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PROFESSIONAL SERVICES AGREEMENT
t
BETWEEN THE CITY OF MIAMI BEACH, FLORIDA
AND AYUDA, INC.
FOR CHILD AND FAMILY SERVICES
i
RELATED TO THE CITY'S SERVICE PARTNERSHIP INITIATIVE
This AGREEMENT made and entered into this 1st day of August, 2013 (effective
date: day of J10ki if 4 r 1 20N, by and between the CITY OF MIAMI BEACH,
FLORIDA (hereinafter refe red to as City), having its principal offices at 1700
Convention Center Drive, Miami Beach, Florida, 33139, and AYUDA, INC., -a Florida
Corporation, (hereinafter referred to as Contractor), whose address is 7144 Byron
Avenue, Miami Beach, Florida 33141.
SECTION 1
1.1 DEFINITIONS
Agreement: This Agreement between the City and Contractor, and any
exhibits and/or attachments hereto.
City Manager: The Chief Administrative Officer of the City.
Contractor: For the purposes of this Agreement, Contractor shall be
deemed to be an independent contractor, and not an agent
or employee of the City.
Services: All services, work and actions by the Contractor performed
pursuant to or undertaken under this Agreement, as
described in Section 2 and Exhibit "A" hereto.
Fee (Compensation): Amount paid to the Contractor to cover the costs of the
Services.
Risk Manager: The Risk Manager of the City, with offices at 1700
Convention Center Drive, Third Floor, Miami Beach, Florida
33139, telephone number (305) 673-7000, Ext. 6435, and
fax number (305) 673-7023.
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Miami Beach Service Partnership
SECTION 2
SCOPE OF WORK (SERVICES)
The Contractor will provide the following services in accordance with The Children's
Trust Miami Beach Service Partnership Grant, dated August 1, 2013:
• Care Coordination Assessment & Plan Development services for up to
nineteen (19) children and their families;
• Care Coordination Plan Review services for up to nineteen (19) children and
their families;
• Care Coordination Plan Check-In services for up to nineteen (19) children and
their families;
• Eight (8) Flexible Care Coordination Plan Check-In services to be utilized in
accordance with client Care Coordination Plans, as needed; and
• Care Coordination Plan Close-Out services for up to nineteen (19) children
and their families.
The scope of work to be performed by Contractor is further detailed in Exhibit "A,"
entitled "Scope of Services." The Contractor shall report to the City of Miami Beach,
Neighborhood Services Department, Office of Community Services, Division Director.
SECTION 3
COMPENSATION
3.1 FIXED FEE
Contractor shall be compensated for the Services, as set forth in Section 2
and Exhibit "A", as follows:
a) Provision of Care Coordination Assessment & Plan Development services for
up to nineteen (19) children and their families at One Hundred Forty Four
Dollars and Twenty Cents ($144.20) per each service for a maximum not to
exceed Two Thousand Seven Hundred Thirty-Nine Dollars and Eighty Cents
($2,739.80);
b) Provision of Care Coordination Plan Review services for up to nineteen (19)
children and their families at Seventy-Eight Dollars and Seventy-Five Cents
($78.75) per Care Coordination Plan Review, for a maximum not to exceed
One Thousand Four Hundred Ninety-Six Dollars and Twenty-Five Cents
($19496.25).
c) Provision of Care Coordination Plan Check-In services for up to nineteen (19)
children and their families, at Twenty-Seven Dollars and Eighty-One Cents
($27.81) per Care Coordination Plan Check-In for a maximum not to exceed
Five Hundred Twenty-Eight Dollars and Thirty-Nine Cents ($528.39);
d) Provision of Eight (8) Flexible Care Coordination Plan Check-In services to be
utilized in accordance with client Care Coordination Plans, at Twenty-Seven
Dollars and Eighty-One Cents ($27.81) per Flexible Care Coordination Plan
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Check-In, for a maximum not to exceed Two Hundred Twenty-Two Dollars and
Forty-Eight Cents ($222.48); and
e) Provision of Care Coordination Plan Close-Out services for up to nineteen (19)
children and their families at One Hundred Three Dollars ($103) per each Care
Coordination Plan Close-Out for a maximum not to exceed One Thousand
Nine Hundred Fifty-Seven Dollars ($1,957).
Contractor's compensation shall be further subject to and conditioned upon all
or any portion of the Services to be provided herein being allowable and within the
Scope of Services delineated in Exhibit "A".
Notwithstanding the preceding, Contractor's total compensation during the
term of this Agreement shall not exceed the maximum allowable sum of Six
Thousand Nine Hundred Forty-Three Dollars and Ninety-Two Cents ($6,943.92).
3.2 INVOICING
Contractor shall submit monthly Reimbursement Requests, Monthly Service
Summary Reports, and accompanying Monthly Client Status Lists, as set forth in
Exhibit "B", which include an itemized, detailed description of the Services, or
portions thereof, provided (including the names of the clients served) and cost(s) for
same. Invoices and supporting documentation shall be submitted to Maria Ruiz,
Division Director, Office of Community Services, 1700 Convention Center Drive,
Miami Beach, Florida, 33139.
3.3 METHOD OF PAYMENT
Payments shall be made within thirty (30) days of the date of invoice, in a
manner satisfactory to and as approved and received by the City Manager and/or his
designee, who shall be the Division Director, Office of Community Services.
SECTION 4
GENERAL PROVISIONS
4.1 RESPONSIBILITY OF THE CONTRACTOR
With respect to the performance of the Services, the Contractor shall exercise
that degree of skill, care, efficiency and diligence normally exercised by recognized
professionals with respect to the performance of comparable services. In its
performance of the Services, the Contractor shall comply with all applicable laws,
ordinances, and regulations of the City, Miami-Dade County, the State of Florida, and
the federal government, as applicable.
4.2 PUBLIC ENTITY CRIMES
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A State of Florida Form PUR 7068, Sworn Statement under Section
287.133(3)(x) Florida Statute on Public Entity Crimes shall be filed with the City's
Procurement Division, prior to commencement of the Services herein.
4.3 DURATION AND EXTENT OF AGREEMENT (TERM)
The term of this Agreement shall commence upon execution of this Agreement
by all parties hereto, and shall terminate on July 31, 2014.
4.4 TIME OF COMPLETION
The Services to be rendered by the Contractor shall be commenced upon
receipt of a written Notice to Proceed from the City subsequent to execution of the
Agreement by the parties, and shall be completed no later than July 31, 2014.
4.5 INDEMNIFICATION
Contractor agrees to indemnify and hold harmless the City of Miami Beach and its
officers, employees and agents, from and against any and all actions, claims,
liabilities, losses, and expenses, including, but not limited to, attorneys' fees, for
personal, economic or bodily injury, wrongful death, loss of or damage to property, at
law or in equity, which may arise or be alleged to have arisen from the negligent acts,
errors, omissions or other wrongful conduct of the Contractor, its employees, agents,
sub-consultants, or any other person or entity acting under Consultant's control, in
connection with the Contractor's performance of the Services pursuant to this
Agreement; and to that extent, the Contractor shall pay all such claims and losses
and shall pay all such costs and judgments which may issue from any lawsuit arising
from such claims and losses, and shall pay all costs and attorneys' fees expended by
the City in the defense of such claims and losses, including appeals.
The Contractor's obligation under this Subsection shall not include the obligation to
indemnify the City of Miami Beach and its officers, employees and agents, from and
against any actions or claims which arise or are alleged to have arisen from negligent
acts or omissions or other wrongful conduct of the City and its officers, employees
and agents. The parties each agree to give the other party prompt notice of any
claim coming to its knowledge that in any way directly or indirectly affects the other
party.
4.6 TERMINATION, SUSPENSION AND SANCTIONS
4.6.1 Termination for Cause
If the Contractor shall fail to fulfill in a timely manner, or otherwise
violate any of the covenants, agreements, or stipulations material to this
Agreement, the City shall thereupon have the right to terminate the
Services then remaining to be performed. Prior to exercising its option
to terminate for cause, the City shall notify the Contractor of its violation
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of the particular terms of this Agreement and shall grant Contractor
seven (7) days to cure such default. If such default remains uncured
after seven (7) days, the City, upon three (3) days' notice to Contractor,
may terminate this Agreement and the City shall be fully discharged
from any and all liabilities, duties and terms arising out of/or by virtue of
this Agreement.
Notwithstanding the above, the Contractor shall not be relieved of
liability to the City for damages sustained by the City by any breach of
the Agreement by the Contractor. The City, at its sole option and
discretion, shall additionally be entitled to bring any and all
legal/equitable actions that it deems to be in its best interest in order to
enforce the City's right and remedies against the defaulting party. The
City shall be entitled to recover all costs of such actions, including
reasonable attorneys' fees. To the extent allowed by law, the defaulting
party waives its right to jury trial and its right to bring permissive counter
claims against the City in any such action.
4.6.2 Termination for Convenience of Cit
y
NOTWITHSTANDING SECTION 4.6.1, THE CITY MAY ALSO, FOR
ITS CONVENIENCE AND WITHOUT CAUSE, TERMINATE THIS
AGREEMENT AT ANY TIME DURING THE TERM HEREOF BY
GIVING WRITTEN NOTICE TO CONSULTANT OF SUCH
TERMINATION, WHICH SHALL BECOME EFFECTIVE SEVEN (7)
DAYS FOLLOWING RECEIPT BY THE CONSULTANT OF THE
WRITTEN TERMINATION NOTICE. IN THAT EVENT, ANY
FINISHED OR UNFINISHED DOCUMENTS AND OTHER
MATERIALS PREPARED AND OR OTHERWISE COMPILED BY
CONSULTANT PURSUANT TO ITS PROVISION OF THE SERVICES
CONTEMPLATED IN SECTION 2 AND IN EXHIBIT "A", SHALL BE
PROMPTLY ASSEMBLED AND DELIVERED TO THE CITY, AT
CONSULTANT'S SOLE COST AND EXPENSE. IF THE
AGREEMENT IS TERMINATED BY THE CITY AS PROVIDED IN
THIS SUBSECTION, CONSULTANT SHALL BE PAID FOR ANY
SERVICES SATISFACTORILY PERFORMED, AS DETERMINED BY
THE CITY AT ITS SOLE DISCERTION, UP TO THE DATE OF
TERMINATION; PROVIDED, HOWEVER, THAT AS A CONDITION
PRECEDENT TO SUCH PAYMENT, CONSULTANT SHALL HAVE
DELIVERED ANY AND ALL DOCUMENTS, MATERIALS, ETC, TO
CITY, AS REQUIRED HEREIN.
4.6.3 Termination for Insolvency
The City also reserves the right to terminate the remaining Services to
be performed in the event the Contractor is placed either in voluntary
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or involuntary bankruptcy or makes an assignment for the benefit of
creditors. In such event, the right and obligations for the parties shall
be the same as provided for in Section 4.6.2.
4.6.4 Sanctions for Noncompliance with Nondiscrimination Provisions
In the event of the Contractor's noncompliance with the
nondiscrimination provisions of this Agreement, as applicable, the City
shall impose such sanctions as the City or the State of Florida may
determine to be appropriate, including but not limited to, withholding of
payments to the Contractor under the Agreement until the Contractor
complies and/or cancellation, termination or suspension of the
Services and/or the Agreement. In the event the City cancels or
terminates the Services and/or the Agreement pursuant to this
Subsection the rights and obligations of the parties shall be the same
as provided in Section 4.6.2.
4.7 CHANCES AND ADDITIONS
Any changes and additions to the terms of this Agreement shall be by a written
amendment, signed by the duly authorized representatives of the City and Contractor.
No alteration, change, or modification of the terms of this Agreement shall be valid
unless amended in writing, signed by the parties hereto, and approved by the City.
4.8 OWNERSHIP OF DOCUMENTS
Any changes and additions to the terms of this Agreement shall be by a
written amendment, signed by the duly authorized representatives of the City and
Contractor. No alteration, change, or modification of the terms of this Agreement
shall be valid unless amended in writing, signed by the parties hereto, and
approved by the City.
4.9 AUDIT AND INSPECTIONS
Upon 24-hour's written notice, the City Manager (on behalf of the City) and/or
such authorized representatives as the City Manager may deem to act on the City's
behalf, may, during Contractor's normal business hours, audit, examine and make
audits of all contracts, invoices, materials, payrolls, records of personnel, conditions
of employment, and any and all other data and/or records and/or documents
relating to all matters covered by this Agreement. Contractor shall maintain any and
all such records, as necessary to document compliance with the provisions of this
Agreement.
Contractor agrees to submit its agency financial audit to the City within 30
days of completion, at least once during the Contract period.
4.10 ACCESS TO RECORDS
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Contractor agrees to allow access during normal business hours to all
records including, without limitation, Contractor's financial records, to the City and/or
its authorized representatives, and agrees to provide such assistance as may be
necessary to facilitate audit by the City and/or its representatives, when and as the
City Manager, in his sole and reasonable discretion, may deem necessary to ensure
compliance with the provisions of this Agreement including, without limitation, as
they pertain to any financial audits (with applicable accounting and financial
standards). Contractor shall allow access during normal business hours to any and
all records, forms, files, and documents which have been generated in performance
of this Agreement, by the City and/or its authorized representatives.
4.11 DATA SECURITY OBLIGATION
Contractor shall maintain an appropriate level of data security for the
personally identifiable information (PII) Contractor is collecting or using in the
performance of this Contract. PH is information that can uniquely identify, contact,
or locate a single person or can be used with other sources to uniquely identify
individuals. Contractor shall maintain and adhere to a written Data Security Policy
.that addresses requirements regarding the protection of PI from unauthorized
access and protection against data breaches and ensures Contractor is in
compliance with applicable federal and state standards with respect to
transmission, receipt and storage of PH on Contractor's computing network and as
paper records. This policy shall address the topics of computer passwords,
screensavers that lock computers, securing physical facilities, storing data, data
use, data confidentiality agreements, and staff training related to the policy.
Additionally, Contractor is responsible for approving and tracking all Contractor
employees who request system or information access and ensuring that user
access has been removed from all terminated employees of Contractor. All
employees and independent contractors performing work or duties related to this
Contract will sign a Data Confidentiality Agreement prior to beginning work related
to this Contract.
4.12 INSURANCE REQUIREMENTS
Contractor shall not commence any work and/or Services pursuant to this
Agreement until all insurance required under this Section has been obtained and
such insurance has been reviewed and approved by the City's Risk Manager.
Contractor shall maintain and carry in full force during the term of this Agreement the
following insurance:
1. Comprehensive General Liability insurance, to include sexual molestation, in
an amount not less than $500,000 combined single limit per occurrence and
$1,000,000 aggregate in a policy year. Deductibles exceeding $1,000 are
discouraged, unless Contractor can provide financial statements to support a
higher deductible. The City of Miami Beach must be designated and shown as
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an additional insured and the certificate holder with respects to this coverage.
The general liability policy must contain coverage for the following:
a. Bodily Injury;
b. Property Damage;
c. No exclusions for Abuse, Molestation or Corporal Punishment;
d. No endorsement for premises only operations.
2. Professional Liability insurance, with coverage amounts not less than
$250,000 per claim and in the aggregate. Defense costs may be inside the
limits of liability and the policy can be written on claims made form. The City of
Miami Beach is not required to be named as an Additional Insured.
Professional liability insurance is generally required when the scope of
services uses professional services that require certification or license(s) to
provide direct services to program participants.
3. Worker's Compensation Insurance covering all employees, non-incorporated
independent contractors or consultants, and incorporated independent
contractors or consultants that do not have worker's compensation coverage
or a valid State of Florida exemption on file with the Department of Labor, as
required by Florida Statutes, Chapter 440. In the event that the Contractor is
no longer exempt from obtaining Worker's Compensation insurance, the
Provider must notify the City of Miami Beach and provide the necessary
certificate of insurance upon the termination of the exemption. The employer's
liability portion will be $500,000/$500,000/$500,000 as a minimum.
All insurance required hereunder must be furnished by insurance companies
authorized to do business in the State of Florida.
Original certificates of insurance for the above coverage must be submitted to
the City's Risk Manager at the Office of the Risk Manager of the City of Miami Beach,
1700 Convention Center Drive, Miami Beach, Florida 33139.
The Contractor is solely responsible for obtaining and submitting all insurance
certificates for its sub-contractors.
All insurance policies must be issued by companies authorized to do business
under the laws of the State of Florida. The companies must be rated no less than
"B+" as to management and not less than "Class VI" as to strength by the latest
edition of Best's Insurance Guide, published by A.M. Best Company, Oldwick, New
Jersey, or its equivalent.
Compliance with the foregoing requirements shall not relieve the Contractor of
the liabilities and obligations under this Section or under any other portion of this
Agreement, and the City shall have the right to obtain from the Contractor specimen
copies of the insurance policies in the event that submitted certificates of insurance
are inadequate to ascertain compliance with required overage.
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All of Contractor's certificates, as required in this Section 4.11, shall contain
endorsements providing that written notice shall be given to the City at least thirty
(30) days prior to termination, cancellation or reduction in coverage in the policy.
The Contractor shall not commence any work and/or Services pursuant to this
Agreement until the City's Risk Manager has received, reviewed and approved, in
writing, certificates of insurance showing that the requirements of this Section (in its
entirety) have been met and provided for.
4.13 ASSIGNMENT, TRANSFER OR SUBCONTRACTING
The Contractor shall not subcontract, assign, or transfer any work under this
Agreement without the prior written consent of the City Manager which consent, if
granted at all, shall be at the Manager's sole and absolute discretion:
4.14 SUB-CONTRACTORS
The Contractor shall be liable for Contractor's services, responsibilities and
liabilities under this Agreement, and the services, responsibilities and liabilities of
sub-contractors, and any other person or entity acting under the direction or control
of Contractor. When the term "Contractor" is used in this Agreement, it shall be
deemed to include any sub-contractors and any other person or entity acting under
the direction or control of Contractor. All sub-contractors must be approved, in
writing by the City Manager, or his designee, prior to their engagement by
Contractor (which approval, if granted at all, shall be at the Manager's sole
discretion and judgment).
4.15 EQUAL EMPLOYMENT OPPORTUNITY
In connection with the performance of this Agreement, the Contractor shall
not discriminate against any employee or applicant for employment because of
race, color, religion, ancestry, sex, age, and national origin, place, of birth, marital
status, or physical handicap. The Contractor shall take affirmative action to ensure
that applicants are employed and that employees are treated during their
employment without regard to their race, color, religion, ancestry, sex, age, national
origin, place of birth, marital status, disability, or sexual orientation, as applicable.
4.16 NO CONFLICT OF INTEREST
The Contractor agrees to adhere to and be governed by the Metropolitan
Miami-Dade County Conflict of Interest Ordinance, as same may be amended from
time to time; and by City of Miami Beach Code, as same may be amended from
time to time.
The Contractor covenants that it presently has no interest and shall not
acquire any interest, direct or indirectly which should conflict in any manner or
degree with the performance of the Services. The Contractor further covenants that
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in the performance of this Agreement, no person having any such interest shall
knowingly be employed by the Consultant. No member of or delegate to the
Congress of the United States shall be admitted to any share or part of this
Agreement or to any benefits arising there from.
4.17 PATENT RIGHTS; COPYRIGHTS; CONFIDENTIAL FINDINGS
Any patentable result arising out of this Agreement, as well as all information,
design specifications, processes, data and findings, shall be made available in
perpetuity to the City, for public use.
No reports, other documents, articles or devices produced in whole or in part
under this Agreement shall be the subject of any application for copyright or patent
by or on behalf of the Contractor or its employees or subcontractors.
4.18 NOTICES
All notices and communications relating to the day-to-day activities shall be
exchanged between a project manager appointed by the Contractor and the
program coordinator designated by the City Manager, who shall be Neighborhood
Services Department, Office of Community Services, Division Director or his/her
designee. The Contractor's project manager shall be designated following execution
of this Agreement by the parties and prior to commencement of the Services.
All other notices and communications in writing required or permitted
hereunder may be delivered personally to the representatives of the Contractor and
the City listed below or may be mailed by registered mail.
Until changed by notice in writing, all such notices and communications shall
be addressed as follows:
TO CONTRACTOR:
Ayuda, Inc.
Attn: Diana Susi, Executive Director
7144 Byron Avenue
Miami Beach, Florida 33141
(305) 864-6885
TO CITY:
City of Miami Beach
Office of Community Services
Attn: Maria L. Ruiz, Director
1700 Convention Center Drive
Miami Beach, Florida 33139
(305) 673-7491
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4.19 LITIGATION JURISDICTION/VENUE
This Agreement shall be governed by, and construed in accordance with, the
laws of the State of Florida, both substantive and remedial, without regard to
principles of conflict of laws. The exclusive venue for any litigation arising out of the
Agreement shall be Miami-Dade County, Florida, if in State court, and the U.S.
District Court, Southern District of Florida, if in federal court.
BY ENTERING INTO THIS AGREEMENT, CONTRACTOR AND CITY
EXPRESSLY WAIVE ANY RIGHTS EITHER PARTY MAY HAVE TO A TRIAL BY
JURY OR ANY CIVIL LITIGATION RELATED TO, OR ARISING OUT OF, THIS
AGREEMENT.
4.20 ENTIRETY OF AGREEMENT
This writing and any exhibits and/or attachments incorporated (and/or
otherwise referenced for incorporation) herein embody the entire Agreement and
understanding between the parties hereto, and there are no other agreements and
understandings, oral or written, with reference to the subject matter hereof that are
not merged herein and superseded hereby.
4.21 LIMITATION OF CITY'S LIABILITY
The City desires to enter into this Agreement only if in so doing the City can
place a limit on the City's liability for any cause of action for money damages due to
an alleged breach by the City of this Agreement, so that its liability for any such
breach never exceeds the sum of $1,000. Contractor hereby expresses its
willingness to enter into this Agreement with Consultant's recovery from the City for
any damage action for breach of contract to be limited to a maximum amount of
$1,000.
Accordingly, and notwithstanding any other term or condition of this
Agreement, Contractor hereby agrees that the City shall not be liable to the
Contractor for damages in an amount in excess of $1,000 for any action or claim for
breach of contract arising out of the performance or non-performance of any
obligations imposed upon the City by this Agreement. Nothing contained in this
paragraph or elsewhere in this Agreement is in any way intended to be a waiver of
the limitation placed upon the City's liability as set forth in Section 768.28, Florida
Statutes.
4.22 BACKGROUND SCREENING
In accordance with Sections 943.0542, 984.01, Chapter 430, 435, 4022
39.001, and 1012.465 Florida Statutes, as applicable, employees, volunteers and
subcontracted personnel who work in direct contact with children or who come into
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direct contact with children must complete a satisfactory Level 2 background
screening prior to commencing work pursuant to this Contract.
For purposes of this section, the term "direct service provider" means a person
18 years of age or older, including a volunteer, who provides services to children,
youth and their families. The term does not include volunteers who assist on an
intermittent basis for less than 20 hours per month.
Level 2 Background screenings must be completed through the Florida
Department of Law Enforcement (FDLE) VECHS (Volunteer & Employee Criminal
History System) Program. Satisfactory background screening documentation will be
accepted for those agencies that already conduct business with either the
Department of Children and Families (DCF) or the Department of Juvenile Justice
(DJJ) or the Miami Dade County Public School System (MDCPS). A clearance letter
from MDCPS Office of Employment Standards indicating the person has
successfully completed a Level 2 screening will be accepted.
If background screenings are completed with VECHS, then Provider shall
complete Attachment E: "Affidavit for Level 2 Background Screenings" each for
contract term. The Affidavit will cover employees, volunteers, and subcontractors
performing services under this contract who are required to complete a Level 2
background screening as defined in this section. Provider shall keep Attachment E:
"Affidavit for Level 2 Background Screenings" in Provider's personnel, volunteers,
and sub-contractors files. Provider shall re-screen each employee, volunteer and/or
subcontractor every five years.
[REMAINDER OF THIS PACE LEFT INTENTIONALLY BLANK]
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IN WITNESS WHEREOF, the parties hereto have caused this Agreement to
be executed by their appropriate officials, as of the date first entered above.
FOR CITY: CITY OF MIAMI BEACH, FLORIDA
ATTEST:
By: /2
Ci y Clerk
La 'd'0
A-
Daf e Date
FOR CONTRACTOR: AYUDA, INC., a Florida corporation
ATTEST:
By: By:
itle: o-^ C if motor- Title:
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Print Name Print Name
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Date Date
Corporate Seal
APPROVED AS TO
FORM & LANGUAGE
F0'1 XECUTION
6;4&
y Attorney Date
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EXHIBIT "A"
"SCOPE OF SERVICES"
The Contractor agrees to provide the following services to youth referred to the
Success University program:
Service Units of Documentation of
Intake (Initial Assessment) 0 Completion and execution of the following documents:
• The Children's Trust Adult Info Form
• The Children's Trust Child Info Form
• The Children's Trust Photography/Video Release
Form
- Miami Beach Service Partnership Authorization for
Release and Exchange of Information
• Miami-Dade County Public Schools Consent Form
for Mutual Exchange of Information
• Miami Beach Service Partnership Attendance Form
• Miami Beach Service Partnership Intake (Initial
Assessment) Form
Review and inclusion of the following documents:
• ISIS Parent Information
• ISIS Student Information
• ISIS Current School Year Attendance Records
• ISIS Prior School Year Attendance Records
• ISIS Current School Year Grade Report
• ISIS Prior School Year Grade Report
• ISIS Current School Year Disciplinary Referral
Report
- ISIS Prior School Year Disciplinary Report
Issuance of appointment for the following:
- Care Coordination Assessment & Plan Development
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Care Coordination 19 Completion and execution of the following documents:
Assessment & Plan • Success University Assessment Form via
Development Community OS;
• Referral Form(s) with documentation of service
provided via Community OS software and referral
authorizations_containing original signatures;
• Acknowledgement of Service Availability Form;
• Attendance form signed by all attendees
Issuance of appointment for the following:
• Family Group Conferencing session (inclusive of
documentation of attendees and transportation needs)
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Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery..
Family Group Conference 0 Completion and execution of the following documents:
• Family Group Conferencing Attendance Form
• Family Group Conferencing Action Plan
• Family Group Conferencing Confidentiality
Agreement
Review and inclusion of the following documents:
• Strengths & Concerns Form
• Eco-Map
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Care Coordination Plan 19 Completion and execution of the following documents:
Review
• Care Coordination Plan, including client(s) and staff
signatures with documentation of service provided via
Community OS software
• Care Coordination Plan Case Notes via Community
OS software
• Parental Stress Scale (PSS):pre-test
• Strengths and Difficulties Questionnaire (SDQ): pre-
test
• For exactly two clients and their families: Adult
Adolescent Parenting Inventory (AAPI): Constructs B
through E:pre-test
• Referral Form(s) with documentation of service
provided via Community OS software, if applicable
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Care Coordination Plan 19 Completion and execution of the following documents:
Check-In
• Updated Care Coordination Plan including staff
signatures and client signatures, if applicable, with
documentation of service provided via Community OS
software
• Care Coordination Plan Case Notes via Community
OS software
• Referral Form(s) with documentation of service
provided via Community OS software, if applicable
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Flexible Care Coordination 8 Completion and execution of the following documents:
Plan Check-In
• Updated Care Coordination Plan including staff
signatures and client signatures, if applicable, with
documentation of service provided via Community OS
software
• Care Coordination Plan Case Notes via Community
OS software
• Referral Forms with documentation of service
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Miami Beach Service Partnership
provided via Community OS software, if applicable
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Care Coordination Plan 19 Completion and execution of the following documents:
Close-Out
• Updated Care Coordination Plan including client and
staff signatures with documentation of service
provided via Community OS software
• Care Coordination Plan Close-Out Case Notes via
Community OS software
• Referral Form(s) with documentation of service
provided via Community OS software, if applicable
• Program Evaluation Form completed by all clients
• Parental Stress Scale (PSS):post-test
• Strengths and Difficulties Questionnaire (SDQ):
post-test
• For the two clients and their families completing the
pre-test version of the same: Adult Adolescent
Parenting Inventory (AAPI): Constructs 8 through E.
post-test
Notification email, to be sent from Contractor to
City staff within 72 hours of service delivery.
Related Definitions:
Intake (Initial Assessment)— The Intake provides prospective clients with an
overview of Success University and the benefits and expectations of program
participation. Parental and client consents required for program participation are
executed at this time, enabling the provision of further services.
The Intake marks the initial consent for service and establishes the appointment for
the completion of the Assessment. A list of forms associated with this service is
delineated in Exhibit B.
Additional information is provided in Exhibit D.
Care Coordination Assessment & Plan Development—The Care Coordination
Assessment & Plan Development ("Assessment") documents the natural supports
and needs of the client and his/her family. The assessment forms must be completed
accurately and completely and submitted to the City, where the client is assigned a
number in The Children's Trust's data management system, SAMIS.
Assessments must meet the following criteria:
• Information collected is documented completely and accurately
• Adherence to grammar and spelling rules for the English language
• A sincere and thorough effort to understand the client, his/her family, and
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Miami Beach Service Partnership
their respective strengths and needs
• Effective engagement to ensure that the client and his/her family are
informed regarding program services and expectations as well as the
means/process by which to access additional services
• Full, thorough, detailed explanation of the program, its timeline, what the
client and his/her family can expect, and Care Coordination.
• All client and family questions are answered completely
• All client and family needs have been identified and subsequently
addressed via Referral
• The factors adversely impacting the primary concern (school attendance,
risk of child maltreatment, or prevention of youth violence) have been
identified and subsequently addressed via Referral
• All Care Coordination goals, steps, and timelines are identified
The Acknowledgement of Service Availability must be completed documenting that
the client and his/her parent were asked if they needed any additional services
beyond those offered.
Assessments must be completed within thirty (30) days of referral.
The Assessment also includes the issuance of an appointment for a Family Group
Conference and the documentation of all invited participants for the conference. The
appointment must be documented via Community OS software under the FGC tab.
Contractor must make a good faith effort to invite as many participants to the FGC as
possible.
Additional information is provided in Exhibit D.
Deferrals — Referrals include the identification of a specific client need and the
subsequent identification of a community-based resource and/or strategy to address
the need.
Referrals must be provided for all service needs recognized in the intake and
assessment and for client -initiated requests — especially those that influence the
primary concern (school attendance, risk of child maltreatment, or prevention of youth
violence). Referrals must be issued with the following client-focused interests in mind:
• Is the referral appropriate within the scope of Success University?
• Does the referral specifically address the need identified?
• Can the client access the services being sought via the referral, and did the
Contractor give detailed instruction on how to do so?
• Is the agency provided in the referral the most accessible, most appropriate
provider for the services needed?
• Is the referral culturally appropriate?
• Does the client consent to receiving the referral?
These referrals must be documented using the Miami Beach Service Partnership
Referral Form and via Community OS software. A' list and attached forms are found
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Miami Beach Service Partnership
in Exhibit B.
Additional information is provided in Exhibit D.
Family Group Conference — The Family Group Conference expounds upon the
information obtained via the Assessment process to focus the natural assets
available in and around the child's support network to ensure school attendance, safe
communities, supportive families, and personal success as defined by the client and
his/her family and friends.
The documentation, which is the product of the conference, must include the
following at a minimum:
• At least three (3) goals identified in the Action Plan
• At least twelve (12) strengths have been identified for the child
• At least three (3) strengths have been identified for the family
Care Coordination Plan Review— The Care Coordination Plan outlines the specific
strategies and steps to be taken by the child and his/her family members to address
school attendance, the risk of child maltreatment, the prevention of youth violence,
and personal and family stability. The plan identifies the issues to be addressed and
the respective community-based agencies, natural supports, or general resources
that will be harnessed in response. The Contractor will review and discuss with the
clients each item listed on the Care Plan individually, and both parties will agree to its
terms collectively. Shared decision-making is the crux of this document; as such, the
Contractor and client may jointly request changes to the Care Plan, which
subsequently must be approved by the City.
The Care Coordination Plan Review is conducted in person with, at a minimum, the
primary client and one parent or legal guardian present. The contact will document
following minimum criteria:
• Detailed review of the entire Care Coordination Plan
• Progress on the Assessment Referrals is reviewed and documented
• All client questions answered in detail
• Detailed direction on how to access each item included on the Care Plan is
provided (e.g., call for an appointment, address, public transit info, etc.)
• The identification of any additional needs or issues were discussed and,
when appropriate, referrals were subsequently issued
• Outcome measurement tools are explained in detail to the client prior to
their completion of the documents
• Outcome measurement tools are completed clearly, accurately, and in their
entirety
A Care Coordination Plan Review is to take place within the following timeframe:
• Within fourteen (14) days of the Assessment
A list and attachment of appropriate forms are found in Exhibit B
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Miami Beach Service Partnership
Care Coordination Plan Check-in —A Care Coordination Plan Check-In provides an
opportunity to monitor the client's progress towards the goals identified via the Care
Coordination Plan as well as to identify any new concerns or issues that require
action through referral. In addition, a status update on child attendance, risk of child
maltreatment, and/or prevention of youth violence, must be included, as appropriate.
A Care Coordination Plan Check-In is at minimum, 45 minutes in length and is
conducted in person or by phone. The contact will document following minimum
criteria:
• Progress on child attendance, risk of child maltreatment, and/or prevention
of youth violence is reviewed and documented
Progress on the Care Coordination Plan is reviewed and documented
• The identification of any additional needs or issues affecting school
attendance, risk of maltreatment, or prevention of youth violence are
discussed and, when appropriate, referrals are subsequently issued
The Care Coordination Plan Check-In is to take place within the following timeframe:
• Seven (7) to twenty-one (21) days of Care Coordination Plan Review
A list and attachment of appropriate forms are found in Exhibit B.
Flexible Care Coordination Plan Check-in — The Flexible Care Coordination Plan
Check-In is identical to the Care Coordination Plan Check-In in scope and
documentation.
Care Coordination Plan Close-Out — The Care Coordination Plan Close-Out
documents the client's successful completion of all items and strategies identified in
the Care Plan. Conversely, failure to complete the Care Plan should trigger a referral
to an alternate program or exploration of alternate educational options for the client.
A Care Coordination Plan Close-Out is conducted in person with both the child/youth
client and the client's parent/guardian. The contact will document following minimum
criteria:
• Progress on child attendance, risk of child maltreatment, and/or prevention
of youth violence is reviewed and documented
• Completion of the Care Coordination Plan is reviewed and documented
• Completion of the Service Evaluation Form by every client
• Completion of Attendance Form, signed by all attendees.
• Outcome measurement tools are explained in detail to the client prior to
their completion of the documents
• Outcome measurement tools are completed clearly, accurately, and in their
entirety.
Should the Contractor encounter challenges in meeting the below stated
service deliverables within the required timeframes, the Contractor may
request an extension. The approval and duration of all extensions are at the
sole discretion of the City.
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Miami Beach Service Partnership
Service Deliverables
Services must be delivered as follows:
rVir
be Un'it of!Service Service Location 'Timefram,e
Intake & Consent 1 for each of up to 0 School or Upon consent of
children/families Client Home client
Care Coordination 1 for each of up to 19 Client Home All eligible
Assessment & Plan children/families Assessments will be
Review completed within
thirty (30) days of
receipt of referral
Care Coordination Plan 1 for each of up to 19 Client Home All eligible Care
Review children/families Coordination Plan
Reviews will be
completed within
fourteen (14) days
of completed
Assessment
Care Coordination Plan 1 for each of up to Client Home All Care
Check-In 19 children/families Coordination Plan
Check-Ins will be
completed within
seven
(7) to twenty-one
(21) days from Care
Coordination Plan
Review completion
Flexible Care Up to 8 total Client Home Flexible Care
Coordination Plan Coordination Plan
Check-In Check-Ins will be
completed as
triggered by client
need.
Care Coordination Plan 1 for each of up to 19 Client Home All Care
Close-Out children/families Coordination Plan
Close-Outs will be
completed within
one hundred eighty
(180) days of
Assessment.
Service Benchmarks
Service Benchmark(s)
Intake (Initial Assessment) e Completed documents as outlined above
- Appointment for Assessment
Care Coordination - Completed Assessment documents as outlined
Assessment & Plan above
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Development - Targeted assessment of primary child concern
(truancy, risk of child maltreatment, or youth violence)
• Referrals Responding to all Service Needs
• Appointment for Family Group Conference
Family Group Conference - Family Group Conference documents as outlined
above
• Reflection of primary child concern in Action Plan
(truancy, risk of child maltreatment, or youth violence)
• At least three (3) goals identified in the Action Plan
• At least twelve (12) strengths have been identified for
the child
• At least three (3) strengths have been identified for
the family
Care Coordination Plan - Care Coordination Plan Review documents as
Review outlined above
• Reflection of primary child concern as driving factor
in Care Plan (truancy, risk of child maltreatment, or
youth violence)
- Deep understanding of the Care Plan by child and
parent/guardian
-Shared decision-making in Care Plan edit
suggestions
Care Coordination Plan - Deep understanding of the Care Plan by child and
Check-In parent/guardian
-Shared decision-making in Care Plan edit
suggestions
Flexible Care Coordination - Deep understanding of the Care Plan by child and
Plan Check-in parent/guardian
-Shared decision-making in Care Plan edit
suggestions
Care Coordination Close- - Care Plan showing at least 76% completion
out - Program Evaluation Form completed by each client
Service Documentation
Services will be deemed as provided when the following documentation is provided
within the noted timeframes:
Service Documentation o • - . •
Care Coordination - Assessment Form; Three (3) business days i
Assessment & -Acknowledgement of Service from provision of
Plan Develo ment
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Miami Beach Service Partnership
Availability Form; service
• Miami Beach Service Partnership
Referral Form(s)
- Notification Email, including FGC
information
Referrals • Miami Beach Service Partnership Three (3) business days
Referral Form(s) signed by staff and from the identification of
receiving client(s). client need
Care Coordination - Care Coordination Plan Form signed Three (3) business
Plan Review by staff and client(s) days from provision of
- Updated Care Coordination Plan, with service
changes as required
- Related case notes, provided via
Community OS
• Notification Email
• Additional Referrals, as required.
Care Coordination • Care Coordination Plan Form signed Three (3) business days
Plan Check-In by staff and client(s) from provision of
• Updated Care Coordination Plan, with service
changes as-required
- Related case notes, provided via
Community OS
• Notification Email
• Additional Referrals, as required.
Flexible Care - Care Coordination Plan Form signed Three (3) business days
Coordination Plan by staff and client(s) from provision of
Check-In - Updated Care Coordination Plan, with service
changes as required
• Related case notes, provided via
Community OS
• Notification Email
• Additional Referrals, as required
Care Coordination - Care Coordination Plan Form signed Three (3) business days
Plan Close-Out by staff and client(s) from provision of
- Updated Care Coordination Plan, with service
changes as required
Related case notes, provided via
Community OS
• Service Evaluation Form
• Notification Email
• Additional Referrals, as required
Penalties for Failure to Perform
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Miami Beach Service Partnership
If the Contractor fails to submit required, accurate documentation in the timeframe
allotted two times, the Contractor will forfeit one (1%) percent of the combined billed
total for the months in which inaccuracies took place.
If the Contractor fails to submit required, accurate documentation in the timeframe
allotted three times within the contract period, the Contractor is subject to the
cessation of any further client referrals but will be allowed to complete the service
units allotted to existing clients. The decision to cease additional referrals rests at the
sole discretion of the City.
"Required, accurate documentation" may refer to:
• Monthly invoices
• Monthly narratives
• Monthly client lists
• Monthly in-kind hours
• Client assessments
• Referral forms
• Family Group Conference documents
• Any documents associated with Care Coordination, including Care Plan
Certification forms, Care Plan Contact forms, Care Plan Close Out forms,
Attendance forms, Service Evaluation forms, and any other documentation
related to this Contract.
If any individual employed by or independently contracted with the Contractor fails to
attend a scheduled client meeting without notifying the City of their impending
absence more than once, the City reserves the right to remove that individual from
the Contractor's staff roster for the purposes-of this Contract.
If the Contractor is unable to fulfill the contracted service level within the allocated
timeframe for each service component, the City reserves the right to reduce service
levels accordingly across the funded service spectrum.
If the Contractor is unable to fulfill the contracted service level and the City
subsequently reduces service and funding levels, the City reserves the right to select
another vendor to fulfill the remaining service units. The City will select the alternate
vendor at its sole discretion.
Engagement Strategies
The Contractor will adhere to the following engagement strategies in the delivery of
Care Coordination services:
• Advise the client and his/her parents and/or guardians of the scheduled
appointment for Family Group Conference at the time of the Assessment.
• Provide client and his/her parents and/or guardians information regarding the
importance of adhering to school attendance policies, if applicable.
• , Provide client and his/her parents and/or guardians information regarding the
Care Coordination process and other available services.
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Miami Beach Service Partnership
• Reintroduce the services available through the Program at each client
interaction.
• Document every interaction with or on behalf client via Community OS.
Employee/ Contractor File Review
The following documentation must be included in the employee/contractor file for
those employees/contractors providing services under this contract.
The following must be included in the employee files:
• Employment Application
Evidence of degree/credentials
• Job Description Signed by Employee
• Evidence of Required Experience
Florida Background Criminal Screening
• National FBI Background Criminal Screening (Level2)
• Affidavit of Good Moral Character
• Proof of Knowledge of Policies & Procedures
• Confidentiality Agreement Re: Client Information
• Documentation of Agency Training/In-Service Training
Documentation of attendance at one CCDH training
• 1-9 Verification on File
Monitoring visits will take place within forty-five (45) days of the commencement of
services. The City will notify the Contractor a minimum of ten (10) business days
notice prior to a monitoring visit.
The City of Miami Beach reserves the right to inspect employee/contractor files with
due notice (at least forty-eight (48) hours in advance of planned site visit) to ensure
adherence to contractual expectations as well as to ensure pre-screening prior to a
monitoring visit by The Children's Trust.
Evaluation
In the continuing effort to ensure programming excellence, clients will be provided
with evaluation forms at the end of each programming component to gauge their
satisfaction with services provided. At a minimum, the Contractor must obtain
evaluation forms from the primary child client and the parent/guardian. The evaluation
forms will be provided by the City and must be administered at the following times:
• Completion of Family Group Conference
• Completion of Care Plan Close Out (program evaluation form)
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Reporting Requirements
The Contractor will provide the City with a Monthly Progress Report and
reimbursement request utilizing the City's Reporting and Reimbursement Forms
(Exhibit C) by 5:00 PM on the third (3rd) of the following month. A client list detailing
the dates, services provided, and clients receiving said services must be included. If
in-kind hours are being submitted, back-up documentation stating the same must be
included. In the event that the third of the month lands on a Saturday, Sunday or
holiday, the report must be submitted the following business day.
Monthly reports and reimbursement requests will be submitted via any of the
following methods:
• Electronic mail
• Facsimile
• Standard mail
• Hand delivery
Monthly reports will not be considered acceptable unless the following is met:
• Forms are completely and accurately filled
• Necessary back-up materials are included (client documentation, expense
receipts, time logs, etc.)
• Reports bear the signature of the person submitting the report on behalf of
the Contractor
The City will document Contractor service level data and monthly reports via Active
Strategy software for inclusion in the monthly report to the Miami Beach Governing
Board as well as the City's website.
Governing Board Attendance
The Contractor is required to have representation at each calendared Governing
Board meeting. In the event you cannot attend in person, arrangements can be made
for a telephonic connection.
If the Contractor fails to have representation at two meetings, the City reserves the
right to reduce contracted service levels at its sole discretion.
Master Calendar
The Contractor will notify the City of any client appointment or anticipated service
delivery at least 72 hours in advance of the appointment or service delivery for
inclusion in the Success University Master Calendar that is distributed to all members
of the Miami Beach Service Partnership via Community OS Software. The Master
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Miami Beach Service Partnership
Calendar will be updated daily and distributed to the Partnership via Community OS
Software.
The Contractor must provide its availability for intake services inclusive of the number
of staff members, the hours they are available and the languages they speak. This list
must be up-to-date at all times.
Memoranda of Understanding
A Memorandum of Understanding (MOU) reflecting the terms of this agreement as
well as commitment to the Miami Beach Service Partnership will be provided and
updated as necessary. The MOU must be submitted to the City of Miami Beach prior
to execution of the service contract and must be executed by the agency Executive
Director or Board of Directors Chairperson.
Monitoring & Performance Reviews
The City of Miami Beach reserves the right to inspect, monitor and/or audit the
Contractor to ensure contractual compliance. This includes, but is not limited to:
• Review of on-site service delivery
• Inspection and review of client, budgetary and employee files (for those
employees providing services under this contract)
The monitoring tool provided by The Children's Trust, Community and Neighborhood
Services System of Care Programmatic Site Visit Form, will be used to guide
inspections and monitoring visits. (Copy included herein.)
Monitoring visits will take place within forty-five (45) days of the commencement of
services. The City will notify the Contractor a minimum of ten (10) business days
notice prior to a monitoring visit.
Partner Performance Ratings
The Contractor agrees that its Partner Performance Rating, the score awarded for
performance on the following measures, will be posted on the City's website on a bi-
annual basis:
• Timely and accurate submission of monthly progress report
• Timely and accurate submissions of monthly financial reports (reimbursement
requests)
• Delivery of contracted service units
• Promotion of the Miami Beach Service Partnership
• Attendance at Miami Beach Service Partnership Governing Board and related
committee(s) meetings
Ratings will be given for each performance measure based on the following:
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Miami Beach Service Partnership
Promotion & Public Relations Requirements
The Contractor agrees to receive Success University Program Brochures and make
them available to clients during all in-person client interactions.
The Contractor agrees to link its website to the City's Success University webpage.
Such link must be in place prior to the execution of this contract.
- • 'Rating • •
Timely and accurate submission of ➢ "0" for failing to submit on time
monthly progress report ➢ 15" for submitting on time
Timely and accurate submissions of ➢ "0" for failing to submit accurate
monthly financial reports report with back-up material on time
(reimbursement requests) ➢ 15" for submitting accurate report on
time
Delivery of contracted service units Possible score of 0 to 50 based upon
completion of projected service units.
Score is calculated by dividing the
completed number of service units by
the total number of referred service
units.
➢ For agencies providing Care
Coordination, possible score of 0 to 40
for completion of projected service
units
➢ For agencies providing Care
Coordination, possible score of 0 to 10
for completion of Care Coordination
plans. Score is calculated by dividing
the completed number of Care
Coordination plans by the total number
of referred Care Coordination clients.
Attendance at Miami Beach Service Possible score of 0 to 20:
Partnership Governing Board and 10 Points for attendance at Governing
related committee(s) meetings Board meetings; 10 points for
Committee attendance (In the event
that there are no committee meetings
scheduled, the value for attendance at
the Governing Board meeting will be
20.)
The Contractor agrees to indicate its membership in the Partnership in all self-
produced marketing materials that are produced for the benefit of youth and families.
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Miami Beach Service Partnership
Training Requirements
Personnel providing services under in this Contract will be required to complete the
following trainings prior to service provision, as delineated below:
Care Coordination Services: City ❑ Program Overview Training
provided trainings ❑ Assessment & Referral Training
❑ Care Coordination Training
❑ Community OS Software Training
❑ Client Evaluation Survey Training
Care Coordination Services: Additional ❑ Family Group Conference Audit
required trainings ❑ CCDH Disability awareness training
Family Group Conferencing Services ❑ Program Overview Training
The total training time required under "Care Coordination Services: City provided
trainings" is two business days. While initial training expenses are covered by the
City, the Contractor agrees to reimburse the City for the early departure (termination)
of any trained staff member prior to this contract's termination on a pro-rated basis as
follows:
Training Cost
Program Overview Training $150.00
Assessment & Referral Training $150.00
Community OS Training $150.00
Client Evaluation Survey Training $150.00
Care Coordination Training $150.00
The Contractor agrees to send at least one representative to attend a City-sponsored
grant writing workshop by July 31, 2014. Alternately, the Contractor may submit
documentation indicating at least one member of its staff has attended another Grant
Writing training in the same period of time.
The Contractor agrees to send its Miami Beach Service Partnership Governing Board
representative to a City-sponsored board member refresher training at a minimum of
once every two years.
Switchboard of Miami Registration
Contractor agency will register with Switchboard of Miami to ensure that agency
information is accurate and updated. This contractual obligation is directed by The
Children's Trust. Agency registration can be done at the following website:
www.switchboardmiami.org
Additional Documentation
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Miami Beach Service Partnership
The following documentation must be submitted with this executed agreement:
• All required insurance certificates
• Copy of current audit
• Copy of required business licenses and permits
• Copy of notice as recipient of funding from The Children's Trust
• Updated Memorandum Of Understanding (MOU) reflecting scope of services
and leverage associated with Success University
[REMAINDER OF THIS PAGE LEFT INTENTION ALLY BLANK]
City of Miami Beach-Ayuda, Inc. Page 29 of 32
Miami Beach Service Partnership
EXHIBIT "B"
DOCUMENTATION
The Contractor agrees to utilize the following forms to document the delivery of
services with copies attached herein:
• Consent Forms:
• The Children's Trust Adult Info Form
• The Children's Trust Child Info Form
• The Children's Trust Photography/Video Release Form
• Miami Beach Service Partnership Authorization for Release and
Exchange of Information
- Miami Dade County Public Schools Consent for Mutual Exchange of
Information
• Success University Enrollment Sign-In Sheet
• Intake (Initial Assessment) Form
• Assessment Form
• Referral Form
• Care Coordination Plan (Blueprint for Success)
• Service Evaluation Form
• Acknowledgement of Service Availability Form
• Success Universit Attendance Form
y
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Miami Beach Service Partnership
r
EXHIBIT 66019
INVOICING
The Contractor agrees to provide the invoicing and services documentation as
indicated utilizing the following forms attached herein:
• Monthly Service Summary Report, and
• Monthly Reimbursement Request
• Monthly Client Status List
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Miami Beach Service Partnership
r
EXHIBIT "®"
ATTACHMENTS
The following reference documents are attached:
• 2013/14 Success University Client Path
• 2013/14 Success University Provider Path
FAQ Sheet
TCT Core Contract
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Miami Beach Service Partnership