Item C14
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: 12-17-2008
Division: Community Services
Bulk Item: Yes X No
Department: Social Services
Staff Contact Person: Sheryl Graham, x4592
AGENDA ITEM WORDING: Approval of Contract #KG061 - 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, This contract is
for Fiscal Year January 1,2009 through June 30, 2010.
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 #KG060 by Debbie Frederick, Assistant County Administrator on June 30, 2008.
CONTRACT/AGREEMENT CHANGES: None
STAFF RECOMMENDATIONS: Approval
TOTAL COST: $81,733,00
BUDGETED: Yes -2LNo
COST TO COUNTY: $9,081.00 (Required Match) SOURCE OF FUNDS: Ad Valorem Taxes
(Required In-Kind Match)
REVENUE PRODUCING: Yes No X AMOUNTPERMONTH_ Year
APPROVED BY: County Ally ~ OMB/Purchasing -1L Risk Managemeot _X_
DOCUMENTATION:
Included X
Not Required_
To Follow
DISPOSITION:
AGENDA ITEM #
Revised 8/06
~
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: State ofFlorida/Department of
Children & Families
Contract: #KG061
Effective Date: January 1,2009
Expiration Date: June 30, 2010
Contract Purpose/Description: Approval of Contract #KG061 Community Care for Disabled Adults (CCDA)
Contract between the Department of Children & Families and the Monroe County Board of County
Commissioners (Monroe County In-Home Services Program) for Fiscal Year January 1,2009 through June 30,
2010
Contract Manager:
Sheryl Graham
(Name)
4589
(Ext. )
Social Services/Stop 1
(Department/Stop #)
For BOCC meeting on
12/17/2008
Agenda Deadline:
12/2/2008
CONTRACT COSTS
Total Dollar Value of Contract: $90,814.00
Budgeted? Yes X No Account Codes:
Grant: $ 81,733.00 (Fiscal Year)
County Match: $ 9,081.00 (Required - In-Kind Match)
Current Year Portion: $
_125_-_61537<11- :JYt.i) J4.<;e-
ADDITIONAL COSTS
Estimated Ongoing Costs: $
(Not included in dollar value above)
Iyr
For:
(eg. Maintenance, utilities, janitorial, salaries, etc)
CONTRACT REVIEW
D~t/.In
Division Directnr J~l?ftj!
Risk Mana~men\l. l d- ,( :0
O~B.lPurCh~g !.?-/ '-I tt1
1/~q/(Jg
Yes
Yes
County Attorney
Yes
Comments:
OMB Form Revised 2/27/01 MCP #
02/29/08
CFDA No.
Client Gli Non-Client D
Multi-District D
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
THIS CONTRACT is entered into between the Florida Department of Children and Families, hereinafter referred to as the
"department," and Monroe County (In Home Services)
hereinafter referred to as the "provider."
I. THE PROVIDER AGREES:
A. Contract Document
To provide services in accordance with the terms and conditions specified in this contract including all attachments and exhibits,
which constitute the contract document.
B. Requirements of Section 287.058, F,S,
To provide units of deliverables, including reports, findings, and drafts, as specified in this contract, which must be received and
accepted by the contract manager in writing prior to payment. To submit bills for fees or other compensation for services or
expenses in sufficient detail for a proper pre-audit and post-audit. Where itemized payment for travel expenses are permitted in
this contract, to submit bills for any travel expenses in accordance with section 112,061, F.S., or at such lower rates as may be
provided in this contract. To allow public access to all documents, papers, letters, or other public records as defined in
subsection 119,011 (11), F ,S., made or received by the provider in conjunction with this contract except that public records which
are made confidential by law must be protected from disclosure. It is expressly understood that the provider's failure to comply
with this provision shall constitute an immediate breach of contract for which the department may unilaterally terminate the
contract.
C. Governing Law
1. State of Florida Law
That this contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in all
respects in accordance with the Florida law including Florida provisions for conflict of laws,
2. Federal Law
a. That if this contract contains federal funds the provider shall comply with the provisions of 45 CFR, Part 74, and/or 45
CFR, Part 92, and other applicable regulations.
b. That if this contract contains federal funds and is over $100,000, the provider shall comply with all applicable
standards, orders, or regulations issued under section 306 of the Clean Air Act, as amended (42 U.S,C, 7401 et seq,), section
508 of the Federal Water Pollution Control Act, as amended (33 U.S.C, 1251 et seq,), Executive Order 11738, as amended and
where applicable, and Environmental Protection Agency regulations (40 CFR, Part 30), The provider shall report any violations
of the above to the department.
c. That no federal funds received in connection with this contract may be used by the provider, or agent acting for the
provider, to influence legislation or appropriations pending before the Congress or any State legislature, If this contract contains
federal funding in excess of $100,000, the provider must, prior to contract execution, complete the Certification Regarding
Lobbying form, Attachment N/A . If a Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may be
obtained from the contract manager. All disclosure forms as required by the Certification Regarding Lobbying form must be
completed and returned to the contract manager, prior to payment under this contract.
d. That unauthorized aliens shall not be employed. The department shall consider the employment of unauthorized
aliens a violation of section 274A(e) of the Immigration and Nationality Act (8 U.S.C, 1324 a) 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 of federal funds, the provider shall comply with Executive Order 11246,
Equal Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in Department of
Labor regulation 41 CFR, Part 60 and 45 CFR, Part 92, if applicable,
f, That if this contract contains federal funds and provides services to children up to age 18, the provider shall comply
with the Pro-Children Act of 1994 (20 U,S.C, 6081). Failure to comply with the provisions of the law may result in the imposition
of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an administrative compliance order on the
responsible entity.
D, Audits, (nspections, Investigations, Records and Retention
1, To establish and maintain books, records and documents (including electronic storage media) sufficient to reflect all
income and expenditures of funds provided by the department under this contract.
2. To retain all client records, financial records, supporting documents, statistical records, and any other documents
(including electronic storage media) pertinent to this contract for a period of six (6) years after completion of the contract or
longer when required by law. In the event an audit is required by this contract. records shall be retained for a minimum period of
six (6) years after the audit report 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.
CF Standard Contract, PDF 0212008
CONTRACT # KG061
02/29/08
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 0,2,
4, To assure that these records shall be subject at all reasonable times to inspection, review, copying, or audit by Federal,
State, or other personnel duly authorized by the department.
5. At all reasonable times for as long as records are maintained, persons duly authorized by the department and Federal
auditors, pursuant to 45 CFR, section 92.36(i)(10), shall be allowed full access to and the right to examine any of the provider's
contracts and related records and documents, regardless of the form in which kept.
6. To provide a financial and compliance audit to the department as specified in this contract and in Attachment ~ and
to ensure that all related party transactions are disclosed to the auditor.
7, To comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by the
office of The Inspector General (section 20,055, 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 768,28, F,S. or other Florida Law, Paragraph F, is not 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 768.28(2),
F.S" the provider accepts full responsibility for identifying and determining the type(s) and extent of liability insurance necessary
to provide reasonable financial protections for the provider and the clients to be served under this contract. 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 botn 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 Infonnation
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 rights, duties, or obligations
under this contract to another governmental agency in the State of Florida, upon giving prior written notice to the provider. In the
event the State of Florida approves transfer of the provider's obligations, the provider remains responsible for all work performed
and all expenses incurred in connection with the contract. This contract shall remain binding upon the successors in interest of
either the provider or the department.
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J, Return of Funds
To return to the department any overpayments due to unearned funds or funds disallowed and any interest attributable to such
funds pursuant to the terms and conditions of this contract that were disbursed to the provider by the department. In the event
that the provider or its independent auditor discovers that an overpayment has been made, the provider shall repay said
overpayment immediately without prior notification from the department. In the event that the department first discovers an
overpayment has been made, the contract manager, on behalf of the department, will notify the provider by letter of such
findings. Should repayment not be made forthwith, the provider will be charged at the lawful rate of interest on the outstanding
balance after department notification or provider discovery,
K. Client Risk Prevention and Incident Reporting
1. That if services to clients are to be provided under this contract, the provider and any subcontractors shall, in accordance
with the client risk prevention system, report those reportable situations listed in CFOP 215-6 in the manner prescribed in CFOP
215-6 or district operating procedures.
2. To immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or
disabled adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ABUSE), As required by
Chapters 39 and 415, F .S" this provision is binding upon both the provider and its employees,
L. Purchasing
1. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative
Industries and Diversified Enterprises, lnc" (PRIDE) identified under Chapter 946, F ,S" in the same manner and under the
procedures set forth in subsections 946,515(2) and (4), F,S. For purposes of this contract, the provider shall be deemed to be
substituted for the department insofar as dealings with PRIDE, This clause is not applicable to subcontractors unless
othelWise 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, F,S,
M. Civil Rights Requirements
1, Not to discriminate against any employee (or applicant for employment) in the performance of this contract because of
race, color, religion, sex, national origin, disability, age, or marital status in accordance with Title VII of the Civil Rights Act of
1964; the Americans with Disabilities Act of 1990; or the Florida Civil Rights Act of 1992, as applicable Further, the provider
agrees not to discriminate against any applicant/client or employee in service delivery or benefits in connection with any of its
programs and activities in accordance with 45 CFR Parts 80, 83, 84, 90, and 91, Title VI of the Civil Rights Act of 1964,
or the Florida Civil Rights Act of 1992, as applicable and CFOP 60-16. These requirements shall apply to all contractors,
subcontractors, subgrantees or others with whom it arranges to provide services or benefits to clients or employees in
connection with its programs and activities,
2. To complete the Civil Rights Compliance Checklist, CF 946, in accordance with CFOP 60-16 and 45 CFR Part 80. This is
required of 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 287,134, F,S,
N. Independent Capacity of the Contractor
1. To act in the capacity of an independent contractor and not as an officer, employee of the State of Florida, except where
the provider is a state agency, Neither the provider nor its agents, employees, subcontractors or assignees shall represent to
others that it has the authority to bind the department unless specifically authorized in writing to do so,
2. This contract does not create any right to state retirement, leave benefits or any other benefits of state employees as a
result of performing the duties or obligations of this contract.
3, To take such actions as may be necessary to ensure that each subcontractor of the provider will be deemed to be an
independent contractor and will not be considered or permitted to be an agent, servant, joint venturer, or partner of the State of
Florida.
4. The department will not furnish services of support (e.g" office space, office supplies, telephone service, secretarial or
clerical support) to the provider, or its subcontractor or assignee, unless specifically agreed to by the department in this contract.
5. All deductions for social security, withholding taxes, income taxes, contributions to unemployment compensation funds
and all necessary insurance for the provider, the provider's officers, employees, agents, subcontractors, or assignees shall be
the sole responsibility of the provider.
O. Sponsorship
As required by section 286.25, F,S" if the provider is a non-governmental organization which sponsors a program financed
wholly or in part by state funds, including any funds obtained through this contract, it shall, in publicizing, advertising, or
describing the sponsorship of the program, state: "Sponsored by (provider's name) and the State of Florida, Department of
Children and Families." If the sponsorship reference is in written material, the words "State of Florida, Department of Children
and Families" shall appear in at least the same size letters or type as the name of the organization.
P. Publicity
Without limitation, the provider and its employees, agents, and representatives will not, without prior departmental written
consent in each instance, use in advertising, publicity or any other promotional endeavor any State mark, the name of the
State's mark, the name of the State or any State affiliate or any officer or employee of the State, or represent, directly or
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indirectly, that any product or service provided by the provider has been approved or endorsed by the State, or refer to the
existence of this contract in press releases, advertising or materials distributed to the provider's prospective customers,
Q. Final Invoice
To submit the final invoice for payment to the department no more than 45 days after the contract ends or is terminated.
If the provider fails to do so, all rights to payment are forfeited and the department will not honor any requests submitted after the
aforesaid time period. Any payment due under the terms of this contract may be withheld until all reports due from the provider
and necessary adjustments thereto have been approved by the department.
R. Use of Funds for Lobbying Prohibited
To comply with the provisions of sections 11.062 and 216,347, F.S" which prohibit the expenditure of contract funds for the
purpose of lobbying the Legislature, judicial branch, or a state agency.
S. Public Entity Crime
Pursuant to section 287.133, F.S., the following restrictions are placed on the ability of persons convicted of public entity crimes
to transact business with the department. When a person or affiliate has been placed on the convicted vendor list following a
conviction for a public entity crime, he/she may not submit a bid, proposal, or reply on a contract to provide any goods or
services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity for the construction or the
repair of a public building or public work; may not submit bids, proposals, or replies on leases of real property to a public entity;
may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public
entity; and may not transact business with any public entity in excess of the threshold amount provided in section 287,017, F.S.,
for CATEGORY TWO for a period of thirty-six (36) months from the date of being placed on the convicted vendor list.
T. Gratuities
The provider agrees that it will not offer to give or give any gift to any department employee. As part of the consideration for this
contract, the parties intend that this provision will survive the contract for a period of two years, In addition to any other remedies
available to the department, any violation of this provision will result in referral of the provider's name and description of the
violation of this term to the Department of Management Services for the potential inclusion of the provider's name on the
suspended vendors list for an appropriate period. The provider will ensure that its subcontractors, if any, comply with these
provisions,
U. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course of or as a result of work or services performed under this
contract, or in anyway connected herewith, the provider shall refer the discovery or invention to the department to be referred to
the Department of State to determine whether patent protection will be sought in the name of the State of Florida, Any and all
patent rights accruing under or in connection with the performance of this contract are hereby reserved to the State of Florida.
2. In the event that any books, manuals, films, or other copyrightable materials are produced, the provider shall notify the
Department of State. Any and all copyrights accruing under or in connection with performance under this contract are hereby
reserved to the State of Florida.
3. The provider, if not a state agency, as that term is defined in subsection 768.28, F.S" shall indemnify and save the
department and its employees harmless from any liability whatsoever, including costs and expenses, arising out of any
copyrighted, patented, or unpatented invention, process, or article manufactured or used by the provider in the performance of
this contract.
4. The department will provide prompt written notification of any claim of copyright or patent infringement. Further, if such
claim is made or is pending, the provider may, at its option and expense, procure for the department, the right to continue use of,
replace, or modify the article to render it non-infringing. If the provider uses any design, device, or materials covered by letters,
patent, or copyright, it is mutually agreed and understood without exception that the compensation paid pursuant to this contract
includes all royalties or costs arising from the use of such design, device, or materials in any way involved in the work
contemplated by this contract.
5. All applicable subcontracts shall include a provision that the Federal awarding agency reserves all patent rights with
respect to any discovery or invention that arises or is developed in the course of or under the subcontract.
V. Construction or Renovation of Facilities Using State Funds
That any state funds provided for the purchase of or improvements to real property are contingent upon the provider granting to
the state a security interest in the property at least to the amount of the state funds provided for at least five (5) years from the
date of purchase or the completion of the improvements or as further required by law. As a condition of receipt of state funding
for this purpose, the provider agrees that, if it disposes of the property before the department's interest is vacated, the provider
will refund the proportionate share of the state's initial investment, as adjusted by depreciation.
W. Information Security Obligations
1. To identify an appropriately skilled individual to function as its Data Security Officer who shall act as the liaison to the
department's security staff and who will maintain an appropriate level of data security for the information the provider is
collecting or using in the performance of this contract. An appropriate level of security includes approving and tracking all
provider employees that request system or information access and ensuring that user access has been removed from all
terminated provider employees,
2. To hold the department harmless from any loss or damage incurred by the department as a result of information
technology used, provided or accessed by the provider.
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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 obtained from the contract manager.
X. Accreditation
That the department is committed to ensuring provision of the highest quality services to the persons we serve, Accordingly, the
department has expectations that where accreditation is generally accepted nationwide as a clear indicator of quality service, the
majority of our providers will either be accredited, have a plan to meet national accreditation standards, or will initiate one within
a reasonable period of time,
Y. Agency for Workforce Innovation and Workforce Florida
That it understands that the department, the Agency for Workforce Innovation, and Workforce Florida, Inc" have jointly
implemented an initiative to empower recipients in the Temporary Assistance to Needy Families Program to enter and remain in
gainful employment. The department encourages provider participation with the Agency for Workforce Innovation and
Workforce Florida.
Z. Health Insurance 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 or supervision 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. For the purpose of disaster planning, the term supervision includes the responsibility of the department, or its
contracted agents to ensure the safety, permanency and well-being of a child who is under the jurisdiction of a dependency
court. Children may remain in their homes, be placed in a non-licensed relative/non-relative home, or be placed in a licensed
foster care setting.
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.
BB. 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 are 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 rate schedule, subject to the availability of funds, The State of Florida's performance and
obligation to pay under this contract is contingent upon an annual appropriation by the Legislature. Any costs or services paid
for under any other contract or from any other source are not eligible for payment under this contract.
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. With the exception of payments to health care
providers for hospital, medical, or other health care services, if payment is not available within forty (40) days, measured from
the latter of the date a properly completed invoice is received by the department or the goods or services are received,
inspected, and approved, a separate interest penalty set by The Chief Financial Officer pursuant to section 55.03, F.S" will be
due and payable in addition to the invoice amount. Payments to health care providers for hospital, medical, or other health care
services, shall be made not more than thirty-five (35) days from the date eligibility for payment is determined, Financial penalties,
will be calculated at the daily interest rate of ,03333%. Invoices returned to a provider due to preparation errors will result in a
non-interest bearing payment delay, Interest penalties less than one (1) dollar will not be paid unless the provider requests
payment.
C. Vendor Ombudsman
A Vendor Ombudsman has been established within the Department of Financial Services. The duties of this office are found in
subsection 215.422, F,S" which include disseminating information relative to the prompt payment of this state and assisting
vendors in receiving their payments in a timely manner from a state agency. The Vendor Ombudsman may be contacted at
(850) 413-5516,
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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
responsible for administration of the program, to the designated address contained in this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A, Effective and Ending Dates
This contract shall begin on January 1. 2009 , or or on the date on which the contract has been signed by the last
party required to sign it, whichever is later. It shall end at midnight, local time in Monroe County
Florida, on June 30, 2010
B. Financial Penalties for Failures to Comply with Requirement for Corrective Action
1. In accordance with the provisions of Section 402,73(1), F.S" and Section 65-29.001, Florida Administrative Code,
corrective action plans may be required for noncompliance, nonperformance, or unacceptable performance under this contract.
Penalties may be imposed for failures to implement or to make acceptable progress on such corrective action plans.
2. The increments of penalty imposition that shall apply, unless the department determines that extenuating circumstances
exist, shall be based upon the severity of the noncompliance, nonperformance, or unacceptable performance that generated the
need for corrective action plan, The penalty, if imposed, shall not exceed ten percent (10%) of the total contract payments
during the period in which the corrective action plan has not been implemented or in which acceptable progress toward
implementation has not been made, Noncompliance that is determined to have a direct effect on client health and safety shall
result in the imposition of a ten percent (10%) penalty of the total contract payments during the period in which the corrective
action plan has not been implemented or in which acceptable progress toward implementation has not been made,
3, Noncompliance involving the provision of service not having a direct effect on client health and safety shall result in the
imposition of a five percent (5%) penalty. Noncompliance as a result of unacceptable performance of administrative tasks shall
result in the imposition of a two percent (2%) penalty,
4, The deadline for payment shall be as stated in the Order imposing the financial penalties, In the event of nonpayment the
department may deduct the amount of the penalty from invoices submitted by the provider.
C. Termination
1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in writing
to the other party unless a sooner time is mutually agreed upon in writing. Said notice shall be delivered by U.S. Postal Service
or any expedited delivery service that provides verification of delivery or by hand delivery to the contract manager or the
representative of the provider responsible for administration of the program,
2. In the event funds for payment pursuant to this contract become unavailable, the department may terminate this contract
upon no less than twenty-four (24) hours notice in writing to the provider. Said notice shall be sent by U,S. Postal Service or any
expedited delivery service that provides verification of delivery. The department shall be the final authority as to the availability
and adequacy of funds. In the event of termination of this contract, the provider will be compensated for any work satisfactorily
completed.
3. This contract may be terminated for the provider's non-performance upon no less than twenty-four (24) hours notice in
writing to the provider. If applicable, the department may employ the default provisions in Rule 60A-1.006(3), 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 right to remedies at law or in equity.
4. Failure to have performed any contractual obligations with the department in a manner satisfactory to the department will
be a sufficient cause for termination. To be terminated as a provider under this provision, the provider must have: (1) previously
failed to satisfactorily perform in a contract with the department, been notified by the department of the unsatisfactory
performance, and failed to correct the unsatisfactory performance to the satisfaction of the department; or (2) had a contract
terminated by the department for cause,
D. Renegotiations or Modifications
Modifications of provisions of this contract shall be valid only when they have been reduced to writing and duly signed by both
parties, The rate of payment and the total dollar amount may be adjusted retroactively to reflect price level increases and
changes in the rate of payment when these have been established through the appropriations process and subsequently
identified in the department's operating budget.
6
CONTRACT # KG061
02/29/08
E, Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
1. The provider name, as shown on page 1 of this 3. The name, address, and telephone number of the
contract, and mailing address of the official payee to whom contract manager for the department for this contract is:
the payment shall be made is:
Monroe County (In Home Services)
1100 Simonton Street
Key West, Florida 33040
Theresa Phelan
Department of Children and Families
1111 12th Street
Key West, Florida 33040
305-292-6810
2. The name of the contact person and street address
where financial and administrative records are maintained is:
4, The name, address, and telephone number of the
representative of the provider responsible for administration
of the program under this contract is:
Sheryl Graham
Monroe County (In Home Services)
1100 Simonton Street
Key West, Florida 33040
Sheryl Graham
Monroe County (In Home Services)
1100 Simonton Street
Key West, Florida 33040
305-292-4592
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 II and Exhibits A, S, C, D and E ,
and any exhibits referenced in said attachments, together with any documents incorporated by reference, contain all the terms
and conditions agreed upon by the parties, There are no provisions, terms, conditions, or obligations other than those contained
herein, and this contract shall supersede all previous communications, representations, or agreements, either verbal or written
between the parties, If any term or provision of this contract is legally determined unlawful or unenforceable, the remainder of
the contract shall remain in full force and effect and such term or provision shall be stricken.
By signing this contract, the parties agree that they have read and agree to the entire contract, as described in
Paragraph III.F, above,
IN WITNESS THEREOF, the parties hereto have caused this
officials as duly authorized.
40
page contract to be executed by their undersigned
PROVIDER:
Monroe County (In Home Services)
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
u!z-z( 6'<
Signature:
Signature:
PrintlType
Name:
PrintlType
Name: Gilda P. Ferradaz
Title:
Monroe County Mayor
Title:
Circuit Administrator
Date:
Date:
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal Tax ID # (or SSN): 59-6000749-128 Provider Fiscal Year Ending Date: 09/30
7 CONTRACT # KG061
07/0 I /2008
Community Care for Disabled AdultslFixed 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 Operating Procedure (CFOP) 75-2, Glossary of
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) Client. Any person ages 18 through 59 having one (1) or more permanent
physical or mental limitations that restrict the person's ability to perform
normal activities of daily living, and impede the person's capacity to live
independently or with relatives or friends without the provision of
community-based services,
(3) Medicaid Institutional Care Program (MICP). A program designed to
provide primary, acute, and long-term care services at capitated federally
matched rates to Medicaid recipients who are determined eligible for a
nursing home level of care,
(4) Nursing home, Any facility that provides nursing services as defmed in
Chapter 464, F.S., and which is licensed in accordance with Chapter 400,
F,S,
(5) Outcomes - Quantitative indicators that can be used by the department to
objectively measure a provider's performance toward a stated goal.
(6) Outputs - Process measures of the quantity(ies) of services delivered,
clients served, or similar units completed.
(7) Performance Measures - Quantitative indicators, outcomes and outputs,
that can be used by the department to objectively measure a provider's
performance.
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(8) Service Providers. Private, for-profit, nonprofit or local government
agencies designated to provide coordination of care for eligible clients,
Service Providers can be case management providers, direct service
providers, or both.
2. General Description
a. General Statement. 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.
b. Authority. Sections 410.601-410.606, F.S., Chapter 65C-2, Florida
Administrative Code (F.A.C.), and the annual appropriations act, with any
proviso language or instructions to the department, constitute the legpl basis
for services to be delivered through the CCDA program.
c. Scope of Service. Services will be targeted toward eligible adults in Monroe
County.
d. Major Program Goal. Under this contract, the CCDA program provides link
to community-based services that 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 )Oung 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
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Contract No. KG061
Monroe County (In Home Services)
07/0 l/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(b) An applicant may present a written statement from a licensed
physician, licensed nurse practitioner, or mental health professional,
which meets the Region's criteria for evidence of a disability, This
written statement must, at a minimum, include the applicant's
diagnosis, prognosis, a broad explanation of level of functioning, and
the interpretation of need for services based on identified functional
barriers caused by the applicant's disabling condition.
(2) Applicants must have an individual income at or below the prevailing
MICP eligibility standard in order to receive free CCDA services.
(3) Applicants with incomes above the standard will be assessed a fee for a
share of the costs, or may be required to provide volunteer services in lieu
of payment.
c. Client Determination
(1) Clients will be assessed for eligibility determination, and prioritized for
services by department 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
CCDA services, shall not exceed the average, annual general revenue
portion of a Medicaid nursing home bed within the Regional 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) To the extent that funds are available, the provider will receive referrals
for clients on whom the Human Service counselors have completed an
Adult Services Screening for Consideration for Community Based
Programs, Exhibit A,
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
B. Manner of Service Provision
1. Service Tasks
a. Task List
(1) Service providers will ensure that appropriate community-based services
are provided to clients in a maimer 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.
(2) The following tasks shall be performed under this contract [check all that
apply L2J].
DAdult Day Care X Case DEmergency Alert
Management Response
X Personal Care DHome Health DGroup Activity
Aide Therapy
X Homemaker DHome Nursing X Home Delivered Meals
DInterpreter DTransportation DMedical Therapeutic
Services
DChore DRespite DPhysical and
Exams
DEscort DAdult Day Health
Care
(3) Details of services to be provided under this contract and the newtiated
parameters of those services include: Case Management to be performed
by Provider staff; Personal Care and Homemaker services to be performed
by subcontracted vendor. Home Delivered Meals to be purchased through
subcontract and then delivered by Provider staff.
(4) Each Regional CCDA program must include case management services
and at least one other community service.
b. Task Limits
The following task limits apply only to the services specified above.
(1) Respite Care services may be provided for up to two hundred forty (240)
hours per client per calendar year, depending upon individual need. The
service may be extended to three hundred sixty (360) hours, as
recommended by the case manager and approved by an immediate
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
supervisor. Documentation of approval must be evident in the case
narrative section of the case manager's file,
(2) Personal Care services will not substitute for the care usually provided by
a registered nurse, licensed practical nurse, therapist, or home health aide.
The personal care aide will not change sterile dressings, irrigate body
cavities, administer medications, or perform other activities prohibited by
Chapter 59A-8, F,A.C.
(3) Homemaker service time does not include time spent in transit to and from
the client's place of residence except when providing shopping assistance,
performing errands or other tasks on behalf of a client.
(4) Several restrictions apply to persons providing Homemaker service
activities. Persons providing services must not:
(a) engage in work that is not specified in the referral from the case
manager;
(b) accept gifts from clients;
(c) lend or borrow money or atiicles from clients;
(d) handle client money, unless authorized in writing by a supervisor or
case manager (documented in the personnel file) and unless bonded or
insured by the employer;
(e) transport clients, unless authorized in writing by a supervisor or case
manager.
(5) The parameters of service delivery, by type of service, are detailed in
CFOP 140-8, Community Care for Disabled Adults Operating Procedures.
(6) Region 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: None.
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,
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(2) The provider will notify the department, in writing, within thirty calendar
(30) days whenever the provider is unable, or expects to be unable to
provide the required quality or quantity of service due to staff turnovers or
shortages.
b. Professional Qualifications
The provider will ensure that staff meets the professional qualifications for
each service, as specified in CFOP 140-8, Community Care for Disabled
Adults Operating Procedures.
c. Staffing Changes
The provider agrees to notify the department's contract manager within two
(2) working days if a key administrative position (e.g., executive director)
becomes vacant. Planned staffing changes that may affect service delivery, as
stipulated in this contract, must be presented in writing to the contract
manager for approval at least ten (10) working days prior to the
implementation of the change.
d. Subcontractors
This contract allows the provider to subcontract for the provision of the
following services under this contract: Personal Care, Homemaker and.
Home Delivered Meals. The provider may not subcontract services not
listed. All subcontracting is subject to the provisions of Section I.J, of the
Standard Contract.
3. Service Location and Equipment
a. Service Delivery Location and Times
(1) Services for this contract will be delivered at the following locations and
times:
SERVICE LOCATION TIMES
Case Management Client's Home As Needed
Personal Care Client's Home As Needed
Homemaker Client's Home As Needed
Home Delivered Meals Client's Home As Needed
(2) CCDA services maybe delivered in the client's home or on-site at a
facility, as negotiated by the department and the provider.
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled AdultslFixed Price
Adult Services Program
(3) Facilities delivering on-site services to clients shall pass an annual
inspection by the local environmental health and fire authorities,
(4) Service providers will meet the minimum service location and time
requirements as specified in CFOP 140-8, Community Care for Disabled
Adults Operating Procedures.
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 Region's program office. Such a waiver
will take into consideration the continuity, safety, and welfare of the
department's clients, and is at the department's sole discretion.
c. Equipment
(1) If equipment is applicable to a specific provider's contract, the provider
must submit an equipment listing (Exhibit N/ A) to the department which
lists the equipment. The equipment required to perform the contracted
services must be negotiated by the department and the provider. To ensure
uniformity, safety, and quality of service to clients, any requests for
equipment change must be presented in writing to the contract manager for
approval at least ten (10) days prior to any proposed change.
(2) The provider must inventory all equipment acquired under this contract
annually. The inventory list must be made available within seven (7) days
upon receipt of written request by the contract manager. The provider
must list the items of equipment on the equipment listing (Exhibit N/ A), as
applicable to the provider's contract for specific services,
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PSMAI No. GAOS
Contract No. KG061
Monroe County (In Home Services)
07/01/2008 Community Care for Disabled Adults/Fixed Price
Adult Services Program
4. Deliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which may
include, but is not limited to, an hour of direct service delivery; a meal; an
episode of travel; or a twenty-four (24) hour period of Emergency Alert
Response maintenance, as defined in CFOP 140-8, Community Care for
Disabled Adults Operating Procedures, All service units, as well as their
description and costs, are listed in CFOP 140-8, Community Care for Disabled
Adults Operating Procedures,
b. Records and Documentation
(1) Client Records (all clients)
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.
(2) Case Management Client records.
Case management agency individual client files shall contain the
following:
(a) a completed client assessment (no more than one (I) )ear old);
(b) a care plan (no more than one (1) year old);
(c) a release of information form;
(d) a copy of a completed Adult Services Information System (ASIS)
form;
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(e) documentation of the client's age, disability, and income;
(t) a completed and scored copy of the Adult Services Screening for
Consideration for Community Based Services; and
(g) a case narrative.
(3) Providers must ensure that all client records accurately match the invoices
submitted for.payment. Records must cross reference to each invoice for
payment.
(4) Providers must maintain documentation necessary to facilitate monitoring
and evaluation by the department.
(5) The case management provider must maintain documentation in the
client's file that all comparable community services and funding sources
have been explored and exhausted before using CCDA funding.
c. Reports
Report Title Reporting Report Date Number DCF Office addresses
Frequency Due of copies to receive report
due
Monthly Monthly The 15th of two Contract
Cumulative month Manager
Summary immediately &
Report following the Program
report period Office
Reporting requirements for this contract include:
(1) Exhibit B, Monthly Cumulative Summary Report, if applicable. Regions
will negotiate with the provider on specific submission requirement
criteria for these reports.
(2) Monthly Cumulative Summary Reports, which include management
program data (e.g., client identifiable data) to the department, according to
negotiated instructions provided by the Regions.
(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 tenninated,
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Contract No. KG061
Monroe County (In Home Services)
07/0112008
Community Care for Disabled Adults/Flxed Price
Adult Services Program
(4) Acceptance of Reports. Where the contract requires the delivery of
reports to the department, mere receipt by the department shall not be
construed to mean or imply acceptance of those reports. It is specifically
intended by the parties that acceptance in writing of required reports shall
constitute a separate act. The department reserves the rigJ1t to reject
reports as incomplete, inadequate, or unacceptable according to the
parameters set forth in the contract. The department, at its option, may
allow additional time within which the provider may remedy the
objections noted by the department or the opportunity to complete, make
adequate, or acceptable, or declare the resulting contract to be in default.
5. Performance Specifications
a. Performance Measures
(1) Ninety eight percent (98%) of adults with disabilities receiving services
will not be placed in a nursing home,
(2) 25: # of qualified disabled adults (ages 18-59) provided case management.
(3) 3: # of qualified disabled adults (ages 18-59) in the CCDA and Aged and
Disabled Adults (ADA) Medicaid Waiver Programs.
b. Description of Performance Measurement Terms
Placed:. The result of an assessment of an individual who is no longer able to
remain in his present place of residence, (To place a client involves
preparation for and follow up of moving a client into a more restrictive
alternative living environment).
c. Performance Evaluation Methodology
Measuring Outcomes. The department will measure the outcomes found in
paragraph B.5.a, above as follows:
(1) 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,
Cystic Fibrosis, and Medicaid waiver programs not transferred to a nursing
home, by the total, fiscal year-to-date number of clients in the Community
Care for Disabled Adults, Home Care for Disabled Adults, Cystic Fibrosis,
and Medicaid wavier programs.
(2) The outcome measurement contained in paragraph B.5.a. (2) above will be
calculated by the total number clients actively receiving case management
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Contract No. KG061
Monroe County (In Home Services)
07/0112008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
from the Community Care for Disabled Adults, Home Care for Disabled
Adults, Cystic Fibrosis, and Medicaid waiver programs by the total
number of qualified disabled adults eligible to receive such services.
(3) The outcome measurement contained in paragraph B.5.a(3) above will be
calculated by the total number clients actively receiving daily living
services from the Community Care for Disabled Adults and the Medicaid
WaIver programs,
d. 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 ofthe
extenuating or mitigating circumstances is the exclusive determination of the
department.
6. Provider Responsibilities
a. All Providers Unique Activities
Health Insurance Portability and Accountability Act. If required by 45
CFR Parts 160, 162, and 164, the following provisions shall apply [45 CFR
164,504( e )(2)(ii)]:
(1) The provider hereby agrees not to use or disclose protected health
information (PHI) except as pennitted or required by this contract, state or
federal law.
(2) 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.
(3) The provider agrees to report to the department any use or disclosure of
the information not provided for by this contract or applicable law.
(4) 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
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
first have agreed to the same restrictions and conditions that apply to the
provider with respect to such information.
(5) The provider agrees to make PHI available in accordance with 45 C.F,R.
164.524.
(6) The provider agrees to make PHI available for amendment and to
incorporate any amendments to PHI in accordance with 45 C.F.R.
164.526.
(7) The provider agrees to make available the information required to provide
an accounting of disclosures in accordance with 45 C.F.R, 164.528.
(8) 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,
(9) 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.
(10)A violation or breach of any of these assurances shall constitute a material
breach of this contract.
b. Direct Service Provider Unique Activities
(1) The provider will be required to use volunteers to the fullest extent
feasible in the provision of services and program operations. The provider
is required to train, supervise, and appropriately support all volunteers
with insurance coverage.
(2) The provider will maintain an accurate and current active caseload list.
(3) The provider will maintain a current monthly billing ledger of all provider
claims submitted to the case management agency or Adult Services local
office, including all corrected claims and adjustments to claims for
services that were delivered to consumers being served through this
contract.
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
(4) The provider will notify the case management agency or Adult Services
local office of all service terminations, service increase requests and
montWy expenditure trends with regards to the terms of this contract.
(5) The provider will explain to each individual requesting consideration for
CCDA services that the program maintains a centralized Waiting List on
which the individual will be placed according to his or her score received
through an Adult Services Screening conducted by an Adult Services
counselor.
(6) The provider shall provide to individuals requesting services a contact
name and phone number to the nearest Adult Services Region Office.
c. Case Management Provider Unique Activities
(1) The case management provider will accept all referrals through the Adult
Services Regional Program Office.
(2) The case management provider will complete ongoing face-to-face
assessments on all pre-screened individuals referred by the Adult Services
Regional Program Office for service consideration and program
application, using the Adult Services Client Assessment, CF-AA 3019.
(3) The case management provider will maintain an accurate and current
active caseload list.
(4) The CCDA case management provider will maintain a current monthly
billing ledger of all provider claims submitted to the agency or the local
Adult Services office, including all corrected claims and adjustments to
claims for services that were delivered to consumers being served through
this contract.
(5) The CCDA case management agency will notify the local Adult Services
office of all service terminations, service increase requests, Exhibit C, and
monthly expenditure trends with regards to the terms of this contract.
(6) The case management provider will explain to each individual requesting
consideration for CCDA services that the program maintains a centralized
Waiting List on which the individual will be placed according to his or her
score received through an Adult Services Screening,
(7) The case management provider shall provide to individuals requesting
services a contact name and phone number to the nearest Adult Services
Region Office,
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Contract No, KG061
Monroe County (In Home Services)
07/0112008 Community Care for Disabled Adults/Fixed Price
Adult Services Program
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 CCDA technical assistance to the
provider, relative to the negotiated terms of this contract and
instructions for submission of required data.
b. Department Determinations
Should a dispute arise, the department will make the final determination as
to whether the contract terms are being fulfilled according to the contract
specifications.
c. Monitoring Requirements
The provider will be monitored in accordance with existing departmental
procedures (CFOP 75-8),
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, 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.
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Contract No. KG061
Monroe County (In Home Services)
07/01/2008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
c. The department agrees to pay for the service units at the unit price(s) and limits
listed below,
FY 2008-2009 Service Unit U nit Price
Service
Case Management Hour $49,89
Personal Care Hour $25,28
Homemaking Hour $21.79
Home Delivered Meals Meal $ 6.30
FY 2009-2010 Service Unit Unit Price
Service
Case Management Hour $49.89
Personal Care Hour $25.28
Homemaking Hour $21.79
Home Delivered Meals Meal $ 6.30
d. The provider's dollar match for this contract is as follows:
(1) For Fiscal Year 2008-2009: $4,670.00
(2) For Fiscal Year 2009-2010: $9,081.00
e. 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 Monthly
Request for Payment and Expenditure Report, Exhibit D, within 15 days following
the end of the month for which payment is being requested. The provider shall submit to
the contract manager an original Monthly Request for Payment and Expenditure
Report, Exhibit D, and no copies, along with supporting documentation. Payment due
under this contract will be withheld until the department has confirmed delivery of
negotiated services.
Payments may be authorized only for service units on the invoice which are in accordance
with the above list and other terms and conditions of this contract. The service units for
which payment is requested may not either by themselves, or cumulatively by totaling
service units on previous invoices, exceed the total number of units authorized by this
contract.
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Monroe County (In Home Services)
07/0l/2008
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
a. The case management provider will collect fees for services provided according to
Rule 65C-2.007, F,A.C,
b. No fees shall be assessed other than those established by the department. Fees
collected in compliance with the department directives will be reinvested in a
manner prescribed by the department.
2. Florida Statewide Advocacy Council
The provider agrees to allow properly identified members of the Florida Statewide
Advocacy Council access to the facility or agency and the right to communicate with
any client being served, as well as staff or volunteers who serve them in accordance
with subsections 402.165(8) (a) & (b), F.S. Members ofthe Florida Statewide
Advocacy Council shall be free to examine all records pertaining to any case unless
legal prohibition exists to prevent disclosure of those records.
3. Transportation Disadvantaged
The provider agrees to comply with the provisions of Chapter 427, F,S" Part I,
Transportation Services, and Chapter 41-2, F,A.C., Commission for the
Transportation Disadvantaged, if public funds provided under this contract will be
used to transport clients.
-..;
23
PSMAI No. GA08
Contract No. KG061
Monroe County (In Home Services)
07/0112008
Community Care for Disabled Adults/Fixed Price
Adult Services Program
4. MyFloridaMarketPlace Transaction Fee
This contract is exempt from the MyFloridaMarketPlace Transaction Fee in
accordance with Chapter 60A-1.032(1) (e), Florida Administrative Code.
5. 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 E) 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.
6. Contract Term
The department and the provider agree that this contract shall be for an eighteen-
month term, at the provider's request.
E. List of Exhibits
1. Exhibit A, AS Screening for Consideration for Community-Based Programs
2. Exhibit B, CCDA Monthly Cumulative Summary Report
3. Exhibit C, Request for Approval of CCDA Care Plan Services Increase
4. Exhibit D, Monthly Request for Payment and Expenditure Report
5. Exhibit E, Incident Report
24
PSMAI No, GA08
Contract No. KG061
Monroe County (In Home Services)
Exhibit A
~lC'HlrDREN
lS2J & FAMILIES AS Screening for Consideration for Community-Based Programs
PART I
1, Name:
A Date of Referral (Initial Contact):
B. D Walk In D Phone D 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 D No
6. Social Security Number:
7. Primary Language:
8, Medicaid D Number:
9. Medicare D Number:
10. Other Insurance:
11, Financial: (for Placement
& Supportive SelVices only)
12. Other Essential Person(s): physician, family member(s), POA, guardian, caregiver
(include address and phone number)
$
$
$
$
$
(SSDI)
(SSI)
(Workers Comp)
(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: Date:
20. Disposition: D Protective Intervention Placement D Protective Intervention Supportive Services D Short-Tenn Case Mgmt
D Infonnation & Referral D CCDA Application D ADA Medicaid Waiver Application D HCDA Application
D CCDA Waiting List - Score _ D ADA Medicaid Waiver Waiting List - Score _ D HCDA Waiting List - Score _
21. Due Process Pamphlet (CF/PI140-43) Given/Mailed by:
Date:
22. Given to Supervisor for Review by:
24, PART I sent to:
Date:
Date:
23. Reviewed/Approved by:
By:
Date:
25. Referred to AS Counselor/Case Manager:
CF-AA 1022, PDF 09/2005
Date:
Page 1 of 4
025
PART II
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26. Check sources of information used for FUNCTIONAL ASSESSMENT Section,
D Individual Requesting SeNices
D Other (specify):
27, Has individual requesting seNices had any ongoing problems with memory or confusion that seriously Interfere with
daily 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 ablllty. 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 physical assistance from another person.
Total Score: Add numbers from "Some help" and "Can't do it at all" columns to points given in question #33, and put
sum in Total Score boxes.
ACTIVITIES OF DAILY LIVING (ACLs)
(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, eouioment, etc.)
28. Dressing (includes getting out clothes and putting
them on and fastening them, and putting on shoes) 0
29. Bathing (includes running the water, taking the bath or
shower and washing all parts of the body including 0
hair)
30. Eating (includes eating, drinking from a cup and
cutting foods) 0
31. Transferring (includes getting in and out of a bed or
chair) 0
32. Toileting (independently includes adjusting clothing,
getting to and on the toilet, and cleaning one's self, If 0
accidents occur and person manages alone, count it
as independent. If reminders are needed to clean up,
change diapers, or use the toilet this counts as some
helD)'
33. Bladder/Bowel Control - How well can you control
your bladder or bowel? 0
- Never have accident (0)
- Occasionally have accidents (2) Enter Score
- Often have accidents (~{
- Alwavs have accidents
ADL Total Score
(Total possible score = 19) 0
026
Page 2 of 4
INSTRUMENTAL ACTIVITES OF DAILY LIVING (IADLs)
(Read all choices before taking answer) Would you say that you need help from another person?
(Does not include assistance from devices)
o = No help 1 = Some help 2 = Can't do it at all
Comments/Care Plan Implications:
(Include services, supplies, eauioment, etc.)
34. Transportation Ability (includes using local
transportation, paratransit, or driving to places beyond 0
walking distance)
35. Prepare Meals (includes preparing meals for yourself
including sandwiches, cooked meals and TV dinners) 0
36. Housekeeping (dusting, vacuuming, sweeping,
laundry) 0
IADL Total Score 0
(Total possible score = 6)
SUPPORT AND SOCIAL RESOURCES OF INDIVIDUAL REQUESTING SERVICES
(No Score for Questions 37-46)
37, Check source(s) of information used for this section.
D 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
RN or Therapist?
44. Adult Day Care
45. Home delivered meals
(Fonnal only)
46. Any other kind of help
(Specify)
027
Page 3 of 4
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 on 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
1, Is individual requesting selVices a victim and at high risk of abuse,
neglect, or exploitation based on Protective Investigator's report? Yes (4 pt.)
2. Is individual requesting selVices a victim and at intennediate risk
of abuse, neglect, or exploitation based on Protective
Investigator's Report? Yes (2 pt.)
3, Does individual live alone or is individual solely responsible for
minor children (under the age of 12) in the home? Yes (1 pt.)
4. Is individual homebound? (See AS Screening for Consideration
for Community-Based Programs INSTRUCTIONS for definition of Yes (1 pt.)
homebound,)
5, Does individual have ongoing memory/confusion problems? Yes (2 pt.)
6. Is individual receiving SSI or SSD because of primary diagnosis
of sensory impainnent? Yes (3 pt.)
7, Functional Assessment: ADLs......,."...,..,."........,..".,......" 0 (enter ADL total score)
IADLs........................................, 0 (enter IADL total score)
8, Support for Individual Requesting SelVices:
Does individual currently receive help/selVices (formal/informal) in
ADL or IADL deficit areas noted? No help (4 pt)
Help is available but overall inadequate or
changing, fragile or problematic (2 pt.)
Help is adequate overall in deficit areas (0 pt.)
For HCDA and CCCA Programs Only:
Individual appears eligible or is receiving comparable selVices
from other departmental programs, APD, or vocational rehabil-
itation, (Does not include AS programs - see waiting list policy
for definition of "comparable selVices:) Specify program(s) to
which individual is being referred for eligibility detennination and
steps taken to refer individual to other program(s).
Minus 40 pt.
CCDA ADA MW
o 0
HCDA
o
TOTAL SCORE
(Total Possible Score = -40 to +40)
Page 4 of 4
028
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Exhibit C
Request for Approval of CCDA Care Plan Services Increase
P
I f
f
art I: ReCIPient norma Ion
Name: Last name, first name, middle name or initial Date of birth:
Social security number: Medicaid/Medicare Medical assistance number:
Current Address: Address where services will be received:
County: County:
Status (Transfer/Existing): D~scribe reason for service funding increase.
If individual is a transfer, indicate originating districUagency: An Adult Services client reassessment was completed on
by and
If individual is an existing consumer with your agency, respective revised care plan revisions made on
indicate current monthly authorized units of service by by , to
service type(s): reflect that this Recipient is justifiably in need of increased
Service(s) based on (check all situations which apply):
o Failing Support System
o Decrease in Functional Capacity
o Rapidly Deteriorating Health
Medicaid waiver eligibility date:
Provider Information
Agency name: Agency contact person:
Agency address:
Phone:
Fax:
E-mail address:
Part II: Summary of Recipient's Presenting Situation. (Refer to form instructions for details about the type of information
required here. Use the space below or include attachment.)
Part III: Proposed New Service Request. (Please indicate the new care plan services being requested and the corresponding,
anticipated service start dates.)
Service Anticipated start date Service Anticipated start date
030
CF-AA 1121, Mar 2005
KG061
Part IV: Specific Description of Proposed New Service(s) As Tailored To Meet Recipient's Need. (Refer to the form
instructions for details about the type of information required here, Use the space below or include attachment.)
Part V: Cost Detail for Proposed New Care Plan Service(s).
A. Attach a Cost Detail page for each service requested in Part 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 unit service rates, please present comparative information: unit rate quotes from a minimum of three other service
agencies providing this same service within a ten mile radius; reasons for choosing this specific vendor; a statement attesting to the
fact that selected vendor is a sole source provider of this service in this geographic area, etc. Attach information as necessary (e.g.,
agency administrative costs, your agency salary scale, etc.). Refer to the form instructions.}
o Failing Support System: List proposed add-on number of monthly service units by service component with annualized
service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Decrease in Functional Capacity: List proposed add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Rapidly Deteriorating Health: List care plan add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
Part VII. Signatures. (Please note: Final approval of all requests for Care Plan increases rest with the Budget Entity Team,
Providers will receive an Award Letter from the Budaet Entity Team (or one of its members) when the plan has been aOI royed,)
Provider Agency: (Signature indicates that the information presented in this Request for Care Plan Services Date:
Increase and attachments are accurate and complete.)
Recipient/Representative: (Signature indicates that the Recipient/Representative has reviewed the Request for Date:
Care Plan Services Increase and attachments,)
District/Regional Program Staff: (Signature indicates that the district/regional program staff and provider have Date:
agreed upon the services to be funded.)
District/Regional Adult Services Program Director: (Signature indicates district/regional approval of the Service Date:
Funding Plan,)
031
KG061
EXHIBIT 0
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 UNITI TOTAL AMOUNT
OR DESCRIPTION OF MATERIALS QUANTITY EPISODE DUE
TOTAL
TOTAL MATCH REQUIRED PAYMENT
FOR CONTRACT: REQUESTED
THIS MNTH. YTD.
LOCAL CASH MATCH Florida D(.~p.(lntTh.":"nt of
Children & FarTlilles
LOCAL IN-KIND ;-..: , ,
--~
TOTAL DEDUCTIONS '. , .
......:....- .,.'.....:.......:........,;-:;.,-
REMAINING MATCH BALANCE ~~.
, .
""""--..._,.,,----~~-
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
"IF THIS INVOICE IS FORA FIXED PRICE CONTRACT, THE REQUEST FOR PAYMENT IMLL BE DETERMINED
BY DIVIDING THE LENGTH OF THE CONTRACT INTO THE CONTRACTED AMOUNT (EX,.$12,OOO(ALLOCATlONj DIVIDED BY
12 MONTHS [THE LENGTH OF THE CONTRACTF$1.000 PAYMENT REQUESl) ON A COST REIMBURSEMENT CONTRACT
THE PAYMENT REQUEST IMLL BE THE MONTHLY REQUEST EXPENSE,
CHILDREN AND FAMILIES USE ONLY
DATE INV. RCD,
APPROVED BY:
DATE
IORG
EO
OBJ
DESC,
AMNT.
IOCA
032
KG061
District Tracking Number (for CRITICAL incidents)
Ftodda Oep.arUnent of
Children & Families
--.....
11 (District)
YEAR Sequence Code
Check if CLOSED
.'-,~_.--.
Program Code: AS, DA, DO, ESS, FS, MH, SA
EXHIBIT E
INCIDENT REPORT
(Critical incidents must be reported to District Administrator within 24 hours of notification.) CHECK IF CRITICAL 0
CONFIDENTIAL
WARNING: The information contained in this report is confidential. You are hereby notified that dissemination, distribution, or
copying of this document is strictly prohibited, unless authorized by the Department of Children & Families.
I. IDENTIFYING INFORMATION
Reporting Party Phone #:
Reporting Party Name
District Program Area:
Specific Program: check all that apply
OAMH OAS DASA DCMH DCSA ODA Doc ODD D ESS 0 FS
Please respond to one of the following as appropriate,
a. Contract Provider Name
b. Foster Home Name c, DS Home Name
d. DCF Facility Name e, Other Name
Is this a licensed facility? 0 Yes 0 No 0 Don't know.
Specific location/address where incident occurred:
Date of Incident
/ /
Time of Incident
DCF Unit #
II. TYPE OF INCIDENT
Check one box only.
1. 0 Abuse/Neglect/Exploitation
2. 0 AggressionfThreat
3. Altercation:
DClient/c1ient OClient/staff 0 Staff/staff
4. 0 Baker Act
. 5. 0 Bomb Threat
6. 0 Client Injury
7, 0 Client Death
8. D Contraband
9. D Criminal Activity
10. D Damage
11. D Drugs
12. D Elopement/Runaway
13. D Emergency Room Visit
14.0 Escape
15. D Hospital Admission
16, D Illness
17. D Media Coverage
18. D Medication Issue
19. D Misconduct
20.0 Physical Aggression
21,0 Self-Injurious Behavior
22. 0 Sabotage
23.0 Sexual Battery
24, 0 Suicide Attempt
25. 0 Suicide Ideation/Threat
26. 0 Theft
27. 0 Vandalism
28.0 Other Incidents
III. PARTICIPANT 5) I WITNESS(ES) (Please check one from each side
FIRST Name LAST Name SS# Birth Date Race Gender Client Employee Other
-1_1_ 0 0 0
_1_1- 0 0 0
-1_'- 0 0 0
033
Participant Witness Other
o 0 0
o 0 0
o 0 0
KG061
CONFIDENTIAL
_1_1-
_1_1-
--.I_L
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
IV. DESCRIPTION OF INCIDENT
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? NoD
YEsD
If yes, specify:
03{J.
KG061
CONFIDENTIAL
VI. INDIVIDUALS NOTIFIED
EXTERNAL NOTIFICATION
Aaency Notified Person Contacted Status DatelTime Called Copy
Abuse Registry Name Report Accepted
1-800-962-2873 0 0
10# Yes 0 NoD
Agency for Health Care
Administration Name: N/A 0 0
Law Enforcement-Department Officer's Name
II I Badge # Case # (if avail) N/A 0 0
Parent/Guardian!
Family Member Name Name: N/A 0 0
Other (Please Specify)
Name: N/A 0 0
Other (Please Specify)
Name: N/A D D
DCF (for providers only) Name: N/A D D
VII. REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
REPORTING / /
EMPLOYEE ---
SUPERVISOR / /
---
DCF INTERNAL NOTIFICATION
IndividuaUAgency Notified DatelTime Called Copy Individual/Aaencv Notified DatelTime Called Copy
Client Relations D D Employee Safety Program 0 0
District Administrator D 0 Florida Local Advocacy Committee 0 D
Division Director/ H.R. Workers' Compensation
Facility Director D D Coordinator (employee related incidents only) D D
District Legal Counsel D D Program Office/Risk Manager D D
OS Support Coordinator/Case D D Others - (Please specify) D D
Manager
EEOC D D Contract Manager D D
Public Information Officer D D Missing Children's Unit D D
VIII. DCF REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
Incident Report / /
Liaison ---
Senior Supervisor / I
INCIDENT DEFINITIONS
Or...
00
KG061
CONFIDENTIAL
The definitions apply to DCF direct or contractual services/employees
1. Abuse/Neqlect/Exploitation. A reportable event where a client/employee is the subject of abuse, neglect, or
exploitation,
2. AqqressionfThreat. The client engages in verbal threats to harm or aggression towards another person.
3. Altercation. A physical confrontation occurring between a client and employee or two more clients at the time
services are being rendered, or when a client is in the physical custody of the department, which results in one or
more clients or employees receiving medical treatment by a licensed health care professional.
4. Baker Act. Client is placed into a facility under the Baker Act.
5, Bomb Threat. Any threat of harm to property or persons involving an explosive device that is received verbally, in
writing, electronically or otherwise,
6. Client Iniurv/lllness. A medical condition of a client requiring medical treatment by a licensed health care
professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring
while in the presence of an employee, in a Department of Children and Families or contracted facility or service
center or who is in the physical custody of the department.
7. Client Death, Any person whose life terminates due to or alleged due to an accident, act of abuse, neglect or
other incident occurring while in the presence of an employee, in a Department of Children and Families operated
or contracted facility or service center, while in the physical custody of the department; or when a death review is
required pursuant to CFOP 175-17,Child Death Review Procedures.
8. Contraband/Druqs (or non-authorized material) Discovery of contraband, Employee/client found with contraband
which includes intoxicating beverage, controlled substance, weapon or device designed to be used as a weapon
or explosive substance, and/or, anything specifically prohibited in writing by the Department (Ref. CFOP 70-12).
9. Misconduct/Criminal Activitv. Action resulting in potential liability. Conduct resulting in a law violation,
Falsification of State or client records by an employee.
10. Contraband/Druqs (or non-authorized material) Discovery of contraband. Employee/client found with contraband
which includes intoxicating beverage, controlled substance, weapon or device designed to be used as a weapon
or explosive substance, and/or, anything specifically prohibited in writing by the Department (Ref. CFOP 70-12).
11. TheftNandalism/Damaqe/Sabotaqe. Loss of state or private property of significant value or importance.
12. Elopement/Runawav. The unauthorized absence beyond eight hours, or other time frames as defined by a
specific program operating procedure or manual, of a child or adult who is in the physical custody of the
department.
13. Emerqencv Room Visit. The client is taken to an emergency medical facility for assessment and/or treatment.
14. Escape. The unauthorized absence as defined by statute, departmental operating procedure or manual of a client
committed to, or securely detained in a Department of Children and Families mental health or developmental
services forensic facility covered by Chapters 393,394 or 916, FS.
15. Hospital Admission, The client is admitted to the hospital for surgery or scheduled medical procedures,
16. Client Iniurv/lllness. A medical condition of a client requiring medical treatment by a licensed health care
professional sustained or allegedly sustained due to an accident, act of abuse, neglect or other incident occurring
while in the presence of an employee, in a Department of Children and Families or contracted facility or service
center or who is in the physical custody of the department.
17. Media Coverage Media coverage that may have an adverse impact of the Department's ability to protect and serve
its clients,
036
KG061
CONFIDENTIAL
18, Medications Issue, The client is prescribed psychotropic medication requiring consent of parent and/or court
order and issue not resolved. Issue of incorrect medication or wrong dosage of correct medication. Dosage of
prescribed medication is omitted, or the client has an adverse reaction to medication. This would not include
suicide attempts by intentional overdose, which are Suicidal Attempts.
19. Misconduct/Criminal Activity. Action resulting in potential liability. Conduct resulting in a law violation.
Falsification of State or client records by an employee,
20. Phvsical Aqqression, The client engages in physical aggressive behavior that is threatening towards persons or
destructive to property or animals, e.g. overturning furniture, throwing objects, striking walls, etc.
21. Self-Iniurious Behavior, The client inflicted upon him/herself or subject self to potential danger (cutting oneself,
walking into traffic).
22. Theft/Vandalism/Damaqe/Sabotaqe, Loss of state or private property of significant value or importance
23. Sexual Batterv. An allegation of sexual battery by a client on a client, employee on a clien~ or client on an
employee as evidenced by medical evidence or law enforcement involvement.
24. Suicide Attempt. An act which clearly reflects the physical attempt by a client to cause his or her own death while
in the physical custody of the department or a departmental contracted or certified provider, which results in bodily
injury requiring medical treatment by a licensed health care professional.
25. Suicidalldeationffhreat. The client talks about killing him/herself or verbally suggests the possibility of killing
him/herself.
26. Theft/Vandalism/Damaqe/Sabotaqe. Loss of state or private property of significant value or importance.
27. Theft/Vandalism/Damaqe/Sabotaqe. Loss of state or private property of significant value or importance,
28. Other Incidents. An unusual occurrence or circumstance initiated by something other than natural causes or out
of the ordinary such as a tornado, kidnapping, riot or hostage situation, which jeopardizes the health, safety and
welfare of clients who are in the physical custody of the department.
F/groups/resplanlincidentslform7101 Rev. 2/25/02
037
KG061
ATTACHMENT "
The administration of resources awarded by the Department of Children and Families to the provider may
be subject to audits as described in this attachment.
MONITORING
In addition to reviews of audits conducted in accordance with OMS Circular A-133 and Section 215.97,
F.S., as revised, the department may monitor or conduct oversight reviews to evaluate compliance with
contract, management and programmatic requirements, Such monitoring or other oversight procedures
may include, but not be limited to, on-site visits by department staff, limited scope audits as defined by
OMS Circular A-133, as revised, or other procedures. Sy 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 Financial Officer or
the Auditor General.
AUDITS
PART I: FEDERAL REQUIREMENTS
This part is applicable if the recipient is a State or local government or a non-profit organization as defined
in OMS Circular A-133, as revised.
In the event the recipient expends $500,000 or more in Federal awards during its fiscal year, the recipient
must have a single or program-specific audit conducted in accordance with the provisions of OMS
Circular A-133, as revised. In determining the Federal awards expended during its fiscal year, the
recipient shall consider all sources of Federal awards, including Federal resources received from the
Department of Children & Families. The determination of amounts of Federal awards expended should
be in accordance with guidelines established by OMS Circular A-133, as revised. An audit of the recipient
conducted by the Auditor General in accordance with the provisions of OMS Circular A-133, as revised,
will meet the requirements of this part, In connection with the above audit requirements, the recipient
shall fulfill the requirements relative to auditee responsibilities as provided in Subpart C of OMS Circular
A-133, as revised.
The schedule of expenditures should disclose the expenditures by contract number for each contract with
the department in effect during the audit period, The financial statements should disclose whether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due
the department shall be fully disclosed in the audit report package with reference to the specific contract
number.
PART II: STATE REQUIREMENTS
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 $500,000 or more in state financial assistance during its fiscal year, the
recipient must have a State single or project-specific audit conducted in accordance with Section 215.97,
Florida Statutes; applicable rules of the Department of Financial Services; and Chapters 10.550 (local
governmental entities) or 10,650 (nonprofit and for-profit organizations), Rules of the Auditor General. In
determining the state financial assistance expended during its fiscal year, the recipient shall consider all
CF 1120, PDF 03/2008
CONTRACT # KG061
088
sources of state financial assistance, including state financial assistance received from the Department of
Children and Families, other state agencies, and other nonstate entities. State financial assistance does
not include Federal direct or pass-through awards and resources received by a nonstate entity for Federal
program matching requirements,
In connection with the audit requirements addressed in the preceding paragraph, the recipient shall
ensure that the audit complies with the requirements of Section 215,97(8), Florida Statutes. This includes
submission of a financial 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 the audit period. The financial statements should disclose whether or not
the matching requirement was met for each applicable contract. All questioned costs and liabilities due
the department shall be fully disclosed in the audit report package with reference to the specific contract
number.
PART III: REPORT SUBMISSION
Any reports, management letters, or other information required to be submitted to the department
pursuant to this agreement shall be submitted within 180 days after the end of the provider's fiscal year or
within 30 days of the recipient's receipt of the audit report, whichever occurs first, directly to each of the
following unless otherwise required by Florida Statutes:
A. Contract manager for this contract (2 copies): .......... Name: Theresa Phelan
Address: 1111 12th Street, Key West, Florida 33040
B. Department of Children and Families
(1 electronic copy and management letter, if issued)
Office of the Inspector General, Provider Audit Unit
Building 5, Room 237
1317 Winewood Boulevard
Tallahassee, FL 32399-0700
C. Copies of the reporting packages for audits conducted in accordance with OMB Circular A-133, as
revised, and required by Part I of this agreement shall be submitted, when required by Section .320(d),
OMB Circular A-133, as revised, by or on behalf of the recipient directly to the Federal Audit
Clearinghouse designated in OMB Circular A-133, as revised (the number of copies required by
Sections .320(d)(1) and (2), OMB Circular A-133, as revised, should be submitted to the Federal
Auditing Clearinghouse), at the following address:
Federal Audit Clearinghouse
Bureau of the Census
1201 East 10th Street
Jeffersonville, IN 47132
and other Federal agencies and pass-through entities in accordance with Sections ,320(e) and (f),
OMB Circular A-133, as revised.
D. Copies of reporting packages required by Part II of this agreement shall be submitted by or on behalf of
the recipient directly to the following address:
Auditor General's Office
Room 401, Pepper Building
111 West Madison Street
Tallahassee, Florida 32399-1450
03/01/2008
CONTRACT # KG061
039
Providers, when submitting audit report packages to the department for audits done in accordance with
OMS Circular A-133 or Chapters 10,550 (local governmental entities) or 10,650 (nonprofit or for-profit
organizations), Rules of the Auditor General, should include, when available, correspondence from the
auditor indicating the date the audit report package was delivered to them. When such correspondence is
not available, the date that the audit report package was delivered by the auditor to the provider must be
indicated in correspondence submitted to the department in accordance with Chapter 10.558(3) or
Chapter 10.657(2), Rules of the Auditor General.
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the terms of this agreement
for a period of six years from the date the audit report is issued and shall allow the department or its
designee, Chief Financial Officer or Auditor General access to such records upon request. The recipient
shall ensure that audit working papers are made available to the department or its designee, Chief
Financial Officer or Auditor General upon request for a period of three years from the date the audit report
is issued, unless extended in writing by the department.
03/01/2008
040
CONTRACT # KG061
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State of Florida
Department of Children and Families
Charlie Crist
Governor
Robert A. Butterworth
Secretary
MEMORANDUM OF NEGOTIATION
Community Care for Disabled Adults (CCDA) Contract KG061
Monroe County (In Home Services)
I.
Introduction
A. Participants:
Kim Wilkes, Monroe County Grants Accountant
Theresa Phelan, DCF Contract Manager
October 23, 2008 at 3 PM
DCF, 1111 12th Street, Key West
B. Meeting Date:
C. Meeting Location:
II. Procurement History
Contract KG061 with Monroe County In Home Services was procured using a regulated exemption (IGA),
the exemption used when purchases of services or commodities are from another governmental agency,
pursuant to Florida Statute s.287.057. The contract effective date is from January 1, 2008 through June
30,2010. Under the previous contract, KG06O, the provider was cited for noncompliance with background
screening and training requirements but presented a corrective action plan which was accepted and
completed. .
III. Narrative Summary of the Negotiations
The provider now subcontracts with HospiceNNA of the Florida Keys, Inc. for the direct services of
Personal Care and Homemaking. The unit cost paid by Monroe County is considerably lower under the
subcontract and the main issue of these negotiations was to determine the rates that the Department will
pay for these services which have been accepted as follows:
Service
Case Mana ement
Personal Care
Homemakin
Home Delivered Meal
Unit of Service
Hour
Hour
Hour
Meal
Rate r Unit
$49.89
$25.28
In addition, it was agreed that the provider would be responsible for the training of subcontracted staff as
the training relates to the requirements of the Department's CCDA Operating Procedure, CFOP 140-8
IV. Conclusion q ~
This contract, effective January 1, 200fthrough June 30, 2010, will provide Case Management, Personal
Care, Homemaking and Home Delivered Meals to eligible plients, age 18 - 59 years, in Monroe County.
Total contract amount is $123,941.00 as follows: FY 2008-2009 - $42,208.00; FY 2009-2010 - $81,733.00.
VI. Signatures:
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Pravl Ignature
Title: Senior Grants Coordinator
fOJdS/OO
,
Date:
Department Signature
Title: Contract Manager
Date: /d/1-- ., ;!> 8'
Monroe County (In Home Services)
Contract # KG061
Contract #KG060
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Aunendment#0002
Date: July 1, 2008
THIS AMENDMENT, entered into between the State of 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 14, Attachment I, Section B.2.d., is hereby amended to read:
Section B.2.d.
Title of Section: Subcontractors
This contract allows the provider to subcontract for the provision of the following
services under this contract: Personal Care, Homemaker and Home Delivered
Meals. The provider may not subcontract services not listed. All subcontracting
is subject to the provisions of Section 1.1. of the Standard Contract.
This amendment shall begin on Julv 1.2008 or the date on which the amendment has
been signed by both parties, whichever is later.
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 one (1) page amendment
to be executed by their officials thereunto duly authorized.
PROVIDER: MONROE COUNTY
SIGNED
BY:
~-i-! l'iy) ,(I:
STA TE OF FLORIDA
DEPARTMENT OF CHILDREN
AND FAMILIES
----_...-----/
SIGNED
BY:
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~AME:
Ramoh Gastesi
~A"'lE: Gilda P. Ferradaz
TITLE:
0/1onroe County Administrator
(ll/ ] {\ /(1/;)
1 I
TITLE: Circuit Administrator
DATE:
DATE: ".7./ ii' f'.' ,0
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FEDERAL ID ~{;'IBER: 59-60007"9
Revised 5-24-07
PAGE I
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CFDA No.
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
Client ~ 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 (in-Home Services) hereinafter referred to as the "provider."
I. THE PROVIDER AGREES:
A. Contract Document
To provide services in accordance with the terms and conditions specified in this contract including all attachments and exhibits, which
constitute the contract document
B. Requirements of Section 287.058, F.S.
To provide units of deliverables, including reports, findings, and drafts, as specified in this contract, which must be received and
accepted by the contract manager in writing prior to payment To submit bills for fees or other compensation for services or expenses
in sufficient detail for a proper pre-audit and post-audit. Where Itemized payment for travel expenses are permitted in this contract. to
submit bills for any travel expenses in accordance with section 112.061, F.S., or at such lower rates as may be provided in this
contract. To allow public access to all documents, papers, letters, or other public records as defined in subsection 119.011 (11), F.S.,
made or received by the provider in conjunction with this contract except that public records Ii'lhich are made confidential by law must
be protected from disclosure. It is expressly understood that the provider's failure to comply with this provision shall constitute an
immediate breach of contract for which the department may unilaterally terminate the contract.
C. Governing Law
1. State of Florida Law
That this contract is executed and entered into in the State of Florida, and shall be construed, performed and enforced in all respects
in accordance with the Florida law including Florida provisions for conflict of laws.
2. Federal Law
a. That if this contract contains federal funds the provider shall comply with the provisions of 45 CFR, Part 74. and/or 45 CFR,
Part 92, and other applicable regulations.
b. That if this contract contains federal funds and is over $100,000, the provider shall comply with all applicable standards,
orders, or regulations issued under section 306 of the Clean Air Act, as amended (42 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 contalllS federal funding
in excess of $100,000, the provider must, prior to contract execution, complete the Certification Regarding Lobbying form, Attachment
N/A If a Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may be obtained from the contract manager. All
disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to the contract manager,
prior to payment under this contract.
d. That unauthorized aliens shall not be employed. The department shall consider the employment of unauthorized aliens a
violation of section 274A(e) of the Immigration and Nationality Act 18 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 of federal funds, the provider shall comply '/lith Executive Order 11246, Equal
Employment Opportunity, as amended by Executive Order 11375 and others, and as supplemented in Department of Labor regulation
41 CFR, Part 60 and 45 CFR, Part 92, If applicable.
f. That if this contract contains federal funds and provides serVices to children up to age 18, ~he provider shall comply vilth the
Pro-Children Act of 1994 (20 US.C. 5081:. Failure to ccmply wth the prOVisions of the law may result in the ImpOSition of a ,:ivil
monetary penalty of up to $1.000 for each 'iiclation and/or the irnpositfon of an administrative compliance order on the respJns,ble
entity
D. Audits, Inspections, Investigations, Records and Retention
1. To establish and maintain books, records and documents I including electrcnic storage i::edia, sL/fclent to reflect ail i"ccme
and expenditures of funds prcvided by the department under this contract
2. To retalll ail cifent records, :rnanCial records, support.ng documents. statrstlcal records. and arf'Jther documentsl:lcud:ng
electroniC sterage media) pertir:ent te th,s contract for a per, cd ef SiX years a:'ter ccmpletion of ("e c,cntract or 'orger ~'Jhe'l requ"ed
by law. In the e'/ent an audit :s reqUired by :his ccntract. 'e':ords snail be retal"ed f,cr a rr;n,illUm ,cer..),j 'cf six, A) j'ears a~er 'he 2'. jit
'eport IS ,ssued cr untIi 'esclut,on of any aud,t findings:r 'it.;)atlon based cn the ter:::s :,f tillS ocrtract at'o additlc;ra! cost te the
:!epartmenL
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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)(1 0), shall be allowed full access to and the right to examine any of the provider's contracts and
related records and documents, regardless of the form in which kept
6. To provide a financial and compliance audit to the department as specified in this contract and in Attachment U and to ensure
that all related party transactions are disclosed to the auditor.
7. To comply and cooperate immediately with any inspections, reviews, investigations, or audits deemed necessary by the office
of The Inspector General (section 20.055, 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 768.28, F.S. or other Florida Law, Paragraph F, is not applicable to contracts
executed between the department and state agencies or subdivisions defined in subsection 768.28(2), FS.
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 renewa/(s) and extension(s)
of it By execution of this contract, unless it is a state agency or subdivision as defined by subsection 768.28(2), F.S, the provider
accepts full responsibility for identifying and determining the type(s) and extent of liability insurance necessary to provide reasonable
financial protections for the provider and the clients to be served under this contract 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. ,il.,ny subcontracts shall be evidenced by a written document. The provider further agrees that the
department shall not be liable to the subccntractor in any way or for any reason. The provider, at its expense will defend the
department against such claims.
3. To make payments to ar:y subcontractor 'Nlthin seven 'Norking days after receipt of full or partial payments from the
department in accordance with section 2870585. F.S. ur:less othenNise stated in the contract between the pro'lider and
subcontractor. Failure to pay INithin se'len (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; cf the arnount due per day from the expiration of
the period allowed for payment. Such penalty shall be In addition to actual payrnents cwed and shail not exceed fifteen (15%) percent
of the outstanding balance due.
4. That the State of Florida shall at a/i times be entlt:ed tc assign or transfer. In whole or part, its rights duLes. or obl!gatcns under
this contract to another governmental agency in t<-:e State cf Florida, upon glv!r:g prior written r:ctice to the prolJi,jer In the e',ent the
State of FlOrida approves transfer of the providers obllgaticns, the provider rer.;alns responsible for all 'Ncrk performed and ail
expenses .ncurred !n connection With the ccntract. This contract shall remain binding upcn the successcrs in r:terest of either tI~e
provider or the deoartment.
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J. Return of Funds
To return to the department any overpayments due to unearned funds or funds disallowed and any interest attributable to such funds
pursuant to the terms and conditions of this contract that were disbursed to the provider by the department. In the event that the
provider or its independent auditor discovers that an overpayment has been made, the prOVider shall repay said overpayment
immediately without prior notification from the department. In tre event that the department first discovers an overpayment has been
made, the contract manager, on behalf of the department, will notify the provider by letter of such findings. Should repayment not be
made forthwith, the provider will be charged at the lawful rate of interest on the outstanding balance after department notification or
provider discovery.
K. Client Risk Prevention and Incident Reporting
1. That if services to clients are to be provided under this contract, the provider and any subcontractors shall, in accordance with
the client risk prevention system, report those reportable situations listed in CFOP 215-6 in the manner prescribed in CFOP 215-6 or
district operating procedures.
2. To immediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person or disabled
adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ABUSE). As required by Chapters 39 and
415, F.S., this proviSion is binding upon both the provider and its employees,
L. Purchasing
1. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative Industries and
Diversified Enterprises, Inc., (PRIDE) identified under Chapter 946, F,S., in the same manner and under the procedures set forth in
subsections 946.515(2) and (4), FS, 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, F,S.
M. Civil Rights Requirements
1. Not to discriminate against any employee in the performance of this contract or against any applicant for employment because
of age, race, religion, color, disability, national origin, marital status or sex in accordance with 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 287,134, 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 Flor;da,
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 assignee, unless speCifically agreed to by the department in this contract.
5. All deductions for social security, ',vithho1ding taxes, income taxes, contnbutlons tc unemployment ccmpensatlon funds and ali
necessary insurance for the prOVider, the provider's officers, employees, agents, subccntractors, or assignees shall be the scre
respcnslbiflty cf the provider
O. SponsorShip
As reqUired by section 2-3625. FS, ,f the prc'/der is a I~on-gcvernrnental c:rganization 'hh'ch Sp.Ollsers a program fir'allced ';,hcl'y er:l
rart ty state funds. rncludrrg any funds cttarred ~tlrO:Jgh this con~ract. it shall, In pub'iCizing, adveJi!slrg, or deserting the sponsorship
cf the program stateSpc;nsored by /pro'Jlder's i-acre;, and the State cf F'orida Cepartment of -::::rrldren and Fam~'es.'f the
spcnsorshlp reference is in m.tten material tr:e 'horrjsSta~e of c:orda, Cepariii1ent Jf Chlidren and Fam:lies' sralr appearn at east
t'le sarre sizeetters or type as :he r:ame cf :he organization
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P. Publicity
\Nithout limitation, the provider and its employees, agents, and representatives wiil not, without prior departmental wntten 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 or indirectly, that any product or ser/ice
provided by the provider has been approved or endorsed by the State, or refer to the existence of this ccntract in press releases,
advertising or materials distributed 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 of this contract may be withheld until all reports due from the provider and necessary
adjustments thereto have been approved by the department
R. Use of Funds for Lobbying Prohibited
To comply with the provisions of sections 11.062 and 216.347, F.S., which prohibit the expenditure of contract funds for the purpose of
lObbying the Legislature, judicial branch, or a state agency.
S. Public Entity Crime
Pursuant to section 287.133, F.S., the following restrictions are placed on the ability of persons convicted of public entity crimes to
transact business with the department: When a person or affiliate has been placed on the convicted vendor list following a conviction
for a public entity crime, he/she may not submit a bid on a contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or the repair of a public building or public work, may not submit bids on
leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant
under a contraot with any public entity, and may not transact business with any public entity in excess of the threshold amount
provided in section 287.017, F.S., for CATEGORY TWO for a period of thirty-six (36) months from the date of being placed on the
convicted vendor list
T. Gratuities
The provider agrees that it will not offer to give or give any gift to any department employee. As part of the consideration for this
contract, the parties intend that this provision will survive the contract for a period of two years In addition to any other remedies
available to the department, any violation of this provision will result in referral of the provider's name and description of the violation of
this term to the Department of Management Services for the potential inclusion of the provider's name on the suspended vendors list
for an appropriate period. The provider will ensure that its subcontractors, if any, comply with these provisions
U. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course of or as a result of work or services performed under this
contract. or in anyway connected herewith, the provider shall refer the discovery or invention to the department to be referred to the
Department of State to determine whether patent protection will be sought in the name of the State of Florida. Any and all patent rights
accruing under or in connection with the performance of this contract are hereby reserved to the State of Florida.
2. In the event that any books, manuals, films. or other copyrightable materials are produced, the provider shall notify the
Department of State. Any and all copyrights accruing under or in connection with performance under this contract are hereby reserved
to the State of Florida.
3. The provider, if not a state agency, as that term is defined in subsection 768.28, F.S., shall indemnify and save the department
and its employees harmless from any liability whatsoever. including costs and expenses, arising out of any copyrighted, patented. or
unpatented invention, process, or article manufactured or used by the provider in the performance of this contract.
4. The department will provide prompt written notification of any claim of copyright or patent infringement Further, if such claim IS
made or is pending, the provider may. at its option and expense, procure for the department, the right to continue use of, replace, or
modify the article to render it non-infringing. If the provider uses any deSign device, or materials covered by letters patent, or
copyright. it is mutually agreed and understood without exception that the ccmpensation paid pursuant to thiS contract includes all
royalties or costs arising from the use of such design. deVice, or matenals in any way involved In the work cCl1templated by thiS
contract
5. All applicable subcontracts shall :nclu,je a previSion that the Federal a....lard:ng agency reser;es all patent rights w!th 'espect to
any disccvery or invention that arses or's developed In the course of cr iJnder ti"e subccntract.
V. Construction or Renovation of Facilities Using State Funds
That any state funds provided for the purchase of ormprovements to real property are ccnt'rgel~t upcn 'i~e pr.:v'der grant'l1g to tr:e
state a secunty interest In 'he property at 'east to the amcUf~t cf tf~e state f'.lids pro'/:ded fer at 'east five, 5) jears (rer; trejate cf
purchase or the completion of the improverT'ents cr as (wirer reqUired by :a'//. ..o,s a cencrten cf receipt .cf state fc;ij'ng (cr triS
p:Jrpose, the prC'.:der agrees Hiat. rf ,t disposes ef tr.e 1=roperty befOre tre depar::::ent's,~terest is 'jacated the p'J',jer;;,ii 'efiJrd tre
proportionate share of the state's init;a! investrT'ent. as adjusted by depree!atC:1
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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 liaison to the
department's security staff and who will maintain an appropriate level of data security for the information the provider is collecting or
using in the performance of this contract. An appropriate level of security includes approving and tracking all provider employees that
request system or information access and ensuring that user access has been removed from all terminated provider employees.
2. To hold the department harmless from any loss or damage Incurred by the department as a result of information technology
used, provided or accessed by the provider.
3. To provide the latest departmental security awareness training to its' staff and subcontractors.
4. To ensure that all provider employees who have access to departmental information are provided a copy of CFOP 5C-6 and
that they sign the DCF Security Agreement form (CF 114) a copy of which may be cbtained from the contract manager,
X. Accreditation
That the department is committed to ensuring provision of the highest quality services to the persons we serve. Accordingly, the
department has expectations that where accreditation is generally accepted nationwide as a clear indicator of quality service, the
majority of our providers will either be accredited, have a plan to meet national accreditation standards, or "vill 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.
88. 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 rate
schedule, subject to the availability of funds. The State of Florida's performance and obligation to pay under this contract is contingent
upon an annual appropriation by the Legislature. Any costs or services paid for under any other contract or from any other scurce are
not eligible for payment under this contract.
8. Contract Payment
Pursuant to section 2,5422, FS, the department has five ,5) working days to Inspect and approve goods and serJices, unless the bid
specifications, purchase order, or this contract specify cthenNise. 'i'/ith the exception cf payments to health care providers :cr hospitai,
medical, or other heaith care services, if paYr:lent .s not available 'IVlthin forty '40) [jays, measured from the latter of the date a properly
con-:pleted invoice is received by the department or the goods or services are received,nspected, and apprcved a separate ,nterest
penalty set by The Chief Financial O:ficer pursuant to section 5503, F.S wiil be due and payable in addition to the invoice amount
Pa'ylrents to health care prOViders for I-::::sp ;tal Illedcal, or other health:are serJlces. shall be :;-:ade not mere than thirty-five 135) days
frem the date eliglbiiity for payment is determrned. Fnancial penaltres will be calcL:lated at the daily Interest I'ate of 03333%. InVOices
returned to a provider due to oreparation errcrs will result ,r: a nor-,rterest beanng pay,:;-:ent delay. i::terest penalties iess t"an one
dollar '/IIJI not be paid unless the pro'.der requests I=ayment
C. Vendor Ombudsman
A ',erdor C:-::budsrTan ras teen establ,sned hth.l: :"e Ceo3ili':ent ef i=r:al:c.ai Ser'/Ices. -he jutes c: t~'s:uce are fcurd:n
sut:sectlcn 2; 5.422. ,= S, :,n,fen :I~c:uje ,::;sser:ll,.at-g :~<er";-:3tion 'eaL e :0 the pro-,cpt c3Yi,er.t:::f :ics stale ar::i aSSisting ler-CC s ,'1
'eceiv,ng Uleir pa'ttre,'1:S 1,'1 a t:r:le,y manner "rem 3 state aQercy. -",e '/en.Jer Cml:::~jsn:an :;:ay be contacted at:35C) 4;3-55'6
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D. Notice
Any notice, that is required under this contract shall be in writing. and sent by U.S. Postal SerJice 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 responSible for
administration of the program, to the designated address contained in this contract.
III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall begin on July 1, 2007, or on the date on which the contract has been signed by the iast party required to sign It.
whichever is later. it shall end at midnight, local time in rfionroe County, Florida, 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 Administrative Code, corrective
action plans may be required for noncompliance, nonperformance. or unacceptable performance under this contract. Penalties may
be imposed for failures to implement or to make acceptable progress on such corrective action plans.
2. The increments of penalty imposition that shall apply, unless the department determines that extenuating circumstances exist.
shall be based upon the severity of the noncompliance, nonperformance, or unacceptable performance that generated the need for
corrective action plan, The penalty, if imposed, shall not exceed ten percent (10%) of the total contract payments during the period in
which the corrective action plan has not been implemented or in which acceptable progress toward implementation has not been
made. Noncompliance that is determined to have a direct effect on client health and safety shall result in the imposition of a ten
percent (10%) penalty of the total contract payments during the period in which the corrective action plan has not been implemented or
in which acceptable progress toward implementation has not been made.
3. Noncompliance involving the provision of service not having a direct effect on client health and safety shall result in the
imposition of a five percent (5%) penalty. Noncompliance as a result of unacceptable performance of administrative tasks shall result
in the imposition of a two percent (2%) penalty.
4. The deadline for payment shall be as stated in the Order imposing the financial penalties. In the event of nonpayment the
department may deduct the amount of the penalty from invoices submitted by the provider
C. Termination
1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the
other party unless a sooner time is mutually agreed upon in writing. Said notice shall be delivered by U.S, Postal Service or any
expedited delivery service that provides verification of delivery or by hand delivery to the contract manager or the representative of the
provider responsible for administration of the program.
2. In the event funds for payment pursuant to this contract become unavailable, the department may terminate this contract upon
no less than twenty-four (24) hours notice in writing to the provider Said notice shall be sent by US. Postal Service or any expedited
delivery service that provides verification of delivery, The department shall be the final authority as to the ava:lability and adequacy of
funds. In the event of termination of this contract. the provider will be compensated for any work satisfactorily completed.
3. This contract may be terminated for the provider's non-performance upon no less than twenty-four (24) hours notice In writing to
the provider If applicable the department may employ the default provisions in Rule 60A-1.006(3), Florida Administrative Code.
Waiver of breach of any provisions of this contract shall not be deemed to be a \Naiver of any other breach and shall not be construed
to be a modification of the terms and conditions of this contract. The provisions herein do not limit the department's right to remedies
at law or in equity.
4. Failure to have performed any contractual obligations with the department in a manner satisfactory to the department will be a
sufficient cause for termination. To be terminated as a provider under this provision, the provider must have: (1) previously failed to
satisfactorily perform in a contract with the department, been notified by the department of the unsatisfactory performance, and failed
to correct the unsatisfactory performance to the satisfaction of the department; or (2) had a contract terminated by the department for
cause.
D. Renegotiations or Modifications
r,~cdifcations cf Wo'/siors of thiS cortract shal! t:e '/a!:d:;I~IY",hen they Ica'/e been redL.ce,j ~c 'fIr/ting ard dL.!Y Signed by both parties
The rate of payment and the tctal dcliar amount may be adjusted retroacti'Jeiy to reffect pnce :evel Increases and changes in ;,he rate
of payment when these ha'le been established through the apprcpr"ations prccess ard subseqL.ently identfied in the departments
,operating cudgel.
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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 ,s:
Monroe County In-Home Services
1100 Simonton Street
Key West, FL 33040
Theresa Phelan
111112rn 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
305-2924589
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
305-2924589
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 II, and any exhibits referenced in said attachments, together with any documents Incorporated
by reference, contain all the terms and conditions agreed upon by the parties. There are no provisions, terms, conditions, or
obligations other than those contained herein, and this contract shall supersede all previous communications, representations, or
agreements, either verbal or written between the parties. If any term or provision of this contract is legally determined unlawful or
unenforceable, the remainder of the contract shall remain in full force and effect and such term or provision shall be stricken.
By signing this contract, the parties agree that they have read and agree to the entire contract, as described in Paragraph III.
F. above.
IN WITNESS THEREOF, the parties hereto have caused this 42 page contract to be executed by their undersigned officials as duly
authorized.
PROVIDER:
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
Signature:
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Gilda P. Ferradaz
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f 1::/~Ad-e::S---
Print/Type
Name:
Title:
Mayor
Print/Type
Name:
Title:
District Administrator
Date:
JUN 2 0 2007
Date:
~ /.J-JY~)
STATE AGENCY 29 DIGIT FLAIR CODE:
Federal Tax ID # (or SSN): 59-0600749
Provider Fiscal Year Ending Date: .,Q3!/30.
MONROE COUNTY ATTORNEY
A~FiRO,VEQ AS }'O FpRM:
l t1d-Ccw-i. ' , J-r.-l r
YNTHIA L. HALL
ASSISTANT COUNTY ATTORNEY
Date 0,) -3 I - ,)..or:+
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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 fOi,.bled 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, F.S.. Chapter 65C-2. Florida Administrative
Code (F.AC.) and the annual appropriations act with any proviso
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PSMAI No. GAD?
Contract No. KG060
i~,1or,roe County in-Home Services
07/01/2007
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Community Care fl.3abled Adults/Fixed Price
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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.
;3 n 07
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PSMAI No. GA07
.~iicnroe Cour;ty in-Heme Serv'lces
::;cntract ~Jo. t<GG60
07/01/2007
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(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 District/Region
Program Office, and only to the extent that funds are available.
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~.:onroe County i r-Home Ser/lces
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PSMAI No. GA07
'=:cntract ~~o. KGC60
07101/2007
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Community Care ff~'~abled Adults/Fixed Price
ty 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 L8JCase DEmergency Alert
Management Response
L8JPersonal Care CHome Health DGroup Activity
Aide Therapy
L8JHomemaker CHome Nursing L8JHome Delivered
Meals
Olnterpreter OTransportation OMedical Therapeutic
Services
OChore ORespite OPhysical and
Exams
OEscort OAdult 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.AC.
(2) Homemaker service time does not include time spent in transit
to ar.d from the client's place of residence except \Nhen providing
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',lonroe County In-Hor-ne SerVices
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PSMAI No. GAD?
r::;cntract i'Jo KGC60
07/01/2007
.-....".'.
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Community Care for( led Adults/Fixed Price
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.
':2/2207
,',ionroe Cour~ty in-Home Services
13
PSMAI No. GA07
Contract No. KC;C60
07/01/2007
f~~;J,':
> 0:--" :<,~--'
t-.;
Community Care fc abled Adults/Fixed Price
Adult Services 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
Case Management
. Homemaking
, Personal Care
· Home Delivered rv1eals
LOCA TlON
: Client's Home
Client's Home
Client's Home
. Clients Home
TIME(S)
As needed
As needed
As needed
As needed
02/22.07
iJlonrce Ccunty Ill-Home Ser/lces
14
PSMAI No. GA07
Ccntract ~~o, KG060
07/01/2007
Community Care f(~abled Adults/Fixed Price
,,'I 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 B, 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. Deliverables
a. Service Units
A service unit is an appropriate, distinct amount of given service, which
may include, but is not limited to, an hour of direct service delivery; a
meal; an episode of travel; or a twenty-four (24) hour period of Emergency
Alert Response maintenance, as defined in CFOP 140-8, COMMUNITY
CARE FOR DISABLED ADULTS Operating Procedures. All service units,
as well as their description and costs. are listed in CFOP 140-8.
COMMUNITY CARE FOR DISABLED ADULTS Operating Procedures.
C3/22107
15
PSMAI No. GA.07
1,1onroe Ccunty !r:-Home SerJices
Contract ~~o. KGJ60
07/01/2007
/~i'
'....... ':-:%,~
, -~---:-~*,~
Community Care fort~bled Adults/Fixed Price
;I'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 client'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 al/ 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.
,J3,2207
',1onroe County in-Horne Services
16
PSMAI No. GA07
Ccntract ~Jo. KG060
07/01/2007
-ff~
-::...........'.~. .
f-_-:J~
Community Care (:~sabled Adults/Fixed Price
AlI Adult Services Program
(5) The case management provider must maintain documentation
in the client's file that all comparable community services and
funding sources have been explored and exhausted before using
COMMUNITY CARE FOR DISABLED ADULTS funding.
c. Reports
I :
I Report Title I Reporting Report Date Due Number DCF Office ,
I ' i
. I Frequency of copies address(es) to !
I I due receive report I
I I ! I
i I I
I
I I The 15th of month i
I Monthly Monthly 1 Contract I
I ,
I I
I Cumulative ! I immediately Manager
I Summary following the month
I I I
Reports I being reported on. I
i
I I I
I r
I I i
I i
i
I r I -----j
I I I
I r I I
I Request for! I I
As needed I As needed 1 I Contract I
Approval of I I Manager I
r r
I
, CCDA Care i
Plan I I I
I
I I
Services I
Increase I
(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 (e.g., client identifiable data) to the department,
according to negotiated instructions provided by the districts.
(3) In the event of early termination of this contract the provider
will submit the final Monthly Cumulative Summary Report ,"vithin
forty-five (45) days after the contract is terminated.
:3/22,07
:,lonroe Ccunty In-Home SerJlces
17
PSMAI No. GAD?
Centract I~JO. KG060
07/01/2007
-)~;~
i-.,_:~___~
,yi
Community Care fc;[tabled Adults/Fixed Price
, 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 B.5.a. above as follows:
(a) The outcome measurement contained in paragraph
B.5.a. (1) above will be calculated by dividing the total, fiscal
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.
IJ3/'22,07
18
PSMAI No. GAD?
Centract ;"Jo. K'3Ci60
~,lonrce Ceunty in-rlome Seriices
07101/2007
....."..'...,
i--~:-I1
Community Care for?~bled 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 \^Jaiting 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
;3/22/07
~,lonroe County in-Heme Services
19
PSMAI No. GAO?
'=:ontract No. KGC60
07/01/2007
<'I'
.....:.:~..j.( ,
t_ o~;~~
Community careO~isabled 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 caseload 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)(ii)]:
(a) The provider hereby agrees not to use or disclose
protected health information (PHI) except as permitted or
required by this contract, state or federal law.
J3/22;07
'''-1onroe County In-Home Services
20
PSMAI No. GAD?
Contract No. KGC60
07/01/2007
C3,22,07
.'/1onroe County in-Home Services
/".
; -........"
r ere,;'
Community Care f~~~abled Adults/Fixed Price
c.f1IAdult Services Program
(b) The provider agrees to use appropriate safeguards to
prevent use or disclosure of PHI other than as provided for
by this contract or applicable law,
(c) The provider agrees to report to the department any use
or disclosure of the information not provided for by this
contract or applicable law.
(d) The provider hereby assures the department that if any
PHI received from the department, or received by the
provider on the department's behalf, is furnished to
provider's subcontractors or agents in the performance of
tasks required by this contract, that those subcontractors or
agents must first have agreed to the same restrictions and
conditions that apply to the provider with respect to such
information.
(e) The provider agrees to make PHI available in
accordance with 45 C.F.R. 164.524,
(f) The provider agrees to make PHI available for
amendment and to incorporate any amendments to PHI in
accordance with 45 C,FR. 164,526.
(g) The provider agrees to make available the information
required to provide an accounting of disclosures in
accordance with 45 C,F,R. 164.528.
(h) The provider agrees to make its internal practices,
books and records relating to the use and disclosure of PHI
received from the department or created or received by the
provider on behalf of the department available for purposes
of determining the provider's compliance with these
assurances,
(i) The provider agrees that at the termination of this
contract, if feasible and where not inconsistent with other
provisions of this contract concerning record retention, it will
return or destroy all PHI received from the department or
received by the provider on behalf of the department, that
the provider still maintains regardless of form. If not
feasible, the protections of this contract are hereby extended
to that PHI which may then be used only for such purposes
as make the return or destruction infeasible.
21
PSMAI No. GAD?
''=;ontract No. KC3060
07/01/2007
~,-'.r).,.'-
r:)~;,
':.-,__-'',74.,
._~.
Community Care fO{~bled 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).
J2.22:07
r,lonroe County in-Home Services
22
PSMAI No. GAD?
CGntract No. KGC60
07/01/2007
Community Care for
led Adults/Fixed Price
~ ~Ir 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 $ 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 ser\jice units on previous invoices, exceed the total
number of units authorized by this contract.
:::3'22.:::7
'':onrce
23
PSMAI No. GA07
:I~-H(::f"e :3er';r::c3
:cntrar::t ~Jc. Kce60
07/01/2007
fict"
(,';,',"',
'. '~'~r
Community Care f~"~abled Adults/Fixed Price
i'ifI' Adult Services Pmgram
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 pro'/ider'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 v/ithin ten (10) working days and select a third
representative. These three representatives shall meet within ten (10)
working days to seek resclution of the dispute. If the representatives'
(:322107
24
PSMAI No. GAD?
C.::ntract lJo. KGC60
r"lonroe County :n-Horne 2er'/lces
07/01/2007
....~.<.'....
t::;,
Community Care
abled 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.A.C., 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 \-'ielfare 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.
::3.22.J7
25
PSMAI No. GA07
:\1onroe
. n-Hcrne SerJces
'=::-:nf:-act t"Jo. Ki3G60
07/01/2007
"
h
Community Care
'.-
'sabled 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 8, Durable Medical Equipment Inventory
2. Exhibit C, Provider Inventory
3. Exhibit 0, 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
222207
26
PSMAI No. GA07
~jicnroe County :n-~':ilie Ser'\/:.::es
Contract ~'o. f<GC60
fi5fi~i~~f~
PART I
1. Name:
<:1""
c ~ ~'. ','<~
< -~-;k'
o,:~p-
...,t'1!i!
r'~_::_ ;,~-'~
.'
E~H.!rr A
AS Screening for Consideration for Community-Based Programs
A Date of Referral (Initial Contact):
B. 0 Walk In D Phone 0 Other:
C. Referral Source (include phone number):
2, Address:
DistricURegion:
3. Phone:
4. Race:_ Gender:_ Age/DOB:
D. Relationship to Individual Being Referred
5, Marital Status:
E. Is Individual Aware of Referral? DYes D No
6. Social Security Number:
7. Primary Language:
8. Medicaid 0 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)
$
$
$
$
$
(5801)
(S81)
(Workers Comp)
(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:
~ 9. AS Counselor's Signature:
Date:
20 :::Jiscos,tion C PrGtect",e Irterventicn Pfacement D Prctective Inter/ention Sl.ppcrc;ve Services
.--,
~ Short-Term Case ~,lgmt
,--,
'---- ,r:forr:atlon & Referral
L CCOA Application
r--1
U ADA 1,1edicald '/Jal',er Applicaticn
~ f-1CDA ,~ppi)caticii
r-'
.-.J CeCA "'Jaiting List - Sccre _ :--J ADA f,ledica,d Waiver ',','aiting List - Sccre _ L HCOA ';Jalt:"9 Lst - Scc;e _
21. Due Precess Pamphlet (CF, PI 140-43) GiveniMalied by
Date
22. Given to Supervisor :or Review by
Date
23. Reviewed/Approved by
Date
:;:4. PART I sent to
Date
By
25. Referred to AS Counselor, Case Manager:
:,;-,::, "~22, P:~ ::C5
Date
sa]e~cf4
2.;
..~
flJl
t"'~"'"
f :~- ,~, ',' -"'-
<,- i~-~~
PART II
FUNCTIONAL ASSESSMENT (ADLs AND IADLs)
26. Check sources of information used for FUNCTIONAL ASSESSMENT Section.
D Individual Requesting Services
D Other (specify):
27. Has individual requesting services had any ongoing problems with memory or confusion that seriously interfere with
daily 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
sum in Total Score boxes.
ACTIVITIES OF DAILY LIVING (ADLs)
(Read all choices before taking answer)
Would you say that you need help from another person?
(Does not Include assistance from devices)
o = No help 2 = Some help 3 = Can't do it at all
Comments/Care Plan Implications:
(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, dnnking from a cup and
cutting foods) 0
31. Transferring (includes getting in and out of a bed Or'
chair) 0
32. Toileting (Independently includes adjusting clothing
getting to and on the tOI!et, and cleaning one's self If 0
accidents occur and person manages alone. count it
as Independent If reminders are needed to clear: up,
I change diapers or use t.'le to:let this counts as scme
I;e!o\ I
33. Bladder/Bowel Control - Hew well can you:cnt:Q'
your bladder or bCi,ei'l 0
-- Never have acoder-t n\
v,
-- - , (",,~Q:'l" ., ~t r ,.....rr
OCGas,cnady ha ,e ac~ v~ ,IS
-- Often ha've acc:c;e~ts
-- A'-Nays ha';e accdents
2, E,,,e Sw,e
?\
Vi
4~
ADL Total Score
(Total possible score::: 19) 0
:::e 2 sf 4
"L8'
&
~,
r.",~,,;.',""
1_-"
INSTRUMENTAL ACTIVITES OF DAILY LIVING (IADLs)
(Read all choices before taking answer) Would you say that you need help from another person?
I,Dces not Include assistance from devices)
o = No help 1 = Some help 2 = Can't do it at all
Comments/Care Plan Implications:
(Include serJlces. suppi:es, eaulPment, etc.)
34. Transportation Ability (includes uSing !ccal I
transportation, paratransit or dnv:ng to places beyond 0
walking distance)
35. Prepare Meals (includes preparing meals for yourself
Including sandWIches, cooked meals and TV dinners) 0
36. Housekeeping (dusting, vacuuming. sweeping,
laundry) 0
IADL Total Score 0
(Total possible score = 6)
SUPPORT AND SOCIAL RESOURCES OF INDIVIDUAL REQUESTING SERVICES
(No Score for Questions 37-46)
37, Check source(s) of information used for this section,
D Individual Requesting Services
o Other (specify):
SERVICES/HELP
Yes No NOTES
Do you receive .,.
38. Personal Care
Assistance (bathing,
dressing, getting out of
bed, tOlleting and eating)
39. Housekeeping (laundry,
cleaning, meals, etc)
40. Transportation
41. Shopping/Errands
42. Personal Finances I
(money management) I
43. Services from a health i
professional such as ar
RN or Therapist? i
i
i 44.
I 45
I .
:
Adult Day Care
Home delivered meals
Forrral oniYI
:
: 46. Any other kind of help
Spec'Y)
r:3rJe 2 ,.:f 4
2.9
',';',',i,'",
0-1;<
. ,"'~
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 'Nas "yes" to
the question "Is individual homebound?", a score of 1 point is placed on 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."
!",t,"'"
, --,-\:-:.:.
~-k
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
1. Is individual requesting services a victim and at high risk of abuse,
neglect, or exploitation based on Protective Investigator's report? Yes (4 pt.)
2. Is individual requesting services a victlr.1 and at Intermediate risk
of abuse, neglect, or exploitation based on Protective
Investigator's Report? Yes (2 pt.)
3. Does individual live alone or is individual solely responsible for
minor children (under the age of 12) in the home? Yes (1 pI.)
4. Is individual homebound? (See AS Screening for Consideration
for Community-Based Programs INSTRUCTIONS for definition of Yes (1 pt.)
homebound)
5 Does individual have ongoing memory/confusion problems? Yes (2 pt.)
6. Is individual receivng SSI or SSD because of primary diagnOSIS
of sensory impairrrent? Yes (3 pt)
7. Functional Assessment: ADLs.. 0 (enter ADL total score)
IADLs 0 (enter IADL total score)
8. Support for Individual Requesting Services:
Does individual currently receive help/ser/ices (formal/informal) In
ADL or IADL deficit areas noted? No help (4 pt.)
Help is available but overall inadequate or
changing, fragile or problematic 12 pt)
Help IS adequate c/erallln deficit areas (0 pt.)
For HCDA and CCDA Programs Only:
Indi'/Idual appears eligible cr is recel'ling comparable ser/lces
from other departmental programs APD, or 'Jocationai rerabil-
:tatlon. Coes n,ot i1clude AS prcg:arrs - see 'Naiting :ist policy
I for defln,tlon of "compa:able services Specfy program's) to
I ",hiOh rfld,v,duals being refe:red for e::gJ;;:ity ,determ;natlofl ard
, steps taken to :efer '~dlvdL.a; tooti:e: v:g:'arris)
, I
i r.1rrL.S 40 pt !
I
I
I
CCDA ADA fvl'vV HCDA
o 0 0
TOTAL SCORE
(Total Possible Score = -40 to +40)
~c.;e ~ cf 4
~
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(......~ -.11'\,."'" ,.;. "} ,In',l>'t')
~,.
--- /,-,. - .~~ t.
'~.~~- ~.-> . . :.
Item Purchased
1.
2.
3.
4.
5.
6.
Exhibit B
Durable Medical Equipment Inventory
Date of Purchase
Purchase Cost
31
Name of Client Receiving Purchased Item
KGC60
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"-~iJ1 x I I (?:~
Request;;for Approval of CCDA Care p(1~ n Services Increase
P rt I R
t I f
r
a eClpren norma Ion
Name: Last r.ame, first name, middle name or initial Date of birth: I
Soc:al secufity number: Medlcaid,Medlcare Med:cal ass,star,ce number' i
Current Address' Address 'hhere services Will be 'ece,ved: I
i
I
Cour,ty: County
Status (Transfer/Existing): Describe reason for service funding increase.
If individual is a transfer, indicate originating districUagency: An Adult Services client reassessment was completed on
by and
If individual is an existing consumer with your agency, respective revised care plan revisions made on
indicate current monthly authorized units of service by by , to
service type(s): reflect that this Recipient is justifiably in need of increased
Service(s) based on (check all situations which apply):
o Failing Support System
o Decrease in Functional Capacity
o Rapidly Deteriorating Health
Medicaid waiver eligibility date:
Provider Information
Agency ,"ame Agency contact person:
Agency address:
Phone:
Fax:
E-mail address:
Part II: Summary of Recipient's Presenting Situation. (Refer to form instructions for details about the type of information
required here. Use the space below or include attachment)
S e ('-/ i ce
Ant.cipated start date
S e :1/: ce
fo,rt..:,pted start date!
':F~AA ~ ~ -= '1 Mar 2005
34
r<GCEO
I
(c
Part IV: Specific Description of Proposed New Service(s) As Tailored To Meet Recipient's Need. (Refer to the form
instructions for details about the type of information required here, Use the space below or Include attachment)
Part V: Cost Detail for Proposed New Care Plan Service(s).
A Attach a Cost Detail page for each service requested in Part 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 unit service rates, please present comparative InformatIOn: Uf7it rate quotes from a mmimum 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 vendor is a sole source provider of this service in this geographic area, etc. Attach information as necessary (e. g.
agency admil1lstrative costs, your agency salary sca/e, etc.). Refer to the form instructions.}
o Failing Support System: List proposed add-on number of monthly service units by service component with annualized
service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Decrease in Functional Capacity: List proposed add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
o Rapidly Deteriorating Health: List care plan add-on number of monthly service units by service component with
annualized service costs projected to safely maintain Recipient at home and to ameliorate this risk factor.
Part VII. Signatures. (Please note Final approval of all requests for Care Plan Increases rest with the Budget Entity Team.
Providers will receive an Award Letter from the Bud et Entit Team (or one of its members when the Ian has been a roved
Provider Agency: (Signature indicates that the II1formatlon presented ,n this Request for Care Plan Services Date:
Increase and attachments are accurate and complete)
RecipienURepresentative: \Signature dld,cates that the Recipient. Representatl'ie ,~as reviewed the Request for
Care Plan Services Increase and attachments.)
Date:
; DistrictReg:onal Program Staff: SgraLre Irdlcates that the dlstrctregona, pcg'ar:: staf' and pCi,je' ra',e
I agreed upon the services to be funded)
Date
: Distr:ctReglonal ,A.duit SeiilCeS Prcgram Drec:cr' Sigrature rrdcates dstr,ct/reg.cra. accrc,alc' ,ne Ser', ce , Date
Fund:ng Pian;
35
;<COGO
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 UNITI TOTAL AMOUNT
OR DESCRIPTION OF MATERIALS QUANTITY EPISODE DUE
TOTAL
TOTAL MATCH REQUIRED PA YMENT
FCR CONTRACT: REQUESTED
THIS MNTH. YTD.
I !\,-' ,U,l J). I ',Ii 1 r~'l, /It ',I
LOCAL CASH MATCH Child ri-~n 8.. F,'lInilit:-.s
LOCAL IN-KIND ~', ~,.,~~
.."JI . '.
TOT.AL DEDUCTIONS "'~l)
..
REMAINING MATCH BALANCE ,.- ". .....
-
SIGNITURE OF PREPARER
APPROVED BY
DATE COMPLETED
TITLE
"IF Th-S N\lC.CE is r=CR A F'YES FR;':E CC~7R;"CT, 7HE REGLEST FeR PA'rNE>fi 'NLl EE CE7ER~/.NEC
BY C.>j,C:'\j.::; -!-E L.ENG":"i-i CF ;;-<E cc~-;-.q,;c-:- 1\-:-0 7!--,E CCN7RAC-E:: "-,IJCl;NT \EX_.S-:2.CCC{AL....C-::AT;,::N: ::,'JI-:es BY
. 2 'v\ONT -5 !-HE lG.':;',- CF ~-:"'E :'::~j-R;'C7)"S; .cee FA'-'MEf'.. T RE-:UESC; C,"4 p (>:S7 F:Elr.....s,...RSE\AEN7 C,>:,"j-:-F;..:T
-i--'E :),t.\I~/ENT RcCc~S~ 1'0:__ ':E -;-.l': V'::-'{:i-L\I GE{:uE'::~ E!:PE~SE
CHILDREN AND FAMILIES USE CNL Y
DATE :NV. RCD.
APPROVED BY:
DATE
jORG
EO
CBJ
CESC.
f"J,1NT
IOCA
KG060
~ If -flt:l.l t)~'f_..)I"~l1l,.."nf ,)1
<:hildrc-n & FL1'n-ilif.....S
..~~,
._-".-- ..;.
.;
--" -'" -~' ~.,
''4i
District Tracking Number (for CRITICAL incidents)
11 (District)
YEAR Sequence Code
Check If CLOSED _
Pro ram Code: AS, DA, DO, 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 D
CONFIDENTIAL
WAR~rNG: The information contained in this report is confidentiaL You are hereby notified that dissemination, distribution, or
copying of this document is strictly prohibited, unless authorized by the Department of Children & Families.
I. IDENTIFYING INFORMATION '.
Reporting Party Phone .rei:
Reporting Party Name
District Program Area:
Specific Program: check all that apply
DAMH DAS DASA DCMH OCSA 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 0 No 0 Don't know.
Specific location/address where incident occurred:
Date of Incident
/ /
Time of Incident
DCF Unit #
II. TYPE OF INCIDENT '
Check one box only.
1. 0 Abuse/Neglect/Exploitation
2. D Aggression/Threat
3. Altercation:
DClient/c1ient DClient/staff 0 Staff/staff
4. D Baker Act
5. 0 Bomb Threat
6. D Client Injury
7. D Client Death
8. D Contraband
9. D Criminal Activity
10. D Damage
11. 0 Drugs
r-""1
12. t-.-.J Elopement/Runaway
13. C Emergency Room Visit
14. U Escape
15. 0 Hospital Admission
16. 0 Illness
17.0 Media Coverage
18. 0 Medication Issue
19. 0 Misconduct
20. 0 Physical Aggression
21. 0 Self-Injurious Behavior
22.0 Sabotage
23. 0 Sexual Battery
24. 0 Suicide Attempt
25. 0 Suicide Ideation/Threat
26. 0 Theft
27. [J Vandalism
28. Li Other Incidents
ss#
Employee Other Participant
a ,
. .
--,
--'
.......J
--,
'---i
.J /
KG060
CONFIDENTIAL
_,_1- 0 0 0 c u C
! 0 0 0 0 0 0
-/-'-
_,_1_ 0 0 [] 0 0 0
IV. DESCRIPTION OF INCIDENT '
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? NOC
YESi~
If yes, specify:
38
KG060
CONFIDENTIAL
VI. INDIVIDUALS NOTIFIED
EXTERNAL NOTIFICATION
Agency Notified Person Contacted Status Date/Time Called Copy
Abuse Registry Name Report Accepted i
1-800-962-2873 0 0
10# Yes 0 NoD I
Agency for Health Care I
Administration Name: N/A I i 0 0 I
Law Enforcement-Department Officer's Name
II ! Badge # Case # (if avail) N/A 0 0
Parent/Guardian/
Family Member Name Name: N/A 0 0
Other P:ease S~ec,ff:
Name: N/A 0 D
Other ,P'ease S~ec,ff,
Name: N/A 0 0
DCF (for providers only) Name: N/A 0 0
VII. REVIEW AND SIGNATURES
NAME SIGNATURE TITLE PHONE # DATE
REPORTING / /
EMPLOYEE ---
SUPERVISOR / /
---
DCF INTERNAL NOTIFICATION
Individual/Agency Notified Date/Time Called Copy Individual/Agency Notified Date/Time Called Copy
Client Relations 0 0 Employee Safety Program 0 0
District Administrator 0 0 Florida Local Advocacy Committee 0 0
Division Director/ HR. Workers' Compensation
Facility Director 0 0 Coordinator .e"'Clcyee f"lated '"c,cer,s :r.'y) 0 0
District Legal Counsel 0 0 Program Office/Risk Manager 0 0
OS Support Coordinator/Case 0 0 Others - (Please specify) ,0 0
Manager I
EEOC Contract Manager iO :0 ,
0 0 i
Public Information Officer I ,0 !D I Missing Children's Unit I 10 I
I I 0 I
VIII. DCF REVIEW AND SIGNATURES '
NAME
SIGNA TURE
TITLE
PHONE # I DATE
!
j _1_1- I
Incident Report
Liaison
I
I Senior Supervisor
I
I
I
I
39
[(G060
.......~....
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ATTAClThfENT 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
In addition to reviews of audits conducted in accordance with OMB Circular A-I33 and Section 215.97,
F.S., as revised, the department may monitor or conduct oversight reviews to evaluate compliance with
contract, management and programmatic requirements. Such monitoring or other oversight procedures
may include, but not be limited to, on-site visits by department staff, limited scope audits as defined by
OMB Circular A- I 33, 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 depaliment's inspector general, the state's Chief Financial Officer or the Auditor
General.
AUDITS
PART I: FEDERAL REQUIREMENTS
This part is applicable if the recipient is a State or local government or a non-profit organization as defined
in OMS Circular A- 133, as revised.
In the event the recipient expends $500.000 or more in Federal awards during its fiscal year, the recipient
must have a single or program-speci fic audit conducted in accordance with the provisions of OMB Circular
A-I 33, as revised. In determining the Federal awards expended during its tiscal year, the recipient shall
consider all SOl/rces of Federal awards, including Federal resources received tl'om the Department of
Children & Families. The determination of amounts of Federal awards expended should be in accordance
with guidelines established by O~1B Circular A-133, as revised. An audit of the recipient conducted by the
Auditor General in accordance with the provisions ofOMB Circular A-133, as revised, will meet the
requirements of this part. In connection with the above audit requirements, the recipient shall fultill the
requirements relative to auditee responsibilities as provided in Subpart C of OMS Circular A- I 33, as
revised.
The schedule of expenditures should disclose the expenditures by contract number for each contract \\ ith
the department in effect during the audit period. The tinancial statements ~hould disclose whether or not
the matching requirement was met for each applicJble contract. Ail questioned costs and liabilities dee the
department shad be tlilly disclosed in the audit report package \\ ith rderel1ce to the specific contract
number.
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PART II: STATE REQl:IRE}lE.\TTS
This part is applicable if the recipient is a nonstate entity as detined by Section :2] 5.97(.2), Florida Statutes.
In the event the recipient expends S500,000 or more in state financial assistance during its tIscal year, the
recipient must have a State single or project-specific audit conducted in accordance vvith Section 215.97,
Florida Statutes; applicable rules of the Department of Financial Services; and Chapters 10,550 (local
governmental entities) or 10.650 (nonprofit cll1d for-protit organizations), Rules of the Auditor General. In
determining the state fInancial assistance expended during its tIscal year, the recipient shall consider all
sources of state financial assistance, including state financial assistance received from the Department of
Children & Families, other state agencies, and other nonstate entities. State financial assistance does not
include Federal direct or pass-through ,mards and resources received by a nonstate entity for Federal
program matching requirements.
In connection with the audit requirements addressed in the preceding paragraph, the recipient shall ensure
that the audit complies with the requirements of Section 215.97(8), Florida Statutes. This inc ludes
submission of a tInancial 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 the audit period. The tInancial statements should disclose \vhdher or not
the matching requirement \vas met for each applicable contract All questioned costs and liabilities due the
department shall be fully disclosed in the audit report package with reference to the specitIc contract
number.
PART III: REPORT SLJBlVlISSION
Any reports, management letters, or other information required to be submitted to the department pursuant
to this agreement shall be submitted within 180 days after the end of the provider's fiscal J ear or within 30
days of the recipient's receipt of the audit report, whichewr occurs first. directly to each of the following
unless athen-vise required by Florida Statutes:
A. Contract manager for this contract (2 copies)
Theresa Phelan
1111 12th Street, ==304
Key West, FL 33040
B. Department of Children & F::llnilies
OffIce of the Inspector GeneraL Provider Audit Lnit
Building 5. Room 237
13] '7 \\inewood Boulevard
T::dlahassee. FL 32399-0",""00
C Copies of tlit: reporting pack3ges for audjts conducted in JCcordance \\ ith o:V18 Cir,:u!ar .-\-133. as
I'c,ised, :.r1Ci rquired by Part [of this Jgreement shall be submitted, ,,\hen required by Section 320Id).
0'v18 Circular A-13:;, JS rev iscd, or on beha! f of the reei [cicl1t directiv to the Federal Audit
Cearinghouse designated in 0\18 Circular A- i 33. as revised ithe nUl;;!cer of I'eq~jired b:.
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Sections .320(d)(1) and (2), OMB Circular A-] 33, as revised, should be submitted to the Federal
Auditing Clearinghouse), at the following address:
Federal Audit Clearinghouse
Bureau of the Census
] 20 I East lOth Street
Jeffersonville, IN <+ 7] 32
and other Federal agencies and pass-through entities in accordance \vith Sections .320(e) and (0,
OMB Circular A-]33, as revised,
D. Copies of reporting packages required by Palt II of this agreement shall be submitted by or on behalf
of the recipient directlv to the following address:
Auditor General's Office
Room 40 I, Pepper Building
III \Vest Madison Street
Tallahassee, Florida 32399-1450
Providers, when submitting audit report packages to the department for audits done in accordance with
o:Ym Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650 (nonprofit or for-profit
organizations), Rules of the Auditor General, should include, v\hen available, correspondence from the
auditor indicating the date the audit repOlt package was delivered to them. \\ 11en such correspondence is
not available, the date that the audit report package vvas delivered by the auditor to the provider must be
indicated in correspondence submitted to the department in accordance with Chapter 10.558(3) or Chapter
10,657(2), Rules of the Auditor General.
PART IV: RECORD RETENTION
The recipient shall retain sufficient records demonstrating its compliance with the terms of this agreement
for a period of six years from the date the audit report is issued and shall allow the depattment or its
designee, Chief Financial Officer or Auditor General access to such records upon request. The recipient
shall ensure that audit working papers are made available to the department or its designee, Chief Financial
Officer or Auditor General upon request for a period of three years from the date the audit repOlt is issued.
unless extended in writing by the depmtment.
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