HomeMy WebLinkAboutResolution 556-1988
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RESOLUTION NO. S16{1988
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A RESOLUTION OF THE BOARD, OF ~UNTY COMMIS-
SIONERS OF MONROE COUNTY, FtORIDA, APPROVING
AND AUTHORIZING THE MAYOR/CHAIRMAN OF THE
BOARD TO EXECUTE A CONTRACT BY AND BETWEEN
MONROE COUNTY, FLORIDA AND THE AREA AGENCY ON
AGING FOR DADE AND MONROE COUNTIES/UNITED WAY
OF DADE COUNTY, CONCERNING MONROE COUNTY IN
HOME SERVICES
BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF
MONROE COUNTY, FLORIDA, that the Mayor/Chairman of the Board is
hereby authorized to execute a contract by and between Monroe
County, Florida and the Area Agency on Aging For Dade and Monroe
Counties/United Way of Dade County, a copy of same being attached
hereto, concerning Monroe County In Home Services.
PASSED AND ADOPTED by the Board of County Commissioners of
Monroe County, Florida, at a regular meeting of said Board held
on the 1st day of November, A.D. 1988.
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
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(Seal)
Attest :...rxrnNY L. EDLHAGE, Clerk
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CONTRACT #:
TITLE:
88-8-887
OAA-III D
GENERAL REVENUE/FEDERAL FUNDS CONTRACT
BETWEEN
AREA AGENCY ON AGING FOR DADE & MONROE COUNTIES/
UNITED WAY OF DADE COUNTY, INC.
AND
THIS CONTRACT is entered into between the AREA AGENCY ON AGING
FOR DADE AND MONROE COUNTIES/UNITED WAY OF DADE COUNTY, hereinafter
referred to as the "Area Agency," and Monroe County Board of
Commissioners, hereinafter referred to as the "Provider".
The Parties agree:
I. The Provider agrees:
A. To provide services according to the conditions specified
in Attachment I.
B. Federal and State Laws and Regulations
1. If this contract contains Federal funds, the
Provider shall comply with the provisions of 45 CFR,
Part 74, and other applicable regulations if speci-
fied in Attachment I.
2. If this contract contains Federal funds and is over
$100,000, the Provider shall comply with all
applicable standards, orders, or regulations issued
pursuant to the Clean Air Act as amended (42 USC
1857 et seg.) and t~e Water Pollution Control ~ct as
amended (33 USC 1368 et seq.).
3. The provider agrees to complete the Civil Rights
Compliance Questionnaire, HRS Forms 946 A and B, if
so requested by the Area Agency.
C. Audits and Records
1. To maintain books, records and documents in
accordance with accounting procedures and practices
whicn sufficiently and properly reflect all
expenditures of funds provided by the Area Agency
under this contract.
2. To assure that these records shall be subject at all
times to inspection, review, or audit by Area Agency
state personnel and other personnel duly authorized
by the Area Agency, as well as by Federal personnel.
3. To maintain and file with the Area Agency such
progress, fiscal, inventory and other reports as the
Area Agency may require within the period of this
contract.
4. To include these aforementioned audit and record-
keeping requirements in all approved subcontracts
and assignments.
5. To allow public access to all documents, papers,
letters or other material subject to the provisions
of Chapter 119, F.S., and made or received by the
Provider in conjunction with this contract. It is
expressly understood that substantial evidence of
the Provider's refusal to comply with this provision
shall constitute a breach of contract.
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D. Retention of Records
1. To retain all financial records, supporting
documents, statistical records, and any other
documents pertinent to this contract for a period of
five (5) years after termination of this contract,
or if an audit has been initiated and audit findings
have not been resolved at the end of five (5) years,
the records shall be retained until resolution of the
audit findings.
2. Persons duly authorized by the Area Agency and
Federal auditors, pursuant to 45 CFR, Part 74.24
(a), (b), and (d) shall have full access to, and the
right to examine any of said records and documents
during said retention period.
E. Monitorinq
1. To provide progress reports, including data
reporting requirements as specified in Attachment I.
These reports will be used for monitoring progress
or performance to determine conformity with intended
program services as specified in Attachment I.
2. To provide access to, or to furnish whatever
information is necessary to effect this monitoring.
3. To permit the Area Agency to monitor the afore-
mentioned service ~rogram operated by the Prov~der
or subcontractor or assignee according to applicable
regulations of the state and Federal governments.
Said monitoring will include access to all client
records.
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F. Indemnification
The Provider shall be liable, and agrees to be liable
for, and shall indemnify, defend, and hold the Area
Agency harmless from all claims, suits, judgements or
damages, including court costs and attorneys fees,
arising out of negligence or omissions by the Provider in
the course of the operation of this contract.
G. Insurance
The responsibility for providing adequate liability
insurance coverage on a comprehensive basis shall be that
of the Provider and shall be provided at all times
during the existence of this contract. Upon the
execution of this contract, the Provider shall furnish
the Area Agency with written verification of the
existence of such insurance coverage.
H. Safeauardina Information
The Provider shall not use or disclose any information
concerning a recipient of services under this contract
for any purpose not in conformity with the State
Regulations and Federal regulations (45 CFR, Part
205.50), except upon written consent of the recipient, or
his responsible parent or guardian when authorized by
law.
I. Client Information
The Provider shall submit to the Area Agency management
and program data, including client identifiable data, as
specified by the Area Agency in Attachment I for
inclusion in the HRS Client Information System.
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J. Assiqnments and Subcontracts
The Provider shall neither assign the responsibility of
this contract to another party nor subcontract for any of
the work contemplated under this contract without prior
written approval of the Area Agency. No such approval by
the Area Agency of any assignment or subcontract shall be
deemed in any event or in any manner to provide for the
incurrence of any obligation of the Area Agency in
addition to the total dollar amount agreed upon in this
contract. All such assignments or subcontracts shall be
subject to the conditions of this contract (except
Section I, Paragraph 0) and to any conditions of approval
that the Area Agency shall deem necessary.
K. Financial Reports
To provide financial reports to the Area Agency as
specified in Attachment I.
L. Return of Funds
The provider agrees to return to the Area Agency any
overpayments due to unearned funds or funds disallowed
pursuant to the terms of this contract that were
disbursed to the provider by the Area Agency. Such funds
shall be considered Area Agency funds and shall be
refunded to the Area Agency. The refund shall be due
within 30 days following the end of the contract or at
the time the overpayment is discovered unless otherwise
authorized by the Area Agency in writing and attached to
this contract.
.
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M. Unusual Incident Reoorting
If services to clients will be provided under this
contract, the provider and any subcontractors shall
report to the Area Agency unusual incidents in a manner
prescribed in HRSR-0-10-1.
N. Transoortation Disadvantaqed
If clients will be transported under this contract, the
provider will subcontract with the designated Community
Coordinated Transportation Provider, in accordance with
the local Memorandum of Agreement, or otherwise comply
with the provisions of Chapter 427, Florida Statutes.
The provider shall submit to the Area Agency the reports
required pursuant to Volume 10, HRS Accounting Procedures
Manual.
O. Purchasinq
It is expressly understood and agreed that any articles
which are the subject of, or required to carry out this
contract shall be purchased 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 Section 946.15(2),
(4), F.S.; and for purposes of this contract the person,
firm, or other business 'entity carrying out the provi-
sions of this contract shall be deemed to be substituted
for this agency insofar as dealings with PRIDE. This
clause is not applicable to any subcontractors, unless
otherwise required by law.
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P. Civil Riqhts Certification
The provider gives this assurance in consideration of and
for the purpose of obtaining Federal grants, loans,
contracts (except contracts of insurance or guaranty),
property, discounts, or other Federal financial
assistance to programs or activities receiving or
benefiting from Federal financial assistance.
The provider assures that it will comply with:
1. Title VI of the Civil Rights Act of 1964, as
amended, 42 U.S.C. 2000d et seq., which prohibits
discrimination on the basis of race, color, or national
origin in programs and activities receiving or benefiting
from Federal financial assistance.
2. Section 504 of the Rehabilitation Act or 1973, as
amended, 29 U.S.C. 794, which prohibits discrimination on
the basis of handicap in programs and activities receiv-
ing or benefiting from Federal financial assistance.
3. Title IX of the Education Amendments of 1972, as
amended, 20 U.S.C. 1681 et seq., which prohibits
discrimination on the basis of sex in education programs
and activities receiving or benefiting from Federal
financial assistance.
4. The Age Discrimination Act of 1975, as amended, 42
U.S.C. 6101 et seq., which prohibits discrimination on
the basis of age in programs or activities receiving or
benefiting from Federal financial assistance.
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5. The Omnibus Budget Reconciliation Act of 1981, P.L.
97.35, which prohibits discrimination on the basis of sex
and religion in programs and activities receiving or
benefiting from Federal financial assistance.
6. All regulations, guidelines, and standards lawfully
adopted under the above statutes.
The provider agrees that compliance with this assurance
constitutes a condition of continued receipt of or
benefit from Federal financial assistance, and that it is
binding upon the provider, its successors, transferees,
and assignees for the period during which such assistance
is provided. The provider further assures that
all contractors, subcontractors, subgrantees or others
with whom it arranges to provide services or benefits to
participants or employees in connection with any of its
programs and activities are not discriminating against
those participants or employees in violation of the above
statutes, regulations; guidelines, and standards. In the
event of failure to comply, the provider understands that
the Grantor may, at its discretion, seek a court order
requiring compliance with the terms of this assurance or
seek other appropriate judicial or administrative relief,
to include assistance being terminated and further
assistance being denied.
II. The Area AgencY Aqrees:
To pay for contracted services according to the conditions of
Attachment I in an amount not to exceed $ 15,000
, subject to the availability of funds.
The Area Agency and the state of Florida's performance and
obligation to pay under this contract is contingent upon an
annual appropriation by the Legislature.
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III. The Provider and Area Aqencv Mutuallv Aqree:
A. Effective Date
1. This contract shall begin on October 1, 1988 or
on the date on which the contract has been signed by both
parties, whichever is later.
2.
This contract shall end on
December 31, 1988
B. Termination
1. Termination at Will
This contract may be terminated by either party upon
no less than thirty (30) days notice, without cause.
Said notice shall be delivered by certified mail,
return receipt requested, or in person with proof of
delivery.
2. Termination Because of Lack of Funds
In the event funds to finance this contract become
unavailable, the Area Agency may terminate the
contract upon no less than twenty-four (24) hours
notice in writing to the Provider. Said notice
shall be delivered by certified mail, return receipt
requested, or in person with proof of delivery. The
Area Agency shall be the final authority as to the
availability of funds.
3. Termination for Breach
Unless the Provider's breach is waived by the Area
Agency in writing, the Area Agency may, by written
notice to Provider, terminate this contract upon no
less than twenty-four (24) hours notice. Said
notice shall be delivered by certified mail, return
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receipt requested, or in person with proof of
delivery. If applicable, the Area Agency may employ
the default provisions in Chapter 13A-1, 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 of this
contract. The provisions herein do not limit the
Area Agency's right to remedies at law or to
damages.
C. Notice and Contact
The name and address of" the Contract Manager for the Area
Agency for this contract is:
Glenn MCKibbin, Director
600 Brickell Avenue, 3rd Floor
Miami, Florida 33131
The representative of the Provider responsible for the
administration of the program under this contract is
T.olli s T.:ITorre In the event that different represen-
tatives are designated by either party after execution of
this contract, notice of the name and address of the new
representative will be rendered in writing to the other
party and said notification attached to the originals of
this contract.
D. Renegotiation or Modification
1. Modification of provisions of this contract shall
only be valid when they have been reduced to writing
and duly signed. The parties agree to renegotiate
this contract if Federal and/or State revisions of
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any applicable laws, or regulations, or
increases/decreases in budget allocations makes
changes in this contract necessary.
2. If this contract contains a fixed-price method of
payment section, and the rate of payment is
determined through the appropriations process, then
this contract may be amended to reflect the new rate
established through the appropriations process
retroactive to the effective date of this contract.
3. If the contract contains either a cost-reimbursement
or a fixed-price method of payment, the rate of
payment and the total dollar amount may be adjusted
prospectively to reflect price-level increases
determined through the appropriations process and
subsequently identified in the department's
operating budget.
E. Name and Address of Payee
The name and address of the official payee to whom the
payment shall be made:
Monroe County Board of Commissioners
1315 Whitehead street
Key West, Florida 33041
F. All Terms and Conditions Included
This contract and its attachments as referenced:
Attachment I:
Conditions
Grant Application Package
Operating Procedures, Unusual
Incidents
Interim Guidelines for Title III
D
Contain all the terms and conditions agreed upon by the
parties.
Attachment II:
Attachment III:
Attachment IV:
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IN WITNESS THEREOF, the parties hereto have caused this 21
page contract to be executed by their undersigned officials as duly
authorized.
AREA AGENCY ON AGING FOR
PROVIDER
DADE AND MONROE COUNTIES/
UNITED WAY OF DADE COUNTY
Signature:
Signature:
Name:
Name:
(Please Print)
(Please Print)
Title:
Title:
Date:
Date:
Federal ID NUmber:
APPROVED AS TO ror-u
AND LEGAL Sf'-T',f"
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AGING AND ADULT SERVICES
OLDER AMERICANS ACT
TITLE III
ATTACHMENT I
A. Services to be Rendered
1. The attached Apolication for Title III Funds, (Attachment
II), and any revisions thereto approved by the Area
Agency, by physical attachment to this contract, is a
part of this legal agreement and prescribes the services
to be rendered by the Provider.
B. Manner of Service Provision:
1. The services will be provided in a manner consistent with
and as described in the Ap9lication For Title III Funds
(Attachment II) and HRSM 140-1.
C. Method of PaYment:
1. Payment shall be on an advance and reimbursement basis in
accordance with HRSM Manual 55-1, appendix B: All
requests for payments will be made using HRS Form 578 _
Request for Payment - Refund Notice. Expenditure reports
will be submitted to support requests for payment, using
HRS From 577 - Report on Receipts and Expenditures.
Replication of both the ~RS Form 577 and HRS Form 578 vis
data processing equipment is permissible: replications
must include all data elements included on HRS forms.
2. The provider may request a monthly advance for each of
the first two months of the contract period, based on
anticipated cash needs. All reimbursement requests for
the third through the twelfth months shall be based on
the submission of monthly actual expenditure reports
3. The Provider may request extraordinary cash in addition
to the above advance requests in accordance with the
projected advance payment and reimbursement schedule
contained in the Grant Application package or as
otherwise necessary when approved by the Area Agency.
The term "extraordinary cash" used here means cash needs
resulting from payables due within a given month for
items generally paid on a one-time; non-recurring basis
during the contract period. Reimbursement payments for
succeeding months will be reduced by the amount of
extraordinary cash expended; in accordance with HRSM
55-1, paragraph 5-12.
4. All interest earned on the advance of federal funds may
be retained by the Provider for the purpose of expanding
service provision in accordance with HRSM 55-1, paragraph
4-15.
5. Any payment due under the terms of this contract may be
withheld pending the receipt and approval by the Area
Agency of all financial reports due from the Provider and
any adjustments thereto.
6. The Provider must submit the final request for payment to
the Area Agency no more than forty-five (45) days after
the contract ends or is terminated; and if the Provider
fails to do so, all rights to payment are forfeited and
the Area Agency will not honor any request submitted
after the aforesaid agreed-upon period.
7. The expenditure reports for the final two months of the
contract shall be submitted by the Provider no more than
five days after the end of the contract.
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8. All monies which have been paid to the Provider which
have not been used to retire outstanding obligations of
the contract being closed out must be refunded to the
Area Agency along with the closeout package which is due
forty-five (45) days after the contract ending date.
9. The Provider agrees to implement the Ao~lication for
Title III Fundinq (Attachment II), according to the
distribution of funds as detailed in the Application for
Title III Funding Budget Summary.
D. Non-Exoendable prooerty:
1. Non-expendable property is equipment, fixtures, and other
tangible personal property of a non-consumable nature,
the value of which is $200 or more, and the normal
operational life of which is one year or more.
Non-expendable property also includes hard-back covered
books, the value or cost of which is $25 or more.
2. Prior written approval is required for the purchase of
any item of non-expendable property not included in the
approved grant application package.
3. All such property shall be listed on the property record
by description, manufacturer's model number, serial
numbers, date of acquisition and unit cost, property
inventory number and information on the condition,
transfer, replacement or disposition of the property.
Such property shall be inventoried annually, and an
inventory report shall be submitted to the Area Agency
annually with updates as property is obtained.
4. Disposition of non-expendable property and unused
supplies for currently funded and/or terminated Service
Providers will be in accordance with HRSM 55-1.
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E. Travel:
1. Section 287.058 (1) (b), F.S., requires that invoices for
any travel expenses should be retained on file in an
auditable format and paid in accordance with the rates
specified in Section S.112.061, governing payments by the
state for travel expenses and HRSM 40-1 (Official Travel
of HRS Employees and Non-Employees).
2. Receipts for car rental and air transportation are
required documents to be retained on file to support
payment. Other incidental expenses that require support
documents to be retained on file by the Provider are
identified in HRSM 40-1.
3. The Provider must retain on file in an auditable format
documentation of all travel expenses to include the
fOllowing data elements: name of traveler, dates of
travel, travel destination, purpose of travel, hours of
departure and return, per diem or meals allowance, map
mileage claimed, vicinity mileage, incidental expenses,
signature of payee and payee's supervisor.
4. The Provider may consolidate the travel expense claims
for each individual to include travel for a specific
period of time. Consolidated reports must be supported
by a travel log which details each trip for which travel
expense is claimed.
F. Financial ReDorts
The Provider agrees to provide an accurate, complete and
current disclosure of the financial results of this contract
as follows:
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1. To submit all requests for payment and expenditure
reports according to the format, schedule and
requirements specified in HRSM 55-1.
2. To submit a contract closeout report to the Area Agency
as specified in HRSM 55-1.
3. A complete and accurate HRS Form 2006, Service Cost
Report must be submitted to the Area Agency on a
quarterly basis. These reports must be submitted by the
Provider no later than the tenth day of the month follow-
ing each quarter and should be cumulative from the
beginning of the contract period to the end of the last
quarter.
G. Financial and ComDliance AUdits:
1. The Provider will have an annual financial and compliance
audit covering its entire organization for its fiscal
year performed by an independent auditor for the fiscal
year ending after September 30, 1986 and annually
thereafter.
2. The annual financial and compliance audits will be in
accordance with Standards for Audits of Governmental
Orqanizations. Proqram. Activities and Functions by the
Comptroller General of the United States, February 27,
1981. The scope of Audits performed will include only
financial and compliance. Compliance findings related to
contracts with Area Agency shall be based on the contract
requirements including any rules, regulations, or
statutes referenced in the contract.
3. Local government providers will comply with the Office of
Management and Budget CirCUlar A-128, "Audits of State
and Local Governments" dated April 15, 1985.
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4. Nonprofit providers will comply with the Office of
Management and Budget Circular A-110, "Grants and
Agreements with Institutions of Higher Education,
Hospitals and Other Nonprofit Organizations".
5. All provider audits (Local Government and Non-Profit)
will comply with OMB Circular A-128 sections 5.f.,
6,7,8,12,13,14 and 15.
6. Audit work papers and reports will be retained for a
minimum of five years from the date of the audit, report,
unless the provider is notified in writing by the Area
Agency to extend the retention period. Audit workpapers
will be made available upon request to the Area Agency or
its designee.
7. One copy of the audit report must be submitted to the
Office of Audit and Quality Control Services, Building 3,
Room 219, 1317 Winewood Boulevard, Tallahassee, Florida
32399-0700.
8. Seven copies to the Area Agency within 100 days after the
end of the provider's fiscal year unless otherwise
required by Florida statutes. If a management letter or
any other reports or correspondence relating to the audit
findings or recommendations are issued in connection with
the audit, copies must accompany the audit report.
H. Subcontracts:
Area Agency approval of the application for Title III funding
shall not constitute Area Agency approval of the Provider
subcontracts. The Provider must submit all contracts for
services under the application to the Area Agency for prior
approval when the proposed subcontractor is a profit making
organization.
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I. Monitoring:
The Provider agrees to comply with the monitoring requirements
of the state and the Area Agency in accordance with Chapter 7,
HRSM 55-1 and Chapter 12, HRSM 140-1.
J. Special provisions:
1. The following clause supersedes Section III-B-1:
Termination At Will:
This contract may be terminated by either party upon no
less than thirty (30) days notice pursuant to 45 CFR Part
74; and shall be delivered by certified mail, return
receipt requested, or in person with proof of delivery.
2. The Provider and the Area Agency agree to perform the
service of this contract in accordance with all Federal,
State, and local laws, rules, regulations and policies
that pertain to Older Americans Act Funds.
3. The Provider assures that it will not assess nor collect
fees from eligible clients within the Title III, Older
Americans Act Program without prior written approval of
the Area Agency.
4. Federal fiscal year funding provided in this contract is
subject to substitution by prior year's carryforward
funds in accordance with procedures identified in Section
4-16, HRSM 55-1. The Area Agency has the authority to
re-award to any Provider current year funds deobligated
by this process. This provision excludes Senior Center
Carryforward Funds.
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5. The Provider will assure through contract provision that
HRS Client Information System Data is recorded and
submitted to the Department in accordance with HRSP
50-10.
6. Coovriqhts and Right to Data:
Where activities supported by this project produce
original writing, sound recordings, pictorial
reproductions, drawings or other graphic representation
and works of any similar nature, the Area Agency has the
right to use, duplicate and disclose such materials in
whole or in part, in any manner, for any purpose
whatsoever and to have others acting on behalf of the
Area Agency to do so. If the material is copyrightable,
the provider may copyright such material, with approval
of the Area Agency, but the Area Agency will reserve a
royalty-free, non-exclusive and irrevocable license to
reproduce, pUblish, and use such materials, in whole or
in part, and to authorize others acting on behalf of the
Area Agency to do so.
7. Bonding:
The provider agrees to furnish a bond from a responsible
commercial insurance company covering all officers,
employees and agents of the provider authorized to handle
funds received or disbursed under this contract in an
amount commensurate with the funds handled, the degree of
risk as determined by the insurance company and
consistent with good business practice.
8. Sponsorship:
The Provider assure that all notices, informational
pamphlets, press releases, advertisements, descriptions
of the sponsorship of the program, research reports, and
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similar public notices prepared and released by the
Provider, shall include the statement: "Sponsored by the
Department of Health and Rehabilitative Services and the
State of Florida". If the sponsorship reference is in
written material, the words, "State of Florida" shall
appear in the same size letters or type as the name of
the organization.
K. Conditions of Award:
1. No later than fifteen (15) days before the effective date
of this contract, the Provider will submit a final,
revised and acceptable application for Title III funding
with any changes found to be necessary for final approval
by the Area Agency.
2. The Provider's contract amount may be revised pending any
changes as a result of Area Agency appeal process.
Upon receipt of any formal written Protest which has been
timely filed, the Area Agency promptly will notify in
writing any other agency or organization that in the
judgement of the Area Agency Contract Manager might be
affected by the protest and furnish copies of all
protesting documentation.
If in the sole determination of the Area Agency, a
disputed contract award may result in the interruption of
services to elderly clients, the Area Agency reserves the
right to contract with a Provider of choice on an interim
basis to maintain the delivery of services until the
protest is resolved.
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SERn~ l:'r:a':rCER stJ~_a.F.Y INFORMl~'!'ICN
~ontract ~~endnent ;
PSA/!)istrict
'(I
Date of ~~is application: 8/88
( ) Revision, Dated:
2. NAME AUD ADDR1::SS OF THE FRES:::DE:iT"-,
(CHAIRMAN) OF THE EOARD OF DIREC'I'DRS: I
of County Commissioners Eugene R Lytton Sr
1. PROVIDER AGENCY NAME, STREET ADDRESS
AND FHONE:
I M County Board
onroe . , .
Monroe County In Home Services Mayor
1315 Whitehead Street 3180 Overseas Highway/Bay Point
Key West, Fl. 33040 Key West, Fl. 33040
305/294-8468 NAME OF GRANTEE AGENCY:
MonroeCounty Board of County Commissioners
3. PROVIDER NUMBER (IF ASSIGNED) : 4. PROPOSED PERIOD OF FUND!NG:
5. ~~VrueR STAFF RESOURCES: I 6. EXECUTI'/E DIRECTOR OF PROVIDER~
I Name: Louis LaTorre
C1I ~ Business (Mailing) Address:
-UNPAID STAFF PAID STAFF e
.,..j ~ .,..j~ 1315 Whitehead Street
f-<~ f-<~
SCSEP (OM TITLE V) res res Key West, Fl. 33040
....~ ~~
Positions Assigned: 31 ....CI) l.4C1)
=' re
r..- eo
2 TOTAL 25 6
Total Budgeted Aqe 60+ ') 5 Business Phone: 305/294-8468
Volunteer Hours: Female lQ 4 Emergency Contact Phone:
Minority 7 0 305-296-7171
1694 Handicapped 2 0
7. TYPE OF ORGANIZATION: 8. APPLICATION DATA: 9. FUNDS REQUESTED: TOTAL
(Check one) (Check one) BUDGET:
( x) Public Agency ( ) New Applicant OM Title IIIB $ $
( ) Private, Non-Profit, ( ) Continuation Ti tla IIIC-l $ $
Charitable ( ) Revision to Title IIIC-2 $ $
( ) Private for Profit Application Title IIIJ;> $ 1 " I nnn nnSl . L U
Dated: Other $ S
10. SERVICES TO BE PROVIDED: 11. SERVICE AREA: 00 Single County
.... \"II ( ) MUlti-County Specify:
I ,
= u U Q List: MONROE
.... .... .... ....
.... .... .... ....
.... lot lot .... ( ) Selected Communities
Homemaking A of a County. Specify:
12. IDENTIFICATION OF AGENCY OFFICIAL
AUTHORIZED TO SIGN APPLICATION:
(Signature)
Name: Eugene R. Lytton, Sr.
Title: MAYOR
Address:
3180 Overseas HIghway/Bay Point
Key West, Fl. 33040
Phone: 305-294-4641
Date Siqned:
13. ADDRESS FOR PAY!'.ENT CHECKS: (Check cna)
on Item U. ( ) Item '6.
C ) Item 12. ( ) Item 112.
",'!.'
-63-
...._~:
MONROE COUNTY IN-HOME SERVICES
DISTRICT XI - TITLE III-D
NARRATIVE
Monroe County In-Home services is the sole provider of Community Care for the
Elderly Program (CCE), in Monroe County. We offer services of Case Management,
Chore. Homemaking, Personal Care and Respite services for the elderly throughout
the entire length of the County. In addition to these services, we also offer
services of Case Management. Homemaking. Personal Care, Respite and Home Delivered
Meals for the eligible disabled adults in our County, through funding of the
Community Care for Disabled Adults Program (CCDA).
Our Community Care for the Elderly Program is funded through the District
XI Area Agency on Aging of Dade and Monroe Counties from CCE Grant Funds.
Matching funds for this Program is provided by the Monroe County Board of County
Commissioners. Monroe County In-Home Services is a division of the County Social
Service Department. Three area offices are located throughout Monroe County ~n
the Upper, Middle and Lower Keys area. Monroe County consists of a string of
islands connected by one overseas highway approximately 130 miles long and in
most areas 2 miles wide. There are approximately 17,000 residents in our County
over the age of 60 years, approximately 40% are below poverty level in income,
additionally minority groups make up approximately 12% of the elderly population.
Currently our CCE Program estimates to serve 585 frail elderly residents in this
current CCE fiscal year. Of this number 62% are over the age of 75 and 45% in this
category are severely impaired.
This request for Title III-D funding is specifically for Homemaking services
for the frail older individuals of our County who have been targeted by our Case
Management Staff as meeting all criteria of the Program and who inherently require
more frequent services to maintain independent living. We are proposing at this
time to provide 1 Homemaker in each area (a total of 3) to provide this specific
service. No funds are requested for administrative costs as the amount to be
allocated would not be sufficient to render substantial services if included.
We will however through our CCE Program provide Case Management and all other
required services to properly maintain these individuals with a complete
Community Support System. The Homemaking service under Title III-D will insure
that these targeted eligible frail older individuals will have adequate support
to live independently.
'~~~~-"r
Monroe County In-Home Services continues to provide and coordinate services
to our elderly residents through information and referral to other available
resource agencies within our County to insure a continuum of services to meet
the individuals needs. Some of these provider agencies are as follows:
Monroe County Social Services for:
Welfare Assistance
Emergency Food Orders
Rent Assistance
Clothing, personal care items
Prescription drugs, medical supplies, physical services
Out-patient - In-patient services
Prosthetic devices
County Nursing Home services, medicaid hospital and nursing home
care and pauper burials for the eligible elderly, indigent and
disabled residents.
Transportation Program
For elderly and disadvantaged
Bayshore Manor - an ACLF for the elderly
Senior Community Service Employment Project - employs 40 - 50 senior citizens
who are on limited income.
Nutrition Program - provides nutritionally balanced hot meals 5 days per
week at 5 congregrate sites and home delivered meals to homebound
elderly.
Monroe County Health Department
TB
Dental Care
Primary Health Care
Library Services
Audio Cassettes
Large Print Books
Library services through Bureau of Blind
Senior Centers
Four established centers located throughout entire
County for peer socialization and support.
. .:~'?~~
I
,i
In addition to the above there are four hospitals and three nursing homes
within the County. One nursing home will be dedicating a wing specifically for
alzheimers patients.
Overall, with our services and those Agencies mentioned Monroe County has
the resources to provide a well balanced Community Care System for the elderly.
GWEN RODRIGUEZ, PROJECT DIRECTOR
MONROE COUNTY IN HOME SERVICES
1315 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TELEPHONE 294-8468
r
'1
(FS)
$T1.1'ul.:::t."'l' or C~EC':'lVE
PC~/DISTRICT Xl
/ 'Z'I'l'LE III B
) TITLE III C-l
( ) TIT~ III C-2 ( ) OTHER (SPECI7Y):
s'rATDlF.~.'I' OF O~EC'rIYE (WHAT service will be done,who will do it, who will race1.ve th~
service.) Monroe County In Home Services proposes to provide Homemaker Services by
hiring three (3) full time Homemakers (one in each area office) to provide
said service to approximate~y 75 unduplicated frail elderly clients with
1462 units of service.
Provider Name: Monroe County In Home Services ( ..,
Original, ,../
D.ted ( fi(
Re,. i.u iQll,
Dated
(~ TITLE II~ 0
l )
DESCRIPTION OF SERVICE ESSENTIALS:
~: Beginning approximately 9/15/88 through 12/31/88, services will be
rendered Monday through Fridays, excluding legal holidays, from
8:30 A.M. until 5:00 P.M.
t.~RE: :
Services will be provided from the three area offices by staff in
the respective homes of the frail elderly clients.
HOW:
-
\ ~"HY :
I -
I
,
Under the superV1S1on of the case management staff, Homemakers will
be trained and assigned to respective targeted frail elderly in the
areas~ for the specific performance of light housekeeping, laundry
and personal shopping for groceries etc.
The purpose of this said service will be to assist the frail elderly residents
of Monroe County with Homemaking services which will prevent or delay pre-
mature institutionalization and allow independent living.
MlWOR WORK TASKS TO ACHIEVE OBJECTIVE:
ESTIMATED DATE
O~ COMPLETION:
TASK Recruit, hire and provide pre-service and in-service training
to three Direct Service Homemakers.
9/23/88
TASK
Target frail elderly eligible clients and schedule for
service to begin.
9/23/88
TASK
Provide CPR and First Aid training for Homemakers
10/15/88
TASK
L
ATTACH CO~rrlNUATION SHEETS AS NEEDED.
-67-
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Contract 1I,.'':lend~
?SA/Dist.rict-AJ
ESTIMATED PROGRAM OUTPU'f
(x) Ori:rinal
Da ted 8/88
( ) Kevision
Dated.
Title III D: In-Home Services for Frail Older Individuals
Provider Name:
Title III D
Services
: COUNTY: MONROE I Count y: : COUNTY:
IUndupli-~ Units IUndupli-: Units IUndupli-: Units
I cated : of l cated : of I cated : of I
lpersons :ServicelPersons :Servicelpersons :Servicel
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TITLE III D
I PSA/D13t:'ict XI
BUDGET EXPtANATICN ~OnK:HEET
\
Homemaker
I 10/1/88
I Homemaker
I 10/1/88
I Homemaker
I 10/1/88
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Sub Total - Salarie~/Waqes
PE?SONNEL: Fringe a~nefits
Su~ Total - Frinqe Benefits
.,..
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P~OVICER ___MONROE COUNTY IN HOME SERVICES
TITLE I II- D I Provider I 'CCE I
Ccst Category 'Admin. 'SERVICE: I Amount ,
'Explanation/Justification " 'Homemaker' I
I-----------------~-------------------------I --------, --------1 ----____1
'2. TRAVEr.: In Area ::J"._,
I IS _'$ _'S 1$
, 3 Homemakers @350 mi/mo, for 3.5 mos. I I I I
I @20~ mL I _0,00', 735.0~1 __I
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XI
aUCGET EXPLANATIO~ WORKSHEET
BUCGETEO CAS~ COSTS \
1989 .
- ..; Oaq.. 2,;('.,
CCDA--'~ra~d ..
AlllOunt 70tal ,
Ca",h t
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TRAVEL: In State, Out of Area
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I
P~A/Distr1ct XI
BUCGE! EXPLANAT!ON WOR~SHEE!
PART 1 - BUO~ETED
PNOVIO~? MONROE COUNTY IN HOME SERVICES _ '"-_
I TITLE III D I CCD
i Cost Category I PROVIDER: I SERVICE:, CCE A
I Explanation/Justification I ADM. ~OMEMAKER I Amount ,Amount
1- - ----- - -- - ------- --------- ----- -- --~ I ----- ---- I _ -- -- -- _ _I _ __ __ __ --I _ _.. ______
iJ. BUILDING S?ACE ': I I
1 _I~--'$_---:r ~
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1 I _________1 _________ ________, _________
I sua !OTAL - BUILDING SPACE'S 0,00 13 0.00 S P
J ! ========= I ========= ========= =========
14. COMMUNICATIONS & U!ILrTIES I I
I Communications 1 I
, 19 0.00 1$
1 I I
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t SUB TO'l'AL - COf1t!MlSNICATIONS & _ ,:$ 0.00 1$
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IS. PRINTING & SUPPLIES I 1
1 Prlntlng I I
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,
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, Miscellaneous cleaning supplies r 9 '$ '-It~.).r? ,s
$JI - I I r5e.88j
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I ---------1 ---______ _________ _________
I __~~~_:OTAL- PRINTING/SU?fLIES IS 0.00 i 3 __.rJ::~ 3
t--_____=================:===========I ========:1 ____=~=== ========= ~========
0.00 T
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CASH COSTS "
1989
Page 3c'l_>~~
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I Cash 1
1 -------__j
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(F31)
PSA/District
XI
BUDGET EXPLfu~ATION WORKSHEET
PART I
- BUD~E7ED CASn ccsrs
1969 "
_-....1_aSl.Jt 4 f > ~
CC;)A ! Gt"and i
Amount :o'=~l I
C .1.ih !
------.-: ---------1
rROVIOER MONROE COUNTY IN HOME
, TITLE III D
I Cost Category
, Expla~ation/Justificat1on
,-------------------------------------
16. EQUIPMENT - ?urc~ases
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, sua TOTAL - EQUIPMENT
/
17. MEALS/FOOD
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IS. SERVICE SUB CONTRACTs
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/9. OTHER
I General Liability Insurance
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SERVICES
I
IPROV}DER: 'SERVICE:
I ADM. I HOMEMAKER'
: -- - -- --__ ,1-_---------,
II, CCE I
Amount I
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f ---:-, I I ; ---
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II $ 0.00, J 0.00 !I $ I $ IS I
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1 =========1: =========1 ========1 ========1 ===="-:==:1
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0,00 I ,$ 200.00 IS! oS IS
0.00 I 33.361
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sua IOTAL- SERVICE SUB CONTRACTS
Error3 and Omissions
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1 = = = = = " = = '" = :: = = = = = = = = =:: = = = = = = = = = :: = = = = = = "i I = = = = =0=.=0,,0: ;! ::: ~ = = = = :: = = : = = : -= : .: " = -: :: : = :: :: I : ~ , :: = .. :: = = !
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----..-
)
ATTACHMENT .III
UNUSUAL INCIDENTS
..
Contractors and their subcontract agencies
shall report, to the Area Agency, unusual
incidents.
BRSR 0-10-1
OPERATING PROCEDURE
No. 0-10-1
S=ATE OF FLORIDA .
DEPARTMENT OF BEAI.TH AND
P~HABILI'l'ATIVE SSRVICES
DISTRICT 11
M::AMI, January 1, 1986'
ADMINISTRATION
INCIDENT REPORTING AND FOLLOW-UP
1. Pu~o.e. This regulation establishes procedures and guide-
lines . or incident reporting CIR). Iz:lcident reporting is a
system.created to provide department management with early notice
of incidents involving department clients, employees, property or
residents of facilities licensed or regulated by it that may
place the depertment at risk, require the direct intervention of
senior-level management, generate public reaction or media
coverage · Data collected will be used to identify ihe~errt
patterns, trends and locations for manag~nt use in preventing
future incidents, identifying problems areas and imprOVing
services.
2.
.-
Scope.
. a;. . This regulation applies to incidents oc~urr"ing in all
facilities and programa operated, funded, licensed or regulated
by the. department.. This includes. district. . and . he.dqu~ters
offic.., county public health units~ institutions, residential
· facili ties, child and adul t ctay CAre centers, CODllDUDi ty mental
health. facilities, mental retardation (ICP/MR) ~ncilities, non-
residential t"ODIIIluni ty programa, foster care, .hel ter , group and
nursing hm.s, adult cong:egate llviDg f.acilities .(ACLF),., devel-
opmental services cluaters, and other programa or facilities,
lic;eDsed, regulated, unc1l1r' contract or funded by BU.. .
b. IncideDta involving. Aid to Families with Dependent
Chi.ldr8D (AJ'I)C), Supplemental Security Income (SSI), Medicaid,
Vocaticma1. Jtehabili tation or Pood Stamp. clients are not to be
reportecl JmJ,... they occur at II department operated, licenaec1,
re9Ul.'t~ funded., or cODtract facility or institution or involve
a progr_ dizectly supervised by the department.
c. It .1. the responSibility of all departmental personnel
to Promptly report all incidents in accordanc~ with the require-
men~8 of 1:hi. policy..
.s Opera~i.ng
0.-1,
,
~.
.....
. ~'.-I
j
< r
January 1, 1986
OP 0-lC-1
f. Alleqations of abuse/neq1ect/exploitation must be
reported immediately to the abuse registry and the dis~rict
advocacy committees and councils regardless of their status as an
incident. Policies and procedures governinq reporting of abuse/-
neglect/exploitation are contained in program specific policies
and manuals.
.
L Definition of Terms
,...
a. Incident. An occurrence involving department clients,
. employees, property or facilities licensed or regulated by HRS
that may place the department at risk, or which require the
direct intervention of senior-level management, which generate
public reaction or media coverage. An incident may involve
circumstances that require further investigation or action by
officials in or outside the depart1nent. Allegations of
abuse/neglect/exploitation must be reported as incidents.
Incidents are divided into three categories: major, serious, and
informational. < The incident index (Attachment '3) to this
operating procedure provides specific examples as a guideline for
identifying major and serious incidents. Other IRis are informa-
tional. _
.
. (1) Major Incident. Any incident that requires.: the
immediate.notification or intervention of the District Admini~-
trator. They' may involve: unexplained death or death by other
than natural causes, .erious injury, a felony cr~e, major
fire or. radiological incident, natural or other disaster,
epidemic, escape fram a secure faCility, riot, public reaction or
media coverage that may involve areas of the depari:ment beyond
the reporting unit, .potentially serious departmental liability or
any combination of these. (S.. incident index Attachment .3 for
a complete list of major inCidents.)
. (2) Serious Incident. Any incident with potentially
significant.consequences for the department such as the theft or
destruction of state property or public reaction or media cover-
age that indireC'tly includes the department or implies depart-
mental li~ilit~. (See incident index Attachment 13 for a
complete liat of aerious inCidents.)
. (3) Informational. Inciden't. Any incident 'that cannot
be cate9CJ%ized using the incident index . (Attachment 13), b\1t
about. which . district management should be advised for fut.u'e
planning, tracking or reference. Thes. would be reported to the
Assi.tant Secretary. for Operations only if',..J:n the judgment of
the Senior Obit Employ.e there are. special circumstances
requiring his/her inVOlvement. .
b. Client. Any person receiving a service or financial
support from a program operated, funded, licensed or requlated by
. the depart:ment. Typically, incidents..occurrinq awayfrolD depart-
ment/vendor facilities and work.it.. (e.9. . person's own home)
3
....
-
"
1
. ,
.january 1, 1986
OP 0-10-1
(a) Telephone the office of the Oistric~ Op_
erations and ~~aqement Consultant CDOMC/OA), at 377-5067,
SC 452-5067, within one (1) hour of ha~ing been notified of the
incident. At this point the supervisor must be ready to answer
~ll items on the unusual incident reporting form (ERS Porm 251).
Telephone reports of incidents occurring after busineas hours, on
weekends or holidays must be made by a Senior Human Services
Program Manager (SHSPM), or equivalent for those entities not
reporting through a SESPM. It will be the reaponsibili~y of each
program office or other entity to establish an internal procedure
to ensure proper reporting requirements. Telephone reports of
incidents occurring after business hours, on weekends, or holi-
days shall be made via the following procedure:
('1 Telephone the I~cident Reporting Answer-
ing Service at , wi thin one U) hour of having been
notified of the ineraen~This call is toll free from the entire
Dade County area. Monroe County incidents should either be
reported via Suncom or direct-dial long distance. Collect .calls
will not be accepted at this number. This telephone number can be
reached from any type of telephone and will be personall'y__a!1-
swered by an operator. .
(2) inform the operator answering the ~umber
that you are calling to report an Incident. The operators have
been instructed only to receive calls relative to incident
reporting at this number. Any other calls will be referred to
the District office. This answering service number is not to be
given out to the general public, and must only be used for after
hours telephone inc~dent reporting.
. (3) Leave your name and a telephone number at
which you can he reached with the operator. ~he operators have
been given instructions for reaching the on-call Incident Report-
ing Coordinator. Th. Coordinator will return the call at the
telephone number which you 9.1 ve the operator wi'thin one . (1) hour
of receiving your ....age.
(~) If after one (1) hour your call has not
been re1:urne4, the above steps should be repeated hourly until
you are .....~1:a~ec1 by the I,ncident Reporting Coordinator..
Cb) Ensure contact with all appropriate individu-
alsand ag.nci.., including, ~or example: .
/'"'
1)
2)
client'. par.nt/9Uar~an/relative
Abuse regi.try (non-working hours) or
Single Intake or Adult Abuse Unit
(working hours)
Law enforcement agency .
Advi.. the higher level supervisor
in the chain of cOIIIIDand and all
appropriate ERS entities (e.g. Bome-
finding and Licensing Units).
3)
4)
..
5
,.
l
Janaury 1, .1986
OP 0-10-1
(b) Ensure timely and thorough completion of HRS
Form 251. The form must be reviewed and signed by the appropri-
ate Senior Human Services Program ~~nager (SHSPM) or other
appropriate individual for those units not reporting through a
SHSPM. The form must be mailed to the office of the DOMC/DA
within one (1) working day of learning of the incident.
Distribution of the form will be pursuant to Section 5.c.(3) (c),
of this operating procedure.
(0) For incidents of alleged abuse/neglect/ex-
ploitation, prepare a follow-up report on BaS Form 1353 ,-,oithin
thirty (30) days after notification of the incident. The form
must contain all required information as well as is statement
documenting the official findings of the abuse/neglect inves-
tigation. The form must be reviewed and:signed by the appropri-
ate Senior Haman Services Program Manager (SHSPM) or other
appropriate individual for those units not reporting through a
SBSPM. Distribution shall be pursuant to Section S.c. (3) (c), o~
this operating procedure. In cases where the abuse/neglect
investigation is not completed and the thirty (30) day require-
ment cannot be met, this information must be relayed to:--'the
office of the DOMC/DA. The incident will be noted as pencung.
The BRB Form 1353 must be submitted as soon as the investigation
is complete. Follow-up reports are not reauired for other
serious or informational IRis.
~ (5) The DOKC/DA shall.:
(a) Within one (1) h~ur of learning of the
incident, advise the Senior Unit Employee, and determine .if it
may require the emergency intervention of the Assistant Secretary
for Operat10ns,place the department at serious risk, result in
public opinion or meclla coverage that may have a significant
impact on the d.epart::ment or meet the criterion for temporary
required reporting to stau headquarters pursuant to Sec'tion
4.d., and. Attachment '1, of this operating procedure. If it meets
the criterion the incident will be reported to the ASO, pursuan't
to the ASO's operating procedure for incident reporting.
.:.. - QrJ Notify the appropriate PrQ9%&m Manager,
Districr AA1a; "'.. suative Services DireC'tor, or Deputy Dis'trict
AdmirU..'tzator.
.
(c) Notify the appropriate BRAC, LTCOC, or
DAC, within 2... hours of receipt of the written III when in the
judgement.of the District ACminis'trator an advocacy committee or
council needs to be aware of the incident.. Advocacy Groups and
Co~ttees have the "s... rasponaibiliti.. relative to confiden-
tiality and records handling and retent10n aa KRS ataff.
(4) I>eve.lop I and maintain the local III
automated system with the asaistance of OMS staff. The system
ahall contain at a minimum, the data ba.es indicated in HRSR
7
~
January 1, 1986
(6) When there has
abuse/neglect/exploitation referral
previous 12 months.
(7) When a client residinq in a cluster facility dies
under any circumstance.
OP 0-10-1
been
for the
an indicated
client wi thir. the
(8) When unattended by a practicing physician or other
recognized medical practitioner.
(9) As the result of an accident where the department
may be liable.
(10) A series of deaths,. within a facility clearly in
excess of normal expectancy for which there is no readily identi-
fiable' cause or explanation.
b. When the client is in the'custody of the department and
the death is from any of the causes or circumstances listed
above, an autopsy will be requested., unless otherwise requii8"d 5y
local ordinance.
c. Requests for other investigations may oriqinate.. with
the local medical examiner,' th~ secretary, an assistance secre-
tary, or the district administrator.
d. Since the primary focus is to prevent deaths under
similar circumstances in the futU%'e~ the investigation report
sho~d reflect an in-depth analysis of the entire case, not just
the events immediately surrounding the death. For example,
reports should reflect: any change in treatment plan; any recent
event concerning a client's family that could have caused de-
pression; any significant change in staff dealing directly with
the client; any change in physical environment; etc.
7. Distribution and Ois1)08i tion of R.~rts.
a. Incident reports should not be placed in an employee's
personnel file. A written notice or any personnel action taken
rela:t:i". to an inciaenot report, if any is appropriate, is the
proper c!ocwDentation.
b. All Iii copies of records and. others will be maintaj.lled
and dispos.d of in accordance with HRSM 15-1 (Records Manage-
ment) . '1'bedistrict records management liaison officer must be
contacted prior to the disposal. r
c. Information on incidents which impact directly on an
individual client(s) will be put in the client's file by includ-
ing either a copy of.the incident report (with other names
or identifying information deleted or excised) or by makinq
appropriate notations in the 'client's record.
d. The office of the OOMCJDA will maintain an automated
data base for uae in the tracking follow-up actions, trend
analysis, corrective action planning, and provision of
9
\
January 1, 1986
OP 0-10-1
ATTACHMENT . 1
TO DISTRICT 11 PROCEDURE FOR
INCIDENT REPORTING
EFFECTIVE DATE: April 23, 1986
~~.~ORARY REQOIRED REPORrING OF INCIDENTS TO ASO
,. Notification of the incidents listed below will be made orally to
the ASO or designee usinq the schedule requirements shown in RRSR
0-10-1 each time one occurs until officially suspended by the
secretary or the ~a8t reporting Q8te is reached. At that time
they will follow the normal IR regulation requirements.
INCIDEN'l' TYPE
ALL INCIDENTS RELATIVE TO A CLIENT
IN A CLOSTER FACILITY:
LAST REPORTING DATE
12-31-86
o
When a client die. under any
circumstances.
INCIDENTS RELATIVE TO ALL CLASS ACTION
SUIT CLIENTS REGARDLESS OF 'l'BEIR PLACE
OF RESIDENCE: '.
o When e class member dies under
any cirC\DD8tance..
12-31-87
ESCAPE BY A CLIER'l' nOM A SBCtJRE
FACILITY OWNED, OPERATED OR FONDED
BY BRS:
12-31-86
ATTACBMElft' .1 to OP 0-10-1
W'
Ji,;,
~
January 1, .1986
OF 0-10-1
8. The date and time of incident. Enter date (month/day/year)
and 1:ime(use military time, 2400 -,midnight and 1200 . noon
etc.) of the incident (if known). If an incident took place
over an extended period, enter the origin&l incident
(start) date and time.
9. Obtain type of incident from the incident index (Attachment
13) Use only the "type- desianation listed in the index.
10. Enter the program component or type of facility. For
example: institution, group home, foster care, secure
detention, etc. Attachment'4 contains the list of proqram
components/types of facilities and their codes. Only the
designated program components/types ~f facilities should be
utilized. The codes will be used in the district automated
IR reporting system and will be entered by the office of the
DOMC/DA.
11. Enter all the client or employee identifying information.
If the date of birth is recorded, change to age as requ~
on the form. For community mental health patients, a c~ent
1.0. may be used, but in all other cases, the client ~
must be listed. Indicate on each line whether person wa.
a participant (P) or a witn~ss (W). Employee Social
Security numbers and position titles must be entered where
appropriate.
12. A brief description of the incident should be entered. Use
as a guide, the questions who, what, when, where, and how.
Indicate whether the information provided is preliminary
or has been verified. If additional space is needed use
the back of the form and check the block so indicating.
13. The name of the person making the report should be entered
here along with his/her title and location. Enter the date
and time (military) the report wa. prepared and Suncom
number (if no Suncam, enter the arca code and local number).
14 · To be filled in by supervisor and the office of the DOMC/DA.
(U..-military time notation).
15. Tall what ha. been done as a result of the incident to care
for the client or employee and to prevent a reoccurrence of
it. For example, if the incident involved an injury, the
immediate corrective action might be: -administered first
aid and called emergency medical service.-
16. The reporter's supervisor or designated person should sign
as the preparer and provide the other information shown.
For HRS Form 251, the apP'ropr~ate SBSPK, or other
appropriate individual for tb08~ units not reporting through
a SBSPM, must initial' the report indicating review and
approval. Por BRS Form 1353, aee '19. .
A2-2
"'t'
~
INClDE/'I,'T Rf:PORT
Ik ''-''''BEl<:
( : )
-
I
~t'___,____
1'11' II( IClIMtNI b SUH.nrl III (OIllHlIl"'IIALIT" IU.VUIKlMlNT~ ANI' ~HOUU' Ht HA"""UJ) A(TOIUm\l<":~.
TYPE OF INCIDENT ( 2 ) . 5.....cll,. V"" \ )
. Occu......,. ( 3 ) ~u'"""Lj I I ]
Me"" 0 ::O".N....O 1"'''_'_.10 l.._.... ~
Ut"'1I(1
---
'-
p,o.,.", Ar..
( 5)
",..m~ 01 'nllll""O" or F.c'''I~
{ 61
Add....
I ., I
I)... ..nd T.m. 01 Incld.-nl
un
Typ. of I..CIllul ( 9)
IDENTIFYING INFORMATION
....,. C."'P.fT yp. f.c,h..
(1 n I
"'am... cFIf'" LA.,I n' Part,r,p.nu II end W""e.~ ..~
ACl KAel SO: 0..... ~.-'a:........- 1.~ ond SSN
.......IC8e'" IF'
o. \\ ....., I v-
1.
2.
3.
elll
4.
s.
6.
7.
BRIEF DESCRIPTION OF INCIDENT
(w.... ---.r. Who... _....r. W"Y dad II '-'? How.... II ,... ~ or __, w-. dad II..........? w... _ -...r. ""'11.0.. _?I
Th. ,ell";,.. ;'...._.i." 0 ..1 ....ct 0.. ,.01,_..".
. -- ~--
(12 )
.... ....ell 0
R...-u.. E..,..
(13\
Tide
0..... Ti_ ., R--,
T...~Ito.. N..
t..... '-/N___,-,
I..uli. iI
(~ ..... F...,. ~c..1
EaMaod ..... C...a.. tS,.m,)!
O. TEll'lME
INDIVIDUALS NOTIFIED
D.\ TiItlME.
0iuIict A ~ - . .....
(14)
~~.... A__q. '-'_
..... ~ n~3C2,'15Z)
...... u....-
l.oIIt T_ c:... ("-h~_.. c....al
s.... ......,
011..' ~ _ c:..u.--
&.-11'
.l~)
,~ F...,.......
Oi.-. .. RM .......~......
oa.. ~)
.IMMEOIA TE CORREcrJVE ACTION
(15)
PP."," a,.
(Hil
"OP. .. lIeell 0
TIll.,
0..
Lou...n
T.~Ito.. N..
C.r.. C..oIN........s...c....)
A ,......ct By
(17)
Till.
Oa..
I:l No F........ R___
(1 B)
A2-4
NOTt: AU. TIMES TO It 24 HOUR DESlCNATION 0001).2400
"'fR~ ~""'" 2~1 J"" M" ,Ob....., 1'liP-"W",.. 1"d11."'a .....~ "'.,. ftnI I.. UH"d1
..-
...
.'.
ShMP:'
INCIDE"''T REPORT
Ik ',-,Mtll:.l-
~
o 2 - }: . X I X eo:
,
X ".
III" I M "ll~n" I l~ SlJHH (" I III ( ONEil ItN1IALlTY I<I.VlIll<lMEN I ~ ANI' SIIOlJl.I) HI. llANIlLt.l' An Ol<llfNQ.Y
TV!>.. or INCIIlI:N"1 ~"""CI'" V""
MA." at ~-...,' 0 1",,,,,,,.,..,,,,,0 .~;::::..nr.. Leon ~d}i 0 IO! 31 P.ur_.A,.. A&AS
ANY ACLF Ador... 323 W. 14th St. Two
......,..!
.~...
.1 "'.'
1'..._,. And 1 ,,,,.. 01 i "'1'10""1
6/2/85
1645
1"'.01 Incl..'" Death
"r.,. (.........(1..... I.c.h..
Ecc, rl
AC:.r
1\..""" nl In,llIUhon n, .'.cdtl\
IDENTIF'YING INFORMATION
1\"",.. i.'trl(. 1..."1l ,,' P.'''C"IP.'''''' .nd w..".......
A~t. I< Act. st:X 0..... lMel""'...........~ .1.... Iftd SSN
,'."tt......., fl',
0' ~ ........,\\
I
A. Client
J. Smith
82 W M
---
~ ...L ..lL
Resident
Resident.
p
-.!i.
:.1.
3.
---
4.
s.
6.
7.
---
BRIEF DESCRIPTION OF INCIDENT
r"".... ~ Wh" w.. .....-...cl~ Why e.t. '-' He...... ..he...,. or e-? ""..... e.t.~? w.. _ _ _..r! W.....I _?)
Th. loU_.... i"'.'_II." ~..I ...ili." 0 i. ...el.........,.,
Mr~ Smith reported to ACLF sta~f that he had observed Mr. Client lea"ing
tne'ACLF at approximatley 4:45 P.M. on Saturday.. ACLF sta:f attemp'ted
to located him and requested the assistance of his family and law
enforcement. Their efforts were unsuccessful. Bis body was located
Sunday beside a railroad track. The medical examiner estimated tha~
he had been dead for about six hours and that he had died of natu:al
causes. Mr. Client was in poor health prior to the incident and no
foul play is suspected.. ..... ."Bock 0
R.,.".a,EIDpl.,... Mr. A. Jones Tide CRC D...IoT._.IR.,... 6/3/85 110
1..cati.. Ma=ianna Service Center T......NL SC 111-1" 1
15erwa ANO, F...." t:.a~1 lA... c.e./h._,.\lu..c....l
Ea...ca.1f M.aIia C...... <S.-cif,)?
DATIJT1ME
6/3/85 0800
Local News
JNDMDUALS NOnrn:o
Item
DA TtlTlME
6/3/85
o..nca Ai.
I...
1500
H_ RipIa AIf_cy c-_
6/2/85
6/2/85
A... ~ 00100-342,'1521.
~~
....11 I I cs-I,I Leon Ctv She=i~~
w.. T_ Cor. 0-........._.. c-..al
1700
1800
SaMe A......,
Of_.1 ~ aN CaniI__
~,...., ........
6/3/85
IMMEDIATE: CORRECTIVE ACTION
2.500
ow... 01 RiM ...-.._,'.
oa-ls.-;t,1 ASO
Contacted family and.law enforcement after a aearch of area failed
to locate Mr. Client. Will request,autopsy results ~rom medical examiner.
P,....... a,
A. Supervisor
Tid.,
BSCS
M~.. ." Iaock 0
0... 6/3/85
T......N., SC 111-1111
111.... C.4.n; ........,S. "'0 III)
L.c...."
Marianna Servi~e Center
A......1f .,
D~ Administrator
Tide
DA
D...
6/4/85
t:I N. F........ R__
A2-6
NOTL AU. TIMES TO liE 24 HOUR OESICNA TION nooo.2400
'..II~C. 5:'..._ ~:; I 1,.~ lC~ '0;........... "'""w"... ""'..Iftft": ..hlt... "'':1\" ""' t. ......11
1.
~
SAMP:"E
L.'U-' AK I iVIt.0. I Ur HlAL j H AI....U Kt.HAol...., . A I I \c.
~~
11/ ..l!~R[~
INCIDE",,'T REPORT
to;:: - x IX I X X -. X >:
""' ...., l.,"~;.S I 1:- SllHH CI III ( (''''''I If ".lIALlT\ ,<f (.ll111<1.Mt 11;." ,,''',, :,f fOl) 1.1 I Ht. HMIII)U,II A("("( 1I<II/Nl..U
~.rvl(".n. U"lf
TYPF OF INClIlf.Nl r.:---=1. _ . I
Ommen,.. Leon ,0 I 2H 9 ... 9 I 9 ! 9 cr::
\1"10' 29 ~..'u"',. Cl Inlnu"..'ac.n",1 CJ tnu"t~ -..--I ...-J ~rlu".rn Ar..
Anv Detention Cente.... Ad,heu 123 "B" Street, An\.towr:.. 'r'"'
"""If" olln'II'Ullnn ft, F.L....h _ _ _____ _
"... ."d T,n'. ollnc.eI~", 5 / 13 / 85 2130
l",,,,.-'
~.
I..
.... -
Tvp. 01 I nnel.n'
Escape
P'o~. Cn",p.f1,p. t..c.b"
c:.Qr"""-C
DE"
IDENTIfYING INFORMATION
".meoltF"II.1.a.U 01 P.'hC1f'UllnIUI .."Ii W..n.......)
AGE l( AU. SF:X (;looooM ~.,..aI u.....v... T.lr .nci SSf\;
.....,..~Il
ttt' ".,.., (1
A. Jones
B. Smith
.' C. Brown
...lL -li.. -H-
W M
W
3
B M
Detainee
DCW II 000-00-0000
DCW II 000-00-0000
p
-
---
v,'
4.
---
s.
---
6.
BRIEF DESCRIPTION OF INCJDEf'..'T
'w.... ~ WI.. _......,;.ftI" Wily doll. __? H<-""'" ,.. ~..........? WIowe dolI.~? \\0... cr-. --:..r. w...... _?l
The 1.11_.".,,,..,......,, ~ .., ..en".1I 0 i. prel........"
R.IHIftill, E..,I~..
Any deten~ion cente=
l..u..." _
Cs...._ A_. F....y, tic. I
-
Two s~aff members were outside in a recreational area with 16 detainees. On4
of the staff members went inside to conduct a 10 minute check on oth~r 'detai~
This left a 16 to 1 ratio of clients to satff in the recreation area., double
the number allowed. Jones escaped during that period by climbing over the
fence. Client is not considered to be a threat to ~self or the community.
Be was being held on two charges of auto theft. Bad a prior record of
shoplifting in April 1984 and status offenses in 1982 and 1983. 0
M.. .. Bou
Do.. a Ti_ .IR.,... 5/14/86 1:
T......N.. SC 111-1111
(A... c-/"_,.~c-I
Mr. C. Brown
Till.
PCW II
INDMDUAl.S NOnrn:.o
"Hctell 114.. c...... ISH_I?
DAn:tnME .
DATUnMt
5/13/86
2200 0..-. ....-J_
"- ~ Ad_c, C_
,...... ~ (1"-342,11521
..... t.a.iaer
.w- [pi
.. C~'IAny"~WTI t>nli~_
I.aac T _ ea.. o..Il.U_.. c:....il
s.... A-,.
OH_ of ~ .... Cenilica_
0....... of RiM Ma....-
OU-Cs...,)
5/13/e5
5/13/85
2145
2210
~ F....., MeN..
IMMEDIA n: CORRECTIVE ACTION
In the future insi~e checks will be conducted by the .hift supervisor so tha~
proper supervision ratios are maintained during the.recreation period. Any-
town police were notified and detainee was apprehended 5/15/86 at 5:10 pm.
l..u....
T.'Io.... N..
114... ." lloeil 0
0- 5/14/8:!
SC 111-1111
"._otI ..,
Mr. B. Dew
Any town, Florida
D. Administrator
Ti.l.
Su~erintenden~ II
(A... C..e/IIi u",....Su..coml
5/15/86
D.,.
A "1"...11 B).
Title
DA
o No F........ R__
A2-8
NOTL ALl. TIMES TO Bi: 2A HOUR DESICNA TION OlJOO.;l4,UIl
.,/;
..
~
January 1, 1986
or 0-10-1
AT'l'ACBMENT t 3 TO
DISTRICT 11 OPERATING
PROCEDURE FOR INCID~~
REPORTING
INCIDENT INDEX
INCIDE~~ CATEGORY
A
*ABDUCTION
Abduction or kidnapping of an active ~ client or
on-duty employee in a work related situation.
Abduction by natu=al parents from a foster home,
group home, institution or other residential
facility, when DO real danger exist for the
client. This would Dot preclude staff from
alerting law enforcement and other efforts to
find and retu~n the client(s).
*ABUSE OR ALLE~ION OF ABUSE CNealect or Exploitation)
a.
b.
Major
Serious
All reports of child or adult abuse/neglect/exploitation Serious
or alleged abuse/neglect/exploitation must be reported
immediately to the Abuse Registry for processing and
entry into the Florida Abuse Reporting Information
System (FARIS). Incident reports will be prepared and
follow-up reports mu.t .indicate the re.ults of
the abuse/neglect/exploitation investigation. If the
results of the official investigation note that the
allegation as being -indicated/substantiated- the
original repert must be upgraCie4 to the -major- incident
category. For any other finding, the report will remain.
in the .-..rious- category.
'* ACCIDEIftl..... VEHICLE
a.
InYOlving employees in vehicles while on work
r.l.~.4 a.siguments, if department liability may
exist.
Involving state vehicle or equipment and r
significant damage.
ADULT ABUSE
b.
,
!-1ajor .
Serious
See
ABUSE
*To be usea in reporting 6~ of Incident-
ATTACBMENT t 3 to OP 0-10-1 .
r,
January 1,. 1986
OP 0-10-1
CA::.o ABUSE
D
*DEATH (also see SUICIDE)
a.
Of an on-duty employee.
Of a client in cluster facility under any
circumstance.
b.
c.
Of a client a8 a result of abuse.
d.
Of a client with an indicated abuse referral
within the previous 12 months.
Of a client ..by other than natural causes (if
suicide, list type of incident as .SUICIDEW).
See list of causes in Section 6.a..
e.
*DISASTER (Natural or other)
Causing a disruption in HRS services, operations
or in an HRS licensed or regulated facili~
(e.g. fire, flood, hurricane, tornado, or local
condition) .
*DRUGS (Includinq alcohol)
a.
OVerdose by clien~ or oD-duty.employee
requiring in-patient hospitalization out-.
side an HRS facility.
.b.
Illegal po.session.
c.
Abus. of drugs (used illegally on .ta~e-
OWDed or operated facility by client or
-.pJ.oya.) ~
.....:a...
!
ZLOPPZIIf ~. . .
*EMPLOYEE.~~SCOKDUCT (RRS or Contracted Provi~.r)
a.
Job related actions resulting in potential
liability for an employ.. or BRS. "
b.
"
Work conduct resulting ~D law v~olatioD.
*'1'0 be used in reporting i.DcideD't8 aa "Type' of Inc1dent-
A3-3
'"
'~':,,:!(":'t'':'_..'~
See
ABUSE
Major
Major
Major
Major
Major
'--.r"_
Major.
Major
See
Can'RABAND
Serious
See
MISSING
CLIENT
Major .
See LAW
VIOLATYOii
,j
r
'I.
January 1, 1986
OP 1-10-1
I
.FACILITY CLOSURE CInvolunta:y)
Closure of facility providing residential care,
day care or other services to HRS.
FALSIFICATION OF RECORDS
FIGHT
,
.'
*FIRE (Resulting in disruption of service prov;sion
or'operation)
a.
In residential facility serving BRS clients
In HRS residential facility.
In state-owned or leased bUilding. (BRS
offices)
b.
c.
d.
, . .
In facility licensed by BRS.
FLOOD
B
-
*BOMICIDE
Homicide by . client or employee.
HURRICANE
1
Major
See LAW
VIOLATION
See
ASSAULT
Major
Ma~r
Majl)r
MajCJr
See
DISASTER
Major
See
DISASTF.R
* ItLNESS (P:am other than chronic condition or rea.ons
atypical of th~se found in the client population)
a.
Of client or employee (work r6lated) requiring
hoapitalizatign outside ar. RRS facility ~Dd which
is determined to be life-threatening by attending
physician. .
Illness resulting from an apparent neglect
situation.
b.
!
c.
Epidemic ~ disea.. outbreak.,
*'1'0 be u..d in r.port~9 incident as ~TYPe of IncidentN
A3-S
j
i
t..
.,
;<'!~ .1-._
Major
Major
See
EPIDEMIC
r .
~
January 1, 1986
OP 0-10-:'
b. On duty employee in possession of contraband ~jor
which involves law enforcement (illegal substance).
c. Falsification of state or client records by Serious
employee.
d. Second or third deqree felony by client or on Serious
duty employee. NOTE: Law violations by CYF clients
on community control are not considered a major or
serious incident.
M
*MEDIA .COVERAGEAND PUBLIC REACTION
(Actual.or Potential)
a.
Public reaction or media coverage that may have a
significant impact on the department.
Major
-."--- -
b.
Public reaction or media coverage that indirectly
includes the department or implies department
liability.
*MEDlCATION ERROR
Serious
_.-~_.__._------ - --.""-"-0'___'-.---...
When life threatening illness or injury
occurs and departmental liability may exist.
Major
*MISSING CLIENT
--- _._--------~
- . ----
.---.----
a. Where clieD~ may be in danger to himaelf Major
(usually frQlll . nursing haDe, A.CI2, group
heme, e~c., or client cannot care for himself
or may require life-saving or significant
medicatien (e.g. diabetic) on a regular basis).
b. From a mental health institution by client with: Y.jor
1. . Suicidal.. =: hamicidal ~endenciea, a. exhibited
..by overt behavior QeDlOnst:ated ",.ithin the.
I 72 hoars prier to elopement.
2. Pending felony chargea.
. .
c.
"
Elopement from a atate mental health hospital thAt
reaults in the client beCOming involved in the
Commitment of a felony in which there is ne threat
to human life, being picked up by law enforcement
agencies or Deing involved in bizarre acting out
behavior.
Serious
*To be ua~d 1n reporting 1nc~dent AS, -TYDe of Inc1dentW
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January 1, 1986
OP 0-10-1
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SEXOAL ABOSE OR MISCONDOCT OR ALLEGATION OF
*STRIKE OR WALROOT (With or without violence)
a. By BRS employees.
b. By clients.
c. By employees of client residential .e,~ice
providers.
Cl. By employees of day care service providers.
e. By contract service provider.
*SOICIDE
By clien1: or on-du1:y employee..
-.
*SUICIDE ATTEMPT
By client or on-duty employee where significant
meClicaltreatment or hospitalization is required.
NOTE: Suicide vestures or threats are defined as
minor self-iu~l~cted injuries which result in no.
real -threat to life or ae1:ions taken that lIliiht
be interpreted aa attention-iettin9 devices.
~heae should not be reported .s an incideDt,. but
deal t wi'th in 'the course of treataent and en1:ered
iD the facility J.o9 or client record.
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*TBE:M' (or SABO'1'AGE or VANDALISM)
Of sta~e or pr1v.~e property of significant value.
*THREAT OP VIOLENa
,.
To an employee in a work-related situation.
v
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VIOLBNCZ
*'1'0 De u8ed in reporting incident8 a. -Type of Inc1dent~
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See ABUSE
OR EMPLOYEE
MISCONDOCT
Major
Major
Major
Major
Major
-- -
.
Major
Major
Serious
Serious
See
ASSAULT
ABUSE
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January 1, 1986
95
ALCOHOL, DRUG ABUSE, MB
10
07
08
99
Community
Forensic Unit
Institution
Other
.' 98
ECONOMIC SERVICES
OP 0-10-1
97
VOCATIONAL REHABILITATION
11
99
HRS Office
Other
30
DISTRICT ADMINISTRATION
Sl Adult Payments Office
01 Assi8tance Payment Office
03. Food Stamp Office
09' WIN Off:i.ce
99 Other
INCIDENT TYPES - MAJOlt OR SERIOOS
10 Abduction
16 Adverse Media Coverage
20 Bomb
22 Doath
24 Drugs
29 Escape
32 Facility Closure
40 BamiciCie
47 Injury
Sl Medication E:ror
60 Radiological .
7S Strike or Walkolrt
81 Suicide Attempt .
92 Threat of Violence
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02 Headquarters Office
98 Service Center
99, other
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14 Accident - Vehicle
18 Assault .
21 Contraband
59 Disaster
27 Employee Misconduct
28 Epidemic or Uealth Emerg.
3S Fire
45 Illness
SO LaY.Violation
S4 Missing Client
67: Riot
80 Suicide
90 '!'he ft
93 Abu.e/Neglect
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STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
AGING AND ADULT SERVICES PROGRAM OFFICE
INTERIM GUIDELINES FOR TITLE III-D
IN-HOME SERVICES FOR FRAIL OLDER INDIVIDUALS
The following are interim guidelines to be used to establish a
program of services under the OAA Title III-D funding allocation.
Reference: Older Americans Act Sections 341, 342, 343, 344
General o~ective: The federal regulations applicable to the
1987 amen ents to the Older Americans Act have not yet been
finalized. The following guidelines are offered in order that~
the available Title III-D federal funds may be appropriately
administered. These guidelines are to apply in the interim until
federal regulations are finalized. If the final regulation are
not in conflict, these guidelines will remain in effect until
necessary revisions to appropriate manuals are in effect.
PART I, SERVICES
Services Funded: The following services as defined in the
Florida State Plan on Aging (FY 1987-90) may be provided to frail
older individuals using Title III-D funds.
1. * Homemaker
2. * Home Health Aide
3. * Chore
4. * Companionship (visiting)
5. * Telephone Reassurance
6. Respite Care, provided in-home
7. Adult day care as a respite service for families
8. Housing Improvement (building modifications with a limit of
$150 per client)
Note that the services indicated by asterisks are the same
services as the priority services under Title III-B. In order to
distinguish Title III-B "Homemaker" services from Title III-D
"Homemaker" services or Title III-B "Chore" from Title III-D
"Chore," the program office will refer to the Title III-D
services as Frail Older Individuals, "FOI." For example:
Homemaker (FOI) will be used to differentiate Title III-O from
Title III-B.
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At this point in time, it is essential to limit the service array
to be funded by Title III-D. For simplicity, Title III-D may be
used to fund only Homemaker, Chore and Resp1te services for Frail
Older Individuals. The AAA has the option to further restrict
this list of services which may be funded.
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PART II, CLIENT ELIGIBILITY
Individual Eligibility: Eligibility for participation in Title
III-D services is based on the criteria described below. Criteria
# 1,2 and 3 are applied criteria. All individuals must meet
'criteria # 1, 2, and 3. Criteria #4 is a collateral criteria:
that is, the information collected under this criteria will be
used for reference purposes only. The criteria will be taken
into account but will not be the basis to deny or limit receipt
of services or eligibility for service.
#1 CRITERIA: AGE
Requirement or Condition: To be eligible for Title III-D In-home
services under this criteria, the individual must be sixty yea~s
of age or older (60+)".
Methodology for Determining Eligibility: Any of these methods 'is
satisfactory;
(a) birth certificate or driver's license indicating date of
birth commensurate with age of 60 or older,
(b) declaration of age by the individual or another person on
behalf of the applicant individual.
.2 CRITERIA: NON-ECONOMIC FACTORS CONTRIBUTING TO THE FRAIL
CONDITION
Reluirement or Condition: For an individual to be determined
el gible under this criteria, the individual must have a
"disability", a "severe disability" or meet the definition of
"frail."
The term "disability means (except when such term is used in the
phrase "severe disability", "developmental disabilities",
"physical or mental disability", "physical and mental
disabilities", or "physical disabilities") a disability
attributable to mental or physical impairment, or a combination
of mental and physical impairments, that results in substantial
functional limitations in one or more of the following areas of
major life activity: (A) self-care, (B) receptive and expressive
language, (C) learning, (D) mobility, (E) self-direction, ,(F)
capacity for independent living, (G) economic self-sufficiency,
(H) cognitive functioning, and (I) emotional adjustment.
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The term "severe disability" means a severe, chronic disabilitv
attributable to mental or physical impairment, or a combination
of mental and physical impairments, that - (A) is likely to
continue indefinitely; and (B) results in substantial functional
limitation in 3 or more of the major life activities specified in
the subsections (A) through (G) of the definition of disability.
The term "frail" means having a physical or mental disabilitv,
including having Alzheimer's disease or a related disorder with
neurological or organic brain dysfunction, that restricts the
ability of an individual to perform normal daily tasks or which
~hreatens the capacity of an individual to live independently.
Methodology for Determining Eligibility: Any of these methods is
satisfactory;
(a) a written statement of disability, severe disability or
frailty from a medical or health care professional licensed
under Chapter 458, 459, or 464 Florida Statutes,
(b) determination of disability, severe disability or frailty
by a qualified case manager of a provider agency funded by.
Older Americans Act, or Community Care for the Elderly.
This determination will be based on an in-home visit and
completion of a form HRS AA 3003 or comparable client
assessment instrument,
(c) determination of disability, severe disability or frailty by.
a qualified HRS Human Services case manager of Horne Care of
the Elderly clients, Adult Protective Services Clients,
CARES or other Adult Services clients. The determination
will be based on an in-home visit and completion of a form
HRS AA 3003 or comparable client assessment instrument.
.3 CRITERIA: NON-ECONOMIC AND NON-HEALTH FACTORS CONTRIBUTING TO
THE NEED FOR SUCH SERVICES
Re~uirement or Condition: For an individual to be determined
el1qible under this criteria, the individual must either lack a
suitable caregiver, or, if there is a caregiver, the caregiver
has a need for counseling or training or there is a need to
provide respite care to permit the careqiver an opportunity for
rest, or change, or to attend to personal needs.
MethOdOlogy for Determining Eligibility: Any of these methods is
satisfactory:
(a) determination by a case manager of OAA, CCE, APS, CARES, HCE
or other HRS clients, based on observation and jUdgement,
(b) declaration of caregiver status by the individual or another
person on behalf of the applicant individual,
(c) declaration by caregiver of applicant individual.
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*4 CRITERIA: GREATEST ECONOMIC NEED
Requirement or Condition: Note: the three criteria preceeding
are sufficient to determine eligibility for the Title III-O FOI
program. Criteria #4 is provided only for reference purposes.
It will be used only for information purposes and will not be
applied to establish program eligibility.
For an individual to be determined as meeting
individual must be of greatest economic need.
as: "the need resulting from an income at or
level established by the Office of Management
this criteria, the
This is defined
below the poverty
and Budget."
A means test will not be included in this criteria. Means test
is defined as the use of an older person's income or resources to
deny or limit receipt of services or eligibility for services.
Methodology for Determining Eligibility: Any of these methods is
satisfactory;
(a) evidence of Medicaid eligibility,
(b) evidence of SSI eligibility,
(c) evidence of Food Stamp eligibility,
(d) evidence of eligibility under Florida Home Care for the
Elderly program,
(e) declaration of income or income level by the individual or
another person on behalf of the applicant individual.
PART III, FINANCIAL RESTRICTIONS
Funding Source: This program will be OAA Title III-D and will be
matched in manner and the same proportion as Title III-B. HRSM
55-1 Financial Management of Older Americans Act Programs will
apply. Provider agencies will be responsible for a minimum of
10% local non-federal financial participation.
Maintenance of Effort:
The Title III-D funds will not supplant existing Federal
(including Title III-B), State or local funding. Title III-D
funds shall be in addition to any other funds. The
interpretation of this requirement is that funding levels may
not be reduced because of the availability of Title III-D.
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PART IV, SERVICE PROVIDER
Title III-D In-Home Services Operational Concept:
Administering Agency: The Title III-D funding will be contracted
to the AAA by HRS as part of the OAA contract. A revision to the
area plan will be required. Area Plan formats 12.A, "Funding
Allocation to the Planning and Service Area" (A16), and 12.B,
"Service Delivery Network" (Ale), will be required as part of the
revision, plus, any changes necessary in 11.A, Estimated Program
Output (A12) to accommodate revisions in persons or units.
. Note: Title III-D amounts rieed not be "equitably" distributed to
counties or service providers. The AAA may balance Title III-B
and Title III-D funding to fit local need, capacity and
circumstances.
Coordinated Agency: The AAA is to coordinate with other
community agencies and voluntary organizations for the purposes
of supporting the FOI service system. The AAA working with the
service provider is to coordinate efforts at obtaining suitable
counseling and training for family caregivers and the persons who
constitute the informal support systems. Assistance and training
should be directed towards these specific subjects: .
management of care,
functional and needs assessment,
assistance in obtaining services
case management, and,
counseling prior to admission to nursing home.
Service Provider: Initially Title III-O FOI services will be
provided only by a service provider agency currently contracted
under the area plan to provide equivalent Title III-B services.
The service provider selected must have the capacity to provide
the in-home services selected for funding; and, have the capacity
to determine individual eligibility for Title III-O services.
A. The client group for this In-Home service program is to be
those individuals who are frail, part~cularly those with
inadequate caregiver supporting systems who are in need of
the service array to be provided.
B. The Title III-D services will be provided only by a service
agency specifically selected or approved by the AAA.
C. There must be a case manager for FOI clients (either CCE or
OAA) unless the AAA approves the exception.
D. The Title III-O program concept is:
1) a specific provider agency _
2) providing specific in-home (FOI) service(s) _
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3) to an individual who has specifically been determined
eligible under ~he criteria provided above by a trained case
manager.
E. The Title III-D funding will be administered in a manner
comparable to other OAA funding. The service provider
agency will budget, perform cost allocation and estimate
persons and clients for the specified FOI services
separately, but in the same manner as Title III-B services,
That is, if the provider is currently contracted for III-B
Homemaker services and it is decided that the provider will
also provide III-D (FOI) Homemaker services, the Budget
Explanation Worksheet of the Service Provider applications
will be revised to indicate a column for Title III-D
Provider Administration and a column for Homemaker FOI.
F. This same methodology will also apply in the Supporting
Budget Schedule by Program Activity. That means Title III-D
will be shown to include Total, Provider Administration and
one or more of the specified FOI services.
G. The Summary Budget of the Service Provider Application will
show a column for Total Title III-D amount.
H. There must be a Statement of Objective to support the Titte
III-D FOI services, however, the text may be the same as the
comparable Title III-B service with the exception of the
description of the target population.
I. The Estimated Program Output page must be revised to
accommodate the additional service units and persons to be
served with Title III-D funding.
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\ PROGRAM AUTHOR I ZED
).
) S.c 341. (a) The Commissioner shall carry out a proqram tor
makinq qrants to States under State plans approved under section 307
to provide in-home services to trail older individuals, includinq
in-home supportive services tor older individuals who are victims of
Alzheimer's disease and related d1sorders with neuroloqical and
orqanic brain dystunction, and to the tamilies ot such victims.
(b) In carryinq out the provisions of this part, each area
aqency shall coordinate with other community aqencies and voluntary
orqanizations providinq counselinq and traininq tor family
careqivers and support service personnel in manaqement of care,
tunctional and needs assessment services, assistance with locatinq,
a~ranqinq for, and coordinatinq services, case manaqement, and
counselinq prior to admission to nursinq home to prevent premature
institutionalization.
DEFINITIONS
, .
See 342. Por purto... of tbi. part--
(1) the term 'in-home services' includes--
CA) homemaker and home health aides:
(B) visitinq and telephone reassurance:
(C) chore maintenance:
(D) in-home respite care tor families, lncludinq adult day
care as a respite service for tamilies: and
(E) minor modification of homes that is necessary to facilitate
the ability of older individuals to remain at home and that is
not available under other proqrams, except that not more than
S150 per client may be expended under this part for such
modification: and
(2) the term 'frail' means havinq a physical or mental
disability, includinq havinq Alzheimer's disease or a related
disorder with neuroloqical or orqanic brain dysfunction, that
restricts the ability of an individual to perform nor~al daily tasks
or which threatens the capacity of an individual to live
independently. STATE CRITERIA
MAINTENANCE OF EFFORT
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Sec 343. The State aqency shall develop eliqibility criteria
for providinq in-home services to frail older individuals whiCh
shall take into account--
(1) aqe:
(2) qreatest economic need:
(3) noneconomic factors contributinq to the frail condition: and
(4) noneconomic and nonhea1th factors contributinq to the need
for such services.
Sec 344. Funds made available under this part shall be in
addition to, and may not be used to supplant, any funds that are or
would otherwise be expended under any Federal, State. or local law
by a State or unit of qeneral purpose local qovernment (includinq
area aqencies on aqinq which have in their planninq and services
areas eXistinq services which primarily serve older individuals who
are victims of Alzheimer's disease and related disorders with
neuroloqical and orqanic brain dYSfunction, and the families of such
Victims).
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