for a minimum periOd of six (6) years after the audit
is issued or until resolution of any audit findings or fitigation based on the terms of this contract, at no additional cost to the
CONTRACT #KG058
04/01/2006
5. At all reasonable times for as long as records are maintained, persons duly authorized by the Department and Federal auditors,
pursuant to 45 CFR, Section 92.36(i) (10), shall be allowed fuff access to and the right to examine any of Ihe Provider's contracts and
related records and documents, regardless of the form in which kept.
6. To provide a financial and compliance audit to the Department as specified in this contract and in Attachment!L and to ensure
that all related party transactions are disclosed to the auditor,
7. To comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by the office
of The Inspector General (Section 20.055, Florida Statutes).
E. Monitoring by the Department
To permit persons duly authorized by the Department to inspect and copy any records, papers, documents, facilities, goods and
services of the Provider which are relevant to this contract, and to interview any clients, employees and subcontractor employees of
the Provider to assure the Department of the satisfactory performance of the terms and conditions of this contract. Following such
review, the Department will deliver to the Provider a written report of its findings and request for development, by the Provider of a
corrective action plan where appropriate. The Provider hereby agrees to timely correct aU deficiencies identified in the corrective
action plan.
F. Indemnification
NOTE: Except to the extent permitted bv s.768.28 , F.S., or other applicable Florida Law, Paragraph 1.F.1. and 2. are not applicable to
contracts executed between state agencies or subdivisions, as defined in subsection 768.28(2), F.S.
1. To be liable for and indemnify, defend, and hold the Department and aU of its officers, agents, and employees harmless from all
ctaims, suits, judgments, or damages, including attorneys' fees and costs, arising out of any act, actions, neglect, or omissions by the
Provider, its agents, employees and subcontractors during the performance or operation of this contract or any subsequent
modifications thereof.
2. That its inability to evaluate its liability or its evaluation of liability shafll10t excuse the Provider's duty to defend and to indemnify
within seven (7) days after notice by the Department by certified mail. After the highest appeal taken is exhausted, only an adjudication
or judgment specifically finding the Provider not liable shall excuse performance of this provision. The Provider shall pay aU costs and
fees induding attorneys' fees related to these obligations and their enforcement by the Department. The Department's failure to notify
the Provider of a claim shall not release the Provider from these duties, The Provider shall not be liable for the sole negligent acts of
the Department.
G. Insurance
To provide continuous adequate liability insurance coverage during the existence of this contract and any renewal(s) and extension(s)
of it. By execution of this contract, unless it is a state agency or subdivision as defined by subsection 768.28(2), F.S., the Provider
accepts full responsibility for identifying and determining the type(s) and extent of liability insurance necessary to provide reasonable
financial protections for the Provider and the clients to be served under this contract. Upon the execution of this contract, the Provider
shall furnish the Department written verification supporting both the determination and existence of such insurance coverage. Such
coverage may be provided by a self-insurance program established and operating under the laws of the State of Florida. The
Department reserves the right to require additional insurance as specified in this contract.
H. Confidentiality of Client Information
Not 10 use or disclose any information concerning a recipient of services under this contract for any purpose prohibited by state or
federal law or regulations (except with the written consent of a person legally authorized to give that consent or when authorized by
taw),
L Assignments and Subcontracts
1. To neither assign the responsibility for this contract to another party nor subcontract for any of the work contemplated under this
contract without prior written approval of the Department which shall not be unreasonably withheld. Any sublicense, assignment, or
transfer otherwise occurring without prior approval of the Department shall be null and void.
2, To be responsible for all work performed and for all commodities produced pursuant to this contract whether actually furnished
by the Provider or its subcontractors. Any subcontracts shall be evidenced by a written document The Provider further agrees that
the Department shall not be liable to the subcontractor in any way or for any reason. The Provider, at its expense, will defend the
Department against such claims.
3. To make payments to any subcontractor within seven (7) working days after receipt of full or partial payments from the
Department in accordance with section 287.0585, F.S., unless otherwise stated in the contract between the Provider and
2
CONTRA.cr #KG058
" 04/01/2006
subcontractor. Failure to pay within seven (7) working days will result in a penalty that shall be charged against the Provider and paid
to the subcontractor in the amount of one-half of one percent (.005) of the amount due per day from the expiration of the period
allowed for payment. Such penalty shall be in addition to actual payments owed and shalf not exceed fifteen (15%) percent of the
outstanding balance due.
4. That the State of Florida shall at all times be entitled to assign or transfer its rights, duties, or obligations under this contract to
another governmental agency in the State of Florida, upon giving prior written notice to the Provider. In the event the State of Florida
approves transfer of the Provider's obligations, the Provider remains responsible for alf work performed and all expenses incurred in
connection with the contract. This contract shall remain binding upon the successors in interest of either the Provider or the
Department
J. Return of Funds
To return to the Department any overpayments due to unearned funds or funds disallowed pursuant to the terms and conditions of this
contract that were disbursed to the Provider by the Department. In the event that the Provider or its independent auditor discovers that
an overpayment has been made, the Provider shaH repay said overpayment immediately without prior notification from the
Department. fn the event that the Department first discovers an overpayment has been made, the contract manager, on behalf oHhe
Department, will notify the Provider by leHer of such findings. Shoufd repayment not be made forthwith, the Provider will be charged at
the lawful rate of interest on the outstanding balance after Department notification or Provider discovery.
K. Client Risk Prevention and Incident Reporting
1. That if services to cHents are to be provided under this contract, the Provider and any subcontractors shall, in accordance with
the client risk prevention system, report those reportable situations fisted in CFOP 215-6 in the manner prescribed in CFOP 215-6 or
district operating procedures.
2. To immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or disabled
adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96A8USE). As required by Chapters 39 and
415, F.S., this provision is binding upon both the Provider and its employees.
L Purchasing
1. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative Industries and
Diversified Enterprises, Inc., (PRIDE) identified under Chapter 946, F.S., in the same manner and under the procedures set forth in
subsections 946.515(2) and (4), F.S. For purposes of this contract, the Provider shall be deemed to be substituted for the Department
insofar as dealings with PRIDE. This clause is not applicable to subcontractors unless otherwise required by law. An
abbreviated list of products/services available from PRIDE may be obtained by contacting PRIDE, (850) 487-3774,
2. To procure any recycled prodUcts or materials, which are the subject of or are required to carry out this contract, in accordance
with the provisions of sections 403.7065, and 287.045, F.S.
M. Civil Rights Requirements
1. Not to discriminate against any employee in the performance of this contract or against any applicant for employment because
of age, race, religion, color, disability, national origin, marital status or sex in accordance with CFOP 60-16.. The Provider further
assures that all contractors, subcontractors, sUbgrantees, or others with whom it arranges to provide services or benefits to cHents or
employees in connection with any of its programs and activities are not discriminating against those clients or employees because of
age, race, religion, color, disability, national origin, marital status or sex. This is binding upon the Provider employing fifteen (15) or
more individuals.
2. To complete the Civil Rights Compliance Questionnaire, CF Forms 946 A and 8, in accordance with CFOP 60-16. This is
binding upon Providers that have fifteen (15) or more employees.
3. Subcontractors who are on the discriminatory vendor list, may not transact business with any publiC entity, in accordance with
the provisions of section 287.134 F.S.
N. Independent Capacity of the Contractor
1. To act in the capacity of an independent contractor and not as an officer. employee of the State of Florida, except where the
Provider is a state agency. Neither the Provider nor its agents, employees, subcontractors or assignees shall represent to others that
has the authority to bind the Department unless specifically authorized in writing to do so.
2. This contract does not create any right to state retirement, leave benefits or any other benefits of state employees as a result of
the duties or obligations of this contract.
3. To take such actions as may be necessary to ensure that each subcontractor of the Provider will be deemed to be an
contractor and wi!! !lot be considered or permitted fa be an agent, servant, jOint venturer, or partner of the State of Florida
4. The Department will not furnish services of support (e.g., office space, office supplies; telephone service, secretarial or clerical
to the Provider, or its subcontractor or assignee, unless specifically agreed to by the Department in this contract.
5, AI! deductions for social security, withholding taxes, income taxes, contributions 10 unemployment compensation funds and all
insurance for the Provider, the Provider's officers, employees, agents, subcontractors, or assignees shall be the sole
of the Provider.
CONTRACT #KG058
, 04/01l2006
O. Sponsorship
As required by section 286.25, F.S., if the Provider is a non-governmental organization which sponsors a program financed wholly or in
part by state funds, including any funds obtained through this contract, it shall, in publicizing, advertising, or describing the sponsorship
of the program, state: .Sponsored by (Provider's name) and the State of Florida, Department of Children and Families." If the
sponsorship reference is in written material, the words "State of Florida, Department of Children and Families" shari appear in the
same size letters or type as the name of the organization.
P. Publicity
Without limitation, the Provider and its employees, agents, and representatives will not, without prior Departmental written consent in
each instance, use in advertising, publicity or any other promotional endeavor any State mark, the name of the State's mark, the name
of the State or any State affilfate or any officer or employee of the State, or represent, directly or indirectly, that any product or .service
provided by the Provider has been approved or endorsed by the State, or refer to the existence of this contract in press releases,
advertising or materials distributed to the Provider's prospective customers.
Q. Finallnvoice
To submit the tinal invoice for payment to the Department no more than 45 days after the contract ends or is terminated. If the
Provider fails to do so, all rights to payment are forfeited and the Department will not honor any requests submitted after the aforesaid
time period, Any payment due under the terms of this contract may be withheld until all reports due from the Provider and necessary
adjustments thereto have been approved by the Department
R. Use of Funds for Lobbying Prohibited
To comply with the provisions of sections 11,062 and 216,347, F,S., which prohibit the expenditure of contract funds for the purpose of
lobbying the Legislature, judicial branch, or a state agency.
S. Public Entity Crime
Pursuant to section 287.133, F.S., the following restrictions are placed on the ability of persons convicted of public entity crimes to
transact business with the Department: When a person or affiliate has been placed on the convicted vendor list following a conviction
for a public entity crime, he/she may not submit a bid on a contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or the repair of a public building or public work, may not submit bids on
leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant
under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount
provided in section 287.017, F.S., for CATEGORY TWO for a period of thirty-six (36) months from the date of being placed on the
convicted vendor list
T, Gratuities
The Provider agrees that it will not offer to give or give any gift to any Department employee. As part of the consideration for this
contract, the parties intend that this provision will survive the contract for a period of two years. In addition to any other remedies
available to the Department, any violation of this provision will result in referral of the Provider's name and description of the violation of
this term to the Department of Management Services for the potential inclusion of the Provider's name on the suspended vendors list
for an appropriate period. The Provider will ensure that its subcontractors, if any, comply with these provisions
U. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course of or as a result of work or services performed under this
contract, or in anyway connected herewith, the Provider shall refer the discovery or invention to the Department to be referred to the
Department of State to determine whether patent protection will be sought in the name of the State of Florida. Any and all patent rights
accruing under or in connection with the performance of this contract are hereby reserved to the State of Florida.
2, In the event that any books, manuals, films, or other copyrightable materials are produced, the Provider shall notify the
Department of State. Any and all copyrights accruing under or in connection with performance under this contract are hereby reserved
to the State of Florida.
3. The Provider, if not a state agency, as that term is defined in subsection 768.28, FS" shalf indemnify and save the Department
and its employees harmless from any liability whatsoever, including costs and expenses, arising out of any copyrighted, patented, or
... unpatented invention, process, or article manufactured or used by the Provider in the performance ofthig contract.
.. 4. The Department will provide prompt written notification of any claim of copyright or patent infringement. Further, if such claim is
...,.. made or is pending, the Provider may, at its option and expense, procure for the Department, the right to continue use of, replace, or
.... modify the article to render it non-infringing. If the Provider uses any design, device, or materials covered by letters, patent, or
copyright, it is mutually agreed and understood without exception that the compensation paid pursuant to this contract incfudes all
royalties or costs arising from the use of such design, device, or materials in any way involved in the work contemplated by this
contract.
5. All applicable subcontracts shall include a proviSion that the Federal awarding agency reserves all patent rights with respect to
any discovery or invention that arises or Is developed in the course of or under the subcontract.
V. Construction or Renovation of Facilities Using State Funds
That any state funds provided for the purchase of or improvements to real property are contingent upon the Provider granting to the
state a security interest in the property at least to the amount of the state funds provided for at least five (5) years from the date of
purchase or the completion of the improvements or as further required by law, As a condition of receipt of state funding for this
4
CONTRACT #I(G058
04/01/2006
purpose, the Provider agrees that, if it disposes of the property before the Department's interest is vacated, Ihe Provider will refund the
proportionate share of the state's initial investment, as adjusted by depreciation.
W. Information Security Obligations
1. To identify an appropriately skilled individual to function as its Data Security Officer who shall act as the liaison to Ihe
Department's Security Staff and who will maintain an appropriate level of data security for the information the Provider is coUecting or
using in the performance of this contract. An appropriate level of security includes approving and tracKing all Provider employees that
request system or information access and ensuring that user access has been removed from all terminated Provider employees.
2. To hold the Department harmless from any loss or damage incurred by the Department as a result of information technology
used, provided or accessed by the Provider.
3. To provide the latest Departmental Security Awareness Training to its' staff and subcontractors.
4. To ensure that aJl Provider employees who have access to Departmental information are provided a copy of CFOP 50-6 and
that they sign the DCF Security Agreement form (CF 114), a copy of which may be obtained from the contract manager.
X. Accreditation
That the Department is committed to ensuring provision of the highest quality services to the persons we serve. Accordingly, the
Department has expectations that where accreditation is generally accepted nationwide as a clear indicator of quality service, the
majority of our Providers will either be accredited, have a plan to meet national accreditation standards, or will initiate one within a
reasonable period of time.
Y. Agency for Workforce Innovation and Workforce Florida
That it understands that the Department, the Agency for Workforce Innovation, and Workforce Florida, Inc. have jointly implemented
an initiative to empower recipients in the Temporary Assistance to Needy Families Program to enter and remain in gainful
employment. The Department encourages Provider participation with the Agency for Workforce Innovation and Workforce Florida.
Z. Health Insurance Portabi!1ty and Accountability Act
Where applicable, to comply with the Health Insurance Portability and Accountability Act (42 U. S. C, 1320d.) as well as all regulations
promulgated thereunder (45 CFR Parts 160, 162, and 164).
AA Emergency Preparedness
If the tasks to be performed pursuant to this contract include the physical care and control of clients, the Provider shall, within 30 days
of the execution of this contract, submit to the contract manager an emergency preparedness plan which shall include provisions for
pre-disaster records protection, alternative accommodations for clients in substitute care, supplies, and a recovery plan that wiff allow
the Provider to continue functioning in compliance with the executed contract in the event of an actual emergency. The Department
agrees to respond in writing within 30 days of receipt of the plan accepting, rejecting, or requesting modifications. In the event of an
emergency, the Department may exercise oversight authority over such Provider in order to assure implementation of agreed
emergency relief provisions.
BS. PUR 1000 Form
The PUR 1000 Form is hereby incorporated by reference. In the event of any conflict between the PUR 1000 Form, and any terms or
conditions of this contract (including the Department's Standard Contract), the terms or conditions of this contract shall take
precedence over the PUR 1000 Form. However, if the conflicting terms or conditions in the PUR 1000 Form is required by any section
of the Florida Statutes, the terms or conditions contained in the PUR 1000 Form shaH take precedence,
II. THE DEPARTMENT AGREES:
A Contract Amount
To pay for contracted services according to the terms and conditions of this contract in an amount not to exceed NJA or the rate
schedule, subject to the availability of funds. The State of Florida's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the Legislature. Any costs or services paid for under any other contract or from any other source are
not eiigible for payment under this contract
B. Contract Payment
to section 215.422, F.S., the Department has five (5) working days to inspect and approve goods and services, unless the
specifications, purchase order, or this contract specify othelWise. With the exception of payments to health care Providers for
medical. or other health Gare services, jf payment is not available within forty (40) measured from the latter of the date a
compfeted invoice is received by the Department or the goods or services are receiVed, inspected, and approved, a separate
penalty set by the Comptrorrer pursuant to section 55.03, F.S., will be due and payable in addition to the invoice amount
to health care Providers for hospital, medical, or other health care services, shall be made not more than thirty-five (35)
from the date eligibility for payment is determined. Financial penalties wiff be calculated at the daily interest rate of .03333%.
returned to a Provider due to preparation errors will result in a non-interest bearing payment delay. Interest penalties less
one (1) dollar will not be paid unless the Provider requests payment
5
CONTRACT #1((;058
, 04/01/2006
C. Vendor Ombudsman
A Vendor Ombudsman has been established within the Department of Financial Services, The duties of this office are found in
subsection 215.422, F.8" which include disseminating information relative to the prompt payment of this state and assisting vendors in
receiving their payments in a timely manner from a state agency, The Vendor Ombudsman may be contacted at (850) 413-5516.
D. Notice
Any notice, that is required under this contract shall be in writing, and sent by U,S, Postal Service or any expedited delivery service
tha't provides verification of delivery or by hand delivery, Said notice shall be sent to the representative of the Provider responsible for
administration of the program, to the designated address contained in this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A Effective and Ending Dates
This contract shall begin on Julv 1, 2006, or on the date on which the contract has been signed by the last party required to sign it,
whichever is later. It shall end at midnight, local time in Monroe County, Florida, on June 30,2007.
B. Financial Penalties for Failures to Comply with Requirement for Corrective Action.
1. In accordance with the provisions of Section 402.73(7), Florida Statutes, and Section 65-29.001, Florida Administrative Code,
corrective action plans may be required for noncompliance, nonperformance, or unacceptable performance under this contract.
Penalties may be imposed for failures to implement or to make acceptable progress on such corrective action plans.
2. The increments of penalty imposition that shall apply, unless the Department determines that extenuating circumstances exist,
shall be based upon the severity of the noncompliance, nonperformance, or unacceptable performance that generated the need for
corrective action plan. The penalty, if imposed, shall not exceed ten percent (10%) of the total contract payments during the period in
which the corrective action plan has not been implemented or in which acceptable progress toward implementation has not been
made Noncompliance that is determined to have a direct effect on client health and safety shall result in the imposition of a ten
percent (10%) penalty of the total contract payments during the period in which the corrective action plan has not been implemented or
in which acceptable progress toward implementation has not been made.
3. Noncompliance involving the provision of service not having a direct effect on client health and safety shall result in the
imposition of a five percent (5%) penalty, Noncompliance as a result of unacceptable performance of administrative tasks shall result
in the imposition of a two percent (2%) penalty.
4. The deadline for payment shall be as stated in the Order imposing the financial penalties. In the event of nonpayment the
Department may deduct the amount of the penalty from invoices submitted by the Provider.
C, Termination
1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the
other party unless a sooner time is mutually agreed upon in writing. Said notice shall be delivered by U.S. Postal Service or any
expedited delivery service that provides verification of delivery or by hand delivery to the contract manager or the representative of the
Provider responsible for administration of the program.
2. In the event funds for payment pursuant to this contract become unavailable, the Department may terminate this contract upon
no less than twenty-four (24) hours notice in writing to the Provider. Said notice shall be sent by U,S. Postal Service or any expedited
delivery service that provides verification of delivery. The Department shall be the final authority as to the availability and adequacy of
funds. In the event of termination of this contract, the Provider will be compensated for any work satisfactorily completed.
3. This contract may be terminated for the Provider's non-performance upon no less than twenty-four (24) hours notice in writing
to the Provider. If applicable, the Department may employ the default proviSions in Rule 60A-1.006(3), FAC. Waiver of breach of any
provisions of this contract shaH not be deemed to be a waiver of any other breach and shall not be construed to be a modification of
the terms and conditions of this contract The provisions herein do not limit the Department's right to remedies at law or in equity.
4. Failure to have performed any contractual obligations with the Department in a manner satisfactory to the Department wifl be a
sufficient Cause for termination. To be terminated as a Provider under this provision, the Provider must have: (1) previously failed to
satisfactorily perform in a contract with the Department, been notified by the Department of the unsatisfactory performance, and failed
to correct the unsatisfactory performance to the satisfaction of the Department; or (2) had a contract terminated by the Department for
cause.
D. Renegotiations or Modifications
...' Modifications of provisions of this contract shaH be valid only when they have been reduced to writing and duly signed by both parties.
iThe rate of payment and the total dollar amount may be adjusted retroactively to reflect price level increases and changes in the rate
of payment when these have been established through the appropriations process and SUbsequently identified in the Department's
opera ling budget.
6
CONTRACT #KG058
04/01/2006
E. Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
1. The Provider name, as shown on page 1 of this
contract, and mailing address of the official payee to
whom the payment sharr be made is:
Monroe County (Monroe County In Home Services)
1100 Simonton Street
Key West, FL 33040
2. The name of the contact person and street address
where financiai and administrative records are
maintained is:
Deloris S~mpson, Senior Administrator
Monroe County In Home Services
1100 Simonton Street
Key West, FL 33040
305~292-4589
3. The name, address, and telephone number of the contract manager
for the Department for this contract is:
Theresa Phelan
1111 1210 Street
Key West, FL 33040
305-292-6810
4. The name, address, and telephone number of the representative of
the Provider responsible for administration of the program under this
contract is:
Deloris Simpson
Monroe County In Home Services
1100 S i m onton Street
Key West, FL 33040
305-292-4589
5. Upon change of representatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the
other party and the notification attached to the originals of this contract.
F. All Terms and Conditions Included
This contract and its attachments, f, II and exhibits A. 8, C, 0 and E to Attachment l. and any exhibits referenced in said attachments,
together with any documents incorporated by reference, contain all the terms and conditions agreed upon by the parties. There are no
provisions, terms, conditions, or obligations other than those contained herein, and this contract shall supersede all previous
communications, representations, or agreements, either verbal or written between the parties. If any term or provision of this contract
is legally determined unlawful or unenforceable, the remainder of the contract shall remain in full force and effect and such term or
provision shall be stricken.
By signing this contract, the parties agree that they have read and agree to the entire contract, as described in Paragraph
III.F. above.
IN WITNESS THEREOF, the parties hereto have caused this 36 page contract to be executed by their undersigned officials as duly
authorized.
PROVIDER: Monroe County
PRINT
NAME:
SIGNED
BY:
NAME:
TITLE:
DATE:
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
PRINT
NAME:
SIGNED
BY:
NAME:
TITLE:
DATE:
-,
/
CONTRACT #KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
A TT ACHMENT I
A. Services to be Provided
1, Definition of Terms
a. Contract Terms
(Refer to the Glossary in CFOP 75-2, Contract Management System for Contractual
Services, which is incorporated by reference herein)
b. Program or Service Specific Terms
(1) Activities of Daily Living - Basic activities performed in the course of daily
living, such as dressing, bathing, grooming, eating, using a commode or urinal,
and ambulating around one's own home.
(2) Case Management Providers - Private, for~profit, nonprofit or local
government agencies designated to provide coordination of care for eligible
clients. This includes ongoing assessment of client needs and eligibility, ongoing
development of care plans, and the arrangement for appropriate services to meet
those needs. Case management providers integrate all available services
through department-approved direct service providers into a sole program of
service delivery uniquely patterned to meet the client's varying service needs.
Case management providers may choose to deliver only case management
services or choose to be dually responsible as both a direct service provider and
a case management provider.
(3) Client - Any person who is eligible and is at least eighteen (18) years through
age fifty-nine (59), has one (1) or more permanent physical or mental limitations
that restrict the client's ability to perform normal activities of daily living, and
impede the client's capacity to live independently or with relatives or friends
without the provision of community-based services.
(4) Direct Service Providers - Private, for-profit, nonprofit or local government
agencies that are registered or licensed to provide direct service support to
eligible clients. Direct services range from the provision of health services
delivered by physicians, nurses, physiotherapists, occupational therapists,
speech therapists, and dietitians, to services delivered by workers such as
homemakers, chore and transportation worker and personal care aides. The
direct service provider may choose to deliver only direct services or choose to be
dually responsible as both a case management provider and a direct service
provider.
(5) Medicaid Institutional Care Program (MICP) - A program that serves
Medicaid recipients who are determined eligible for a nursing home level of care,
which provides primary, acute, and long-term care services at capitated
federally-matched rates,
(6) Nursing home" Any facility which provides nursing services as defined in
Chapter 464, Florida Statutes., and which is licensed in accordance with Chapter
400, Florida Statutes.
03/03/06
8
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(7) Outcomes - Means the result, impact, or benefit of a program's activities on
the clients, customers, or users of the services.
(8) Outputs - Means the actual service or product delivered.
(9) Performance Measures - Quantitative indicators used to assess whether the
activities the provider is performing are achieving the desired results.
2. General Description
a. General Statement
(1) The Community Care for Disabled Adults (CCDA) Program is designed to
assist disabled adults, age eighteen (18) through fifty-nine (59), in utilizing
available community and personal resources enabling them to remain in their
own homes, and preventing their premature or inappropriate institutionalization.
(2) Service providers will ensure that appropriate community-based services are
provided to clients in a manner designed to meet the client's changing needs, to
assist the cHent in avoiding or reducing unnecessary dependence on the
delivered services, and to increase the client's self-reliance.
b. Authority
Sections 410.601-410.606, Florida Statutes (F,S.), Chapter 65C-2, Florida Administrative
Code, and the annual appropriations act, with any proviso language or instructions to the
department, constitute the legal basis for services to be delivered through the CCDA
program.
c. Scope of Service
Services will be targeted toward eligible adults in Monroe County.
d. Major Program Goal
Community-based services provided under this contract are designed to prevent
inappropriate institutionalization of disabled adults.
3. Clients to be Served
a. General Description
Adults with disabilities, age eighteen (18) through fifty-nine (59), who are no longer
eligible to receive children'S services, and are too young to qualify for community and
home-based services for the elderly, if authorized by the Adult Services Program Office,
may be served under the provisions of this contract.
b. Client Eligibility
(1) Applicants must have one or more permanent physical or mental limitations,
that restrict the ability to perform normal activities of daily living, as determined
through the initial functional assessment and medical documentation of disability,
Determination of a permanent disability must be established and evidenced in
one of the following ways:
03/03/06
9
PSMAI No. GAO?
Contract # KG058
07/01/2006
03/03/06
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(a) An applicant may present a check, awards letter, or other proof
showing receipt of Social Security Disability Income, or some other
disability payment (e,g., Worke(s Compensation); or
(b) An applicant may present a written statement from a licensed
physician, licensed nurse practitioner, or mental health professional,
which meets the district's criteria for evidence of a disability. This written
statement must, at a minimum, include the applicant's diagnosis,
prognosis, a broad explanation of level of functioning, and the
interpretation of need for services based on identified functional barriers
caused by the applicant's disabling condition,
(2) Applicants must have an individual income at or below the prevailing MICP
eligibility standard in order to receive free CCDA services.
(3) Applicants with incomes above the standard will be assessed a fee for a
share of the costs, or may be required to provide volunteer services in lieu of
payment.
c. Client Determination
(1) Clients will be assessed for eligibility determination, and prioritized for
services by district Department of Children and Families staff, in accordance with
subsection 410.604 (2), Florida Statutes,
(2) The Adult Services Program Office will make the final determination of
service authorization.
d. Contract Limits
(1) The total annual cost estimated or actual, for an individual receiving CCDA
services, shaH not exceed the average, annual general revenue portion of a
Medicaid nursing home bed within the district area.
(2) Clients must not be receiving comparable services from any other state
entity. In order to prevent duplication of services, client files must contain
documentation verifying that af! comparable community services and funding
sources have been explored and exhausted.
(3) The provider shaH deliver services only to those persons who have
completed the Adult Services Screening for Consideration for new Community
Based Services, Exhibit A, have been scored by that instrument, and were
referred to the provider by the District/Region Program Office, and only to the
extent that funds are avaiiable.
10
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
B. Manner of Service Provision
1. Service Tasks
a. Task List
(1) The following tasks will be performed under this contract (check a!l that
apply rZ)).
DAdult Day Care X Case Management DEmergency Alert Response
X Personal Care DHome Health Aide DGroup Activity Therapy
X Homemaker DHome Nursing X Home Delivered Meals
DJnterpreter DTransportation DMedical Therapeutic
Services
DChore DRespite DPhysfcal and Exams
DEseort DAdult Day Care
(2) Details of the service tasks to be provided under this contract and the
negotiated parameters of those services are listed in CFOP 140-8, Community
Care for Disabled Adults Operating Procedures, herein incorporated by
reference,
(3) Each district CCDA program shall include case management services and at
least one other community service.
b. Task Limits
The following task limits apply to the services specified in 8.1 ,a. above.
(1) Respite Care services may be provided for up to two hundred forty (240)
hours per client per calendar year, depending upon individual need. The service
may be extended to three hundred sixty (360) hours, as recommended by the
case manager and approved by Adult Services Program Office. Documentation
of approval must be evident in the case narrative section at the case manager's
file.
03/03/06
11
PSMAf No. GA07
Contract # KG058
(2) Personal Care services will not substitute for the care usually provided by a
registered nurse, licensed practical nurse, therapIst, or home health aide. The
personal care aide wi!! not change sterile dressings, irrigate body cavities,
administer medications, or perform other activities prohibited by Chapter 59A-8,
Florida Administrative Code.
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(3) Homemaker service time does not include time spent in transit to and from
the cHent's place of residence except when providing shopping assistance,
performing errands or other tasks on behalf of a cHent.
(4) Several restrictions apply to persons providing Homemaker service activities.
Persons providing services must not
la) engage in work that is not specified in the Homemaker assignment;
(b) accept gifts from clients;
(c) fend or borrow money or articles from clients;
(d) handle client money, unless authorized in writing by a supervisor or
case manager (documented in the personnel file) and unless bonded or
insured by the employer;
(e) transport clients, unless authorized in writing by a supervisor or case
manager.
(5) The parameters of service delivery, by type of service, are detailed in CFOP
140-8, Community Care for Disabled Adults Operating Procedures.
(6) District task limits, which exceed those in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures, and are distinctive to this contract, are
listed here: N/A.
2. Staffing Requirements
a. Staffing Levels
(1) The provider wilJ meet the minimum staffing requirements for each service,
as specified in CFOP 140-8, Community Care for Disabled Adults Operating
Procedures.
(2) The provider will notify the department, in writing, within thirty calendar (30)
days whenever the provider is unable, or expects to be unable to provide the
required quality or quantity of service due to staff turnovers or shortages.
b. Professional Qualifications
The provider wHf ensure that staff meets the professional qualifications for each service,
as specified in CFOP 140-8, Community Care for Disabled Adults Operating Procedures.
03/03/06
12
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult SelVices Program
c. Staffing Changes
The provider agrees to notify the department's contract manager within two (2) working
days jf a key administrative position (e.g., executive director) becomes vacant. Planned
staffing changes that may affect the delivery of services to be provided under this
contract, must be presented in writing to the contract manager for approval at least ten
(10) working days prior to the implementation of the changeo
d. Subcontractors
This contract does not allow the provider to subcontract for the provision of any services
under this contract
3. Service Location and Equipment
a. Service Delivery Location and Times
(1) CCDA services may be delivered in the client's home or on~site at a facility,
as negotiated by the department and the provider.
(2) Facillties delivering on-site services to clients shall pass an annual inspection
by the local environmental health and fire authorities.
(3) Service providers will meet the minimum service location and time
requirements as specified in CFOP 140~8, Community Care for Disabled Adults
Operating Procedures.
(4) Services for this contract wifl be delivered at the following locations and
times:
SERVICE LOCATION TIME(S)
Case Manaaement Client's Home As needed
Homemakina CHent's Home As needed
Personal Care Client's Home As needed
Home Delivered Meals Client's Home As needed
b. Changes in Location
The provider must notify the department of changes in the location of service delivery.
Once the service delivery location is agreed upon, any proposed change must be
presented in writing to the contract manager for approval, fifteen (15) working days prior
to implementation of that proposed change. In the event of an emergency, temporary
changes in location may necessitate waiver of this designated standard by the district's
program office. Such a waiver will take into consideration the continuity, safety, and
welfare of the department's cHents, and is at the department's sole discretion.
03/03/06
13
PSMAJ No. GA07
Contract # KG058
c~ Equipment
(1) The provider must comply with CFOP 140-8 and submit an equipment list as
applicable to a specific provider's contract. The equipment required to perform
the contracted services must be determined by the department and the provider
and documented on the equipment list, if applicable. To ensure uniformity,
safety, and quality of service to clients, any requests for equipment change must
be presented in writing to the contract manager who will confer with the Adult
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
Services District Program staff, for approval at least ten (10) days prior to any
proposed change,
(2) The provider must inventory all equipment acquired under this contract
annually. The inventory list must be made available within seven (7) days upon
receipt of written request by the contract manager. The provider must list the
items of equipment on the equipment listing, Exhibit S, as applicable to the
provider's contract for specific services,
4. Deliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which may include, but
is not limited to, an hour of direct service delivery; a meal; an episode of travel; or a
twenty-four (24) hour period of Emergency Alert Response maintenance, as defined in
CFOP 140-8, Community Care for Disabled Adults Operating Procedures. All service
units, as well as their description, are listed in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures.
b. Records and Documentation
(1) Case management agency individual client files shall contain the following:
(a) a completed Adult Services Client Assessment (not more than one
(1) year old);
(b) a District Program Office approved care plan (not more than one (1)
year old);
(c) a departmental release of information form;
(d) a copy of a completed Client Information System (CIS) form;
(e) documentation of the client's age, disability, and income;
(f) a completed and scored copy of the Adult Services Screening for
Consideration for Community Based Services; and
(g) 2n ongoing, dynamic case narrative section.
{2} Providers shall maintain information on each client served by this contract,
which includes the following:
(a) documentation of the client by name or unique identifier:
{b) current documentation of eligibility for services;
(e) dates of service proviSion and service billing;
{d) information documenting the client's need for service increase;
(e) the number of service units provided; and
03/03/06
14
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(f) all other forms or records necessary for program operation and
reporting, as set forth by the department.
(3) Providers must ensure that all client records accurately match the invoices
submitted for payment. Records must cross reference to each invoice for
payment.
(4) Providers must maintain documentation necessary to facilitate monitoring
and evaluation by the department.
(5) The case management provider must maintain documentation in the client's
file that all comparable community services and funding sources have been
explored and exhausted before using CCDA funding.
c. Reports
(1) Reporting requirements for this contract include Exhibit C, Monthly
Cumulative Summary Reports. Districts will negotiate with the provider on
specific submission requirement criteria for these reports.
(2) Providers of case management services agree to submit Monthly Cumulative
Summary Reports, which include management program data (e.g., client
identifiable data) to the department, according to negotiated instructions provided
by the districts.
(3) In the event of early termination of this contract, the provider will submit the
final Monthly Cumulative Summary Report within forty-five (45) days after the
contract is terminated.
d. Reports Table
I I -.. I I
Report Reporting Report Date Number of DC F Offices I
Title Frequency Due copies to receive report
due
Monthly I Monthly The 10th of 2 Contract
Cumulati month Manager
ve immediately &
following the
reporting
period
Program
Office
I Summary I
) Reports I
,
i
; J : ; ;
I ) I I I
~____>_~_____,_"L>,__~~_~___,._~,___~.__,~__,_~L,_~_,~__~_l~^~~~~~__~"~~~~L
5. Performance SpeCifications
"I. Performance Measures
(1) 100 % of adults with disabilities receiving services wilt not be placed in a
nursing home.
(2) Twenty qualified disabled adults (ages 18.59) will be provided
03/03/06
15
PSMAf No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
case management by the CCDA program.
(3) Twentywone qualified disabled adults (ages 18w59} will receive daily living
services from the CCDA and Aged and Disabled Adults (ADA) Medicaid Waiver
Programs.
b. Description of Performance Measurement Terms
Placed - The result of an assessment of an individual who is no longer able to remain in
his present place of residence. (To place a client involves preparation for and follow up
of moving a client into a more restrictive alternative living environment).
c. Performance Evaluation Methodology
(1) Measuring Outcomes. The department will measure the outcomes found in
paragraph B.5.a. above as follows:
(a) The outcome measurement contained in paragraph B.5.a. (1) above
will be calculated by dividing the total, fiscal yearwtowdate number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs not
transferred to a nursing home, by the total, fiscal yearwto-date number of
clients in the Community Care for Disabled Adults, Home Care for
Disabled Adults, Cystic Fibrosis, and Medicaid wavier programs.
(b) The outcome measurement contained in paragraph B.5.a. (2) above
will be calculated as the total number clients actively receiving case
management from the Community Care for Disabled Adults, Home Care
for Disabled Adults, Cystic Fibrosis, and Medicaid waiver programs.
(c) The outcome measurement contained in paragraph 8.5.a(3) above
will be calculated as the total number clients actively receiving daily living
services from the Community Care for Disabled Adults and the Medicaid
waiver programs.
(2) By execution of this contract the provider hereby acknowledges and agrees
that its performance under the contract must meet the standards set forth above
and will be bound by the conditions set forth in this contract. If the provider fails
to meet these standards, the department, at its exclusive option, may allow a
reasonable period, not to exceed 6 months, for the provider to correct
performance deficiencies. If performance deficiencies are not resolved to the
satisfactlon of the department within the prescribed time, and if no extenuating
circumstances can be documented by the provider to the department's
satisfaction, the department must terminate the contract The department has
the sole authority to determine whether there are extenuating or mitigating
circumstances.
6. Provider Responsibilities
<!e Direct Service Provider Unique Activities
(1) The provider will be required to use volunteers to the fullest extent feasible in
the provision of services and program operations. The provider is required to
03/03/06
16
PSMAI No. GA07
Contract # KG058
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
train, supervise, and appropriately support all volunteers with insurance
coverage.
(2) The provider will maintain an accurate and current active caseload list.
(3) The provider will maintain a current monthly billing ledger of all provider
claims submitted to the case management agency or Adult Services local office,
including aU corrected claims and adjustments to claims for services that were
delivered to consumers being served through this contract.
(4) The provider will notify the Adult Services local office of all service
terminations, service increase requests and monthly expenditure trends with
regards to the terms of this contract within two weeks immediately following
identification of such action.
(5) The provider will explain to each individual requesting consideration for
CCDA services that the program maintains a centralized Waiting List on which
the individual will be placed according to his or her score received through an
Adult Services Screening conducted by department Adult Services staff.
(6) If required by 45 CFR Parts 160, 162, and 164, the following provisions shall
apply (45 CFR 164.504(e){2)(ii)J:
(a) The provider hereby agrees not to use or disclose protected health
information (PH!) except as permitted or required by this contract, state
or federal law.
(b) The provider agrees to use appropriate safeguards to prevent use or
discfosure of PHI other than as provided for by this contract or applicable
law.
(e) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(a) The provider agrees to make PH! avaHable in accordance with 45
C.F.R 164.524.
(I) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R
164.526.
(91 The provider agrees to make available the information required to
provide an accounting of disclosures in accordance with 45 CFR.
164.528.
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider On behalf of the
03i03J06
17
PSMAI No. GA07
Contract # KG058
07/01/2006
03/03/06
Community Care for Disabled Adults/Fixed Price
Adult Services Program
department available for purposes of determining the provider's
compliance with these assurances.
(i) The provider agrees that at the termination of this contract, if feasible
and where not inconsistent with other provisions of this contract
concerning record retention. it will return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form. If not f~asible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
(j) A violation or breach of any of these assurances shaH constitute a
material breach of this contract.
b. Case Management Provider Unique Activities
(1) The case management provider will accept all District Program Office
referrals through the Adult Services Program Office. The initial referral package
to the case management provider will include the initial Adult Services Client
Assessment (CF-AA 3019) and care plan completed by department staff and all
required supporting documentation.
(2) The case management provider wiH complete all ongoing face-to-face
assessments on all pre-screened individuals referred by the District Program
Office for service consideration and program application, using the Adult
Services Client Assessment, CF-AA 3019.
(3) The case management provider will maintain an accurate and current active
caseload list.
(4) The CeDA case management provider wi!! maintain a current monthly billing
ledger of all provider claims submitted to the agency or the local Adult Services
office, including all corrected claims and adjustments to claims for services that
were delivered to consumers being served through this contract.
(5) The case management provider will notify the local Adult Services office of
all service terminations, service increase requests and monthly expenditure
trends with regards to the terms of this contract within two weeks immediately
fat/owing identification of such action.
(6) The case management provider wili explain to each individual requesting
consideration for eCDA services that the program maintains a centralized
Waiting List on which the individual will be placed according to his or her score
received through an Adult Services Screening to be completed by an Adult
Services counselor.
(7) If required by 45 CFR Parts 160, 162, and 164, the following
provisions shall apply [45 CFR 164.504(e)(2)(ii)]:
(a) The provider hereby agrees not [0 use or disclose protected health
information (PHI) except as permitted or required by this contract, state
or federal law.
18
PSMAI No. GA07
Contract # KG058
07/01/2006
03/03/06
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(b) The provider agrees to use appropriate safeguards to prevent use or
disclosure of PHI other than as provided for by this contract or applicable
law.
(c) The provider agrees to report to the department any use or
disclosure of the information not provided for by this contract or
applicable law.
(d) The provider hereby assures the department that if any PHI received
from the department, or received by the provider on the department's
behalf, is furnished to provider's subcontractors or agents in the
performance of tasks required by this contract, that those subcontractors
or agents must first have agreed to the same restrictions and conditions
that apply to the provider with respect to such information.
(e) The provider agrees to make PHI available in accordance with 45
C.F.R. 164.524.
(f) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R.
164.526.
(g) The provider agrees to make available the information required to
prOVide an accounting of disclosures in accordance with 45 C.F.R.
164.528.
(h) The provider agrees to make its internal practices, books and
records relating to the use and disclosure of PHI received from the
department or created or received by the provider on behalf of the
department available for purposes of determining the provider's
compliance with these assurances.
(i) The provider agrees that at the termination of this contract, if feasible
and where not inconsistent with other provisions of this contract
concerning record retention, it will return or destroy all PHI received from
the department or received by the provider on behalf of the department,
that the provider still maintains regardless of form. If not feasible, the
protections of this contract are hereby extended to that PHI which may
then be used only for such purposes as make the return or destruction
infeasible.
(j) A violation or breach of any of these assurances shall constitute a
material breach of this contract.
c. Coordination with Other Providers/Entities
The case management provider must coordinate, as necessary, with the Agency for
Persons with Disabilities, the Department of Children and Families, the Department of
Education, the Department of Health, and the Florida Statewide Advocacy Council, to
serve those clients who are eligible for services through two (2) or more service delivery
continuums.
19
PSMAI No. GAD?
Contract # KG058
07/01/2006
Community Care for Lilsabled Adults/Fixed Price
Adults Services Program
7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply aU new providers with a copy of
the Community Care for Disabled Adults Operating Procedures. CFOP 140-8.
(2) The department will provide CCDA technical assistance to the provider.
relative to the negotiated terms of this contract and instructions for submission of
required data.
(3) The department will screen all clients referred for CCDA services and will
complete the initial assessment and care plan for aU new clients.
b. Department Determinations
Should a dispute arise, the department will make the final determination as to whether
the contract terms are being fulfilled according to the contract specifications.
c. Monitoring Requirements
The provider will be monitored in accordance with existing departmental procedures
(CFOP 75-8).
C. Method of Payment
1. Payment Clauses
a. This is a fixed price (unit cost) contract. The department shall pay the provider for the
delivery of service units provided in accordance with the terms of this contract for a total
dollar amount not to exceed $N/A, subject to the availability of funds.
b. The department shall make payments to the provider for the provision of services up
to the maximum number of units of service at the rates shown below.
c. The department agrees to pay for the service units at the unit price(s) and limits listed
below.
Service Units Unit Price Maximum # of Units
Case Manaqement $ 54.39 200
Personal Care $ 40,70 160
Homemaker Services $ 33.47 1,250
Home Delivered Meals $ 7.00 3,215
d. The provider's dollar match for this contract is 10% of total contract expenditures.
€L Cash or in kind resources may be used to meet this match requirement
2. Invoice Requirements
The provider shall request payment through submission of a properly completed Invoice. Exhibit
0, within 10 (ten) days folfowing the end of the month for which payment is being requested. The
20
PSMAI No. GAO?
Contract # KG058
03/03/06
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
provider shall submit to the contract manager an original Invoice, Exhibit 0, and no copies, along
with supporting documentation. Payment due under this contract will be withheld until the
department has confirmed delivery of negotiated services.
Payments may be authorized only for service units on the invoice which are in accordance with
the above list and other terms and conditions of this contract The service units for which
payment is requested may not either by themselves, or cumulatively by totaling service units on
previous invoices, exceed the total number of units authorized by this contract
3. Supporting Documentation
a. It is expressly understood by the provider that any payment due the
provider under the terms of this contract may be withheld pending the receipt and
approval by the department of all financial and program reports due from the provider as
a part of this contract and any adjustments thereto. Requests for payment, which cannot
be documented with supporting evidence, will be returned to the provider upon inspection
by the department.
b. The provider must maintain records documenting the total number of recipients and
names (or unique identifiers) of recipients to whom services were provided and the dates
the services were provided so that an audit trail documenting service provision can be
maintained.
4. MyFloridaMarketPlace
This contract is exempt from the MyFloridaMarketPlace Transaction Fee in accordance with
Chapter 60A~1.032(1 )(e), Florida Administrative Code.
D. Special Provisions
1. Fees
a. The case management provider will collect fees for services provided according to
Rule 65e~2.007, Florida Administrative Code,
b. No fees shalf be assessed other than those established by the department. Fees
collected in compliance with the department directives will be reinvested in a manner
prescribed by the department.
2. Florida Statewide Advocacy Council
The provider agrees to allow properly identified members of the Florida Statewide Advocacy
Council access to the facility or agency and the right to communicate with any client being
served, as weil as staff or volunteers who serve them in accordance with subsections 402.165(8)
(a) & (b), Florida Statutes. Members of the Florida Statewide Advocacy Council shall be free to
examine all records pertaining to any case unless legal prohibition exists to prevent disclosure of
those records.
3. Non-Expendable Property
<I. Non-expendable property is defined as tangible personal property of a nonconsumable
nature that has an acquisition cost of $1,000 or more per unit, and an expected useful life
of at least one year; and hardback bound books that are not circulated to students or the
general pubHc, the value of cost of which is $250 or more. Hardback books with a value
or cost of $25 or more should be classified as an aeo expenditure if they are circulated
03/03/06
21
PSMAI No. GA07
Contract # KGOS8
07/01/2006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
to students or to the general public. The provider will use the Provider Inventory List,
Exhibit B to report all capital assets purchased through funding provided by the
Department for prior and current year contract
b. AI! such property, purchased under this contract. shall be listed on the property
records of the provider. Said listing shall include a description of the property, model
number, manufacturer's serial number, funding source, information needed to calculate
the federal and/or state share, date of acquisition, unit cost, property inventory number,
and information on the location, use condition, transfer, replacement, or disposition of the
property.
c. All such property, purchased under this contract, shall be inventoried annually, and an
inventory report shall be submitted to the department along with the final expenditure
report. A report of non-expendable property shall be submitted to the department along
with the expenditure report for the period in which it was purchased.
d. Title (ownership) to all non-expendable property acquired with funds from this contract
shall be vested in the department upon completion or termination of the contract.
e. At no time shall the provider dispose of non-expendable property purchased under
this contract except with the permission of, and in accordance with instructions from the
department.
f. A formal contract amendment is required prior to the purchase of any item of non-
expendable property not specifically listed in the approved contract budget.
4. Morals Clause
The provider understands that performance under this contract involves the expenditure of
public funds from both the state and federal governments, and that the acceptance of such
funds obligates the provider to perform its services in accordance with the very highest
standards of ethical and moral conduct Public funds may not be used for purposes of
lobbying, or for political contributions, or for any expense related to such activities, pursuant
to Section I R of the Standard Contract of this contract. The provider understands that the
Department is a public agency which is mandated to conduct business in the sunshine,
pursuant to Florida Law, and that all issues relating to the business of the Department and
the provider are public record and subject to full disclosure. The provider understands that
attempting to exercise undue influence on the Department and its employees to allow
deviation or variance from the terms of this contract other than negotiated, publicly disclosed
amendment, is prohibited by the State of Florida. The provider's conduct is subject to all
state and federal raws governing the conduct of entities engaged in the business of providing
services to government.
5. Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, Florida Statutes., Part r,
Transportation Services, and Chapter 41-21 Fiorida Administrative Code, Commission for the
Transportation Disadvantaged, if public funds provided under this contract will be used to
transport clients,
6. Incident Reporting
The Provider is required to document all reportable incidents, as defined in the District 11
Uniform Incident Reporting Protocol for Incident Reporting and Client Risk Prevention For
Critical and Non-Criticallnddents which is incorporated herein by reference.
03103/06
22
PSMAI No. GA07
Contract # KG058
07/0112006
Community Care for Disabled Adults/Fixed Price
Adult Services Program
For each critical incident occurring during the administration of its program, the Provider
must, within 24 hours of the incident, complete and submit the District's approved Incident
Report (Exhibit E) to the respective department program incident report liaison. It is the
Provider's responsibility to use the most current District 11 approved incident report for this
purpose. A copy of the incident report must also be placed in a central file marked
"Confidential Incident Report" Dissemination of the report within the department will be the
responsibility of the department's program incident report liaison.
Incidents that threaten the health, safety or welfare of any person or that place any person in
imminent danger must be reported immediately to the department by telephonic contact. The
information contained in the incident report is confidential. The dissemination, distribution or
copying of the report is strictly prohibited, unless authorized by the Department
7. MyFloridaMarketPlace Transaction Fee
The State of Florida, through the Department of Management Services, has instituted
MyFloridaMarketPlace, a statewide eProcurement system. Pursuant to subsection
287.057(23), Florida Statutes (2002), all payments shall be assessed a Transaction Fee of
one percent (1.0%), which the provider shall pay to the State.
For payments within the State accounting system (FLAIR or its successor), the Transaction
Fee shall, when possible, be automatically deducted from payments to the provider. If
automatic deduction is not possible, the provider shaH pay the Transaction Fee pursuant to
Rule 60A-1.031 (2), Florida Administrative Code. By submission of these reports and
corresponding payments, provider certifies their correctness. All such reports and payments
shall be subject to audit by the State or its designee.
The provider shall receive a credit of any Transaction Fee paid by the provider for the
purchase of any item(s) if such item(s) are returned to the provider through no fault, act, or
omission of the provider. Notwithstanding the foregoing, a Transaction Fee is non-refundable
when an item is rejected or returned, or declined, due to the provider's failure to perform or
comply with specifications or requirements of the agreement
Failure to comply with these requirements shall constitute grounds for declaring the provider
in default and recovering procurement costs from the provider in addition to all outstanding
fees. PROVIDERS DELINQUENT IN PAYING TRANSACTION FEES MAY BE EXCLUDED
FROM CONDUCTING FUTURE BUSINESS WITH THE STATE.
8. Contract Term
The department and the provider agree that this contract shall be for a one year term due to
compliance concerns. If the provider faUs to meet these standards, the department at its
exclusive option, may allow a reasonable period, not to exceed six months, for the provider to
correct performance deficiencies. The six month period fOf the provider to come into
compliance with current concerns will end on September 22,2006. If performance
deficiencies are not resolved to the satisfaction of the department within the prescribed time,
and if no extenuating circumstances can be documented by the provfder to the
satisfaction, the department must terminate the contract The department has the sole
authority to determine whether there are extenuating or mitigating circumstances.
03/03/06
23
PSMAI No. GA07
Contract # KG058
EXHIBIT A
f~f~~~~ffl
AS Screening for Consideration for Community-Based Programs
PART I
1 Name:_
A. Date of Referral (Initial Contact):
B. 0 Walk In 0 Phone 0 Other:
2 Address:
C. Referral Source (indude phone number):
District/Region:
3. Phone:
D. Relationship to Individual Being Referred:
4. Race:_ Gender:_ Age/DOB:
5, Marital Status:
E. Is Individual Aware of Referral? 0 Yes 0 No
6. Social Security Number:
7. Primary Language:
8. Medicaid 0 Number:
9. Medicare 0 Number:
1 Q. Other Insurance:
11. Financial: (for Placement
& Supportive Services only)
12. Other Essential Person(s): physician, family rnerl1ber(s), POA, guardian. caregiver
(include address and phone number)
(SSDI)
(SSI)
(Workers Comp)
(Other)
(Other)
Emergency Contact (and phone):
13. Directions to Home (as needed):
$
$
$
$
$
14. Problem/Diagnosis:
15, How Long a Problem?
17. Services Requested:
16. Urgency of Need:
18. Other Agencies Contacted for Help:
i 9. AS Counselor's Signature: Date:
20 Disposition: 0 Protective Intervention Placement 0 Protective Intervention Supportive Services 0 Short-Term Case Mgmt
n Information & Referrai 0 CCDA Application 0 ADA Medicaid \fJaiVBr HCOA l\ppJicat!on
[] CCDA Waiting List" Score _ [] ADA Medicaid Waiver Waiting List - Score ~ HCDA Walling List - Score ~"
21. Due Process Pamphlet (CF/P! 140-43) GivenfMailed by:
Date:
Date:
23 Reviewed/Approved by:
By:
Date:c
22c Given to Supervisor for Review by:
Date:
24. PART I sent to:
25. Referred to AS Counselor/Case Manager:
CF-AA 1022. PDF 0912005
Date:
Page i of 4
9!/
PART II
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26. Check sources of information used for FUNCTIONAL ASSESSMENT Section.
o Individual Requesting Services o Other (specify):
27. Has individual requesting services had any ongoing problems with memory or confusion that seriously interfere with
daily Hving activities?
Describe:
Indicate name and phone number of physician/other who is treating individual for memory/confusion problem(s):
(Address all questions to the individual requesting services if possible. The purpose of these questions is to
determine actual ability to do various activities. Sometimes, caregivers help the individual with an item regardless
of the person's ability. Ask enough questions to make sure the individual requesting services is telling you what
he/she can or cannot do.)
Response Definitions:
No help: Individual can perform activity without assistance from another person.
Some help: Needs physical help, reminders or supervision during part of the activity.
Can't do it at all: Individual cannot complete activity without mtal physical assistance from another person.
Total Score: Add numbers from "Some help" and "Can't do it at all" columns to points given in question #33, and put
sum in Total Score boxes.
ACTIVITIES OF DAILY LIVING (ADLs)
(Read all choices before taking answer)
Would you say that you need help from another person?
(Does not include assistance from devices)
o = No help 2 = Some help 3 = Can't do it at all
Comments/Care Plan Implications:
(lncfude services, suoolies, eauioment, etc,)
28. Dressing (includes getting out clothes and putting
them on and fastening them, and putting on shoes) 0
29. Bathing (includes running the water, taking the bath or
shower and washing all parts of the body including 0
hair)
30. Eating (includes eating, drinking from a cup and
cutting foods) 0
31. Transferring (includes getting in and out of a bed or
chair) 0
32. Tolleting (independently includes adjusting clothing,
getting to and on the toilet, and cleaning one's self. If 0
accidents occur and person manages alone, count it
as independent. If reminders are needed to clean up,
change diapers, or use the toilet this counts as some
help)'
33. Bladder/Bowel Control - How well can you control
! your bladder Of bowel? 0 I
I
I -~ Never have accident (0) I
._ Occasionally have accidents (2) Enter Score
-- Often have accidents (3) I
.- Alwavs have accidents (4)
; , ~
ADL Total Score
(Total possible score := 19) 0
Page 2 of 4
'))-
INSTRUMENTAL ACTIVITES OF DAILY LIVING (IADLs)
(Read all choices before taking answer) Would you say that you need help from another person?
(Does not include assistance from devices)
o = No help 1 = Some help 2 = Can't do it at all
Comments/Care Plan Implications:
(Include services, supplies, equipment, etc.)
34. Transportation Ability (includes using local
transportation, paratransit. or driving to places beyond 0
walking distance)
35, Prepare Meals (includes preparing meals for yourself
including sandwiches, cooked meals and TV dinners) 0
36. Housekeeping (dusting, vacuuming, sweeping,
laundry) 0
IADL Total Score 0
(Total possible score = 6)
SUPPORT AND SOCIAL RESOURCES OF INDIVIDUAL REQUESTING SERVICES
(No Score for Questions 37-46)
37, Check source(s) of information used for this section.
o Individual Requesting Services
o Other (specify):
SERVICES/HELP
Yes No NOTES
Do you receive .,.
38. Personal Care
Assistance (bathing,
dressing, getting out of
bed, toileting and eating)
39. Housekeeping (laundry,
cleaning, meals, ete)
40. Transportation
41. Shopping/Errands
42. Personal Finances
(money management)
43. Services from a health
professional such as an I
RN or Therapist? I
\"" Adult O'Y C.", i
I
i
i 45. Home delivered meals , I
I (Formal only) I
.- - .
46. Any other kind of help
(Specify)
Page 3 01 4
J~