Item C24
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: June 18, 2008
Division: Community Services Division
Bulk Item: Yes
No -X-
Department: In-Home Services
Staff Contact Person: Sheryl Graham #4592
AGENDA ITEM WORDING:
Approval to amend State of Florida Department of Children and Families contract #KG060, extending
the contract for an additional six months. The new effective end date of the contract shall be December
31, 2008. The additional County match shall be $4,483.00 for the period from July 1, 2008 through
December 31, 2008.
ITEM BACKGROUND:
The Board approved contract #KG060 - Community Care for Disabled Adults (CCDA) Contract
between the State of Florida, Department of Children & Families and the Monroe County Board of
County Commissioners/Monroe County In-Home Services. The contract was originally for Fiscal Year
July 1, 2007 through June 30, 2008. An amendment was needed to extend the contract for six months
to allow time for the County to determine services and rates with a subcontracting agency.
PREVIOUS RELEVANT BOCC ACTION:
06/20/2007 BOCC approved Contract #KG060
CONTRACT/AGREEMENT CHANGES:
Extension of contract expiration date from June 30, 2008 to December 31,2008
STAFF RECOMMENDATIONS: Approval.
TOTAL COST:
$44,830
BUDGETED: Yes X--
No
COST TO COUNTY:
$4,483.00
SOURCE OF FUNDS: 125-6153707
REVENUE PRODUCING: Yes
No
AMOUNT PER MONTH N/A YEAR N/A
APPROVED BY: County Arty -X- OMBlPurchasing ~
Risk Management X
DOCUMENTATION:
Included
Not Required_ To Follow X
DISPOSITION:
AGENDA ITEM #
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Dept of Child & Families Contract #_ KG060
Effective Date: 7/1/07
Expiration Date: 12/31/08
Contract Purpose/Description:
Amendment #0001 to Contract # KG060, extending the contract for an additional six
months. The new effective end date of the contract shall be December 31. 2008. The additional
County match shall be $4,483.00 for the period from July 1,2008 through December 31, 2008
Contract Manager: Sheryl Graham 4592 Community Svcsl #1
(Name) (Ext. ) (Department/Stop #)
for BOCC meeting on 6/18/2008 Agenda Deadline: 6/03/2007
CONTRACT COSTS
Total Dollar Value of Contract: $ 44,830.00
Budgeted? Yes[g] No 0 Account Codes:
Grant: $ 40,347.00
County Match: $ 4,483.00
Current Year Portion: $
125-6153707-_-_-_
- - - -
------
- - - -
-----
- - - -
-----
Estimated Ongoing Costs: $NAlyr
(Not included in dollar value above)
ADDITIONAL COSTS
For:
(eg. maintenance, utilities, ianitorial, salaries, etc.)
CONTRACT REVIEW
Changes
pa)e Ip . Needed
Division Director ~C? 1 YesO NoIT
Risk Management (J<' J lJt YesO Noif
O.M.B./Purchasing (;/0:;: YesO NoD
County Attorney qy 0/ rfi{ YesO NgK]
Comments:
OMB Form Revised 2/27/01 Mep #2
~-
--~
State of Florida
Department of Children and Families
Charlie Crist
Governor
Robert A. Butterworth
Secretary
Alan Abramowitz
Regional Director
May 21, 2008
Deb Barsell
Monroe County Community Services
1100 Simonton Street
Key West, FL 33040
Dear Ms. Barsell:
Enclosed please find the proposed amendment to your Department of Children and Families
contract for Community Care for Disabled Adults (CCDA). The amendment extends the
contract for six months to allow time for the County to determine services and rates with a
subcontracting agency.
I would appreciate your returning two signed copies of this amendment for execution by the
Department.
Please call with any questions or concerns, thanks.
Sincerely,
~:~
Contract Manager
Circuit 16
1111 12'h Street, Suite 310, Key West, Florida 33040
Mission: Protect the Vulnerable, Promote Strong and Economically Self-Sufficient Families, and
Advance Personal and Family Recovery and Resiliency
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 # KG060.
1. Page 6, Standard Contract, Section III.A. is hereby amended to read:
A. Effective and Ending Dates
This contract shall begin on July 1, 2007, or on the day 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 December 31, 2008.
2. Page 23, Attachment I, paragraphs C.1.c and d are hereby amended to read:
c. The department agrees to pay for the service units at the unit price(s) and limits listed
below:
Service Units (7/1/2007-6/3020/08) Unit Price Maximum # of Units
Case Manaqement $58.73 185
Personal Care $41 .08 180
Homemaker Services $31.06 1,369
Home Delivered Meals $ 6.50 3,223
Service Units (7/1/2008-12/312008) Unit Price Maximum # of Units
Case Manaqement $58.73 100
Personal Care $41 .08 150
Homemaker Services $31.06 650
Home Delivered Meals $ 6.50 1,250
d. The provider's dollar match is $9,081 for the period from July 1, 2007 through June 30,
2008. The provider's dollar match is $4,483.00 for the period from July 1, 2008 through
December 31,2008. Case management services may be exempt from match requirement at
the discretion of each district. Cash or in kind resources may be used to meet this match
requirement.
This amendment shall begin on June 30. 2008 or the date on which the amendment has been
signed by both parties, whichever is later.
Monroe County (In Home Services)
1
Contract # KG060
All provisions in the contract and any attachments thereto in conflict with this amendment shall
be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at
the level specified in the contract.
This amendment and all its attachments are hereby made a part of the contract.
IN WITNESS THEREOF, the parties hereto have caused this two page amendment to be
executed by their undersigned officials as duly authorized.
PROVIDER: MONROE COUNTY
FLORIDA DEPARTMENT OF
CHILDREN AND FAMILIES
SIGNED BY:
SIGNED BY:
NAME:
Mario Di Gennaro
NAME: Gilda P. Ferradaz
TITLE:
Monroe County Mayor
TITLE: Circuit Administrator
DATE:
DATE:
FEDERAL EID # (or SSN): 59-6000749
Monroe County (In Home Services)
2
Contract # KG060
"
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: 6-20-2007
Division: Community Services
Bulk Item: Yes l No
Department In-Home Services
Staff Contact Person: Deloris Simpson
AGENDA ITEM WORDING: Approval of Contract #KG060 - Community Care for Disabled
Adults (CCDA) Contract between the State of Florida, Department of Children & families and the
Monroe County Board of County CommissionerslMonroe County In-Home Services. This contract is
for Fiscal Year July 1,2007 through June 30, 2008.
ITEM BACKGROUND: The approval of this contract will enable Monroe County In-Home Services
to continue providing services to Monroe County's disabled adult's ages 18 to 59 under the
Community Care for Disabled Adults (CCDA) program.
PREVIOUS RELEVANT BOCC ACTION: Prior approval granted to amendment #0001 to CCDA
Contract #KG058 on November 15, 2006
CONTRACT/AGREEMENT CHANGES: None
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $81.730.09
BUDGETED: Yes -X-No
COST TO COUNTY: $9,081.00 (Required Match) SOURCE OF FUNDS: Ad Valorem Taxes
$19.615.22 (Additional Match)
Total Match $28,696.22
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH_ Year
e l-'t-\
APPROVED BY: County Arty ~/ OMBlPurchasing --X-Risk Management _X_
DOCUMENTATION:
Included X
Not Required_
DISPOSITION:
AGENDA ITEM #
Revised 8/06
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: State of FloridalDepartment of
Children & Families
Contract: #KG060
Effective Date: July 1,2007
Expiration Date: June 30, 2008
Contract PurposelDescription: Approval of Contract #KG060 Community Care for Disabled Adults (CCDA)
Contract between the Department of Children & Families and the Monroe County Board of County
Comnussioners (Monroe County In-Homeffces Progrn~) for Fiscal Year Joly 1,2007 through lune 30, 2008
Contract Manager DeIOri~~ 4589 Soc..1 Sennces/Stop I
(Name) 7" (Ext.) (Department/Stop #)
For BOCC meeting on 6/2012007
Agenda Deadline:
6/5/2007
CONTRACT COSTS
*
Current Year Portion: $ 115
I :A~ - 4/1)' - ,101-- 1lt~ i2.cSb
Total Dollar Value of Contract: $110,426.31
Budgeted? Yes X No Account Codes:
Grant: $ 81,730.09 (Fiscal Year)
County Match: $ 9,081.00 (Fiscal Year) (Required)
$19,615.22 (Additional)
$28,696.22 (Total Match)
Estimated Ongoing Costs: $ /yr
(Not included in dollar value above)
ADDITIONAL COSTS
For:
(eg. Maintenance, utilities, jamtorial, salaries, e(c)
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15, s:V\t
CONTRACT REVIEW
Division Director
r;rp/O,
(p~' :s-{)}
0(4-lo=,
~1:)~)/o,?
Changes
Needed r
Yes ~
Yes ~
Risk Mana!Nment ~
t:C \)l ,~\
O.M.B./Purch~ng
Yes No
County Attorney
Yes No
Comments:
OMB Form Revised 2/27/01 MCP #
{i~'31-D~
3/06/07
i
CFDA No.
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
Client [8J 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 fin-Home Services) hereinafter referred to as the "provider"
I. THE PROVIDER AGREES:
A. Contract Document
To provide services in accordance with the terms and condilions specified in this contract including all attachments and exhibits, which
constitute the contract document.
B. Requirements of Section 287.058, F.S.
To provide units of deliverables, incfuding reports, findings, and drafts, as specified in this contract, which must be received and
accepted by the contract manager in writing prior to payment. To submit bills for fees or other compensation for services or expenses
in sufficient detail for a proper pre-audit and post-audit. Where Itemized payment for travel expenses are permitted In this contract, to
submit bills for any travel expenses in accordance with section 112.061, F.S, or at such lower rates as may be prOVided in thiS
contract. To allow public access to all documents, papers, letters, or other public records as defined in subsection 119.011 (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 discfosure. It is expressly understood that the provider's failure to comply with this provision shall constitute an
immediate breach of contract for which the department may unilaterally terminate the contract.
C. Governing Law
1. State of Florida Law
That this contract is executed and entered into in the State of Florida, and shall be construed. performed and enforced in all respects
in accordance with the Florida faw incfuding Florida provisions for conflict of laws
2. Federal Law
a. That if this contract contains federal funds the provider shall comply with the provisions of 45 CFR. Part 74, and/or 45 CFR.
Part 92, and other applicable regulations
b. That If this contract contains federal funds and is over $100,000, the provider shall comply with all applicable standards,
orders, or regulations Issued under section 306 of the Clean Air Act, as amended (42 USC. 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. }III
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 USC. 1324 a) and section 101 of the Immigration Reform and
Control Act of 1986. Such violation shall be cause for unilateral cancellation of this contract by the department
e. That If this contract contains $10,000 or more offederal 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, Pal1 92, if applicable
f. That if this contract contains federal funds and provides services to children up to age 18, the provider shall comply 'IJlth the
Pro-Children Act of 1994 (20 US. C 6081) Failure to comply With the provisions of the law may result In the ,rnposltlon of a civil
monetary penalty of up to $1,000 for each violation and/or the impOSition of an administrative cOllliCliance order on the responsible
entity.
D. Audits, Inspections, Investigations, Records and Retention
1. To establish and maintain books, records and documents (including ele:tronlC storage media) suffiCient to reflect all Income
and expenditures of funds prOVided by Ihe department under thiS contl'act.
2. TO retain all client records, finanCial records, sr.;pportlng documents statistical records, and any other documents (including
electrcnlC storage media) pertll:ent to thiS contract for a period of SIX (6) years after completion of the centract or longer when reqUired
by law. In the event an audit IS reqUired by thiS contract records shall be retained for a minimum period of SIX years 8fter the audit
reiCort IS issued or until resolution of any audit findings or litigation based on the terms of thiS contract. at no additional cost to the
department
\fOl1fUe (""!IllY Ill-Home ScnlCe5
(()\JTRACT i! "'GUllO
3/06/07
3. Upon demand, at no additional cost to the department, the provider will facilitate the duplication and transfer of any records or
documents during the required retention period in Section I, Paragraph D. 2.
4. To assure that these records shall be subject at all reasonable times to inspection, reView, copying, or audit by Federal, State.
or other personnel duly authorized by the department.
5. At all reasonable times for as long as records are maintained, persons duly authorized by the department and Federal auditors,
pursuant to 45 CFR, section 92.36(i)(10), shall be allowed full access to and the right to examine any of the provider's contracts and
related records and documents, regardless of the form in which kept.
6. To provide a financial and compliance audit to the department as specified in this contract and In l\ttachment !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 oy the office
of The Inspector General (section 20.055, F,S.).
E. Monitoring by the Department
To permit persons duly authorized by the department to Inspect and copy any records, papers, documents, facilities, goods and
services of the provider which are relevant to this contract, and to interview any clients, employees and subcontractor employees of
the provider to assure the department of the satisfactory performance of the terms and conditions of this contract. Following such
review, the department will deliver to the provider a written report of its findings and request for development, by the proVider of a
corrective action plan where appropriate. The provider hereby agrees to timely correct all deficiencies identified in the corrective action
plan
F, Indemnification
1. Except to the extent permitted by section 76828, F.S. or other Florida Law, Paragraph F, is nat applicable to contracts
executed between the department and state agencies or subdivisions defined in subsection 768.28(2), F.S.
2. That to the extent permitted by Florida Law, the provider shall indemnify, save, defend, and hold the department harmless from
any and all claims, demands, actions, causes of action of whatever nature or character, arising out of or by reason of the execution of
this agreement or performance of the services provided for herein. It is understood and agreed that the provider is not required to
indemnify the department for claims, demands, actions or causes of action arising solely out of the department's negligence.
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 76828(2), FS, the provider
accepts full responsibility for identifying and determining the type(s) and extent of liability IIlsurance necessary to provide reasonable
financial protections for the provider and the clients to be served under this contract. The limits of coverage under each policy
maintained by the provider do not limit the provider's liability and obligations under this contract. Upon the execution of this contract.
the provider shall furnish the department written verification supporting both the determination and existence of such insurance
coverage. Such coverage may be provided by a self-insurance program established and operating under the laws of the State of
Florida. The department reserves the right to require additional insurance as specified in this contract.
H. Confidentiality of Client Information
Not to use or disclose any information concerning a recipient of services under this contract for any purpose prohibited by state or
federal law or regulations except with the written consent of a person legally authorized to give that consent or when authorized by law
I. Assignments and Subcontracts
1. To neither assign the responsibility for this contract to another party nor subcontract for any of the work contemplated under this
contract without prior written approval of the department which shall not be unreasonably withheld Any sublicense, assignment, or
transfer otherwise occurring without prior approval of the department shall be null and void.
2. To be responsible for all work performed and for all commodities produced pursuant to this contract whether actually furnished
by the provider or its subcontractors. Any subcontracts shall be evidenced by a written document. The provider further agrees that the
department shall not be liable to the subcontractor in any way or for any reason. The provider, at Its expense, Will defend the
department against such claims.
3. To make payments to any subcontractor within seven (7) working days after receipt of fUll or partial payments from the
department in accordance with section 287.0585 F.S unless otherwise stated in the contract between the provider and
subcontractor. Failure to pay within seven (7) working days will result in a penalty that shall be charged against the provider and paid
by the provider to the subcontractor in the amount of one-half of one percent (005) of the amount due per day from the expiration of
the period allowed for payment. Such penalty shall be in addition to actual payments owed and shall not exceed fifteen (15%) percent
of the outstanding balance due.
4. That the State of Florida shall at all times be entitled to assign or transfer, In whole or part, its rigrts, duties, or cbligations under
this contract to another governmental agency in the State of Florida, upon giving prior \wltten notice to the prOVider 'n the event the
State of Florida approves transfer of the prOViders obligations, the provider remains responsible for all work performed and all
expenses incurred in connection With the contract. ThiS contract shall remain binding upon the Successors In interest of either the
prOVider or the department
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3/06/07
j
J. Return of Funds
To return to the department any overpayments due to unearned 'unds or funds disallowed and any Interest attributable to such funds
pursuant to tr:e terms and conditions of this contract that were disbursed to the provider by the department. In the event that the
provider or its Independent auditor discovers that an overpayment has been made, the provider shall repay said overpayment
immediately without pnor notification from the department. in the event that the department first discovers an overpayment has been
made, the contract manager, on behalf of the department will notify the provider by letter of such findings. Should repayment not be
made forthwith, the provider will be charged at the lawful rate of Interest on :he outstanding balance after department notification or
provider discovery.
K. Client Risk Prevention and Incident Reporting
1. That If services to clients are to be provided under this contract the pro'Jrder and any subcontractors shall, in accordance with
the client risk prevention system, report those reportable situations listed in CFOP 215-6 in the manner prescribed in CFOP 215-6 or
district operating procedures.
2. To immediately report knowledge or reasonable suspicion of abuse, neglect. or exploitation of a child, aged person, cr disabled
adult to the Florida Abuse Hotlme on the stateWide toll-free telephone number (1-800-96ABUSE) As required by Chapters 39 and
415. F.S, this proviSIOn is binding upon both the prOVider and its employees.
L. Purchasing
1. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative Industries and
Diversified Enterprises, Inc, lPRIDE) identified under Chapter 946, FS, 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, (800) 643-8459
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, FS.
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 Title VII of the Civil Rights Act of 1964.
The provider further assures that all contractors, subcontractors, subgrantees, or others with whom it arranges to provide services or
benefits to clients 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 In accordance with 45 CFR Parts 80
83, 84, and 90 This is required for all contracted service providers that have one (1) or more clients
2. To complete the Civil Rights Compliance Questionnaire, CF Forms 946 A and B, in accordance with CFOP 60-16 and 45 CFR
Part 80. This is required for all 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 287134, FS.
N. Independent Capacity of the Contractor
1. To act in the capacity of an Independent contractor and not as an officer, employee of the State of Florida, except where the
provider is a state agency. Neither the provider nor its agents, employees, subcontractors or assignees shall represent to others that It
has the authority to bind the department unless specifically authorized in writing to do so.
2. This contract does not create any right to state retirement, leave benefits or any other benefits of state employees as a result of
performing the duties or obligations of this contract
3. To take such actions as may be necessary to ensure that each subcontractor of the provider will be deemed to be an
independent contractor and will not be considered or permitted to be an agent, servant Joint venturer, or partner of the State of Florida.
4. The department will not furnish services of support (e.g., office space, office supplies, telephone service, secretarial or clencal
support) to the provider, or its subcontractor or assr';Jnee, unless speCifically agreed to by the department in this contract
5. All deductions for SOCial security. withholding taxes, income taxes, contnbutions to unemployment compensation funds and all
necessary insurance for the prO\/lder, the prOVider's officers, employees, agents, subcontractors, or assgnees shall be the sole
responslbil:ty of the provider
O. Sponsorship
As reqUired by section 28625 FS. fthe prcvder 's a non-governmental organization w'llch spcnscrs a program financed 'Nhol!y orn
part by state furds, Including al1Y funds obtained thrcugh thiS contract. It shail. In publiciZing, advertiSing, or descnblng the sponsorship
of the program, stateSponscred by ,provider's name) and the State of Florida Department of Children and Families" if the
sponsorShip reference is ,n written matenal the words State of F!orrda. Departrlent of Children and Families' shaH appear In at least
the same size letters or type as the name cf :he organization
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P. Publicity
\iVlthout limitation, the provider and Its empl.oyees, agents, and representatives will not. without prior departmental written consent in
each instance, use in advertising, publicity or any other promotional endeavor any State mark, the name of the State's mark. the name
of the State or any State affiliate or any officer or employee of the State, or represent, directly cr 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 matenals dlstnbuted to the provider's prospective customers.
Q. Finallnvoice
To submit the final invoice for payment to the department no more than 45 days after the contract ends or is terminated. If the provider
fails to do so, all rights to payment are forfeited and the department will not honor any requests submitted after the aforesaid time
period Any payment due under the terms <if 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 1 {062 and 216347, FS., 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: \;Vheh 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 287017, FS, 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 tllis 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 cr as a result of work or services performed under this
contract, or in anyway connected herewith, th~ 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, shall indemnify and save the department
and its employees harmless from any liability whatsoever, Including costs and expenses, arising out of any copynghted. patented or
unpatented invention, process, or article manufactured or used by the provider in the performance of this contract.
4. The department will provide prompt written notification of any claim of copyright or patent infnngement. Further, if such claim IS
made or is pending, the provider may at its option and expense, procure for the department, the right to continue use of, replace, or
modify the article to render it non-infringing. If the provider uses any design device, or materials covered by letters, patent, or
copyright. it is mutually agreed and understood without exception that the compensation paid pursuant to this contract Includes all
royalties or costs arising from the use of such deSign. cJevlce. or matenals in any way Involved in the work contemplated by this
contract.
5. All applicable subcontracts shallnclude a prcvisic'l that the Federal award!ng agency reserves all patent fights With respect to
any discovery or Invention that anses or is developed !n 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 cont:ngent upon the provider granting to the
state a security interest in the prope'iy at ieast :0 the amount of ~he state furds prOVided for at least five (5) years from the date of
purohase or the completion of the Improvements or as further reqUired by law. As a condition of receipt of state funding for U'IS
purpose, the provider agrees that, rf It disposes of the property before the department's Interest rs 'Jacated the provider will rGfund the
proportionate share of the s:ate's Initial Investment as adjusted by depreciation
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W. Information Security Obligations
1. To identify an appropriately skilled individual to function as its Data Security Officer who shall act as the tiaison to the
department's security staff and who will maintain an appropriate level of data security for the information the provider is collecting or
using in the performance of this contract. An appropriate level of secunty 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 cr damage ,ncurred 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 all provider employees who have access to departmental information are provided a copy of CFOP 50-6 and
that they sign the DCF Security Agreement form (CF 114) a copy of which may be cbtalned 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 dear indicator of quality service, the
majority of our providers will either be accredited, have a plan to meet national accreditation standards, or will initiate one Within a
reasonable period of time.
Y. Agency for Workforce Innovation and Workforce Florida
That it understands that the department. the Agency for Workforce Innovation, and Workforce Florida, Inc., have jointly implemented
an initiative to empower recipients in the Temporary Assistance to Needy Families Program to enter and remain in gainful
employment. The department encourages provider participation with the Agency for Workforce Innovation and Workforce Florida.
Z. Health Insurance Portability and Accountability Act
Where applicable, to comply with the Health Insurance Portability and Accountability Act (42 U S. C. 1320d.) as well as all regulations
promulgated thereunder (45 CFR Parts 160, 162, and 164).
AA. Emergency Preparedness
If the tasks to be performed pursuant to thiS contract Include the physical care and control of clients, the provider shall, within 30 days
of the execution of this contract, submit to the contract manager an emergency preparedness plan which shall include provisions for
pre-disaster records protection, alternative accommodations for clients in substitute care, supplies, and a recovery plan that will allow
the provider to continue functioning in compliance with the executed contract in the event of an actual emergency. The department
agrees to respond in writing within 30 days of receipt of the plan accepting, rejecting, or requesting modifications In the event of an
emergency, the department may exercise oversight authority over such provider in order to assure implementation of agreed
emergency relief provisions.
Be. PUR 1000 Form
The PUR 1000 Form is hereby incorporated by reference, In the event of any conflict between the PUR 1000 Form, and any terms or
conditions of this contract (including the department's Standard Contract), the terms or conditions of thiS contract shall take
precedence over the PUR 1000 Form. However, If the conflicting terms or conditions in the PUR 1000 Form is required by any section
of the Florida Statutes, the terms or conditions contained in the PUR 1000 Form shall take precedence
II. THE DEPARTMENT AGREES:
A. Contract Amount
To pay for contracted services according to the terms and conditions of this contract In an amount not to exceed $N/A or the '-ate
schedule, subject to the availability of funds. The State of Florida's performance and obilgatien to pay Linder this contract is contll1gent
upon an annual appropriation by the Legislature. Any costs or services paid for under any other contract or from any other source are
not eligible for payment under this contract.
B. Contract Payment
Pursuant to section 215.422, F.S., the department has five (5) working days to Inspect and approve goods and services, unless the bid
specifications, purchase order, or this contract speCify otherwise. 'Nith the exception of payments to health care prOViders fer hospital
medical, or other health care services, if payment is not available Within forty (40) days, measured from the latter of the date a properly
completed invoice is received by the department or the goods or services are received, Inspected, and approved, a separate interest
penalty set by The Chief FinanCial Officer purSuant to section 5503, FS, vilil be due and payable in addition to the invoice amount.
Payments to health care providers for hospital. medical, or other health care services, shall be made not more than thirty-five (35) days
from the date eligibility for payment is determined. FinanCial penalties will be calculated at the dally interest rate of 03333% InVOices
returned to a provider due to p(eparation errors will result in a non-interest beanng paY!T1ent delay. Interest penalties less than one 11)
dollar wliI not be paid unless the provider requests payment.
C. Vendor Ombudsman
A Vetldor 'Jmbudsman has been established Within the Cepartment of FinanCial Sell/Ices. The duties of thiS office are found In
subsectlcn 215422, F.S , '.vhlch :nclude disseminating information relative to the prompt payment of iillS state and aSSisting lendors ,,1
receiVing their paymel:ts in a timely manner from a state agency The 'jender Cmbudsn;ar may be contacted at 1::350) 413-5516
\-lul1l'oe ("ltllll: 111-1 feme Sl'J" ices
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D. Notice
Any notice, that is required under this contract shall be in writing and sent by U.S. Postal Service or any expedited delivery service
that provides verification of delivery or by hand delivery Said notice shall be sent to the representative of the provider responsib'e for
administration of the program to the designated address contained In this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall begin on July 1, 2007, 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 ~Aonroe County, FrO/ida, on June 30, 2008.
B. Financial Penalties for Failures to Comply with Requirement for Corrective Action.
1. In accordance with the provisions of Section 402.73(1), FS, and Section 65-29.001, FlOrida Adminrstrative 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 (1 O~<)) of the total contract payments during the period m
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 US 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 satisfactonly 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-1006(3), Florida Administrative Code.
Waiver of breach of any provisions of this contract shall not be deemed to be a waiver of any other breach and shall not be construed
to be a modification of the terms and conditions of this contract. The provisions herein do not limit the department's nght to remedies
at law or in equity.
4. Faifure to have performed any contractual obligations with the department in a manner satisfactory to the department will be a
sufficient cause for termination. To be terminated as a provider under thiS proviSion, the provider must have: (1) previously failed to
satisfactorily perform in a contract with the department. been notified by the department of the unsatisfactory performance, and failed
to correct the unsatisfactory performance to the satisfaction of the department; or (2) had a contract termmated by the department for
cause.
D. Renegotiations or Modifications
Modlfcations of proviSions of thiS contract shall be vali,j only when they have teen reduced to Writing and duly slgne,d by both parties
The rate of payment and the total dollar amount may te adjusted retreactively te reflect pr'ce leve' increases and changes In the rate
of payment when these have been established through the appropnatlons pro:ess and subsequently Identified In the department's
operating budget.
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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 shall be made is:
3. The name, address, and telephone number of the contract manager
for the department for this contract is:
Monroe County In-Home Services
1100 Simonton Street
Key West, FL 33040
Theresa Phelan
1111 12m Street
Key West, FL 33040
305-292-6810
2. The name of the contact person and street address
where financial and administrative records are
maintained is:
Deloris Simpson, Senior Administrator
Monroe County In-Home Services
1100 Simonton Street
Key West, FL 33040
305-292-4589
4. The name, address, and telephone number of the representative of
the provider responsible for administration of the program under this
contract is:
Deloris Simpson
Monroe County In-Home Services
1100 Simonton Street
Key West, FL 33040
305-292-4589
5. Upon change of representatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the
other party and the notification attached to the originals of this contract.
F. All Terms and Conditions Included
This contract and its attachments, I and /I, and any exhibits referenced in said attachments, together with any documents Incorporated
by reference, contain all the terms and conditions agreed upon by the parties. There are no provisions, terms, conditions, or
obligations other than those contained herein, and this contract shall supersede ail 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 42 page contract to be executed by their undersigned officials as duly
authorized.
PROVIDER:
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Monroe County (In-Home Services)
Signature:
Signature:
PrintlType
Name:
Title:
Mario DiGennaro
Mayor
PrintlType Gilda P. Ferradaz
Name:
Title: District Administrator
Date:
Date:
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal Tax ID # (or SSN): 59-0600749
Provider Fiscal Year Ending Date: ~/30.
\fdnrne ('.'Ul1t.\ In-flume S<'T\'I(,~S
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Community Care for Disabied Adults/Fixed Price
Adult Services Program
ATTACHMENT I
A. Services to be Provided
1. Definition of Terms
a. Contract Terms
Contract terms used in this document can be found in the Florida
Department of Children and Families Glossary of Contract Terms, which
is incorporated herein by reference and can be obtained from the contract
manager.
b. Program or Service Specific Terms
(1) Activities of Daily Living - Basic activities performed in the
course of daily living, such as dressing, bathing, grooming, eating,
using a commode or urinal, and ambulating around one's own
home.
(2) Case Management Providers - Private, for-profit, or nonprofit
agencies designated to provide coordination of care for eligible
clients. This includes assessment of client needs and eligibility,
development of care plans, and the arrangement for appropriate
services to meet those needs. Case management providers
integrate all available services through departmentally-approved
direct service providers into a sole program of service delivery
uniquely patterned to meet the client's varying service needs.
Case management providers may choose to deliver only case
management services or choose to be dually responsible as both a
direct service provider and a case management provider.
(3) Client - Any person who is eligible and is at least eighteen (18)
years through age fifty-nine (59), has one (1) or more permanent
physical or mental limitations that restrict the client's ability to
perform normal activities of daily living, and impede the client's
capacity to live independently or with relatives or friends without the
provision of community-based services.
(4) Direct Service Providers - Private. for-profit, or nonprofit
agencies that provide direct service support to eligible clients.
Direct services range from the provision of health services
delivered by physicians, nurses, physiotherapists, occupational
therapists, speech therapists, and dietitians, to services delivered
by workers such as homemakers, chore and transportation worker
and personal care aides. The direct service provider may provide
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Community Care for Disabled Adults/Fixed Price
Adult Services Program
one or more aspects of care. The direct service provider may also
choose to deliver only direct services or choose to be dually
responsible as both a case management provider and a direct
service provider.
(5) Medicaid Institutional Care Program (MICP) - A program that
serves Medicaid recipients who are determined eligible for a
nursing home level of care, which provides primary, acute, and
long-term care services at capitated federally-matched rates.
(6) Nursing home - Any facility which provides nursing services as
defined in Chapter 464, F.S., and which is licensed in accordance
with Chapter 400, F.S.
(7) Outcomes - Quantitative indicators that can be used by the
department to objectively measure a provider's performance toward
a stated goal.
(8) Outputs - Process measures of the quantity(ies) of services
delivered, clients served, or similar units completed.
(9) Performance Measures - Quantitative indicators, outcomes and
outputs, that can be used by the department to objectively measure
a provider's performance.
2. General Description
a. General Statement
(1) The COMMUNITY CARE FOR DISABLED ADULTS (CCDA)
Program is designed to assist disabled adults, age eighteen (18)
through fifty-nine (59), in utilizing available community and personal
resources enabling them to remain in their own homes, and
preventing their premature or inappropriate institutionalization.
(2) Service providers will ensure that appropriate community-
based services are provided to clients in a manner designed to
meet the client's changing needs, to assist the client in avoiding or
reducing unnecessary dependence on the delivered service(s), and
to increase the client's self-reliance.
b. Authority
Sections 410.601-410.606, FS.. Chapter 65C-2, Florida Administrative
Code IF.AC.) and the annual appropriations act. with any proviso
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Adult Services Program
language or instructions to the department, constitute the legal basis for
services to be delivered through the COMMUNITY CARE FOR
DISABLED ADULTS program.
c. Scope of Service
Services will be targeted toward eligible adults, in the following counties:
Monroe County.
d. Major Program Goal
Community-based services provided under this contract are designed to
prevent inappropriate institutionalization of disabled adults.
3. Clients to be Served
a. General Description
Adults with disabilities, age eighteen (18) through fifty-nine (59), who are
no longer eligible to receive children's services, and are too young to
qualify for community and home-based services for the elderly, may be
served under the provisions of this contract.
b. Client Eligibility
(1) Applicants must have one or more permanent physical or
mental limitations, that restrict the ability to perform normal
activities of daily living, as determined through the initial functional
assessment and medical documentation of disability.
Determination of a permanent disability must be established and
evidenced in one of the following manners:
(a) An applicant may present a check, awards letter, or
other proof showing receipt of Social Security Disability
Income, or some other disability payment (e.g., Worker's
Compensation); or
(b) An applicant may present a written statement from a
licensed physician, licensed nurse practitioner, or mental
health professional, which meets the district's criteria for
evidence of a disability. This written statement must. at a
minimum. include the applicant's diagnosis. prognosis, a
broad explanation of level of functioning, and the
interpretation of need for services based on identified
functional barriers caused by the applicant's disabling
condition.
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Adult Services Program
(2) Applicants must have an individual income at or below the
prevailing MICP eligibility standard in order to receive free
COMMUNITY CARE FOR DISABLED ADULTS services.
(3) Applicants with incomes above the standard will be assessed a
fee for a share of the costs, or may be required to provide volunteer
services in lieu of payment.
c. Client Determination
(1) Clients will be assessed for eligibility determination, and
prioritized for services by district or provider case management
staff, in accordance with subsection 410.604 (2), F.S.
(2) The department will make the final determination of client
eligibility.
d. Contract Limits
(1) The total annual cost estimated or actual, for an individual
receiving COMMUNITY CARE FOR DISABLED ADULTS services,
shall not exceed the average, annual general revenue portion of a
Medicaid nursing home bed within the district area.
(2) Clients must not be receiving comparable services from any
other entity. In order to prevent duplication of services, client files
must contain documentation verifying that all comparable
community services and funding sources have been explored and
exhausted.
(3) The provider shall deliver services only to those persons who
have completed the Adult Services Screening for Consideration for
new Community Based Programs, Exhibit A, been scored by that
instrument, and were referred to the provider by the DistricURegion
Program Office, and only to the extent that funds are available.
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Adult Services Program
B. Manner of Service Provision
1. Service Tasks
a. Task List
(1) The following tasks will be performed under this contract.
DAdult Day Care lS]Case DEmergency Alert
Management Response
[gJPersonal Care DHome Health DGroup Activity
Aide Therapy
[gJHomemaker DHome Nursing [2;JHome Delivered
Meals
D Interpreter DTransportation DMedical Therapeutic
Services
DChore DRespite DPhysical and
Exams
DEscort DAdu/t Day
Health Care
(2) Details of services to be provided under this contract and the
negotiated parameters of those services include: (Descriptions and
minimum requirements for each service listed are listed in "The
CFOP 140-8, COMMUNITY CARE FOR DISABLED ADULTS
Operating Procedures").
(3) Each district COMMUNITY CARE FOR DISABLED ADULTS
program shall include case management services and at least one
other community service.
b. Task Limits
The following task limits apply only to the services specified above.
(1) Personal Care services will not substitute for the care usually
provided by a registered nurse, licensed practical nurse, therapist.
or home health aide. The personal care aide will not change sterile
dressings, irrigate body cavities, administer medications, or perform
other activities prohibited by Chapter 59A-8. F.A C.
(2) Homemaker service time does not include time spent in transit
to and from the clients place of residence except when providing
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Adult Services Program
shopping assistance, performing errands or other tasks on behalf
of a client.
(3) Several restrictions apply to persons providing Homemaker
service activities. Persons providing services must not
(a) engage in work that is not specified in the Homemaker
assignment;
(b) accept gifts from clients;
(c) lend or borrow money or articles from clients;
(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.
(4) The parameters of service delivery, by type of service, are
detailed in ''The CFOP 140-8, COMMUNITY CARE FOR
DISABLED ADULTS Operating Procedures",
(5) District task limits, which exceed those in CFOP 140-8,
COMMUNITY CARE FOR DISABLED ADULTS Operating
Procedures, and are distinctive to this contract, are listed here:
N/A.
2. Staffing Requirements
a. Staffing Levels
(1) The provider will meet the minimum staffing requirements for
each service, as specified in CFOP 140-8, COMMUNITY CARE
FOR DISABLED ADULTS Operating Procedures.
(2) The provider 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.
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Adult Ser\lices Program
b. Professional Qualifications
The provider will ensure that staff meets the professional qualifications for
each service, as specified in CFOP 140-8, COMMUNITY CARE FOR
DISABLED ADULTS Operating Procedures.
c. Staffing Changes
The provider agrees to notify the department's contract manager within
two (2) working days if a key administrative position (e.g., executive
director) becomes vacant. Planned staffing changes that may affect
service delivery, as stipulated in this contract, must be presented in writing
to the contract manager for approval at least ten (10) working days prior to
the implementation of the change.
d. Subcontractors
This contract 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) COMMUNITY CARE FOR DISABLED ADULTS services may
be delivered in the client's home or on-site at a facility, as
negotiated by the department and the provider.
(2) Facilities delivering on-site services to clients shall pass an
annual inspection by the local environmental health and fire
authorities.
(3) Service providers will meet the minimum service location and
time requirements as specified in CFOP 140-8, COMMUNITY
CARE FOR DISABLED ADULTS Operating Procedures.
(4) Services for this contract will be delivered at the following
location(s) and times:
SERVICE
i Case Mana ement
I Homemakin
Personal Care
i Home Delivered Meals
LOCA TlON
I Client's Home
I Client's Home
Client's Home
i Clients Home
TIME S
i As needed
: As needed
! As needed
; As needed
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Adult Services Program
b. Changes in Location
The provider must notify the department of changes in the location of
service delivery. Once the service delivery location is agreed upon, any
proposed change must be presented in writing to the contract manager for
approval, ten (10) working days prior to implementation of that proposed
change. In the event of an emergency, temporary changes in location
may necessitate waiver of this designated standard by the district's
program office. Such a waiver will take into consideration the continuity,
safety, and welfare of the department's clients, and is at the department's
sole discretion.
c. Medical Equipment
(1) If medical equipment purchase is made to meet the Activities of
Daily Living or Instrumental Activities of Daily Living service needs
of a client being served through this provider contract, the provider
must submit a durable medical equipment inventory, Exhibit S, to
the department which lists each piece of equipment to be
purchased. The equipment required to perform the contracted
services must be approved by the department. To ensure
uniformity, safety, and quality of service to clients, any requests for
equipment change must be presented in writing to the contract
manager for department 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
provider inventory, Exhibit C, as applicable to the provider's
contract for specific services.
4. DeliverabJes
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 and costs, are listed in CFOP 140-8,
COMMUNITY CARE FOR DISABLED ADULTS Operating Procedures.
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Adult Services Program
b. Records and Documentation
(1) Case management agency individual client files shall contain
the following:
(a) a completed client assessment (not more than one (1)
year old);
(b) a care plan (not more than one (1) year old);
(c) a release of information form;
(d) a copy of a completed Client Information System (CIS)
form;
(e) documentation of the dent's age, disability, and income;
(f) a completed and scored copy of the Adult Services
Screening for Consideration for Community Based Services;
and
(9) a case narrative.
(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;
(c) dates of service provision and delivery;
(d) information documenting the client's need to receive
services;
(e) the number of service units provided; and
(f) all other forms or records necessary for program
operation and reporting, as set forth by the department.
(3) Providers must ensure that all client records accurately match
the invoices submitted for payment. Records must cross reference
to each invoice for payment.
(4) Providers must maintain documentation necessary to facilitate
monitoring and evaluation by the department.
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Adult Services Program
(5) The case management provider must maintain documentation
in the client's file that all comparable community services and
funding sou~~es have been explored and exhausted before using
COMMUNITY CARE FOR DISABLED ADULTS funding.
c. Reports
i I
I Report Title I
, I
! I
I
I
I
Monthly
Cumulative I
Summary I
Reports !
I
I I
! I
I Request for I
I Approval of I
I CCDA Care I
I Plan I
I Services I
LJ.r:1.9rease I
Reporting
Frequency
Report Date Due
Number
of copies
due
DCF Office
address(es) to
receive report
I
Monthly
The 15th of month
immediately
following the month
being reported on.
i
-+-
I
I
-J
I
Contract I
Manager
1
Contract
Manager
As needed
As needed
1
(1) Reporting requirements for this contract include, Exhibit 0,
Monthly Cumulative Summary Reports, if applicable. Districts will
negotiate with the provider on specific submission requirement
criteria for these reports. Included in the reports shall be copies of
activity sheets which shall include the service provided, signature of
client receiving the service and the staff member providing the
servIce.
(2) Providers of case management services agree to submit
Monthly Cumulative Summary Reports, which include management
program data (eg., 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.
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Adult Services Program
5. Performance Specifications
a. Performance Measures
(1) 100 % of adults with disabilities receiving services will not be
placed in a nursing home.
(2) Twenty qualified disabled adults (ages 18-59) will be provided
case management.
(3) Twenty qualified disabled adults (ages 18-59) will be in the
COMMUNITY CARE FOR DISABLED ADULTS program.
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 8.5.a. above as follows:
(a) The outcome measurement contained in paragraph
B. 5.a. (1) above will be calculated by dividing the total, fiscal
year-to-date number of clients in the Community Care for
Disabled Adults, Home Care for Disabled Adults, and
Medicaid waiver programs not transferred to a nursing
home, by the total, fiscal year-to-date number of clients in
the COMMUNITY CARE FOR DISABLED ADULTS, Home
Care for Disabled Adults, and Medicaid wavier programs.
(b) The outcome measurement contained in paragraph
B.5.a. (2) above will be calculated by the total number clients
actively receiving case management from the COMMUNITY
CARE FOR DISABLED ADULTS, Home Care for Disabled
Adults, and Medicaid waiver programs by the total number of
qualified disabled adults eligible to receive such services.
(c) The outcome measurement contained in paragraph
B.5.a(3) above will be a sum calculation of the total number
clients actively receiving daily living services from the
COMMUNITY CARE FOR DISABLED ADULTS program.
,)3/22/07
18
PSMAI No. GAD?
Contract ~Jo KG060
~Aonroe County in-Home Services
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(2) By execution of this contract the provider hereby acknowledges
and agrees that its performance under the contract must meet the
standards set forth above and will be bound by the conditions set
forth in this contract. If the provider fails to meet these standards,
the department, at its exclusive option, may allow up to six months
for the provider to achieve compliance with the standards. If the
department affords the provider an opportunity to achieve
compliance and the provider fails to achieve compliance within the
specified time frame, the department must cancel the contract in
the absence of any extenuating or mitigating circumstances. The
determination of the extenuating or mitigating circumstances is the
exclusive determination of the department.
6. Provider Responsibilities
a Direct Service Provider Unique Activities
(1) The provider will be required to use volunteers to the fullest
extent feasible in the provision of services and program operations.
The provider is required to train, supervise, and appropriately
support all volunteers with insurance coverage including liability.
(2) The provider will maintain an accurate and current active
case load list.
(3) The provider will maintain a current monthly billing ledger of all
provider claims submitted to the case management agency or Adult
Services local office, including all corrected claims and adjustments
to claims for services that were delivered to consumers being
served through this contract.
(4) The provider will notify the case management agency or Adult
Services local office of all service terminations, service increase
requests and monthly expenditure trends with regards to the terms
of this contract.
(5) The provider will explain to each individual requesting
consideration for COMMUNITY CARE FOR DISABLED ADULTS
services that the program maintains a centralized Waiting List on
which the individual will be placed according to his or her score
received through an Adult Services Screening conducted by an
Adult Services counselor.
b. Case Management Provider Unique Activities
D3/22/07
'v1onroe County In-Home Services
19
PSMAI No. GA07
Contract No. KCJ060
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(1) The case management provider will accept all referrals through
the AS District Program Office.
(2) The case management provider will initiate services on only the
referrals made through the AS District Program Office.
(3) The case management provider will complete all ongoing face-
to-face assessments on all active clients using the Adult Services
Client Assessment, CF-AA 3019.
(4) The case management provider will maintain an accurate and
current active case load list.
(5) The COMMUNITY CARE FOR DISABLED ADULTS case
management provider will maintain a current monthly billing ledger
of all provider claims submitted to the agency or the local Adult
Services office, including all corrected claims and adjustments to
claims for services that were delivered to consumers being served
through this contract.
(6) 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. See Exhibit E, Request for Approval of CCDA
Care Plan Services Increase.
(7) The case management provider will explain to each individual
requesting consideration for COMMUNITY CARE FOR DISABLED
ADULTS services that the program maintains a centralized Waiting
List on which the individual will be placed. As funds become
available to serve individuals from the wait list, each individual on
the COMMUNITY CARE FOR DISABLED ADULTS wait list will be
given program consideration according to his or her score received
through a completed Adult Services Screening.
c. Provider Activities Pertaining to both Direct Service Providers and
Case Management Providers
(1) If required by 45 CFR Parts 160, 162, and 164, the following
provisions shall apply [45 CFR 164.504(e)(2)Oi)J:
(a) The provider hereby agrees not to use or disclose
protected health information (PHI) except as permitted or
required by this contract, state or federal law.
03/22/07
~v1onroe County In-Home Services
20
PSMAI No. GAD7
Contract No. KG060
07/01/2007
0.3,22/07
Monroe County In-Home Services
Community Care for Disabled Adults/Fixed Prrce
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 CFR. 164.526.
(9) 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 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.
21
PSMAI No. GAD?
Contract No. KG060
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(j) A violation or breach of any of these assurances shall
constitute a material breach of this contract.
d. Coordination with Other Providers/Entities
The case management provider must coordinate, as necessary, with the
Agency for Persons with Disabilities, the Department of Children and
Families, the Department of Education, the Department of Health, and the
Florida Statewide Advocacy Council, to serve those clients who are
eligible for services through two (2) or more service delivery continuums.
7. Departmental Responsibilities
a. Department Obligations
(1) The department will supply all new providers with a copy of
the COMMUNITY CARE FOR DISABLED ADULTS Operating
Procedures, CFOP 140-8.
(2) The department will provide COMMUNITY CARE FOR
DISABLED ADULTS technical assistance to the provider, relative
to the negotiated terms of this contract and instructions for
submission of required data.
b. Department Determinations
Should a dispute arise, the department will make the final determination
as to whether the contract terms are being fulfilled according to the
contract specifications.
c. Monitoring Requirements
The provider will be monitored in accordance with existing departmental
procedures (CFOP 75-8).
03/22/07
Monroe County In-Home Services
22
PSMAI No. GA07
Contract No. KG060
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
C. Method of Payment
1. Payment Clause
a. This is a fixed price (unit cost) contract. The department shall pay the
provider for the delivery of service units provided in accordance with the
terms of this contract for a total dollar amount not to exceed $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 Management $58.73 185
Personal Care $41 08 180
Homemaker Services $31.06 1,369
Home Delivered Meals S 6.50 3,223
c. The provider's dollar match for this contract is $9,081.00. Case
management and transportation services may be exempt from match
requirement at the discretion of each district.
d. Cash or in kind resources may be used to meet this match
requirement.
2. Invoice Requirements
The provider shall request payment through submission of a properly completed
Invoice, Exhibit F, within 10 days following the end of the month for which
payment is being requested. The provider shall submit to the contract manager
an original Invoice, Exhibit F, and no copies, along with supporting
documentation. Payment due under this contract will be withheld until the
department has confirmed delivery of 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.
03;22/07
Monroe County In-Home SeI'J,':es
23
PSMAI No. GA07
Con:ract No KG060
07101/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
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.
D. Special Provisions
1. Fees
No fees shall be assessed for services provided under this contract other than
those collected in compliance with Rule 65C-2.007, F.A.C.
2. Dispute Resolution
a. The parties agree to cooperate in resolving any differences in
interpreting this contract or in resolving any dispute related to or arising
out of this contract. Within five (5) working days of execution of this
contract, each party shall designate one person to act as the
representative for dispute resolution purposes, and shall notify the other
party of the person's name and business address and telephone number.
Within five (5) working days from delivery to the designated representative
of the other party of a written request for dispute resolution, the
representatives will conduct a face-to-face meeting to resolve the
disagreement amicably. If the representatives are unable t50 reach a
mutually satisfactory resolution, either representative may request referral
of the issue to the provider's Executive Director and the Department's
District Program Director. Upon referral to this second step, the
Executive Director and the District Program Director shall confer in an
attempt to resolve the issue.
b. If the Executive Director and the District Program Director are unable
to resolve the issue within ten (10) days, the parties' appointed
representatives shall meet within ten (10) working days and select a third
representative These three representatives shall meet within ten (10)
working days to seek resolution of the dispute. If the representatives'
03/22;07
Monroe County In-Home Services
24
PSMAI No. GA07
Contract No. KGe60
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
good faith efforts to resolve the dispute fail, the representatives shall
make written recommendations to the Secretary who will work with both
parties to resolve the dispute. The parties reserve all their rights ans
remedies under Florida law.
3. Florida Statewide Advocacy Council
The provider agrees to allow properly identified members of the Florida
Statewide Advocacy Council access to the facility or agency and the right to
communicate with any client being served, as well as staff or volunteers who
serve them in accordance with subsections 402.165(8) (a) & (b), F.S. Members
of the Florida Statewide Advocacy Council shall be free to examine all records
pertaining to any case unless legal prohibition exists to prevent disclosure of
those records.
4. Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, F.S., Part I,
Transportation Services, and Chapter 41-2, F.AC., Commission for the
Transportation Disadvantaged, if public funds provided under this contract will be
used to transport clients.
5. MyFloridaMarketPlace Transaction Fee
This contract is exempt from the MyFloridaMarketPlace Transaction Fee in
accordance with Chapter 60A-1.032(1 )(e), Florida Administrative Code.
6. Incident Reporting
The provider is required to document all reportable incidents, as defined in
CFOP 215-6, Incident Reporting and Client Risk Prevention, which is
incorporated herein by reference.
For each critical incident occurring during the administration of its program, the
provider must, within 24 hours of the incident, complete and submit an Incident
Report (Exhibit G) to the contract manager for this contract. 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 contract manager.
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
contract manager 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.
G3/22/07
rAonroe County In-Home Services
25
PSMAI No, GA07
Contrad No. KG060
07/01/2007
Community Care for Disabled Adults/Fixed Price
Adult Services Program
7. Contract Term
The department and the provider agree that this contract shall be for a one year
term at the provider's request.
E. List of Exhibits
1. Exhibit A, Adult Screening for Consideration for Community-Based Programs
2. Exhibit S, Durable Medical Equipment Inventory
2. Exhibit C, Provider Inventory
3. Exhibit D, Monthly Cumulative Summary Reports
4. Exhibit E, Request for Approval of CCDA Care Plan Services Increase
5. Exhibit F, Invoice
6. Exhibit G, Incident Report
03;22,07
Monroe County in-Home SerJ!ces
26
PSMAI No. GA07
Contract No KC;060
E.1-t4.a" A
@ri~I~n~~
PART'
1. Name:
AS Screening for Consideration for Community-Based Programs
A. Date of Referral (Initial Contact):
B. 0 Walk In 0 Phone 0 Other:
2 Address:
C. Referral Source (include phone number):
District/Region:
3. Phone:
4. Race.
Gender:
Age/DOB:
D. Relationship to Individual Being Referred
5. Marital Status
E. Is Individual Aware of Referral? DYes 0 No
6. Social Security Number
7. Primary Language:
8. Medicaid D Number
9 Medicare 0 Number:
10. Other Insurance:
11 Financial: (for Placement
& Supportive Services only)
12. Other Essential Person(s) physician, family member(s), POA, guardian, caregiver
(include address and phone number)
$ (SSDI)
$ (SSI)
$ (Workers Camp)
$ (Other) Emergency Contact (and phone)
$ (Other) 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:
19. AS Counselor's Signature:
20 O:SCoSltlon D Protective inter/ention Placement
Date:
Il
LJ Proteclive Intervention SLpportlve ServIces
== Short-Term Case Mgmt
U Information & Referral
r--l
LJ CCOA AcpllcatIon
C ADA Medoalo I,Nalver A.PCIlcatIcn
C HCDA ApplIcatIon
L.J CCOA Wal~lng List - Score _ C ADA MedicaId Waiver Wailing List - Score _ L.J HCDA Wa:Mg List - Score _
21 Due Process Pamphlet (CF:PI140-43) Given/Mailed by
Date
22 Given to Supervisor for Review by
Date
23. Rev'ewediApproved by
Date
24. PART I sent to
25 Referred to AS Counselor/Case Manager:
Date
By
Date.
CF-A.;;.. 1()22, POF Ij9i2:);J5
D 3ge 1 Df 4
1.1
PART /I
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26. Check sources of information used for FUNCTIONAL ASSESSMENT Section.
D Individual Requesting SelVices 0 Other (specify):
27, Has individual requesting services had any ongoing problems with memory or confusion that seriously interfere with
dally living 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 total phvsical 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
sLIm 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:
(Include services, supplies, equipment, 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, drrnking from a cup and
cutting foods) 0
31. Transferring (incll.;des getting In and out of a bed or
chair) 0
32. Toifeting (Independently includes adjusting clothing,
getling to and on the toilet. and cleaning one's se:r If 0
accidents occur and person manages alone, count It
as Independent If ;emrnders are needed to clean up,
change diapers, or use the toilet this counts as some
he:o) i
i 33. Bladder/Bowel Control - How well can you control I
I your :;Iadder or bowel? 0 !
.. Never have aCCident {OJ
I .- OccaSionally ha'/e aCCidents (2) Enter Sccre
I -. Often have acc:dents (~\,
-,
i -- Alwavs have aCCidents 4)
ADL Total Score
(Total possible score = 19) 0
P-3ge 2 cf 4
L&
INSTRUMENTAL ACTlVITES OF DAILY LIVING (IADLs)
(Read all choices before taking answer) Would you say that you need help from another person?
!,Ooes not Include assistance from deVices)
o = No help 1 = Some help 2 = Can't do it at all
Comments/Care Plan Implications:
I.!nclude SeI'.'ICeS, suppl:es, eQUipment, etc)
34. Transportation Ability (Includes uSing 'ocal I
transportaticn, paratransit, or dnvlng to places beyond 0
walking distance) I
35. Prepare Meals (Includes preparing meals for yourself I
including sandWiches, cocked 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, etc)
40. Transportation
41. Shopping/Errands
42. Personal Finances
(money management)
43. Services from a health
professional such as an I
RN or Thera !st?
I
/44.
145.
Adult Day Care
I
I
I
----.J
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i
p
I
I
I
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I
I
Home delivered meals
Formal only)
r
I
i 46.
I
I
Any other kind of help
'S~eclfy)
r-age 3 'Jf 4
2.,
PART III - SCORING MATRIX
For items 1,2,3,4,5 and 6 in the scoring matrix below, enter the value (in parenthesIs) following the question response
which corresponds to the response obtained during the interview or through reviews. Example: If the answer was "yes" to
the question "Is individual homebound?", a score of 1 point is placed en the line next to the answer line marked "Yes"
For item 7, enter the score for ADLs and IADLs from the screening form. For item 8, subtract 40 pOints If the individual
interested in HCDA or CCDA services appears eligible or IS receiving comparable services from other programs. See the
Adult Services Waiting List Policy for Community-Based Programs for a definition/description of 'comparable services."
Comments From Individual Requesting Services That May Result in Re-Adjustment of Score:
Total Score: Add and subtract (as appropriate) the individual scores for each item to determine the total score and place
the score in the box marked Total Score.
Domain/Question Score
Is individual requesting services a v!ctlm and at high risk of abuse,
neglect or exploitation based on Protective Investigator's report?
IADLs
Yes (4 pt.\
Yes (2 pt )
Yes (1 pt.)
Yes (1 pt)
Yes (2 pt.\
Yes (3 pt )
0 (enter ADL total score)
0 (enter IADL total score)
2. Is individual requesting services a victim and at ,ntermediate risk
of abuse, neglect, or exploitation based on Protective
Investigator's Report?
3 Does individual live alone or IS individual solely responsible for
minor children (under the age of 12) In the home?
4. Is individual homebound? (See AS Screening for ConSideration
for Community-Based Programs INSTRUCTIONS for definition of
homebound )
5 Does individual have ongoing memory/confusion problems?
6 Is individual receiVIng SSI or SSD because of primary diagnOSIS
of sensory impairment?
7 Functional Assessment: ADLs
8. Support for Individual Requesting Services'
Does individual currently receive help/services (formal/informal) In
ADL or IADL deficit areas noted?
No help 14 pt.)
Help IS available but o'veral/ ,nadequate or
changing, fragile or problematic (2 pt.)
Help IS adequate oJeral1 in deficit areas (0 pt)
For HCDA and CCDA Programs Only:
IndiVidual appears eligible or IS receiving c'JrT1parable services
from other departmental programs APD, or vocational rehabil-
Itation iDoes r,ot Include AS programs - see waiting list poliCY
for definition of 'comparable serVices.) SpecJy programls! to
'hhlCh Indl'vldualls being referrea for eligibility determlllatlOn and
steps taken to refer Ind:v!!dua! to ether vograrT1'S)
tviint)S 40 Dt
CCDA ADA M\N HCDA
---L -L -L
TOTAL SCORE
(Total Possible Score = -40 to +40)
P8ge~0f4
~
" . '.d.. I ,-;' >1;0-" .' ,~'
> (,t-.',lj....r\ 6 }chH~,('-\
~-,-~~~
-~- ~1
Item Purchased
1.
2.
3.
4.
5.
6.
Exhibit 8
Durable Medical Equipment Inventory
Date of Purchase
Purchase Cost
31
Name of Client Receiving Purchased Item
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Exhibit E
Request for Approval of CCDA Care Plan Services Increase
Part I: Recipient Information
Name Last name, tlCst name, middle na;T,e or Ini~la[ I Date of borH"'
I
Soe-al security number' Medlcald,lvledlcace Medical assistance number ~
Current Address Address 'Nhere services Will be rece!\/ed
I
I
County, Ccuntl
Status (Transfer/Existing): Describe reason for service funding increase
If individual is a transfer, indicate originating district/agency: An Adult Services client reassessment was completed on
by and
If individual is an existing consumer with your agency, respective revised care plan revisions made on
indicate current monthly authorized units of service by by , to
service type(s): reflect that this Recipient is justifiably in need of increased
Service(s) based on (check all situations which apply)
o Failing Support System
o Decrease in Functional Capacity
o Rapidly Deteriorating Health
Medicaid waiver eligibility date
Provider Information
jI,gency name Agency contact person'
Agency address:
Phone:
Fax:
I
I E-mail address:
Part II: Summary of Recipient's Presenting Situation. (Refer to form instructions for details about the type of information
required here, Use the space below or Include attachment)
Part III: Proposed New Service Request. 'Please :nclcate tre new:are pian services being requested a~d tre corresponding,
antlc:ated serVice start dates)
Service AntlCI ated start date i Serv,ce Antclpated start date
CF-AA 1121 Mar 2005
~4
KG060
r
]
Part IV: Specific Description of Proposed New Service(s) As Tailored To Meet Recipient's Need. (Refer to the form
instructions for details about the type of information required here. Use the space beiow or Include attachment.)
Part V: Cost Detail for Proposed New Care Plan Service(s).
A Attach a Cost Detail page for each service requested in Part III. Each Cost Detail page should reflect the total
annual cost of serving the consumer for that service type.
Part VI: Care Plan Modification of Number of Service Units. The Budget Entity Team will not consider authorization to
increase service unit quantity of an authorized service on a Recipient's care plan for any of the following documented
reasons unless this section is accurately and fully completed.
[To justify unJl service rates, please present comparative Information' Ui1it rate quotes from a minimum of three other service
agencies providing this same service within a ten mile radius: reasons for choosing this specific vendor: a statement attesting to the
fact that selected vel,dor is a sole source provider of this service In this geographic area. etc Attach information as necessary (e g.
agency admimstrative costs, your agency salary scale, ete.). Refer to the form InstrucllOns}
o Failing Support System List proposed add-on number of monthly service units by service component with annualized
service costs projected to safely maintain Recipient at home and to ameliorate this risk factor
o Decrease in Functional Capacity: List proposed add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Rapidly Deteriorating Health: List care plan add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor
Part VII. Signatures. (Please ncte Final approval of all requests for Care Plan increases rest with the Budget Entity Team
Providers Will receive an Award Letter from the Budqet Entitv Team (or one of its members) when the plan has been aPI roved)
Provider Agency: ISlgnature indicates that the Informalion presented in thiS Request for Care Plan Services Date
Increase and attachments are accurate and complete)
Recip lent/RepresentatiVe: (Signature Indicates that the ReCipient Representative has reViewed the Request for Date:
Care Plan Services Increase and attachments) I
I
I
I
i
District/Regional Program Staff ,Signature Indicates that the d:st'lct!'eg'cral pro'gra"1 staff and prOVide' have Date
agreed upon the serVices '0 be funded) !
I
! District/Regional Adult Services Prcgram Director: ,S,gnature 'ndicates dlstricti'eg:ona apprO'/al Jf the Serv'ce
Funding Plan.)
Date
35
KG060
Exhibit F
DEPARTMENT OF CHILDREN AND FAMILIES
ADULT SERVICES OFFICE
MONTHLY REQUEST FOR PAYMENT AND EXPENDITURE REPORT
PROVIDER FED. 10 #
NAME AND MAILING ADDRESS OF PAYEE
CONTRACT AMNT
REIMBURSEMENT YTD
CONTRACT BALANCE:_
DATE:
CONTRACT#:
PERIOD OF SERVICE PROVISION
NAME OF SERVICE UNITSI AMOUNT PER UNITt TOTAL AMOUNT
OR DESCRIPTION OF MATERIALS QUANTITY EPISODE DUE
TOTAL
TOTAL MATCH REQUIRED PAYMENT
FOR CONTRACT REQUESTED
THIS MNTH YTD.
i "." I'.L, {). I', " lit 'l ,. ( ,I
LOCAL CASH MATCH c: t)I'(~IPn p~ I<-,-llllilir>~~
.-~...., .-- ,
LOCAL IN-KIND ~...~.......
'.... ...
TOTAL DEDUCTIONS -.. .~.
..
REMAINING MATCH BALANCE ,,-
. -.,
~.
-~f!J
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
-'r THS -NI...-OICE IS FeR A rrxEC PRiCE COf\;-:'R,J.CT. iHE RE':liES T FOP p,}vME~7" ''^.,ll BE CE7ERM,NED
8',1 C;'I;Cf~';G i1--:E LE~G:f-.! OF ThE ':::::NT~ACT I\~O TI-'E C-:N-:"P/I_C"'E0 ,':"/IIC:Jt\iT EX. .S,:;.CCC(AL",C'::A Tl(;r~; :,,,,DE: ey
<;: ~'..~CN- r-3 :-:-!-1E LENGT- CF ;~E S,::'N~R}'CT;,::S1 Cree FA'. VEN' F.:E<J"l;ES-:-; eN A CCST F/E 1,JB,.:RSP.rlENT c:~r:R~,:-:-
~r'C PAYr...1E~tT RE)~_ES":" .V'cL EE -,-<E VCNTI-U I:;EC:..JEST" DPPiSE
DATE !NV. RCD.
APPROVED BY
CHILDREN AND FAMILIES USE ONLY
DATE
IORG
EO
OBJ
DESC.
AMNT
IOCA
?~
_0
KG060
f lr . ;'.'" l)~ -~_'_H T r!\','nf of
Childrcn &- r~'n"lHiQs
District Tracking Number (for CRITICAL incidents)
.~~,...,
. .
- /-,~ - ':
- '.
'. .
11 (District)
----
YEAR Sequence Code
Check If CLOSED
I Program Code AS, DA 00. ESS, FS, MH, SA
EXHIBIT G
DISTRICT 11 INCIDENT REPORT
(Critical incidents must be reported to District Administrator within 24 hours of notification.) CHECK IF CRITICAL 0
CONFIDENTIAL
\VARL"IING: The information contained in this report is confidential. You are hereby notitied that dissemination, distribution, or
copying of this document is strictly prohibited, unless authorized by the Department of Children & Families.
I. IDENTIFYING IN FORMA nON '
Reporting Party Phone Ii:
Reporting Party Name
District Program Area:
Specific Program: check all that apply
OAMH OAS OASA DCMH DCSA ODA Doc ODD 0 ESS 0 FS
Please respond to one of the following as appropriate.
a. Contract Provider Name
b, Foster Home Name c. OS Home Name
d. DCF Facility Name e. Other Name
Is this a licensed facility? DYes D No 0 Don't know.
Specific location/address where incident occurred:
Date of Incident
/ /
Time of Incident
DCF Unit #
II. TYPE OF INCIDENT .
Check one box only,
1. D Abuse/Neglect/Exploitation
2. D AggressionlThreat
3. Altercation:
DClient/client OClient/staff D Staff/staff
4. D Baker Act
5. 0 Bomb Threat
6. 0 Client Injury
7. 0 Client Death
8. 0 Contraband
9, 0 Criminal Activity
10. 0 Damage
11. C Drugs
12. 0 Elopement/Runaway
13, 0 Emergency Room Visit
14. 0 Escape
15. 0 Hospital Admission
16. 0 Illness
17. 0 Media Coverage
18. 0 Medication Issue
19. 0 Misconduct
20. 0 Physical Aggression
21.0 Self-Injurious Behavior
22.0 Sabotage
23. CJ Sexual Battery
24. 0 Suicide Attempt
25. 0 Suicide IdeationlThreat
26. 0 Theft
27. 0 Vandalism
28. 0 Other Incidents
Birth Date
, ,
---
Other
,r--'!
c.......J '--
.~
, '--
...., r--'!
, LJ
'---'
--, ~
......J '--'
..--,
--.J c.......J
CJ ....,
; i
---'
''"1
.J J
KG060
CONFIDENTIAL
Birth Date Employee
_/_/- 0 0 0 0 U C
0 11 0 0 [] r-
' . LJ LJ
---
_I_i_ 0 0 0 C [] 0
. ...
Give Detailed Account - (Who, What, When, Where, Why, How) - Add Pages If Necessary
V. CORRECTIVE ACTION AND FOLLOW UP
Immediate corrective action taken
Is follow-up action needed? NOn
YESL]
If yes, specify:
38
KG060
CONFIDENTIAL
VI. INDIVIDUALS NOTIFIED
EXTERNAL NOTIFICATION
Aaencv Notified Person Contacted Status Date/Time Called Copy
Abuse Registry Name ! Report Accepted ! I
1-800-962-2873 I 0 0 I
I ,
10# I Yes LJ NoD I
Agency for Health Care [ I
Administration I C 0 i
Name: N/A I
Law Enforcement-Department Officer's Name i I
'I 1 Badge # Case # (if avail) N/A I n 0 I
'--'
ParenllGuardian/ 1
Family Member Name Name: N/A 0 0
Other ,?'ease Sl'eCd,l
Name: N/A 0 0
Other ,Please Srecily)
Name: N/A C 0
OCF (for providers only) Name: N/A 0 0
VII. REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
REPORTING / I
EMPLOYEE ---
SUPERVISOR / I
---
IndividuaIlA enc Notified Individual/A enc Notified
Client Relations 0 Employee Safety Program 0
District Administrator 0 0 Florida Local Advocacy Committee 0
Division Director/ HR. Workers' Compensation
Facility Director 0 0 Coordinator -er:<p:Ojee rr>latFd ,r,(;,_ler:s ::r1'f) 0
District Legal Counsel 0 0 Program Office/Risk Manager 0
OS Support Coordinator/Case 0 0 Others - (please specify) '0
Manager
EEOC 0 0 Contract Manager
Public Information Officer D 0 i Missing Children's Unit 0 '0
1
VIII. DCF REVIEW AND SIGNATURES .
NAME
SIGNA TURE
TITLE
PHONE #
I DATE
I I I :
.___1
!
I
1 I I
I
! Incident Report
! Liaison
I
I Senior Supervisor
i
39
KG06U
A TT ACJ-llvIENT II
The administration of resources awarded by the Department of Children & Families to the provider may be
subject to audits as described in this attachment
:\IONITORING
[n addition to reviews of audits conducted in accordance with OMB Circular A-133 and Section 21:'.97,
F.S., as revised, the department may monitor or conduct oversight reviews to evaluate compliance with
contract, management and programmatic requirements. Such monitoring or other oversight procedures
may include, but not be limited to, on-site visits by department staff, limited scope audits as defined by
OMS Circular A-133, as revised, or other procedures. By entering into this agreement, the recipient agrees
to comply and cooperate with any monitoring procedures deemed appropriate by the department. In the
event the department determines that a limited scope audit of the recipient is appropriate, the recipient
agrees to comply with any additional instructions provided by the department regarding such audit. The
recipient further agrees to comply and cooperate with any inspections, reviews, investigations, or audits
deemed necessary by the department's inspector general, the state' s Chief Financia[ Officer or the Auditor
General.
AUDITS
PART I: FEDER.\L REQVIREMENTS
This part is applicable if the recipient is a State or local gOvernmcnt or a non-profit organization as defined
in OMB Circular A-133, as revised.
[n the event the recipient expends S500.000 or more in Federal awards during its fiscal year, the recipient
must have a single or program-specific audit conducted in accord3nce Ivith the provisions ofOl'v1B Circular
A-] 33, as revised. In determining the Federal awards expended during its fiscal year, the recipient sh311
consider all 'iourc.::, of Federal awards, including Federal resources received from the Department of
Children & Families. The determination of amounts of Federal aW3rds expendeJ should be in accordance
II ith guidelines established by OMB Circular ,\-133, as revised. /\n audit of the recipient conducted by the
Auditor General in accordanc<: with lhe provisions of OrvlB Circular .\-133, as revised, will meet the
requirements of this part. In connection with the above audit requirements, the recipient sha!l fultlll the
requirements relative to auditee responsibilities as provided in Subpart C ofOMB Circular A-133, as
revised.
The schedule of expenditures should disclose the expenditures b~ contract number for each contr:!ct with
the department in effect during the audit period. The tinanci;}! statements should disclo~e whether or not
the matching requirement was met for each applicable contract. All questioned Celsts and liabilities elLC the
department shall be fuily disclosed in [he clud:t report paCKage II ith referel~ce to [he sp<.:citlc contract
number.
02/0 1/06
40
KG060
PART II: STATE REQVlREMENTS
This part is applicable if the recipient is a nonstate entity as defined by Section 215.97(2), Florida Statutes.
In the event the recipient expends S500,OOO or more in state financial assistance during its fiscal year, the
recipient must have a State single or project-specific audit conducted in accordance with Section 215.97.
Florida Statutes; applicable rules of the DtOpartment of Financial Services; and Chapters 10.550 (local
governmental entities) or 10.650 (nonprotlt and for-profit organizations), Rules of the Auditor General. In
determining the state tlnancial assistance expended during its fiscal year, the recipient shall consider all
sources of state financial assistance, including state financial assistance received from the Depallment of
Children & Families, other state agencies, and other nonstate entities. State financial assistance does not
include Federal direct or pass-through awards and resources receivtOd by a nonstate entity for Federal
program matching requirements.
In connection wah the audit requirements addressed in the preceding paragraph. the recipient shall ensure
thLl[ the audit complies with the requirements ofScction 215.97(8), Florida Statutes. This includes
submission of a tlnancial reporting package as defined by Section 215.97(2), Florida Statutes, and Chapters
10.550 or 10.650, Rules of the Auditor General.
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during Ihe audit period. The financial statements should disclose VI hether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due the
department shall be fully disclosed in the audit repotl package with reference to the specific contract
number.
PART Ill: REPORT SlJBNIISSION
Any repOlls, management letters, or other information required to be submitted to the department pursuant
to this agreement shall be submitted within 180 days after the end of the provider's t1seal year or within JO
days of the recipient's receipt of the audit repon, whichever occurs first, directly to each of the following
unless otherv.ise required by Florida Statutes:
A. Contract manager t()r this contract (2 copies)
Theresa Phelan
I III 12th Street, :1304
Key West, FL 33040
B. Department of Children & Families
Office of the Inspector General, Provider Audit Unit
Building 5, Room 23 7
13] '1 \'-'incwood Boulevard
Tallahassee. FL 32399-0-:-00
C. Copies of the reponrng packJges tor audits conducted in accordance \\'Ith or'vlG Circular A-133, as
revised. and reqUired by Part I of this agreement shall be submitted. \\hcn requlr"d by SecrioIl3.:'O(d).
0\18 Circul3r ;\-133. as revised, or on behalf of the lecipient directly to the Federal /\,udit
Clearinghouse designated ill O\rs ClrculJr A-133, as revised [the number of copies required b:-
02/0 li06
..ll
KG060
Sections .320(d)(1) and (2), OMB Circular A-133, as revised, should be submitted to the Fedc:ral
Auditing Clearinghouse), at the following address:
Federal Audit Clearinghouse
Bureau of the Census
] 20 I East lOth Street
Jeffersonville, IN ~7J32
and other Federal agencies and pass-through entities in accordance with Sections .nO( e) and u\
O:vfB Circular A-I33, as revised.
D. Copies of reporting pacbges required by Part II of this agreement shall be submitted by or on behalf
of the recipient directly to the following address:
A.uditor General's Office
Room 40 I, Pepper Building
II ] West Madison Street
Tallahassee, Florida 32399- I ~50
Providers. when submitting audit report packages to the department for audits done in accordance "ith
O:VlB Circular A-I33 or Chapters 10 550 (local govemmenral entities) or 10650 (nonprofit or for-profit
organizations), Rules of the Auditor General, should include. when available. correspondence trom the
auditor indicating the date the audit report package was delivered to them. V/hen such correspondence is
not available, the date that the audit report package was deliyered by the auditor to the provider must be
indicated in correspondence submitted to the department in accordance with Chapter 10,558(3) or Chapter
10,657(2), Rules of the Auditor General
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the krms of this agre':l1lent
for a period of six years from the date the audit report is issued and shall allow the department or its
designee, Chief Financial Officer or Auditor General access to such records upon request. The recipient
shall ensure that audit working papers are made a,aiJable to the department or its designee, thiefFinClncial
Officer or Auditor General upon request for a period of three years from the date the audit report is issued,
unless extended in writing by the department.
02/01/06
~:2
KG060