97-22376 RESO
RESOLUTION NO.
97-22376
A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF
THE CITY OF MIAMI BEACH, FLORIDA, AUTHORIZING AND
DIRECTING THE SUBMISSION OF AN APPLICATION IN THE
AMOUNT OF $416,181.77 TO THE STATE OF FLORIDA
DEPARTMENT OF CHILDREN AND FAMILIES SERVICES (CFS),
FOR CONTINUATION OF FUNDING OF THE LOG CABIN
TRAINING CENTER, FROM THE STATE OF FLORIDA
DEPARTMENT OF CHILDREN AND FAMILIES SERVICES FOR
THE FOLLOWING PROGRAMS: THE DEVELOPMENTAL
TRAINING PROGRAM CONSISTING OF AN INDEPENDENT
LIVING SKILLS PROGRAM AND TRANSPORTATION SERVICES;
AND THE SUPPORTED INDEPENDENT LIVING PROGRAM (SIL),
BOTH DESIGNED TO BENEFIT DEVELOPMENTALLY DISABLED
ADULTS; AND, TO APPROPRIATE FUNDS AND EXECUTE
CONTRACT(S) FOR THE FINAL GRANT AWARD(S), FOR THE
PERIOD OF JULY 1,1997 TO JUNE 30,1998.
----
.~
WHEREAS, the State of Florida, Department of Children and Families Services (CFS) i;
desirous of having the City of Miami Beach apply for continued funding to provide indepencler t
living skills training, supported employment training, transportation services, and supp01ej
independent living for developmentally disabled adults; and
WHEREAS, the City has been successfully operating CFS programs since 1983 and wishe;
to continue to provide these essential services; and
WHEREAS, the City of Miami Beach Log Cabin Training Center is currently servin.~
Medicaid-eligible clients, and the Log Cabin Training Center is a certified Medicaid provider; anj
WHEREAS, the City is desirous of submitting a Grant application for continued fundin~L i 1
order to provide essential support and services to developmentally disabled adults in the estimatej
amount of $416,181.77 for the period from July 1, 1997, through June 30,1998; and
WHEREAS, the City will prepare a final budget in accordance with the applicable G-ar t
period and the amount negotiated with CFS; and
WHEREAS, it is necessary that such funds be appropriated for the final Grant award
NOW THEREFORE, BE IT RESOLVED BY THE MAYOR AND CITY COMMISSION Of:
THE CITY OF MIAMI BEACH FLORIDA:
Section 1.
That the Administration is authorized to prepare and submit an applicatiol
to the State of Florida Department of Children and Families Services (CFS ,
in accordance with the Grant period and the amount negotiated with CFE.
Section 2.
That the Administration is authorized to appropriate funds for the final G"ant
award.
Section 3.
That the Mayor and City Clerk are herein authorized and directecl t,)
execute, when awarded, the Grant Agreement in order to provid,~
independent living skills training, supported employment training, and
transportation services for up to fifty-three (53) developmentally disable.,!
adults at the Miami Beach Log Cabin Training Center.
PASSED AND ADOPTED THIS 7TH DAY OF fAY, 1997.
1;1"11 r- __
ATTEST:
~ 0 l..4 J- r tlAck
City Clerk
APPROVED AS TO
FORM & lANGUAGE
& FOR EXECUTION
1tI11Jtr/h:
Ci AttOmev
~
CITY HALL 1700 CONVENTION CENTER DRIVE MIAMI BEACH FLORIDA 33139
L
CITY OF MIAMI BEACH
COMMISSION MEMORANDUM NO. ~
TO:
Mayor Seymour Gelber and
Members of the City Commission
DATE:
May 7, 1997
FROM:
Jose Garcia_pedrospla.~ ..
City Manager .
!
i
SUBJECT:
A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF
MIAMI BEACH, FLORIDA, AUTHORIZING AND DIRECTING THE SUBMISSION
OF AN APPLICATION IN THE AMOUNT OF $416,181.77 TO THE STATE OF
FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES SERVICES (CFS), FOR
CONTINUATION OF FUNDING OF THE LOG CABIN TRAINING CENTER, FROM
THE STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES
SERVICES FOR THE FOLLOWING PROGRAMS: THE DEVELOPMENTti,L
TRAINING PROGRAM CONSISTING OF AN INDEPENDENT LIVING SKILLS
PROGRAM AND TRANSPORTATION SERVICES; AND THE SUPPORTED
INDEPENDENT LIVING PROGRAM (SIL), BOTH DESIGNED TO BENEFIIT
DEVELOPMENTALLY DISABLED ADULTS; AND, TO APPROPRIATE FUNDS
AND EXECUTE CONTRACT(S) FOR THE FINAL GRANT AWARD(S), FOR THE
PERIOD OF JULY 1,1997 TO JUNE 30,1998.
ADMINISTRATION RECOMMENDATION
Approve the Resolution.
BACKGROUND
Th.e City's Log Cabin Training Center (LCTC) is located at 8128 Collins Avenue, contiguous to tte
Log Cabin Plant Nursery. It operates various programs designed to benefit developmentall:l-
disabled adults. Said programs are administered by the City's Economic and Communi:y
Development Division of the Development, Design, and Historic Preservation Department.
In 1983, the City's LCTC began operating the Independent Living Skills Training (or Development 31
Training Program). The program is funded through a grant from the State of Florida Department
of Children and Family Services (CFS) and strives to teach clients basic living skills, which will allON
them to become self-reliant. These skills include, for example, housekeeping, cooking, horticultun;,
interview techniques, and others. The program not only prepares participants for these roles, but
provides daily transportation to and from the site. Successful graduates of the program are then
able to maintain a household and engage in meaningful employment. Clients participating in th s
DATE
C. '""1 ~'L
.~-l-cll
AGENDA ITEM
COMMISSION MEMORANDUI\'I
MAY 7, 199"
PAGE T"I/(I
program are referred from either CFS or are sponsored by their own families. CFS-fundecl
participants in the program are limited to thirty-four (34).
In 1989, the City's LCTC became involved with the Supported Employment Program, another C=S.
funded program for developmentally disabled adults. The program focuses exclusively or
preparing and training clients to assume jobs utilizing the skills learned through the Developmental
Training Program. Both of these programs, although funded separately, are intricately linked }
counselor makes the initial contact with a prospective employer to secure potential positions fo .
graduates of the program, and then matches the client's skills and abilities with the job duties Cln<
responsibilities required by the position. Follow-up and progress reviews are conducted by thE
counselor to ensure that the client is able to perform on the job effectively. CFS-fundec
participants in the program are limited to sixteen (16).
In 1993, the City's LCTC began operating the Supported Independent Living Skills Progrclm
another CFS-funded program. The purpose of the program is to provide an independent Iivin~
environment for the clients currently being served through the City's program(s). Through the :31L
grant component, clients in the program are provided with appropriate rental housing. Specific
support services and supervision are provided by present staff and a Supported Living Coach, ir
order to ensure the clients' health and safety in their new environment. CFS-funded participant~
in the program are limited to three (3).
ANAL YSIS
The City must apply annually to CFS for funding for the Developmental Training and the Suppor:ec
Independent Living Programs, as the grant awards are not guaranteed from year to year, nor arE
funds automatically allocated to the City. A grant application in the amount of $416,181.77 ha~
been prepared which includes narrative programs descriptions and proposed operating budg!3t~
for the following components: Independent Living Skills Training; Supported Employment Training
Transportation Services; and Supported Independent Living. Currently, the City's LCTC provicle~
services for up to fifty-two (52) CFS-funded developmentally disabled adults. The application bein~
submitted to CFS requests funding for the provision of services for up to fifty-three 053;
developmentally disabled adults.
CFS has tentatively informed the City that it will consider the same grant requests under j he
Independent Living Skills Training (Developmental Training) Program (which also includes j he
Supported Employment Training Program and transportation services) and for the Supponec
Independent Living Program. Combining these programs currently results in a total grant amoun1
of $327,983 for Fiscal Year 1996-97. The new program period begins on July 1, 1997 and ends or
June 30, 1998, in order to coincide with the State of Florida's Fiscal year.
As a requirement of the grant application, CFS requires that the City adopt resolutions whch
demonstrate the Commission's authorization to apply to the State of Florida Department of C=S
for funding of these essential programs. Matching funds are required for the Developmertal
Training Program and for the Supported Employment Program. The Supported Independent Liv ng
Program has no direct match requirements. Match requirements will be met from in-kind sources.
COMMISSION MEMORANDUtv'
MAY 7, 1!l9i
PAGE THREE
While over one-half of the LCTC's operating budget is provided by CFS, the balance is supporter
by a Community Services' Block Grant and the City's General Fund. Funding at the level requester
from CFS will allow the City to continue providing services for up to fifty-three (53) developmentall)
disabled adults. After the City's grant application has been negotiated and approved by CF~, c
contract (s) for the final grant award(s) will be executed by the Mayor and City Clerk.
CONCLUSION
The Administration recommends the adoption of the attached Resolution which authorizes I he
submission of an application to the State of Florida Department of Children and Family Servio3s,
in the amount of $416, 181.77, for continuation of funding for the Log Cabin Training Center, for I he
following programs: (1) the Developmental Training Program (Consisting of an Independent liVing
Skills Program and Transportation Services); and (2) the Supported Independent Living Program,
both designed to benefit developmentally disabled adults; authorizing the execution of contract(s)
for the final grant award(s) for the period of July 1, 1997 to June 30, 1998; and appropriating fur ds
in compliance with the terms of the executed contract(s).
JGP/~M/JeSpnk
f2fC'H ILDREN
" FAMILIES
Lawton Chiles
Governor
Edward A. Feaver
SecretaFY
District 11
Dade & Monroe Counties
Anita M. Bock
District AdministratJr
.COMMITTED TO EXCELLENCE-
DOCUMENTATION OF NEGOTIATION AGREEMENT
THIS AGREEMENT, is entered into between the State of Florida, Department of Children and
Families, Developmental Services Program Office known as the Department and City of Miami
Beach known as the Provider.
The following parties agree to the following items and terms set forth.
AGREEMENT:
The rate per unit of service as listed on this document, applies to the services specifiec
below whether funded through this Rate Agreement or Medicaid Waiver.
SERVICES TO BE FY 97-98 FY 97-98 FY 97-98 FY 97-
PROVIDED FY 97-98 CONTRACTUAL TOTA
NEGOTIATED CONSUMERS CALCULATIONS G/R
RATES TO BE SERVED FUNDI'
Adult Day Training $ 24.50 Daily 7 24.50 x 7 x 230
Supported Employment $ 426.00 Monthly 15 426.00 x 15 x 1 2
Transportation $ 95.28 Monthly 4 95.28 x 4 x 12
Supported Living $ 485.00 Monthly 2 485.00 x 2 x 12
98
---_.-._~
L
IIG
_~1,39,445~QQ
lI76,680~00
$4,573.44
--~--
lI11,640.00
--~.-
I TOT AL CONTRACTUALI
FUNDING
:..!:: 32,338.441
Department of Childrenlfd Families: 7 'I
BUdgets/Contracts:~~ /- ~.-
/ --
// ./
Contract ~k-/
Provider Representatives:
Name:
Title:
Date:
Angelo Parrino, Deputy Division Director, Divisions of Adult Care and Family Support
401 NW 2nd Avenue, Suite N-812, Miami, Florida 33128
Working in partnership with local communities to help people be self-sufficient
and live in stable families and communities.
]1/1/97
CFDA No.
Grants and Aids ___
Client X Non-Cliflt 0
Multi-Dislric 0
STATE OF FLORIDA
DEPARTMENT OF CHILDREN AND FAMILIES
STANDARD CONTRACT
THIS CONTRACT is entered into between the State of Florida, Department of Children and Families, hereinafter referred to as the "( epartment",
and CITY OF MIAMI BEACH,hereinafter referred to as the "provider".
THE PARTIES AGREE:
I. THE PROVIDER AGREES:
A To provide services in accordance with the conditions specified in Attachment 1.
II. Requirements of Section 287.058, FS
To provide units of deliverables, including reports. findings. and drafts, as specified in Attachment I, to be received and accepted by the contract m:nager prior
to payment. To comply with the criteria and final date by which such criteria must be met for completion of this contract as specified in Section III, Plragraph A.
of this contract. To submit bills for fees or other compensation for services or expenses in sufficient detail for a proper pre-audit and post-audithenof. Where
applicable, to submit bills for any travel expenses in accordance with section 112.061, FS. The department may, if specified in Attachment I. est Iblish rates
I'Jwer than the maximum provided in section 112.061, FS. To allow public access to all documents, papers, letters, or other materials subject to tile ~.'ovisions of
Chapter 119, FS, made or received by the provider in conjunction with this contract. It is expressly understood that the provider's refusal to c omll Iy with this
provision shall constitute an immediate breach of contract.
G. To Agree to the Following Governing Law
11. State of Florida Law
This contract is executed and entered into in the State of Florida, and shall be construed. performed, and enforced in all respects in accordanc,! wi h the laws,
rules, and regulations of the State of Florida. Each party shall perform its obligations herein in accordance with the terms and conditions of the cc ntrc ct.
:!. Federal Law
II. If this contract contains federal funds, the provider shall comply with the provisions of 45 CFR. Part 74, andlor 45 CFR. Part 92. and (lthe applicable
regulations as specified in Attachment I.
b. If this contract contains federal funds and is over $100,000. the provider shall comply with all applicable standards. orders, or regulatiors i!, ,;ued under
section 306 of the Clean Air Act, as amended (42 U.S.C. 1857(h) et seq.), section 508 of the Clean Water Act, as amended (33 U.S.C. 1368 et !eq. , Executive
Order 11738, and Environmental Protection Agency regulations (40 CFR Part 15). The provider shall report any violations of the above to the departnent.
C;. If this contract contains federal funding in excess of $100,000, the provider must, prior to contract execution. complete the Certificc,tior Regarding
l.obbying form, Attachment NA. If a Disclosure of Lobbying Activities form, Standard Form LLL, is required, it may be obtained from the cOlltra:t manager.
All disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to the contract manager.
d. Not to employ unauthorized aliens. The department shall consider the employment of unauthorized aliens a violation of section 274 '(e) of the
Immigration and Naturalization Act. Such violation shall be cause for unilateral cancellation of this contract by the department.
(). Audits, Records, and Records Retention
11. To establish and maintain books, records. and documents (including electronic storage media) in accordance with generally acce~ted accounting
procedures and practices which sufficiently and properly reflect all revenues and expenditures of funds provided by the department under this cor trar :.
:!. To retain all client records, financial records. supporting documents. statistical records, and any other documents (including electronic stollge media)
pertinent to this contract for a period of five (5) years after termination of the contract. or if an audit has been initiated and audit findings have no: be m resolved
at the end of five (5) years, the records shall be retained until resolution of the audit findings or any litigation which may be based on the terms of :his;ontract.
:1. Upon completion or termination of the contract and at the request of the department, the provider will cooperate with the department to f Icilitate the
duplication and transfer of any said records or documents during the required retention period as specified in Section I, Paragraph 0.2. above.
.1. To assure that these records shall be subject at all reasonable times to inspection, review, or audit by Federal, state, or other personnel ~ull authorized
by the department.
!i. Persons duly authorized by the department and Federal auditors, pursuant to 45 CFR, Part 92.36(i)(10), shall have full access to and the right to examine
any of provider's contract and related records and documents, regardless of the form in which kept. at all reasonable times for as long as records are 'etained.
fl. To provide a financial and compliance audit to the department as specified in Attachment 11 and to ensure that all related party t 'am3ctions are
disclosed to the auditor.
j'. To include these aforementioned audit and record keeping requirements in all approved subcontracts and assignments.
E. Monitoring by the Department
To permit persons duly authorized by the department to inspect any records. papers. documents. facilities. andlor goods and services of the providEr which are
relevant to this contract. andlor to interview any clients and employees of the provider to assure the department of the satisfactory performance of th", terms and
c:onditions of this contract. Following such evaluation the department will deliver to the provider a written report of its findings and will inclJde written
recommendations with regard to the provider's performance of the terms and conditions of this contract. The provider will correct all noted leficiencies
identified by the department within the specified period of time set forth in the recommendations. The provider's failure to correct noted deficienciesllay, at the
!,ole and exclusive discretion of the department, result in anyone or any combination of the following: (1) the provider being deemed in breach cr dE fault of this
c:ontract; (2) the withholding of payments to the provider by the department; and; (3) the termination of this contract for cause.
1'. Indemnification
NOTE: Paragraph I.F.1. and 2. are not applicable to contracts executed between state agencies or subdivisions, as defined in section 768 28, ~S.
1. The provider shall be liable for and shall indemnify, defend, and hold harmless the department and all of its officers, agents, and em~loYles from all
c;/aims, suits, judgments, or damages, consequential or otherwise and including attorneys' fees and costs, arising out of any act, actions, negler;!, c,. omissions
by the provider, its agents, or employees during the performance or operation of this contract or any subsequent modifications thereof, whether dlrec' or indirect,
clnd whether to any person or tangible or intangible property.
:~. The provider's inability to evaluate liability or its evaluation of liability shall not excuse the provider's duty to defend and indemnify within sev m (7) days
clfter such notice by the department is given by certified mail. Only adjudication or judgment after highest appeal is exhausted specifically finding I he rovider not
1
CONTRA( T r O. KL521
1/1/97
liable shall excuse performance ofthis provision. The provider shall pay all costs and fees related to this obligation and its enforcement by the dE'par ment. The
department's failure to notify the provider of a claim shall not release the provider of the above duty to defend.
G. Insurance
To provide adequate liability insurance coverage on a comprehensive basis and to hold such liability insurance at all times during the existence of l'lis contract
Bind any renewal(s) and extension(s) of it. Upon execution of this contract. unless it is a state agency or subdivision as defined by section ~'.68..~8, FS, the
provider accepts full responsibility for identifying and determining the type(s) and extent of liability insurance necessary to provide reasc'natle financial
protections for the provider and the clients to be served under this contract. Upon the execution of this contract, the provider shall furnish the de~artnent written
verification supporting both the determination and existence of such insurance coverage. Such coverage may be provided by a self-ins~ran e program
Eistablished and operating under the laws of the State of Florida. The department reserves the right to require additional insurance IS , pecified in
Attachment 1 where appropriate.
Ii. Safeguarding Information
Not to use or disclose any information concerning a recipient of services under this contract for any purpose not in conformity with state regulatic'nslind Federal
law or regulations (45 GFR, Part 205.50), except upon written consent of the recipient, or his responsible parent or guardian when authorized by Ilw.
I. Assignments and Subcontracts
'I. To neither assi~ln the responsibility of this contract to another party nor subcontract for any of the work contemplated under this contr~ct \'ithout prior
written approval of the department which shall not be unreasonably withheld. Any sublicense, assignment, or transfer otherwise occurring shall b'~ null and void.
:!. The provider shall be responsible for all work performed and all expenses incurred with the project. If the department permits the provide' to;ubcontract
all or part of the work contemplated under this contract, including entering into subcontracts with vendors for services and commodities. it is unlerslood by the
provider that the depal1ment shall not be liable to the subcontractor for any expenses or liabilities incurred under the subcontract and the provide I" sh ill be solely
liable to the subcontractor for all expenses and liabilities incurred under the subcontract. The provider, at its expense, will defend the departme nt E~ainst such
c:laims.
:1. The State of Florida shall at all times be entitled to assign or transfer its rights, duties, or obligations under this contract to another governrr entll agency in
the State of Florida, upon giving prior written notice to the provider. In the event the State of Florida approves transfer of the provider's obligati01s. he provider
remains responsible for all work performed and all expenses incurred in connection with the contract. In addition, this contract shall bind Ihe ;uccessors,
assigns, and legal representatives of the provider and of any legal entity that succeeds to the obligations of the State of Florida.
.1. Unless otherwise stated in the contract between the provider and subcontractor, payments made by the provider to the subcontractor mu .it be within
seven (7) working days after receipt of full or partial payments from the department in accordance with section 287.0585, FS. Failure to pay with 1 seven (7)
working days will result in a penalty charged against the provider and paid to the subcontractor in the amount of one-half of one (1) percent of.helmount due
per day from the expiration of the period allowed herein for payment. Such penalty shall be in addition to actual payments owed and shall not exc:ee< fifteen (15)
percent of the outstanding balance due.
.J. Return of Fundls
To return to the department any overpayments due to unearned funds or funds disallowed pursuant to the terms of this contract that were cisbl rsed to the
provider by the department. In the event that the provider or its independent auditor discovers that an overpayment has been made, the pro\idel shall repay
"aid overpayment within 40 calendar days without prior notification from the department. In the event that the department first discovers an o'./er~ .ayment has
IJeen made, the depal1ment will notify the provider by letter of such a finding. Should repayment not be made in a timely manner, the departrlen will charge
nterest of one (1) perc;ent per month compounded on the outstanding balance after 40 calendar days after the date of notification or discovery.
K. Incident Reporting
1. Client Risk PrElventlon
If services to clients will be provided under this contract, the provider and any subcontractors shall, in accordance with the client risk prevention syitem, report
Ihose reportable situations listed in HRSR 215-6 Paragraph 5. in the manner prescribed in HRSR 215-6 or district operating procedures.
2. Abuse, Neglect, and Exploitation Reporting
In compliance with Chapter 415, FS, an employee of the provider who knows or has reasonable cause to suspect that a child, aged person, or ,lisalled adult is
or has been abused, neglected, or exploited shall immediately report such knowledge or suspicion to the Florida Abuse Hotline on the single statel.i'ide toll-free
telephone number (1-i300-96ABUSE).
L. Transportatiorl Disadvantaged
If clients are to be transported under this contract, the provider will comply with the provisions of Chapter 427, FS, and Rule Chapter 41-2, FAG. 'he provider
shall submit to the department the reports required pursuant to Volume 10, Chapter 27, HRS Accounting Procedures Manual.
M. Purchasing
1. PRIDE
It is agreed that any articles which are the subject of, or are required to carry out this contract shall be purchased from Prison Rehabilitativt! In ~ustries and
Diversified Enterprises, Inc. (PRIDE) identified under Chapter 946, FS. in the same manner and under the procedures set forth in subsections 941 .515(2) and
(4), FS. For purpose:; of this contract, the provider shall be deemed to be substituted for the department insofar as dealings with PRIDE. This cause Is not
applicable to subcontractors unless otherwise required by law. An abbreviated list of products/services available from PRIDE may be >btained by
contacting PRIDE.
(904) 487-3774.
2. Procurement e,f Materials with Recycled Content
It is expressly understood and agreed that any products or materials which are the subject of, or are required to carry out this contract, shal be procured in
accordance with the provisions of sections 403.7065, and 287.045, FS.
N. Civil Rights Rnqulrements
Note: N.1. applies only to providers with fifteen (15) or more employees. N.2. applies only to providers providing direct services to clients iill! if fi teen (15) or
more individuals are employed.
1. The provider will not discriminate against any employee in the performance of this contract, or against any applicant for employment, >ec."use of age.
race. creed, color, disability, national origin, or sex. The provider further assures that all contractors, subcontractors, subgrantees, or OthNS I../ith whom it
arranges to provide services or benefits to participants or employees in connection with any of its programs and activities are not discriminating ~Ilainst those
participants or employees because of age, race, creed, color, disability, national origin, or sex.
2. Compliance Questionnaire
In accordance with HRSM 220-2, the provider agrees to complete the Civil Rights Compliance Questionnaire, HRS Forms 946 A and B, if service! are directly
provided to clients mlt if 15 or more individuals are employed.
2
CONTRA,::T ~O. KL521
]/1/97
C). Independent Clllpaclty of the Contractor
1. In performance of this contract, it is agreed between the parties that the provider is an independent contractor and that the provider is solely lilble for the
performance of all tasks contemplated by this contract which are not the exclusive responsibility of the department.
2. Except where the provider is a state agency, the provider, its officers. agents, employees, subcontractors, or assignees, in performance of thiS contract,
shall act in the capacily of an independent contractor and not as an officer, employee. or agent of the State of Florida. Nor shall the provider rep' ese It to others
tl1at it has the authority to bind the department unless specifically authorized to do so.
~" Except where tile provider is a state agency, neither the provider, its officers. agents, employees, subcontractors, nor assignees are Entit~d to state
retirement or state leave benefits, or to any other compensation of state employment as a result of performing the duties and obligations of this co ntre :t.
~I. The provider agrees to take such actions as may be necessary to ensure that each subcontractor of the provider will be deemed to be an i Idependent
c:ontractor and will not be considered or permitted to be an agent, servant, joint venturer, or partner of the State of Florida.
!i. Unless justified by the provider and agreed to by the department in Attachment I, the department will not furnish services of support (e.~I.. ofice space,
Clffice supplies, telephone service, secretarial, or clerical support) to the provider, or its subcontractor or assignee.
Ei. All deductions for social security. withholding taxes, income taxes, contributions to unemployment compensation funds, and all necessary iriurance for
the provider, the provider's officers, employees, agents, subcontractors, or assignees shall be the responsibility of the provider.
f'. Sponsorship
As required by section 286.25, FS, if the provider is a nongovernmental organization which sponsors a program financed wholly or in part Illy tate funds,
including any funds obtained through this contract, it shall, in publicizing, advertising, or describing the sponsorship of the program, state: "Spnsored by
(provider's name) and the State of Florida, Department of Children and Families." If the sponsorship reference is in written material, the words ":;tal of Florida,
Department of Children and Families" shall appear in the same size letters or type as the name of the organization.
(;1. Final Invoice
To submit the final invl)ice for payment to the department no more than 45 days after the contract ends or is terminated. If the provider fails to do SI , all right to
payment is forfeited and the department will not honor any requests submitted after the aforesaid time period. Any payment due under the terms of 11is contract
may be withheld until all reports due from the provider and necessary adjustments thereto have been approved by the department.
R Use Of Funds For Lobbying Prohibited
To comply with the p'ovisions of section 216.347, FS, which prohibit the expenditure of contract funds for the purpose of lobbying the LeglslalJre, judicial
branch, or a state age 1CY.
~~. Public Entity Crime
Pursuant to section 2 ~7 .133. FS, the following restrictions are placed on the ability of persons convicted of public entity crimes to transact bl sin, ss with the
department: When a person or affiliate has been placed on the convicted vendor list following a conviction for a public entity crime, he/she may lotubmit a bid
,)n a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction O' th" repair of a
public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a conlract >r, supplier,
!)ubcontractor, or comultant under a contract with any public entity. and may not transact business with any public entity in excess of the thresl old amount
provided in section 287.017, FS, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list.
r. Patents, Copyrights, and Royalties
1. If any discovery or invention arises or is developed in the course or as a result of work or services performed under this contract, or in an:/Wa ' connected
herewith, the provider shall refer the discovery or invention to the department to be referred to the Department of State to determine whether patel. t protection
will be sought in the name of the State of Florida. Any and all patent rights accruing under or in connection with the performance of this coni rac are hereby
reserved to the State .)f Florida.
2. In the event the.t any books, manuals, films, or other copyrightable materials are produced, the provider shall notify the Department of StIlle. Any and all
copyrights accruing under or in connection with the performance under this contract are hereby reserved to the State of Florida.
3. The provider, without exception, shall indemnify and save harmless the State of Florida and its employees from liability of any nature O' kir d, including
cost and expenses fo' or on account of any copyrighted, patented, or unpatented invention, process, or article manufactured by the provider. lhe >rDvider has
no liability when such claim is solely and exclusively due to the Department of State's alteration of the article. The State of Florida will providu prlmpt written
notification of claim of copyright or patent infringement. Further. if such claim is made or is pending, the provider may, at its option and expense. pn cure for the
Department of State, the right to continue use of, replace, or modify the article to render it non-infringing. If the provider uses any design, devce, )r materials
covered by letters. patent. or copyright, it is mutually agreed and understood without exception that the bid prices shall include all royalties or CliStS .arising from
the use of such design, device, or materials in any way involved in the work.
II. THE DEPARTMENT AGREES:
A. Contract Amount
To pay for contracted services according to the conditions of Attachment 1 in an amount not to exceed $NA, subject to the availability of fundl. The State
of Florida's performance and obligation to pay under this contract is contingent upon an annual appropriation by the Legislature. The costs .of 5. ~rvices paid
under any other contr~ct or from any other source are not eligible for reimbursement under this contract.
B. Contract Payment
Pursuant to section 215.422, FS, the department has five (5) working days to inspect and approve goods and services, unless the bid specificatiol s, purchase
order, or this contract specifies otherwise. With the exception of payments to health care providers for hospital, medical, or other health l:are services, if
payment is not availllble within 40 days, measured from the latter of the date the invoice is received or the goods or services are received im pected, and
approved, a separate interest penalty set by the Comptroller pursuant to section 55.03, FS, will be due and payable in addition to the invoice arr.our:. To obtain
the applicable interest rate, contact the district fiscal office/contract administrator. Payments to health care providers for hospital, medical, or (the health care
services. shall be maje not more than 35 days from the date eligibility for payment is determined, at the daily interest rate of .03333%. lnvoic,es I~turned to a
vendor due to preparation errors will result in a payment delay. Interest penalties less than one dollar will not be enforced unless the vendor reque:ts payment.
Invoice payment requirements do not start until a properly completed invoice is provided to the department.
c. Vendor Ombudsman
A Vendor Ombudsmlln has been established within the Department of Banking and Finance. The duties of this individual include acting as anldvocate for
vendors who may be experiencing problems in obtaining timely payment(s) from a state agency. The Vendor Ombudsman may be contacted al (914) 488-2924
or 1-800-848-3792. tte State of Florida Comptroller's Hotline.
3
CONTRACT ~O. KL521
1/1/97
III. THE PROVIDER /l NO DEPARTMENT MUTUALLY AGREE:
A. Effective and [ndlng Dates
This contract shall begin on 07/01/97 or on the date on which the contract has been signed by both parties, whichever is later. It hall end on
06/30/98.
1:1. Tennlnatlon
'1. Tennlnatlon at Will
This contract may be lerminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the other party unllss;! lesser time
is mutually agreed upon in writing by both parties. Said notice shall be delivered by certified mail, retum receipt requested, or in person with pro)f 0 delivery.
:!. Tennlnatlon Bf,cause of Lack of Funds
In the event funds to nnance this contract become unavailable. the department may terminate the contract upon no less than twenty-four (241 hc.urs notice in
writing to the provider. Said notice shall be delivered by certified mail. retum receipt requested, or in person with proof of delivery. The departmen shall be the
final authority as to the availability and adequacy of funds. In the event of termination of this contract, the provider will be compensatl~d"Dr any work
satisfactorily completed prior to notification of termination.
:1. Tennlnatlon fo r Breach
This contract may be erminated for the provider's non-performance upon no less than twenty-four (24) hours notice in writing to the provider. If alllplicable, the
department may em pi >y the default provisions in Chapter 60A-1.006 (3). FAC. Waiver of breach of any provisions of this contract shall not be de,,'med to be a
waiver of any other br lach and shall not be construed to be a modification of the terms of this contract. The provisions herein do not limit the d,epatment's right
to remedies at law or i1 equity.
-I. Tennlnation fo r Failure to Satisfactorily Perfonn Prior Agreement
Failure to have perfon1ed any contractual obligations with the department in a manner satisfactory to the department will be a sufficient cause fCI.r te mination.
To be terminated as a provider under this provision. the provider must have: (1) previously failed to satisfactorily perform in a contract with the d.lpallment. been
notified by the departnlent of the unsatisfactory performance. and failed to correct the unsatisfactory performance to the satisfaction of the depaltmEnt; or (2)
had a contract termin.ted by the department for cause.
G. Renegotiation lr Modification
Modifications of provi~ ions of this contract shall only be valid when they have been reduced to writing and duly signed by both parties. The rate oflayment and
the total dollar amour t may be adjusted retroactively to reflect price level increases and changes in the rate of payment when these have heel established
through the appropriat ions process and subsequently identified in the department's operating budget.
I). Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
'1. The provider mime, as shown on page 1 of this contract, and mailing
address of the official layee to whom the payment shall be made is:
CITY OF MIAMI BEACH
"8128 COL -INS AVENUE
MIAMI BEACH, FLORIDA 33141
(305) 993-Z008
3. The name, address, and telephone number of the contract manager for
the department for this contract is:
DON HILL
401 NW 2ND AVENUE
MIAMI, FLORIDA 33128
(305) 808-6292
:!. The name of thl! contact person and street address where financial and
administrative records are maintained is:
AGI LONG
8128 COL-INS AVENUE
MIAMI BEACH, FLORIDA 33141
(305) 993- Z008
4. The name, address, and telephone number of the repr'!seli tative of the
provider responsible for administration of the program under tllis lontract is:
AGI LONG
8128 COLLINS AVENUE
MIAMI BEACH, FLORIDA 33141
(305) 579-3400
ti. Upon change of rE presentatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the othl,r p Irty and the
notification attached tc the originals of this contract.
10. All Terms and::onditlons Included
This contract and its .ttachments as referenced, ATTACHMENTS I and II. EXHIBITS A. B. C. O. E. F G. H and I, contain all the terms and olnddons agreed
upon by the parties. ~'here are no provisions, terms, conditions, or obligations other than those contained herein, and this contract shall superledE all previous
communications, repmsentations, or agreements, either verbal or written between the parties. If any term or provision of the contract is founl to be illegal or
~Inenforceable. the rer lainder of the contract shall remain in full force and effect and such term or provision shall be stricken. ,_".
I have read the above (Dntract and understand each section and paragraph.
IN WITNESS THER ~F, the parties hereto have caused this SJ page contract to be executed by their undersigned officials as duly authorized.
PROVIDER: STATE OF FLORIDA, DEPARTMENT OF
CITY OF CHILDREN AND FAMILIES
SIGNED BY:
NAME:
TITLE:
)
',., .. k)
..-:r'. . '/ .-
..y' /../.J ,y j. ",':-,/'
Iqrm'A M. BOCK
ISTRICT ADMINISTRATOR
SIGNED BY:
NAME:
TITLE:
ATTEST:
STATE AGENCY 29 DIGIT SAMAS CODE:
Federal EID # (or SSrI): VF596000372001
CITY CLE ASW
FORM & lANGUAGE
& fOR EXE~ca' Year Ending Date: %~.
APPIlOV~ AS TO-tv..
AND L~~ SUFFI~N,cy
~ 4 f~/~!~^/'.
. AIIorney - ~ s;.n~ District LeCtI counsel
{; .-lrJ - ti ?
CONTRACT I/O. KL5ll
1/1197
III. THE PROVIDER A NO DEPARTMENT MUTUALLY AGREE:
A. Effective and Ending Dates
This contract shall b 19in on 07/01/97 or on the date on which the contract has been signed by both parties, whichever is later. It shall end on
!)6/30/9S.
I~. Termination
11. Termination at Will
This contract may be 1 ~rminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the other party unle'.s c lesser time
is mutually agreed upe n in writing by both parties. Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of Ie livery.
.!. Termination Bl cause of Lack of Funds
In the event funds to inance this contract become unavailable, the department may terminate the contract upon no less than twenty-four (24) hOI rs 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 departrrent I.hall be the
final authority as to tle availability and adequacy of funds. In the event of termination of this contract, the provider will be compensated fer any work
satisfactorily complete j prior to notification of termination.
~l. Termination fo . Breach
This contract may be I erminated for the provider's non-performance upon no less than twenty-four (24) hours notice in writing to the provider. I apiJlicable, the
department may emplllY the default provisions in Chapter 60A-1.006 (3), FAC. Waiver of breach of any provisions of this contract shall not be jeell1ed to be a
waiver of any other bn tach and shall not be construed to be a modification of the terms of this contract. The provisions herein do not limit the deparlment's right
to remedies at law or i 1 equity.
~L Termination fo . Failure to Satisfactorily Perform Prior Agreement
Failure to have perforr led any contractual obligations with the department in a manner satisfactory to the department will be a sufficient cause fOI terl1ination.
To be terminated as a provider under this provision, the provider must have: (1) previously failed to satisfactorily perform in a contract with the de Jartnent, been
notified by the departn lent of the unsatisfactory performance, and failed to correct the unsatisfactory performance to the satisfaction of the depart mer t; or (2)
had a contract termina ted by the department for cause.
C. Renegotiation lr Modification
Modifications of provis ions of this contract shall only be valid when they have been reduced to writing and duly signed by both parties. The rate of plyment and
the total dollar amour t may be adjusted retroactively to reflect price level increases and changes in the rate of payment when these have bllen established
through the appropriat ons process and subsequently identified in the department's operating budget.
I). Official Payee and Representatives (Names, Addresses, and Telephone Numbers):
3. The name, address, and telephone number of the contrlct nanager for
the department for this contract is:
DON HILL
401 NW 2ND AVENUE
MIAMI, FLORIDA 33128
(305) 808-6292
'1. The provider nc me, as shown on page 1 of this contract, and mailing
address of the official layee to whom the payment shall be made is:
CITY OF ~ !lAM I BEACH
8128 COLl.lNS AVENUE
MIAMI BEJI,CH, FLORIDA 33141
(305) 993- ZOOS
.!. The name of th., contact person and street address where financial and
cldministrative records are maintained is:
AGI LONG
8128 COLl.lNS AVENUE
MIAMI BEJI,CH, FLORIDA 33141
(305) 993-. ZOOS
4. The name, address. and telephone number of the represen ative of the
provider responsible for administration of the program under th is cntract is:
AGI LONG
8128 COLLINS AVENUE
MIAMI BEACH, FLORIDA 33141
(305) 579-3400
fi. Upon change of rE presentatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the othe' pc 1y and the
notification attached tc the originals of this contract.
1:. All Terms and I ;onditlons Included
This contract and its Ii ltachments as referenced, ATTACHMENTS I and II. EXHIBITS A. B. C. D. E. F G. H and I, contain all the terms and condit ons agreed
L1pon by the parties. 1 here are no provisions, terms, conditions, or obligations other than those contained herein, and this contract shall supers1lde all previous
c:ommunications, repn ,sentations, or agreements, either verbal or written between the parties. If any term or provision of the contract is found to )e illegal or
':;Inenforceable, the rer lainder of the contract shall remain in full force and effect and such term or provision shall be stricken. I_II'
I have read the above c mtra and understand each section and paragraph.
STATE OF FLORIDA, DEPARTMENT OF
CHILDREN AND FAMILIES
IN WITNESS THERI :OF the parties hereto have caused this SJ page contract to be executed by their undersigned officials as duly authorized.
PROVIDER:
CITY OF
SIGNED BY:
NAME:
TITLE:
ATTEST:
ANITA M. BOCK
DISTRICT ADMINISTRATOR
CLERNftOVfD Afto
Fi?~& ~~ Year Ending Dat~s~fl-r'v..
~~~ SUFFIClE~CY.,
~ ~~~;~:';'I
STATE AGENCY 29 [)IGIT SAMAS CODE:
I'ederal EID # (or SSl"): VF596000372001
CONTRACT ro..KLS.ll
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
ATTACHMENT I - PERFORMANCE CONTRACT
7/1/97
Contract Number KL521
STA TEMENT OF WORK
A. SERVICES TO BE PROVIDED
1. Definition Of Terms:
a. Contract Terms:
1 . State - means the State of Florida.
2. Department - means the Department of Children and Family Services
3. Provider - means an individual or organization from which services are procured.
4. Developmental Disability - means a disorder or syndrome which is attributabl{ t(
mental retardation, cerebral palsy, spina bifida, autism and Prader- Willi syndrome; anI
which constitutes a substantial handicap that can reasonably be expected to contitlUi
indefinitely.
5. District - means a service district of the department.
6. Mental Retardation - means significantly subaverage general intellectual functiorinl
existing concurrently with deficits in adaptive behavior manifested prior to thl
individuals 18th birthday.
b. Program Specific Terms:
1. Case Management - means identifying, developing, coordinating, and acces~ inl
supports and services on behalf of an individual, or assisting the individual or famil:l t( .
access supports and services on their own.
2. Day Training Program ( DTP ) - means a non-residential community based facilit:
open for service at least six hours per day for at least 230 days a year that provide ..
individuals with basic training and habilitation.
3 Home and Community Based Waiver - provides necessary supports and service:. t(
people who have a developmental disability so that they may remain in the communit:
and avoid placement in an institution. The waiver is funded by the Federal Health Can
Financing Administration (HCF A) and matching state dollars.
4. H.P.1.0, H.P.2.0 - refers to Habilitation Programming Minimum Standards.
5. In-Service Training - means advanced training which improves knowledge, skills, an(.
attitudes.
6. IPP - means Individual Program Plan.
5
7. Non-Residential Supports and Services - means training activities provided t<,
individuals in community-integrated settings. Non-residential support services an
limited to the amount, duration and scope of the service described on the individl aI'
support plan and current approved cost plan. Non-residential services provided on aJ
hourly basis cannot exceed twelve (12) hours per day. If services are provided daily, th,
maximum number of days of service cannot exceed the total number of days in a gi vel
month.
8. Residential Habilitation - means services that involves the development anI
implementation of training activities in the residential facility. This programrr in);
includes assistance with the acquisition, reduction or elimination of inappropriatl:
behaviors, retention or improvement of skills related to activities of daily living.
9. Respite - means short-term, temporary care that is provided to a person witl:
developmental disabilities to meet the planned or emergency needs of the person witl,
developmental disabilities or the family or other caretaker.
10. Community Based Employment - means employment located or provided in a normal
employment setting that provides at least 20 hours employment per week in an integratel
work setting, with earnings paid on a commensurate wage basis, and for which suppor..
or follow-along services are needed for continuing job maintenance.
11. Supported Living - means a category of individually determined services designed and
coordinated in such a manner as to provide assistance to adults who require ongoinr:
supports to live as independently as possible in their own homes.
12. Special Medical Services - means nursing services and the availability of physic an:
services provided on a 24-hour-basis to customers with complex medical needs.
13. Training - means a planned sequence of learning events designed to produce a positive
change in performance.
14. Transportation - means rides to and from home and community based servlce~; t"
enable the individuals to receive supports and services.
15. Support Plan - An authorizing document for services which provides a common ree onl
for the customer, the family and/or guardian and persons involved in providing suppJrt;
and services.
16. Waiver Support Coordinator (W.S.C.) - Individual responsible for ensuring that th.:
customers they serve, receives coordination of services by obtaining and coordinadn,:
supports and services to achieve the outcomes identified on the support plan.
17. Budget Request Form - A financial document detailing the cost to operate the program
6
2. General Description:
a. General Statement
The provider will ensure the provIsIOn of services to eligible Developmental Service:
customers in accordance with Developmental Services Manuals, Standards and Regulation:
as identified in Section II. General Description, Paragraph, b., (Authority). The services ti'l
be provided are intended to fulfill the customer's potential to achieve his/her maximum leve..
of independent living. Services shall be provided to individuals if they have a confinnel!1
diagnosis of at least one of the following developmental disabilities: Mental Retardatlion,
Spina Bifida, Autism, Prader- Willi Syndrome and Cerebral Palsy, as defined in th,,:
Department of Children and Family Services, Guide to Support Coordination, HRSM 161)-3.
HRSM 160-4, HRSM 160-5, and all other applicable standards. Characteristics 0'
individuals to be served include but are not limited to:
1. Individuals with moderate to severe maladaptive behaviors in need of reduc:ioJ',
programs.
2. Individuals with acquisition needs in the areas of communication, daily living skill~.
human growth, self care skills, socialization skills, vocational/job related skills and/o'
any area identified in the consumer support plan
3. Individuals who are incontinent of bladder or bowel.
4. Individuals who are ambulatory or non-ambulatory.
5. Individuals who have disabilities in addition to those aforementioned.
b. Authority:
1. To comply with Florida Statutes 393, the American with Disabilities Act (ADA) ani
requirements. All providers must comply with the requirements contained ill
Developmental Services form 2012, Habilitative Programming Minimum Standard~.
HRSM 160-4, Behavioral Management Guidelines, the Guide to Support Coordination.
and all applicable Federal and State licensing standards, as well as all other applicabl :
standards, criteria and guidelines of the Department, including 10F-11 and 10F-8, LTR( I
minimum Standards, 2014, 2016, 2018, Developmental Training Program Standard~.
Department of Children and Family Services-Developmental Services form 2006.
2. To adhere to the guidelines contained in HRSM 160-4 (Behavioral Programming) and
HRSM 160-8 (Customer Programming). Manuals may be obtained from th.:
Developmental Services Program Office upon request.
3. The provider will submit reports and records required to process requests for paymen: b:'
the department as specified in the Developmental Services V ouchering Procedure:
Manual Volume 2, Chapter 6.1 and 6.2, February 1990 or as revised.
c. Scope:
All services shall be performed in accordance with the policies, procedures, ru le~ .
regulations, and laws of the State of Florida. All services are to reflect treatmen
requirements and service delivery as indicated in Department of Children and Fanil:"
Services Guide to Support Coordination, HRSM 160-1, HRSM 160-4, and HRSM 16' )-8
Services are to be provided throughout the duration of this contract.
7
d. Major Program Goals
The purpose of this contract is to advance the department's mission to reduce the severity o'
developmental disabilities. The department's priority is to ensure that all customers recdvc.
education, training, therapy, transportation, and medical care to help achieve their potentia
for independent living, and to experience valued life events as do other citizens.
3. Clients To Be Served:
a. General Description:
Adults who have a confirmed diagnosis of at least one of the following developmelta
disabilities: Mental Retardation, Spina Bifida, Autism, Prader- Willi Syndrome, and Cerebra
Palsy, as defined in the Guide to Support Coordination, HRSM 160-3, HRSM 160-4, HRS~
160-5, and all other applicable standards, shall be served under this contract.
b. Client EligibilitylDetermination:
Each applicant for services provided by the Developmental Services Program must bt
determined eligible to receive services through a screening or evaluation process prior- t( ...
being accepted as a client. If the applicant is eligible he or she becomes a client of the.
Department of Children and Family Services, and is granted all rights for services containe(
within Florida Statute, Chapter 393.
If the provider has knowledge of any circumstances affecting eligibility of any per SOl
authorized to receive services under this contract, the provider shall notify the Contrac
Manager, the Waiver Support Coordinator or the HSC III immediately. In the event of;.
dispute regarding customer eligibility/determination, the department shall have the authorit:
to make the final decision.
c. Contract Limits:
Services identified in section B., Manner of Service, Section I., Paragraph a., (Task Lists'
shall be provided to individuals as defined by this agreement, subject to the availabili~' 0 '
funds. The department will have final authority on the availability of funds.
B. MANNER OF SERVICE PROVISION:
1. Service Tasks:
a. Task List:
The provider agrees to provide the following services and adhere to the respective standard:; a ..
indicated:
Transportation
Transportation services provides commuting services to and from home and community based serv.:ce~
to enable individuals to receive the supports and services identified on the support plan. Transporta1iOl L
services are limited to the amount, duration and scope of the service described on the individual'..
support plan and current approved cost plan Transportation providers shall hold all applicable:
licenses issued by the Department of Highway Safety and Motor Vehicles and shall secure
insurance. Applicants shall provide the department with proof of license and insurance. Al
8
drivers and driver's aides employed (full or part time) shall be currently certified by the State 0:'
Florida, and maintain 100% adherence to all Department of Motor Vehicles rules and regulatiom
concerning safety, licensure and other standards.
Background screening is required under Chapter 393, F.S. Medicaid enrollment require; ,
Florida Department of Law Enforcement (FDLE) check on any provider, officer, director, agent
managing employees, affiliated persons, volunteers or any partner or shareholder having ;1 :
percent or greater ownership.
All Vehicles used to transport customers must have the following:
1. Current license plate, current registration, and other licenses as required.
2. Regular maintenance to ensure safety.
3. Must maintain full automobile coverage. ie. collision, liability, personal injury.
4. A First Aid kit which will be re-supplied as needed, and replaced annually to ensurl
compliance with expiration dates.
5. Seat belts, and if required, infant seats or wheelchair floor locks which are to be used a .
all times to secure customers while being transported.
6. A 2 Y2 pound dry chemical extinguisher.
The provider further agrees to ensure that:
1. Written policies and procedures regarding transportation of customers are readily
available.
2. Within thirty (30) days of employment, all drivers employed by the agency will be trainee
on the written policies and procedures regarding the transportation of customers.
Documentation shall be maintained on file indicating that this training has occurred.
3. The medical/behavioral needs of the customer will determine the required level of stafflnf
needed to ensure safety when transporting customers.
COMMUNITY BASED EMPLOYMENT:
Community Based Employment is competitive work in an integrated work setting with on-gcin:~
supports and services for individuals with disabilities for whom competitive employment has ne t
traditionally occurred, or has been interrupted or intermittent as a result of a disabil it) .
Community Based Employment models include individual community based employm;:nl,
mobile work crews and enclaves.
Phase I shall refer to those intense activities that are required to obtain and maintain continue I
employment. It is the initial stage of community based employment and concludes with th.~
stabilization of the individual with disabilities to the mutual satisfaction of the individual and th.:
employer.
Phase II/Follow Along shall refer to the activities both on and off the job site that are required fe r
the individual with disabilities to maintain employment.
Stabilization shall refer to the demonstrated ability of the person with disabilities to perf,)rrl
his/her job duties to the satisfaction of the employer with reasonable independence anI
9
consistency. More specifically, in the individual model, stabilization refers to employe
acceptable job performance for a specified period of time (60 continuous days) during whicl
time, the hours of ongoing supports do not exceed 20% of the weekly work hours of the.
individual. For the mobile work crew or enclave model, stabilization refers to job performance.
that has been acceptable to all parties for a period of 60 days.
Services provided will include customer assessment, job development and analysis, customer-job
matching, job placement and job related training on and off the work site. Additional service<:
provided includes advocacy such as facilitating natural supports and positive social interaction:
with co-workers and supervisors and any miscellaneous training and/or counseling that is needeu
to acquire and maintain employment.
The provider agrees to provide or complete the following services or tasks:
1. Develop individual program plans for each customer that clearly state desired outcomes for thd
customer.
2. Facilitate the completion of an annual customer satisfaction survey to be placed on file for eac h
customer receiving supported employment services.
3. Ensure that the status of the desired outcomes for each customer is accurately recorded and
documented.
4. Ensure that the program participants are receiving the same benefits as other employees with the
same work status (full time or part time) who are employed at the work site.
5. Document contact with the customer at the worksite at least three (3) times a month. Include
date, time, duration, location and pertinent notes.
6. Document contact with the customer's supervisor on at least on a monthly basis.
7. Ensure that no more than 20% of the customer's co-workers are persons with disabilities except i I
the case of mobile work crews or enclaves.
8. Document all efforts utilized to identify and procure employment for all customers who receive
services from the provider.
9. Complete and submit the Supported Employment Monthly Report form (Exhibit G), no later thall
five (5) days following the close of each month.
10. Notify the department immediately when changes in coaching staff occur i.e. identify staff who
are hired or leave employment.
Desired Outcomes Phase I /General
The provider agrees to ensure the following desired outcomes:
1. 80% of the customers who enter the program during the contract period will achieve 60 day
stabilization within six (6) months of entry into the program.
2. 80% of the customers who receive Phase I services will have their desired outcomes met, as
identified in their individual program plans (I.P.P.).
3. Provider achieves 80% or better compliance when monitored using the Supported Employment
Monitoring Checklist.
Desired Outcomes Phase II / Mobile Work Crews/Enclaves:
1. 80% of the customers who are placed, will remain successfully placed throughout the contracT
period.
10
2. 80% of the customers who are employed will have their desired outcomes met, as identified in
their individual program plan (I.P.P.).
3. Provider achieves 80% or better compliance when monitored using the Supported Employment
Monitoring Checklist.
Supported Living: Standard - Guide to Supported Living in Florida (F.A.C.
Rule lOF-ll)
Supported Living refers to a category of individually determined services designed ane
coordinated in such a manner as to provide assistance to adults who require ongoing supports t(
live as independently as possible in their own homes, to be integrated into the community, and t(
participate in community life to the fullest extent possible.
Supported Living services provided shall include a functional assessment of the individual':
capacities in the community and the individual preferences. Additionally, assistance to tht
customer in completing a quarterly housing survey based on the Housing and Urbm
Development housing quality standards found in 24 CFR, Chapter VIII, Subpart F, Sectior
887.251, and services and/or supports as outlined in the following section will be provided. Al
supports and services will be provided in compliance with the Chapter IOF-ll, Florid:
Administrative Code.
The provider agrees to provide support in the following areas:
Housing procurement
· Household maintenance/management
· Safety/emergency procedures
· 24-hour emergency assistance
· Meal planning/preparation
· Shopping/consumer skills
· Clothing care
· Self care/manners/sexuality
· Money management/banking
· Utilizing third party benefits
· Time management
· Recreation/leisure
· Mobility/travel skills
· Civic responsibility
· Advocacy
· Interpersonal communication
· Facilitation of one-to-one relationships
· Support counseling
· Self medication
The Provider agrees to provide or complete the following services or tasks:
1. Facilitate the completion of an annual customer satisfaction survey to be placed on file
for each customer receiving Supported Living services.
11
2. Conduct an annual functional assessment that identifies the training and assistance neede<..
by each recipient of supported living services.
3. Identify specific desired outcomes directly related to supported living services.
4. Provide the training and/or assistance needed by each recipient of supported livinl,
services as documented in the annual functional assessment and Stratl.~g:
Guide/Individual Program Plan.
5. Ensure that an on-call system is maintained which allows customers to access services for
emergency assistance, 24 hours per day, 7 days per week.
6. Document service delivery by maintaining case notes and time intervention logs.
7. Establish and document face to face contact with the customer preferably at the
customer's home, on at least a weekly basis.
8. Provide Supported Living coaching services with a customer/coach ratio not exceedinf
seven (7) customers to one (I) coach.
9. Notify the department immediately when changes in coaching staff occur, i.e. identify :ill
staff who are hired or leave employment.
10. Develop strategies for each individual receiving services that includes clearly stated
desired outcomes.
11. Submit Financial Profiles at least thirty (30) days prior to the month for which they are to
become effective.
12. Assist customers in establishing personal bank accounts.
13. In cases where customers misuse funds or require restrictions, i.e. co-signers, controls of
financial management by the provider etc., a written plan of action/agreement is to be
developed and signed by the customer and support coordinator.
Desired Outcomes:
1. 80% of the customers will have their desired outcomes met as indicated in their Individual
Program Plan (LP.P.) during the contract period.
2. Provider achieves 80% or better when monitored using the Supported Living Monitoring
Checklist.
12
Adult Day Training-Standard: Developmental Training Program Minimum Standard'i:
(Oct. 85)
Adult Day Training refers to training and related services provided to develop skills needed tll
function as independently as possible. These services are often designed to prepare individual;
to live in less restrictive settings, work in the competitive labor market, or function mon:
independently in the community. Services typically includes developmental training in a vaLet:"
of life skills areas, adult basic education, behavioral services, and sheltered employmen It
opportunities.
All Adult Day Training (A.D.T.) programs shall provide Certified Behavior Analyst (CBA I
services as needed (based on the IPP) to ensure proper program design and implementaton.
ADT programs will comply with the requirements contained in Department of Children an,l
Family Services, form 2006, Developmental Training Program Standards.
The provider agrees to ensure that the following services are received:
1. An annual formal and informal assessment to determine customer's level of functionin~; a;
described in the support plan.
2. The interdisciplinary team responsible for programming will consist of the individual, a scci, I
worker, a parent or guardian and other members as required and appropriate.
3. Targeted behaviors relate to the Support Plan, and are measurable.
4. Maintain documentation that short term objectives are:
a) derived from baseline data.
b) written in measurable terms.
c) related to targeted behaviors.
5. Programmatic changes are made on the basis of progress data.
6. That each customer's program consists of activities throughout the day for the achievement cf
the short term objectives and target behaviors identified on the customer's IPP.
7. The activities are age appropriate and culturally normative.
8. Emergency restraints and all programs designed to reduce or eliminate behaviors adhere to thl
regulations and procedures outlined in Department of Children and Family Services 160-4 an I
the Rule on Behavioral Management.
9. An implementation plan is maintained for all customers indicating the following:
a) Implementation plans are derived from baseline data.
b) Implementation plan includes a list of reinforcers to be used and when. .
c) Implementation plan includes a description of prompt levels.
d) Implementation plan includes criteria for changing prompts.
e) Implementation plan includes criteria for changing short term objectives.
2. Staffing Requirements:
a. Staffing Levels
Provider must maintain staffing, facilities and equipment as identified in the 97/98 (Bu1ig( t
Request Form) on file with the department, in order to deliver the agreed upon services. Th ~
provider will give written notification to the department immediately upon being unabk t)
provide the required quality or quantity of services. All service providers requiring Stat~ (f
Florida licensing ie. Physicians, Psychologists, Registered Nurses, Certified Behavior Analysts
13
(C.B.A.) and Associate Behavior Analysts (A.B.A.) or any other profession requiring licensme
shall provide the department with current State of Florida license or certification.
b. Professional Qualifications:
All staff who interact with the customer must be trained. Training should include but not bl
limited to: The Department of Children and Family Services, Guide to Support Coordination
HRSM 160-1, HRSM 160-3, HRSM 160-4, HRSM 160-5, the Bill of Rights of Persons Who an
Developmentally Disabled, and all other applicable standards.
c. Staff Changes:
Written notification must be submitted to the department when the person(s) who is authorize<
to bind the agency is no longer performing such functions. Notification of such changes shoul<
be submitted to the department thirty (30) days prior to making any changes. The departmen
will give written verification acknowledging changes and provide commentary regardingm~
concerns.
d. Subcontractor:
Funds made available pursuant to this contract shall not be used by the provider ane/o:
subcontractor for the purpose of initiating or pursuing litigation against the Departml:nt
The provider must request prior written approval from the department before.
subcontracting any service(s). The department will give written approval befcm
subcontracting any services.
3. Service Location & Equipment:
a. Service Delivery Location:
1. Services shall be provided in the County(ies) of: Dade
2. Services shall be provided by: CITY OF MIAMI BEACH
3. Services shall be at the following location(s) as identified in Section III, Paragraph D
2., of the Standard Contract.
b. Service Times:
All service times are to be in accordance with Department of Children and Family Services,
Guide to Support Coordination, HRSM 160-1, HRSM 160-4, HRSM 160-5 HRSM 160-8, and al
other applicable standards. In case of emergencies, the Waiver Support Coordinator, and the
Quality Assurance Units on call person should be notified. The Quality Assurance Unit can b<~
contacted via the on-call beeper at (305) 939-9246.
c. Changes in Location:
The movement of any customer to another service location requires prior authorization from thl
department. A written request (EXHIBIT F) must be submitted to the department thirty (30
days prior to any move. The department must give a written approval before any move from)nl
location. Any emergency rendering the provider incapable of providing services will require tht
immediate notification of the department.
d. Equipment:
The facility must be maintained in accordance with the Department of Children and Famil~
Services, Guide to Support Coordination, HRSM 160-1, HRSM 160-4, HRSM 160-5, HRSM
14
160-8, American Disabilities Act (ADA) requirements, and all other applicable standards. Th,
provider shall make the determination as to the appropriate programmatic equipment required tc"
deliver services as defined by this contractual agreement, with the proviso that the departmen.
shall have final authority when deemed necessary.
4. Deliverables:
a. Service Units:
The Department agrees to pay for the service units at the unit price(s) and limits listed below:
SERVICES
Transportation
Supported Living
Community Based Employment
Adult Day Training
UNIT OF MEASURE
Monthly
Monthly
Monthly
Daily
UNIT PRICE
$95.28
$485.00
$426.00
$24.50
b. Reports:
1 The provider agrees to submit a copy of the annual Compliance Audit or a Letter c f
Attestation prepared by a Certified Public Accountant, as clarified in Attachmen1 n.
This report shall be delivered to the contract manager no later than one hundred eight I
(180) days after the effective date of this contract.
2. The provider agrees to submit an actual expenditure report for the six (6) month pedo I
from July 1, 1997 through December 31, 1997. Such report shall be submitted no latu
than March 1, 1998.
3. The provider agrees to complete self monitoring document ( Exhibit E) on a quartl~rl"
basis. The checklist, when completed, must be signed by the person authorized to hin 1
the agency, and returned to the appropriate contract manager no later that the fifth (Stl)
day following the month of the quarter.
4. Documentation verifying the funding source and amount of the 12 Yz% required bCll
match shall be submitted no later than December 31, 1997 and shall be subject to th.~
approval of the department.
5. The provider agrees to submit to the department, a copy of the evacuation plan, thirt r
(30) days after the execution of this contract.
6. The provider agrees to submit to the department, a Monthly Supported Employner t
Report, (Exhibit G), no later than five (5) days following the close of each month.
7. The provider agrees to submit to the department, original signed Security Agreemer t
Form (CF 114) thirty (30) days after the execution of the contract.
c. Records and Documents:
1. The provider must maintain records documenting the total number of recipients an j
names (or unique identifiers) of recipients to whom services were provided and tb
date(s) on which services were provided so that an audit trail documenting servic e
provisions can be maintained.
2. The provider must keep accurate records of expenses for the facility and providl: a1
expenditure report when requested by the department.
3. The provider agrees to maintain a current record of each consumer served.
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5. Performance Specifications:
a. Outcomes and Outputs:
By contracting for the services identified in Section B. Manner of Service Provision, thl
departments mandate is to ensure that the customers derive such benefits as commullit;
inclusion, use of natural and generic supports, enhancement of their skills/abilities anI
promotion of maximum independence. Additionally, the department requires assuranceha
funds expended for the provision of these services, are performed efficiently by identifying anI
reducing wasteful and unneeded services. Subsequently, ensuring the effectiveness of servicl
delivery will enable the customer to meet their maximum level of independent living, and emun
that the state has used its funds in the most cost effective manner.
b. Standard Definition:
ADULT DAY TRAINING
85% of individuals served acquire or maintain critical skills, functions and/or outcomes as.
identified on each individual's support plan within specified time frames.
Achieve a satisfactory or better rating of 90% on client satisfaction surveys.
COMMUNITY BASED EMPLOYMENT
100% of individuals in supported employment are earning at or above minimum wage for f.LI.
Months.
25% of individuals in supported employment have an annual income above federal poverty
guidelines.
100% of individuals in supported employment program do not need paid supervision from ;
provider in excess of 20% of the individuals average work hours.
100% of individuals in supported employment who work less than an average of 20 hours pe
week have at least quarterly documentation of attempts to increase work hours lnl
justification for continuing to work at that level if anticipated for the next quarter.
Achieve a satisfactory or better rating of 90% on client satisfaction surveys.
SUPPORTED LIVING
.l.Q.Q% of individuals in supported living are the lessee or owner of the home in which they res de
.l.Q.Q% of supported living clients who live in housing in which persons with disabilities account.
for no more than 10% of the homes or apartments residents in the identifiable area.
Achieve a satisfactory or better rating of 90% on client satisfaction surveys.
TRANSPORTATION
Achieve a satisfactory or better rating of 90% on client satisfaction surveys.
c. Monitoring and Evaluation Methodology:
By execution of this contract, the provider hereby acknowledges and agrees that its performancl
under the contract must meet the standards set forth above and will be bound by the condition
set forth below. If the provider fails to meet these standards, the department, at its exclusivl
option, may allow up to six months for the provider to achieve compliance with the standards. I.
the department affords the provider an opportunity to achieve compliance, and the provider fail
to achieve compliance within the specified time frame, the department will terminate the cont'ac
16
in the absence of any extenuating or mitigating circumstances. The determination of the
extenuating and/or mitigating circumstances is the exclusive determination of the department.
ADMINISTRATIVE AND PROGRAMMATIC MONITORING:
1. All contracted programs and services will be monitored via on-site visits by district saf1'
no less than once a year. The purpose of the monitoring is to give assurance to the
department that funds expended to purchase services are not and will not be misusec OJ
mismanaged, that services appropriately meet the needs of the individuals being sen ed
and that documentation will be available and complete upon inspection.
2. The Contract Managers, the Quality Assurance Unit and the Financial :Ille
Administrative Monitoring Unit will conduct annual monitoring of the facilities. "~he
department will give written notification to the provider when the monitoring will be
conducted. Unannounced monitoring will be conducted as needed. A written response
regarding the outcome of the monitoring will be sent to the provider within thirty (30:
days after the monitoring. The provider will be given thirty (30) days in whid te
submit a written response to the department addressing any issues or areas of concern~
identified in the monitoring report.
3. Within six months of participation in the program, the provider will obtain results from ~
client satisfaction survey in which each client is asked to determine his/her level o.
satisfaction with the services of the facility. It is the responsibility of the provider te
ensure that all client satisfaction survey are completed by either the consumer, fami lie~
or legal guardian. At no time shall the satisfaction surveys be completed by th.
provider. The provider shall maintain results of the customer satisfaction forms on fih
for inspection by the department.
4. Provider must collect and maintain all data, statistics, reports, records, surveys and ;10)
other supporting documentation, relative to the performance standards identified ir
Section V., Performance Specifications, Paragraph B., (Standard Definition). Thi~
information must be maintained in the files for review by the department.
5. In the event the contract is terminated as a results of the provider failing to achieve th(
standards set forth in the contract, the provider may not contract for the same service~
within 12 months of the date of termination as the result of a formal competi1 iv(
procurement or as the result of a single source procurement.
d. Performance Definitions:
1. Federal Poverty Guideline - Are issued each year In the Federal Register by th(
Department of Health and Human Services.
2. Minimum Wage- Rate of pay as defined by the Department of Labor.
3. All Months - refers to the length of time the individual is employed.
17
6. Provider Responsibilities:
1. The provider agrees to provide services to customers as it is defined in this contract.
2. The provider assures that the human rights of all customers as applicable and specified iT
section 393.13(3), Florida Statutes, are protected and that it will abide by the provisiJn:
of Chapter 415, Florida Statutes, pertaining to protection from abuse, neglect 10<
exploitation of aged and/or disabled persons and children. The provider will report al
suspected cases of abuse or neglect of children, disabled or elderly individuals to tht.
department's central abuse registry at l-800-96-ABUSE.
3. The provider agrees to provide full access and cooperation with the Waiver Suppor
Coordinator( s), and the Human Services Counselor( s) III, in order to provide serv ce.
identified in the Support Plan, whenever applicable.
4. The provider agrees to purchase surety bond coverage from a responsible commen::ia
surety company to cover all officers, employees and agents of the provider authorizecl
to handle funds received or disbursed under this contract. The bond shall be in aJ.
amount commensurate with the funds handled, the degree of risk (as determined by th"
surety company) and consistent with good business practice. Documentation valida'inv;
insurance purchase, should be provided to the department within thirty(30) days afte .
execution of this contract.
5. The provider will have in place termination, suspension, or reduction of custome'
services policies developed by the provider and approved by the district in accordanc,:
with policies set forth in FAC lOF-8.
6. The provider will give written notification to the Contract Manager, the Placemen:
Coordinator, the Waiver Support Coordinator and the Human Services Counselor(s: II
of any customer vacancies and anticipated customer vacancies.
7. The provider agrees to attend training as recommended and required by the departmem.
All staff will have a current certification in CPR, Heimlich Maneuvers and trainin~ i 1
procedures to handle emergencies. All providers, their staff and clients will comp let~
HIV/AIDS training at least biannually. Documentation of training should be maintained
on file for review.
8. The provider agrees to have written admission and discharge criteria. Such criteria sha I
be made available to the department upon request.
9. The provider agrees to conform to all local zoning ordinances and land restrictions.
10. The provider shall establish and maintain communication with the surroundin.~
neighborhood and community organization, and residents. All responses relatiw t)
concerns from the community, shall be maintained in a separate file and copies will b:
submitted to the department upon request.
11. The provider agrees to cooperate with the recruitment of personal advocates for t:ac 1
customer, providing them with the training needed to assure the protection of th.~
customer's human, civil and legal rights.
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12. The provider will supply customer data as requested by the department.
13. The provider shall ensure that prompt medical and/or dental attention will be obtaile<
and coordinated with the Waiver Support Coordinator(s) and/or Human Service:
Counselor(s) III. as warranted, for medical and/or dental injuries or illness, utili:zin!
Medicaid, Medicare, and other insurance as defined in HRS 160-2, Chapters 8 - 13.
14. The provider will ensure that all customers will be assessed in accordance with tht
Department's Habilitative Programming Minimum Standards (HRS- DS Form 2(i 12
October 85), and Developmental Training Program Standards, HRS-DS Form 2(106
Such assessment shall occur within 30 days of placement.
15. Individual Program Plans (IPP) will be developed and implemented, for all custom;:rs
based on the results of the assessments. IPP's will be developed within 30 day~ o'
placement.
16. Based on a sampling of the IPP's by the department, the provider will meet a minimun
of (90%) of the identified goals on the customer's IPP's.
17. The provider will ensure a minimum of 90% compliance with HP 1.0 (progran
guidelines) and H.P. 2.0, where applicable.
18 The provider will ensure that all new admissions to the program shall have an approve(
Authorization Form (Exhibit F) from Developmental Services. The approval form lllUS
be approved and signed by the Placement Coordinator, the Contract Manager and i '
required, the Budget and Contracts Supervisor prior to enrollment for services under thi
contract. The provider will not be reimbursed for any services provided prior to sucl
approval.
7. Department Responsibilities:
1. The department reserves the right to remove customers without notice upon allegation~: 0 '
abuse or neglect of customers in the facility/program. Confirmed cases of abuse or neglec
of customers in the facility/program is grounds for termination of this contract in accordancl
with applicable Florida Statutes, rules and/or agency regulations.
2. The department reserves the right to mediate any disputes that arise between the prov de .
and the Waiver Support Coordinator. The Department will have the final authority in al
disputes.
3. The department shall not be held liable for payment if the customer is admitted to the faci lit:
without a written authorization form (Exhibit F) signed by the Placement Coordinator ant
the Contract Manager.
4. The department shall have the right to determine what services shall be reimbursed urde .
this contract.
5 The department shall make final determinations regarding any disputes concerning th,
retention of records and documents.
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c. METHOD OF PAYMENT:
1. Invoice Requirements:
a. This is a fixed price (unit cost) contract. The department shall pay the provider fOl
the delivery of service units provided in accordance with the terms of this conttacl
for a total dollar amount not to exceed $ N/A, subject to the availability offunds.
b. The department agrees to pay the provider for services at the unit price(s) anc
unites) of measure found in Section B (Manner of Service Provision) paragraph IV
a. (Service Units).
c. The provider shall request payment on a monthly basis through the submission of (
properly completed invoice (Exhibit A) and back-up (Exhibit(s) B, C, and G) a~
required. Invoices must be submitted within 10 days following the end of the montl
of service. If a service is funded by more than one category, the provider IT USI
submit a separate certification (Invoice) for each category. The provider i~
responsible for ensuring the accuracy of unit count in each category. Upon receip
of a correct invoice, the department will process an invoice in accordance vritl
Department of Children and Family Services Accounting Procedures Manual
Volume 2, Vouchering, Chapter 6.2 Developmental Services and the Developmellta
Services ABC System User's Guide, Invoice Module.
d. Payment for services by the Department of Children and Family Service!
Developmental Services, shall be considered payment in full. The provider shall no
receive or accept payment for the customers care or training from/or on behalf of (
customer in excess of the amount determined and authorized by the department.
e. Vacation, holidays and in-service time is not reimbursable as a service day fo
computing units of service under this contract. Hours and days of service shall rree
minimum standard requirements, shall be described and met as per agency proposal
and per any other special provision or other section of this contract.
f. Payments may be authorized only for service units on the invoice which an il
accord with the above list and other terms and conditions of this contract. The
service and units for which payment is requested may not either by themselves, 0
cumulatively by totaling service units on previous invoices, exceed the total num be
of units authorized by this contract.
g. For the purpose of reimbursement, enrollment is related to continuing attendallce
No day of absence will be reimbursed. The provider shall maintain attendancl
records for each reimbursable service.
h. In the case of a non-material breach, the department retains the right to withl,olc
payment of funds in total or in part, until such time as the breach is corrected.
I. The Department of Children and Family Services, Developmental Services shall no
reimburse the Provider for any ineligible person served.
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J. Receipts are required for all expenses incurred, (e.g., office supplies, printing, long
distance telephone calls, etc.) and must be maintained on file by the provider fOI
audit and monitoring purposes.
k. Travel:
I. A Department of Children and Family Services travel voucher ( State of Florid::
Voucher for Reimbursement of Traveling Expenses - Form C-676), Exhibit J reus
be completed and maintained on file by the provider. Original receipts fOl
expenses incurred during officially authorized travel; items such as car rental and ail
transportation, parking and lodging, tolls and fares; must be maintained on file-m
the provider. Section 287.058 (I) (b), F.S., requires that bills for any travel expens(
shall be maintained in accordance with Section 112.061, F.S., governing paymwt~
by the state for traveling expenses. Department of Children and Family Services 40.
1 (Official Travel of Department of Children and Family Services Employees ,me
Non-Employees) provides further explanation, clarification, and instruclior
regarding the reimbursement of traveling expenses necessarily incurred during thl
performance of official state business.
2. Prior approval is required in accordance with Section 112.061 F.S., fo
conference travel and must be certified on Form C-676C, Exhibit J ( State o'
Florida Authorization to Incur Travel Expense) with a copy of the program 0
agenda of the conference attached. Reimbursement is in accordance with "1" abc.ve
The Department of Children and Family Services 40-1 provides further explanat on
clarification and instruction.
3. The provider must retain on file documentation of all travel expenses to inclJdl
the following data elements: name of the traveler, dates of travel, travel destinat on
purpose of travel, hours of departure and return, per diem or meals allowance, nal
mileage, incidental expenses, signature of payee and payee's supervisor.
2. INVOICE REQUIREMENTS: Home and Community Based Services(Medicaid
Waiver)
a. The service, units of service and rates found in section B, Manner of Serl'icl
Provision, #4 Service Units, will be used to reimburse the Provider for the provi~ iOJ
of services to Developmental Services/Home and Community Based Serv ce ..
Medicaid Waiver (HCBS) eligible customers who are authorized to receive ~;ai,
services.
b. To receive reimbursement for services, the provider shall submit a separate invoic,:
(Medicaid Waiver and General Revenue) for all eligible Medicaid Waiver customer:
on a monthly basis. Invoices will be sent to the appropriate Waiver Suppor
Coordinator, (W.S.C.) pursuant to the procedures found in section B, Manne' 0'
Service Provision, Paragraph IV., (Deliverables) Section a., (Service Units). The
( W.S.C.) has the responsibility of approving and processing payment for al
authorized Medicaid Waiver services within five (5) working days of receipt 0' aJ I
invoice. For General Revenue Payments, the (W.S.C.) shall initial and approve th:
invoice indicating that these services are authorized to be paid, and forward th,:
approved invoices to the Developmental Services Budget and Contract Unit fa'
payment.
21
c. During the life of this agreement, the required documents may change dm tl"
Developmental Services/Home and Community Based Services Medicaid Wave'
expansion requirements. Should documentation requirements be changed, th,.:
Department and the Provider agree to make changes through a memorandurr 0'
understanding or a formal amendment to this agreement at the discretion of th:
Department.
d. Vacation, holidays and in-service time is not reimbursable as a service day fo'
computing units of service under this contract. Hours and days of service shall mee!:
minimum standard requirements, shall be described and met as per agency propc,sai,
and per any other special provision or other section of this contract.
e. The provider shall request payment on a monthly basis through the submission )ft
properly completed invoice (Exhibit A) and back-up (Exhibit(s) Band q a;
required. Invoices must be submitted within 10 days following the end of the month
of service. The provider is responsible for ensuring the accuracy of unit count in
each category. Upon receipt of a correct invoice, the W.S.C. will process an invl)ic<~
in accordance with Department of Children and Family Services Accountin~
Procedures Manual, Volume 2, Vouchering, Chapter 6.2 Developmental Service;
and the Developmental Services ABC System User's Guide, Invoice Module.
f. Payments may be authorized only for service units on the invoice which an: i I
accord with the above list and other terms and conditions of this contract. Th .~
service and units for which payment is requested may not either by themselve~, c r
cumulatively by totaling service units on previous invoices, exceed the total number
of units authorized by this contract.
g. For the purpose of reimbursement, enrollment is related to continuing attendancl.
No day of absence will be reimbursed. The provider shall maintain attendanc.~
records for each reimbursable service.
3. Program Specific Requirements for Payments (Agreements that includes Adult IDa '(
Training Services)
a. Local match for the Developmental Training Program is required at 12 Yz% of th~
total program cost. Rule 45-CFR 74 (Exhibit D identifies matching information.
D. SPECIAL PROVISIONS:
ALL REFERENCE TO THE DEPARTMENT OF HEALTH ANl)
REHABILITATIVE, AND THE DEPARTMENT OF CHILDREN ANl)
FAMILIES, HERE AND THROUGHOUT THE CONTRACT, SHALL B:.C
CONSTRUED AS THE DEP ARTMENT OF CHILDREN AND F AMIL '{
SERVICES
1. Grievances and Fair Hearings
The provider shall establish written procedures so that applicants for services and CUITel t
customers may present grievances about the operation of the contract. The provider will ad vi~ e
22
applicants of the right to appeal a denial or exclusion from the program services, of failun: t(
take account of a customer's choice of services and of his/her right to a fair hearing to the f na
governing authority of the agency.
2. Human Rights Advocacy Committee (HRAC) Access
a. The provider shall post in a readily accessible location visible to all. customers ei1 he ..
procedures or a poster informing customers how they may contact the HRAC.
b. The provider shall allow the HRAC access to the facility and the right to speak with an;
person who is developmentally disabled, staff or volunteers, in accordance with Section
402.165 and 402.166 Florida Statutes.
3. Copyrights
a. Where activities supported by this contract produce original wrItmg, sound recordings
pictorial reproductions, drawings or other graphic representations and works of any sim ila'
nature, the department has the right to use duplicate and disclose such materials in whoh: 0 .
in part, in any manner, for any purpose whatsoever and to have others acting on behalf of th:
department to do so. If the materials so developed are subject to copyright, trademlrk,
patent, legal title, then every right, interest, claim, or demand of any kind in and to an:'
patent, trademark or copyright or application for the same, will vest in the State of Florida,
Department of State, for the exclusive use and benefit of the state. Pursuant to sec:ioll
286.021, Florida Statutes, no person, firm or corporation, including parties to this contrac:
shall be entitled to use the copyright, patent or trademark without the prior written conser t o.c
the Department of State.
b. Any earnings realized by the Provider as a result of contract-related and supported activi1ie~ .
including royalties received from copyrights on publications or other works developed unde .
this contract, interest income from fees, or sale of assets purchased with contract funds shal l
not be expended without the prior written approval of the Department. The Departmen t
reserves the right to require those funds to be used to reduce costs borne by Federal
Government or the Department or both.
4. Work And Gain Economic Self-Sufficiency (WAGES):
In accordance with the Department of Health and the Department of Children and Family
Services Interagency Agreement, the Department of Health has agreed to assist the Departme1t
of Children and Families and the Department of Labor and Employment Security in the
implementation ofW AGES. WAGES is an initiative to empower recipients in the Temporar;r
Assistance to Needy Families Program to enter and remain in gainful employment. Employmert
of WAGES participants is a mutually beneficial goal for the provider and the State of Florida in
that it provides qualified entry level employees needed by many providers and provides
substantial savings to the citizens of Florida.
The provider or its agent agree to notify the Department of Children and Family Services of all
entry level employment opportunities associated with this contract which require a high school
education or less. The Department of Children and Family Services will contact the WAGES
Coordinator in the Department of Labor and Employment Security regional office and request
that WAGES participants be referred to the provider. In the event that the provider or its agent
23
employs a person who was referred by the WAGES office, the provider will notify the
department.
5. Multi-district Rate Agreement
Other Department of Children and Family Services districts may participate in this agreemer:t a
the rates specified in (Section IV) Summary of Rates and Services. Each of the Department 0 .
Children and Family Services districts is responsible for its own payment to the provider for tht
services provided to customers of that district. The district that is financially responsible for thl
customer will prepare the invoice (Department of Children and Family Services DS-3029A) an,
forward it to the provider. The provider will return the signed invoice with corrections noted tl"
the responsible district for processing.
6. Access to Records
All customers records including, but not limited to medical, psychiatric and psychologica
records, any and all other customers records shall be the sole property of the department ane
shall remain at the provider's facility upon termination of this contract. The department s1al
have reasonable access to all manuals, policies, procedures, personal records, and other writel
materials produced or developed by the provider pursuant to this contract at any time during thl
course of this contract. Upon termination of this contract, said material shall remain at thl
provider's facility until the department, or any subsequent provider has had reasonabll
opportunity to reproduce and duplicate said materials.
7. Right To Inspect
The Provider agrees that the department may enter the premises where services are providec, a .
any time deemed appropriate during the term of this contract.
8. Use of Funds for Lobbying Prohibited
The provider agrees to comply with the provisions of section 216.347, F.S., which prohibits thl
expenditure of contract funds for the purpose of lobbying the Legislature or a state agency.
9. Emergency Preparedness
The provider agrees to be responsible for the care, maintenance and, if necessary, the relocaljOl
of customers during any natural disaster or period of civil unrest. The provider shall submit thei .
evacuation plan to the Quality Assurance Unit for review. The plan should be submitted thirt:
(30) days after the execution of this contract. The Quality Assurance Unit shall, within thirt: .
(30) days of receipt, give a written response to the provider regarding the status of the evacuariOJ
plan.
10. Non-expendable Property
a Non-expendable property is defined as tangible personal property of a nonconsumabll
nature that has an acquisition cost of $500 or more per unit and an expected usefullifj~ 0 .
at least one year, and hardback bound books that are not circulated to students or thl
general public, the value or cost of which is $100. Hardback books with a value or cos
of $25 or more should be classified as an OCO expenditure only if they are circulated tt .
students or to the general public.
b All such property, purchased under this contract, shall be listed on the property record.
of the provider. Said listing shall include a description of the property, model num!)er
24
manufacturer's serial number, date of acquisition, unit cost, property inventory numbel
and information on the condition, transfer, replacement or disposition of the property.
c. All such property, purchased under this contract, shall be inventoried, and an inventory
report shall be submitted to the department along with the final expenditure report. A
report of non-expendable property shall be submitted to the department along with th{
expenditure report for the period it was purchased.
d. Title/ownership to all non-expendable property acquired with funds from this contrac
shall be vested in the department upon completion or termination ofthis contract.
e. At no time shall this provider dispose of non-expendable property purchased under 'hi~
contract except with permission of, and in accordance with instructions from th{
department.
f. A formal contract amendment is required prior to the purchase of any item 0
nonexpendable property not specifically listed in the approved contract budget.
Title to Vehicles (TRANSPORTATION DISADVANTAGED).
a. Procedures for acquisition of vehicles for transportation of Department of Children ,m(
Family Services clients acquired directly by the department or a contracted provider an
contained in Department of Children and Family Services 40-5. The following claus{
must be used in all cost reimbursement contracts which provide for the purchase o.
vehicles for transportation of Department of Children and Family Services clifnt~
(transportation disadvantaged), using Department of Children and Family Servjce~
funds:
b. Title to Vehicle (TRANSPORTATION DISADVANTAGED): Title (ownership) to al
vehicles acquired with funds from this contract shall be vested in the department upor
completion or termination of the contract. The provider will retain custody and con TO
during the contract period, including extensions and renewals.
11. Insurance
The provider will obtain and maintain liability insurance on all motor vehicles ownedm(
operated by the provider, and used in conjunction with the operation of the group home OJ
program. The provider will also obtain and maintain liability insurance coverage of reside 1tS
staff, and visitors, as required by the Division of Risk Management, and Department o'
Insurance. Documentation of liability insurance should be submitted to the department wi1hir
thirty (30) days of execution of this contract.
12. Board Members
The department encourages the provider to develop and maintain a culturally diversified board
representative of the diverse population in Dade county.
13. Background Screening
All personnel including volunteers and relatives, must comply with section 393.0655, Florid,
Statute, regarding background screening requirements. The provider shall, within five (5
25
working days after starting work at a facility, submit to the facility for submission, within forty-
eight (48) hours to the department a complete set of fingerprints taken by an authorized la\\
enforcement agency or an employee of the department who is trained to take fingerprints. "'h{
provider will ensure that a re-screening of all personnel including volunteers and other relathes
is conducted after a five year period, in accordance with Chapter 95-228, Section 50, Law~ oj
Florida (Oct. 95)
14. Impact Zone Planning
The provider will make available to the Department of Children and Family Services, Distdc
11, zip code data on where their service recipients reside as well as certain other clien
identifying information as requested. This information will be used to facilitate the Departmen
of Children and Family Services impact zone planning.
15. SECURITY DATA INTEGRITY - CF OPERATING PROCEDURE NO. 50-6
As referenced in Administrative Rule 44-4.080(1)(a)(b), Employee Requirements, and Chapte
815, Florida Statutes, "Florida Computer Crimes Act", all employees and contract emplo)ee:
with access to data through computer related media must read and sign the security agreerr en
form (CF 114) as identified in Exhibit H. Fulfillment of security responsibilities shall be
mandatory and violations may be cause for civil penalties, or criminal penalties under chap:er
119, 812, 815, 817, 839, or 877, Florida Statutes, or similar laws.
The provider will ensure that Exhibit H will be signed by all required personnel, and a c )p:
retained in their file.. The signed original must be sent the contract manager which will hi
retained in the contract file. A copy of the CF OPERATING PROCEDURE NO. 50-6 i.
available upon request.
26
ATTACHMENT II
FINANCIAL AND COMPLIANCE AUDIT
This attachment is applicable, if the provider or grantee, hereinafter referred to as
provider, is any local government entity, nonprofit organization, or for-profit
org~ization. An audIt performed by the Auditor General shall satisfy the requirements
OnhlS attachment.
PARTI: FEDERALLY FUNDED
This Rart is applicable if the provider is a local government entity or nonprofit
organization and receives a total of $25,000 or more in federal fUnds yassed through the
department during its fiscal year. The provider has "received" federa funds when it has
obtained the cash from the department or when it has incurred reimbursable expenses.
Local governments shall comr>lY with the audit requirements contained in Office of
Management and Budget (OMB) Circular A-128, Audits of State and Local
Governments. Nonprofit providers shall comply with OMB Circular A-133, Audits of
Institutions of Higher Learning and Other Nonprofit Institutions, except as modified
herein. Such audits shall cover the entire organization for the organization's fiscal year.
The audit report shall include a schedule of financial assistance that discloses each state
contract by number.
Compliance findings related to contracts with the department shall be based on the
contract r~uirements, including any rules, regulations, or statutes referenced in the
contract. The financial statements shall disclose whether or not the matching requirement
was met for each apI>.licable contract. All questioned costs and liabilities due to the
departm~nt shall be fully disclosed in the audit report with reference to the department
contract mvolved.
If the provider has received any funds from a grants and aids approQriation, the provider
will afso submit a compliance report in accordance with the rules or the Auditor General,
Chapter 10.600, and indicate on the schedule of financial assistance which contracts are
funded from state grants and aids appropriations.
The provider agrees to submit the required reports as shown in Part IV.
PART II: STATE FUNDED
This part is applicable if the provider is a nonprofit organization that receives a total of
$100,000 or more from the department during its fiscal year, which is not paid from a rate
contract based on a set state or area-wide fixed rate for service; and of which less than
$25,000 is federally funded. The provider has "received" funas when it has obtained the
cash from the department or when it has incurred reimbursable expenses.
The provider agrees to have an annual financial audit performed by independent auditors
in accordance with the current Government Auditing Standards issued by the Comptroller
General of the United States. Such audits shall cover the entire organization for the
organization's fiscal year. The scope of the audit performed shall cover the financial
statements and include reports on internal control and comr>liance. The audit report shall
include a schedule of financial assistance that discloses eacn state contract by number.
Compliance findings related to contracts with the department shall be based on the
contract r~uirements, including any rules, regulations, or statutes referenced in the
contract. The financial statements shall disclose whether or not the matching requirement
was met for each apI>.licable contract. All questioned costs and liabilities due to the
departm~nt shall be lully disclosed in the audit report with reference to the department
contract mvolved.
If the provider has received any funds from a grants and aids approQriation, the provider
will afso submit a compliance report in accordance with the rules or the Auditor General,
Chapter 10.600, and indicate on the schedule of financial assistance which contracts are
funded from state grants and aids appropriations.
Page 1 of2
07/01/96
27
The provider agrees to submit the required reports as shown in Part IV.
PART III: CHAPTER 10.600, OR NO AUDIT REQUIREMENT
This part is applicable if the provider is either (1) a for-profit organization, (2) a local
government entity receiving less than $25,000 m federal funds from the der>artment
auring its fiscal y'ear, (3) a nonRrofit organization receiving less than $100,UOO from the
department, of which less than $25,000 is federally funded, during its fiscal year, or (4) a
nonprofit organization receiving a total of $100,000 or more from the department from a
rate contracfbased on a set state or area-wide fixed rate for service, of which less than
$25,000 is federally funded. The provider has "received" funds when it has obtained cash
from the department or when it has incurred reimbursable expenses.
If the provider receives funds from a grants and aids appro.priation, the provider shall
have an audit, or submit an attestation statement, in accoraance with the rules of the
Auditor General, Chapter 10.600. The audit report shall include a schedule of financial
assistance which discloses each state contract by number and indicates which contracts
are funded from state grants and aids appropriations.
The provider agrees to submit the required reports as shown in Part IV.
Otherwise, if the provider does not receive funds from a grants and aids appropriation, the
provider has no audit or attestation requirement required by this attachment.
PART IV: SUBMISSION OF REPORTS
Copies of the audit report and any management letter by the independent auditors, or
attestation statement" required by this attachment shall be submitted within 180 da~ after
the end of the proviaer's fiscal year to the following, unless otherwise required by Florida
Statutes:
A. Office of Internal Audit (OSIA)
1317 Winewood Boulevard
Building 1, Room 301G
Tallahassee, Florida 32399-0700
B. Contract manager for this contract.
C. Submit to this address only those rer>orts prepared in
accordance with OMB Circular A-D3:
Federal Audit Clearinghouse
P. O. Box 5000
Jeffersonville, Indiana 47199-5000
D. Submit to this address only those reports prepared in
accordance with the rules of the Auaitor General,
Chapter 10.600:
Jim Dwyer
Office of the Auditor General
P.O. Box 1735
Tallahassee, Florida 32302
The provider shall ensure that audit workingjJapers are made available to the department,
9r its designee, upon request fo.r a period onlve years from the date the audit report is
Issued, unless extended m wntmg by the department.
Page 2 of2
07/01196
28
fj(LCIH ILDREN
" FAMILIES
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
ATTEST A TION STATEMENT
CONTRACT NUMBER (8):
I ,
, hereby attest, under
(head of provider entity)
penalties of perj ury, that
(provider entity name)
has complied with all provisions of the contracts listed above during the fiscal year
ended
(month, day, year)
(signature)
(title)
(date)
One copy of this attestation statement shall be submitted within 180 days after tile
provider's fiscal year end to each of the following:
1. Office of Internal Audit (OSIA)
1317 Winewood Boulevard
Building 1, Room 304A
Tallahassee, Florida 32399-0700
2. Contract manager for this contract.
3. Jim Dwyer
Office of the Auditor General
P.O. Box 1735
Tallahassee, Florida 32302
This statement does not need to be notarized.
29
EXHIBIT A
DISTRICT ELEVEN
DEPARTMENT of CHILDREN and FAMILY SERVICES
DIVISION OF ADULT CARE & FAMILY SUPPORT
INVOICE REQUEST FOR SUBSIDIES/SERVICES RENDERED
VENDOR NAME:
CONTRACT NUMBER:
ADDRESS:
MONTH OF SERVICE:
SERVICE PROVIDED:
VENDOR ID #:
FUNDING CATEGORY: I. F. S..
CLIENT NAME SOCIAL SECURITY RATE NUMBER AM
NUMBER PER UNIT OF UNITS REi:
1
2
3
4
5
6
7
8
9
10
11
12
13
I I TOTAL I I 1=
DUNT
,3!!,i::STED
Ii CERTIFY THAT GOODS AND SERVICES ITEMIZED ON THIS AUTHORIZATION INVOICE, HAVE BEEN RECEIVED \ND
ARE A PROPER CHARGE AGAINST THE STATE FUNDS APPROPRIATED FOR THIS PROGRAM. SUPPORT RECI:W::D FOR
I'N HOME SUBSIDY OR SUPPORTED LIVING STIPEND WILL BE USED FOR THE PURPOSES PREVIOUSLY AGR::EliJ
UPON IN WRITING.
PROVIDER/CUSTOMER SIGNATURE
DATE
SIGNATUREJA rE
Department of Children & Famil~ Services
30
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EXHIBIT D
SUBPART G
Cost Sharing or Matching
~ 74.50 Scope of subpart.
(a) This subpart contains rules (or satisfying Fed.
eral requirements (or cosHh:ulng or matching. These
rules apply whether the cost sharing or matching is
required by Feder:!l statute or by other terms of tbe
grant.
(b) HHS and a grantee may eotcr into an instiru-
lional cost-sharing agreement covering all of HHS's
research project grants to that grantee in the aggregate.
Except as provided by the instirutional cost-sbaring
agreement, this subpart applies to the satisfaction of
the grantee's obligation under the agreement, as weU as
to the satisfaction of cost-sharing or matching require-
ments that apply onJy to a single grant.
S H.51 Definitions..
For purposes of this subpart:
"Cost sharing or matching" means tbe value of
third-party in-kind contributions and that portion of
the costs of a grant-supported project or program not
borne by the Fcderal Government.
"Equipment" has the same meaning given to that
term in ~ 74.132, except that instead of "acquisition
cost," the words "market value at the time of donation"
shall be substituted.
"Suppljes" means aU tangible personal property
other than ":quipmenC' as defined in this section.
"TQi.rd-p,lr~ in-kind contributIons" mea.05 ~l)
...Q! ~ which benefit a grant.supported project or
program and which are contributcd by non-Fcder21
third panics without charge to the grantec, the sub-
gr3ntec, or a cost-type con~ractor u:lccr the gnnt or
subgIJ.:H.
~ 7~.52 Basic rule: Costs :Jnd contributions accepl'
able.
Wiul th~ qU:1lifications ;.Ind ace,Hions listed :n
~ iot.53. a cost-sharing or :n~tch:!1g rcql!;:e~eDt omJj'
:l
be satisfied by eith~r or both of the following .
(a) Allowable COSlS incurred by the granee, sub-
gramee, or a cost-type contr<Jctor under the grant or
subgrant. This includes allowable costs borne by noo-
Federat grams or by other cash donations tr)m noo-
Federal third panics.
(b) The value of third-party in-I:ind Cont :'ibulioos
applicable to Lhe period to which the COst-staring or
matching requiremem applies.
~ 7~.53 Qualiti~tions and exceptions..
(a) Costs born~ by other F~dera1 grants. (1) Ex-
cept as provided by Federal statut.c. a cost-51 acing or
matching requirement may not be met bY::O!t5 borne
by another Federal grant Th~ prohibitiol does oat
apply to costs borne by general program ino)m: earned
(rom a COOlfact awarded under another Feder t..I grant.
(2) For the purposes of this pan, genelral revenue
sharing fuods under 31 v.S.C. 1221 are not cC[lSidercd
a Fedcral grant. Therefore, jn the absence of my pro-
vision of Federal statute to the contrary, allow;! )Ie costs
borne by these funds may count towards ~.ati;tying a
cost-sharing or matching requiremenL
(b) COSlS or cOnlribuliotU counl~d lOMar.:~ otJur
F~dera{ cOSl-sharing r~quir~m~nlS. Neither O,sts nor
the values of third-party in-bnd conlfibuuc os may
count lowards IJrisfying a. cosHhu0g 01. r lalching
requircment of an HHS grant if they !lave teet or will
be countcd lOwuds satisfying 3. cost-sharing 01 match-
ing rcquircment of another Federal graot, a Federal
procurelDc:lt .:onlr3.ct, or any other award oC Federal
funds.
(c) Casu lin(lnc~d by yenua{ praf,?ram incamt:.
Costs financed by scnaat i'rognm Inco:nc, a.s ~:~ed
in ~ i..Lot::!, i~lJlI not .:ount towards ~atisfY:Dg a ';OS1-
sha~ing or mJICJlng ~~qairemenl of :hc HHS gr .~Dl sup-
porting the JCllvity giving rise :0 ,~c income UI. Jess !CC
terQ;1s ~f the grant c.<pressly rr~i( th~iQ(;oa = !O be
33
("
usea (or cost sharing or malching. (This is the alterna-
tive (or use o( g.:neral progr3m income described in
37~A:!(d).)
(d) RecorCJ. COSts and third-parry in-kind contri-
butions counting towards satisfying a cost-iharing <>r
matc:ting requin:ment must be \'etifiable from tbe rec-
ords of recipients or cost-type Contractors. These rec-
ords must show bow' the value placed on third-party
in-kind contributions was arrived at. To the extem
ieJ.sible, volunteer services shall be supported by the
)ame methods that the organization uses to support the
allocability of its regular personnel costS.
(e) Special standards for third-parry in-kind contri-
butions. (1) Third-p~ ie-kind contributions shall
count towards satis(yin~ a eost-sbario~ or matching
requirement" only where, y the pany readying Ihe con-
tributions were to pay for them, the --payments would
be allowable costs.
(2) ~..Jhirrl-p~rty iFl \-inrl rnntribution shaU not
count as direct cost sharine or matching where, if the
~artv recdvinl?: Ihl: contribution Were to pay for i~_~e
payment would be. an indirect cas!. Cost-sharing or
matching credit for such contributions shall be given
only if the' recipient or contractor has established,
along with its regular indirect cost rate, a special rate
(or allocating to individual projects or programs the
value of the contributions. (Information on how to
establish these rates can be oblained from the Division
of Cost Allocation in any lfl{S regional office's
Region~l Administrative Support Cenler.)
(3) The values placed on third-parry in-kind con-
tributions [or cost-sharing or matching purposes shall
conform to the rules in the succeeding sections of this
subpart. li a third-party in-kind contribution is of a
type not ueated in those sections, the value placed
upon it shall be fair and reasonable.
~..
974.54 Valuation of donated servIces.
(a) Voluntar Juvices. Unpaid services provided
to a recipient by iudividuals shall be valued at rates
consistent with those ordinarily paid tor similar work
in the recipient's organization. li the recipient does
not have employees performing similar work. the rates
shall be consistent with those ordinarily paid by other
employers for similar work in the same labor market.
ill eimer case, a reasonable amount for fringe benefits
may be included in the valuation.
(b) Employus 01 other Organizations. When :lJ1
employer other th3n a rccipient or cost-~'Pe contractor
furnishes free of char~e the services of an emplo)'ee
:n the employee's normal line of work, the suvices
s~aU ~ valued at t~e emplo~'cc's regular ratc of pay
exclusive. of the emplo)'cr',s fringe benelits and over-
he3d. costs.. U !.he services are in a different liOc ~ol
;.. ~~.',":';~};;"!" :,' ' ..
wod"p~,agrapa ~ a) of this sc.cuonshall ~PP!Y.~i
-H .. .. ..... t-~
~ 74.55 ValUAtion of donaled suppli(s and loaned
eqwpment or space.
(a) U a third party donates supplies tl e CQatIlbu-
tioo shall be valued at the marlcet valuc)fhe supplics
at the time of donation.
(b) U a third party donates the 'use OJ equipment
or space in a building but retains title, tl: e cootribu-
tion shall be valued at me fair rental rate 0 l!le equip-
ment or space.
~ 74.56 Valuation of donated equipmenl. buildings,
and land.
It a third party donates equipment., bl ildings, or
land, and title passes to a recipient, thc t!l:::atment of
the donated property shall depend upon tbe purpose of
the grant or subgrant, as follows:
(a) A. wards for capital expenditures. If t le purpQsc
of the grant or subgrant is to assist .the rccil,ient in the
acquisition of property, the markct \ ah e of that
property at the time of donation may t e:ouotcd as
cost sharing or matching.
(b) Other awards. U assisting in !beacl uisition ot
property is not the purpose of the granl O. subgrant,
the following rules apply:
(1) U approval is obtained from the awarding
party, the market value at the time of de n8 jon ot the
donated equipment or. buildings and tl:..e fair rental
rate of the donated land may b.: couoted as cost shar-
ing or matching. In the case of a subgrant, the terms
of the HEW grant may require that the approval be
obtained from the granting agency as w:U as the
grant~e. In all cases, the approval may be ,~vcn oaly
if a purchase ot [he cquipment or reot;} 0: the land
would be approved as an allowablc dircct cc st.
(2) U approval is not obtained uod:r paragraph
(b) (1) of this section, no amounl mar t e couoted
tor dooated land, and only depreciatiou ,)r use allow-
ances may be counted for donated eq uiI ment anq
buildings. The deprcciation or use allow;: nc:.s (or this
property are not treated as tllird-party in kind con-
tributions. Instead, they are treated as casli incurred
by the recipient They are compUled <nd allocated
(usually as indirect costs) in accordftnce wib the cost
principles specificd in subpart Q of-this p..rt, in the
same way as deprcciatio~ or use allowallcc; for ;>ur-
chased equipment and buildings. The a..rJIOI nt of ce-
preciation or use allowances for dooate:1:quipcent
and buildings is based on the property's :na:1:et value
at the time it was dooated. ' .
~ 74.57 Appraisal o( real p~operty.
In some cases under U 74.55 and i~56. it will be
necessary to establish the market value ;,f 'land or a
building or the (air rental raCe of land or ')l iipace i1! a
.building. In these cases, the gr:l.OOng ag,:ncy cay
34
EXHIBIT_ -L-
DEPARTMENT OF CHILDREN AND FAMIL Y SERlll(:;ES
DISTRICT XI DEVELOPMENTAL SERVICES PROG'RAM
PROVIDER SELF-MONITORING CHECK LIST
Name Of Service Provider:
Date:
NAME (print)
SIGNATURE:
TITLE:
35
INSTRUCTIONS FOR COMPLETING SELF-MONITORING
CHECKLIST
The self-monitoring checklist is not a substitute for the departments annual monitoring. It
should be used as a tool to remind the provider of the requirements needed to maintal.n
compliance with the contract. Before the department conducts its annual monitoring, the
more comprehensive monitoring tool will be shared with all providers prior 0 the date of
monitoring.
1. The checklist must be completed by all providers on a monthly basis. When
completed, it must be signed by the individual authorized to bind the agency, and
submitted to the contract manager.
2. ALL providers must complete the GENERAL MONITORING
REQUIREMENTS and the FINANCIALIBUDGET monitoring form.
3. Providers must complete the section of the self-monitoring checklist that contains
those services that they provide. For those services that do not apply, please mark
"N/A" on the form and return.
4. Please return the entire package to the contract manager upon completion.
PLEASE NOTE: SOME SECTIONS OF THE SELF-MONITORING
CHECKLIST HAVE MULTIPLE PAGES.
36
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICf XI DEVELOPMENTAL SERVICES PROGRAM
GENERAL MONITORING - ALL SERVICES
PROVIDER SELF - MONITORING CHECKLIST
Pag.. 1 of 2
CONTRACT NAME:
ADDRESS:
PHONE NUMBER:
CONTRACT MANAGER:
CONTACT PERSON:
DATE OF MONITORING:
1) Are records available that documents that all staff
trained to meet the customers needs, and that
training is updated as needed?
2) Does provider maintain personnel files indicating the
required qualification of all staff interacting with the
consumer?
3) Is time and attendance record kept for, and signed
by all staff?
4) Does the provider maintain documentation of training
and information fiven to direct staff regarding customers?
5) Does the provider maintain documented evidence
that staff is trained and knowlegeable in all emergency
procedures including, but not limited to CPR, first aid,
and emergency evacuation?
6) Are all records organized in a systematic manner?
7) Are customer's record and files confidentially
maintained?
8) Does provider maintain a current Support Plan for
each in their files?
9) Is staffing pattern met if required by the contract?
(see attached matrix for medical services only)
37
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICf XI DEVELOPMENTAL SERVICES PROGRAM
GENERAL MONITORING - ALL SERVICES
PROVIDER SELF-MONITORING CHECKLIST
P;lg;! 2 of 2
CONTRACT NAME:
ADDRESS:
PHONE NUMBER:
CONTRACT MANAGER:
CONTACT PERSON:
DATE OF MONITORING:
YES NO
10) Does provider maintain records documenting:
1) What services are provided to each customer?
2) Date that services were provided?
3) That records are maintained in customer's files?
11) Are there records available that documents that
backgroung screening is completed for all personnel,
and is in accordance with section 393.0655, Florida
Statutes, updated as needed?
38
DEPARTMENT OF CHILDREN AND FAMILY SERVlCES
DISTRICT XI DEVELOPMENTAL SERVICES PROGRAM
FINANCIAL/BUDGET ISSUES
PROVIDER SELF-MONITORING CHECKLIST
CONTRACT NAME:
ADDRESS:
PHONE NUMBER:
CONTRACT MANAGER:
CONTACT PERSON:
DATE OF MONITOR~NG:
~~~~:::::~~:~g~~:::::::::::::::::::::::::::::::::::::i:::::::.:.:::::::.
.:::::::::.;:::::::::::::l$.:.....S.......U..'..,.,..::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.
:::::::::::::::/:::::f;:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::f
"' .. . ...............
..............................................
;.;.:-:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:-:-:.:.:-:.:.:.:.:-:-:
.;.:.;.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.:.
...............................................
..............................................
...............................................
..............................................
.............................................................................................
..........:rio.... .itn:lIft~;';;S" .............................
j~1jjjjjjj1m~~:i:J!m$ll~:::~::~~t~tr~f~~~{
1) Does the provider have in place an accounting mechanism
for tracking reeipts and expenditures for this contract? If so, is
there documented evidence that the system is updated timely?
2) Does the provider maintain documentation that the positions
in payroll agree with the budget/program requirements?
3) Is the rate per service charged on the provider's monthly
invoices, the same as the rate specified in the contract?
4) Is there documentation that the provider maintains a fidelity
bond covering the activities of all officers, employees, and
agents authorized to handle funds?
5) Is there documented evidence that the provider maintain
appropriate property, liability and other insurance as required by
the contract?
6) Does the provider maintain documentation which indicates
customers attendance in the program as it relates to billing?
7) If applicable, is there documented evidence indicating that
client's trust funds are updated at least on a monthly basis?
8) Are records available that document the receipt and
expenditure of client funds?
39
Page i 0' 3
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICT XI DEVELOPMENTAL SERVICES
ADULT DAY TRAINING SERVICES
PROVIDER SELF-MONITORING CHECKLIST
CONTRACT NAME:
CONTRACT MANAGER:
ADDRESS:
CONTACT PERSON:
PHONE NUMBER:
DATE OF MONITORING:
1) Are records available which document that all customer file
contain an Individualized Program Plan (IPP)?
2) Does provider maintain files indicating that an appropriate
formal and informal assessment to determine cuctomer's
level of functioning as described on the Support Plan?
3) Does the provider maintain documentation regarding the
the team responsible for programming? If so, does
interdisplanary team consist of the social worker, therapist
and parent or guardian?
4) Does the provider maintian documentation of targeted
behaviors that relate to barriers in the Support Plan? Are they
measurable?
5) Does the provider maintain documentation of the short term
ojectives? If so, are:
A - Short term objectives derived from baseline data?
B - Short term ojectives written in measurable terms?
C - Do the short term objectives relate to target behaviors?
6) Are progress data maintained in customer's record and files?
7) Does provider maintain a record of programatic changes that
are made on the basis of progress data?
8) Does the provider maintain records indicating that each
customer vocational and educational program consists of
activities throughout the day for the achievement of the Short
Term Objectives and target behaviors in the customer's IPP?
40
Pare ~ of 3
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICT XI DEVELOPMENTAL SERVICES
ADULT DAY TRAINING SERVICES
PROVIDER SELF-MONITORING CHECKLIST
CONTRACT NAME:
CONTRACT MANAGER:
ADDRESS:
CONTACT PERSON:
PHONE NUMBER:
DATE OF MONITORING:
.~pl.Jl:7rPAY.TRAINING
SERVICES
YES NO
COMMENTS
9) If so, are these activities age appropriate and culturally
normative?
-----
10) Does the provider maintain documentation regarding the use
of emergency constraints? If so, is the use of emergency
restraints and all program designed to reduce or eliminate
behaviors adhere to the regulations and procedures outlined
in HRSM 160-4 and the Rule on behavioral management?
11) Are there records available that document that the customer
can demonstrate the skill that the IPP says were achieved
through programming?
--.------.--- ---
12) Does the provider maintain an implementation plan for each
customer? If so,
-----
A - Are the implementation plans derived from baseline data?
B - Do the implementation plans include a list of reinforcers
to be used and when?
~-- t---
I
I
------~------ ---
--------
C - Do the implementation plans include a description of
prompt?
--------
o - Do the implementation plans include a description of
prompt levels?
E - Do the implementation plans include a criteria for
changing prompt levels?
F - Do the implementation plans include a criteria for
changing Short Term Objectives?
G - Are the short term objectives that have been achieved
dated and signed by a staff member?
41
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICT XI DEVELOPMENTAL SERVICES
ADULT DAY TRAINING SERVICES
PROVIDER SELF-MONITORING CHECKLIST
CONTRACT NAME:
CONTRACT MANAGER:
ADDRESS:
CONTACT PERSON:
PHONE NUMBER:
DATE OF MONITORING:
Aoul..tPAv..rnAlNJNG
SERVICES.
13) Are there records available that documents that the customer
is regularly using the new skill?
14) Are there records available that documents that programming
has enabled the customer to advance to a setting which
allows him or her to function more independently?
42
:la! Ie 3 of 3
CO IV(~, ENTS
Page 1 0 I 1
DEPARTMENT OF CHILDREN AND FAMILY SERVICES
DISTRICT XI DEVELOPMENTAL SERVICES PROGRAM
TRANSPORTATION SERVICES
PROVI DER SELF - MONITORI NG CH ECKLlST
CONTRACT NAME:
CONTRACT MANAGER:
ADDRESS:
CONTACT PERSON:
PHONE NUMBER:
DATE OF MONITORING:
TRAN~PQR...."T.Q.N:
YE NO
COMMENTS
1) Is there documented evidence indicating that the vehicles
used to transport customers have current registration, license
plate and all other license as appropriate?
2) Does provider maintain documentation indicating that all
drivers and drivers aides are certified by the State of Florida
and manintain 100% adherence to all Department of Motor
Vehicle rules and regulations concerning saftey, licensure.
and other standard?
3) Does provider maintain documentation indicating that all
vehicles used to transport customers are maintained to
ensure safley?
4) Are all vehicles used to transport customers equipped with
seat belts, and if required ,infant seat, and wheel chair locks?
5) 15 there documented evidence that all vehicles used to
transport customers are properly insured against accidents
to customers and against public liability
6) Does provider maintain a transportation log of vehicles used
to transport customers?
7) Does log indicate:
A - Date Of Travel
B - Mileage:
Beginning
Ending
C - Destination
o - Name(s) of Client Transported
8) Are all vehicles used to transport customers equipped with a
a basic first aid kit and a fire extinguisher?
43
Department of Children and Family Services
Division of Adult Care and Family Support
Supported Living Monitorin$ Checklist
Provider Name:
Date of Monitoring:
Address:
Contact Person:
Phone Number:
Contract Manager:
Contract Number:
Monitor:
Issues
I. Does the provider have an annual customer satisfaction
survey on file for each customer receiving supported living
services?
2. Has the provider developed strategies for each
individual receivirlg services that include clearly stated
desired outcomes?
3. Does the provider have a functional assessment that
identifies the training and assistance needed by each
recipient of supported living services?
4. Does the provider have documentation that the training
and/or assistance needed by each recipient of supported
living services was provided?
5. Does the provic/i!r have an on call system in place which
allows their customers to access services for emergency
assistance. 24 hours er da . 7 da:s er week?
6. Does the provider have written grievance procedures
that are used to resolve conflicts between the individual
and lor guardian and the provider.?
7. Has the provider assisted customers in establishing
personal bank accounts? '
8. In cases where a customer mIsuses funds or requires
restrictions i.e. cosigners. control offinancial management
by the provider etc., does the provider have a written plan
of action/agreement signed by the customer and support
coordinator?
44
....... ......... . .....y ....... ........ ... /
i) ......
Issues Yes No Comments ....
> ... .................. ...~
8. Does the provider maintain the name, address and
phone number of the doctorlclinic, dentist and hospital of
choice?
.-
9. Does the provider have onfile a current support plan?
.-
10. Does the provider maintain a list of people who
provide natural and paid supports?
-
11. Is a current financial profile on file for each customer?
.-
12. Does the file contain documentation of service delivery
including case notes and time intervention logs?
.-
13. Does each customer's file contain a housing survey
updated quarterly based upon the Housing and Urban
Development standards found in 24 CFR ,Chap. VIII,
subpart F. section 887.251? .-
14. Does the provider have documentation of face to face
contact with the customer, preferably at the customer's
home, on at least a weekly basis? -
15. Does the provider have documentation that shows that
each supported living coach meets the requirements of
Chapter 1OF-11, FAC? .-
16. Have 80% of customers had their desired outcomes met
as indicated in their Individual Program Plans during the
contract period? .-
Core Standards
.iilll::.:i.:i:::I:.11::.....:~..::.::.~.:::..::.:::.::..::.::iollr:!~!.".I.:~.i..I.:~.:llli.I~I~[~:I:I.:..::!.~:i:1~:i!!I~::lt~1~11!!llli~~i:::.::::I.:::~:::..::;::::~:
:I::II:II!II::::: ::ii:I~II~I~II!!!lli!lillllllll.!..I~.!~!111'1~~~~I.II.11":1
1. Can the provider document that 100% of the individuals
in supported living are the lessor or owner of the home in
which they reside?
2. Can the provider document having achieved a
satisfactory or better rating on 90% of client satisfaction
surve 'S?
3. Do 100% of customers live in housing where people with
disabilities account for no more than 10% of the
population within the identifiable area, i.e. apartment
com lex?
f:\aftryou\sldocs\sIch9798.doc
45
Department of Children and Family Services
Division of A4ult Care & Family Support
Supported Employment Monitoring Checklist
Provider Name:
Address:
Phone Number:
Contract Number:
J. Does the provider have a written agency employment
program that addresses job development, job
lacement. on site train in and stabilization strate ies?
2. Does the provider have individual program plans for
each customer that clearly state desired outcomes for
that customer?
3. Are records available to document the status of the
desired outcomes for the customer?
4. Are program participants receiving the same benefits
as other employees with the same work status (fuff time
or part time) who are employed at the work site.?
5. Did the agency facilitate the completion of a current
customer satisfaction survey?
6. Does the provider have a current support plan
located within each customer's file?
7. Are records available that document contact with the
customer at the worksite at least three times per month
including date, time, duration, location and pertinent
notes?
8. Does the provider have records that document
contact with the customer 's supervisor on at feast a
monthly basis?
Date of Monitoring:
Contact Person:
Contract Manager:
Monitor:
46
Issues
9. Does the provider have documentation that 80% of
all customers who entered the program during the
contract period achieved 60 stabilization within 6
months 0 each artici ant's en! into the ro ram?
10. Does the provider have documentation that 80% of
all customers had 100% their desired outcomes met as
identified in the most recent Individual Program Plan
that covers a completed 12 month period?
1 J. Does the provider have documentation that 70% of
all customers receiving phase Il services remained
successfully employed throughout the contract period
(or up to the date ofreview)?
Core Standards
I. Can the provider document that 100% of customers
are earning at or above minimum wage?
2. Can the provider document that 1 OOOA of customers
are earning at or above minimum wage for all months
that the customer is em 10 ed?
3. Can the provider document that 25% o/individuals
employed have annual incomes above the federal
over ideline 7,740 annua// ?
4. Can the provider document that 100% of individuals
in phase Il do not need paid supervision in excess of
20% 0 the individual's avera e work hours.?
5. Can the provider document having achieved a
satisfactory or better rating on 90% of client
satis action surve s?
6. Do 100% of the customers receiving supported
employment services work an average of at least 20
hours er week?
I.: Iaflryoulsedocslsech979 8 .doc
Yes N ()
47
CLIENT SERVICES AUTHORIZATION FORM
EXHII:I r F
ISECTION A I
(1) CUSTOMER NAME: . (2) D.O.B:_'_'_ _(3) SS #:
(4) CURRENT PLACEMENT: (5) PROPOSED PLACEMENT:
(6) CURRENT D.T.P.: (7) PROPOSED D.T.P.:
(8) VENDOR NUMBER: VENDOR NUMBER:
(9) REASON FOR SERVICES:
(10) L.T.R.C. REPLACEMENT NAME: (11) D.T.P. REPLACEMENT NAME:
(12) REASON FOR D.T.P./ LT.R.C. REPLACEMENT: 1 SECTION B
...... I .... :::
FINANCIAL INFORMATION
FUNDING SOURCES /YES NO AMOUNT REPRESENTATIVE PAYEE OTHER FUNDING SOURCE
MED/WAIVER PARTICIPANT
S.S.1. RECIPIENT
S.S.A RECIPIENT
.-
OTHER THIRD PARTY
......... SECTION C I ................
SERVICES RATE AND UNIT FUNDING ONGOING CONTRACT NON ONE TIME EXPECTED 01'
OF MEASUAE CATEGORY EXPENSE CONTRACT EXPENSE DATE OF PI
PLACEMENl FA
J=.}:.R.C. ROOM AND BOARD --.--- --
D.T.P. I.F.S. MEOW
---
TRANS. I.F.S. MEOW
--
MEDICAL I.F.S. MEOW
RES. HAB. I.F.S. MEOW
SUP. EMP. I.F.S. i
- - -- -- ..n T
S.L. COACH I.F.S. MEOW
--
OTHER S.B. I.F.S. MEOW
~J()N_~
(1) SUBMllTED BY (2) HSPS PLACEMENT (3) CONTRACT MANAGER (4) OMC 1 BUDGET
(NEW CUSTOMER/ONE T
DATE DATE DATE DATE
.-
(5) OMC II DATE I SECTION E I
CC:
HSPS II (BUDGET)
HSPS II (PLACEMENT)
(1) CONTRACT MANAGER
(2) FIELD UNIT INPUT INTO ABC IMMEDIATELY
(3) W.S.C. INPUT INTO ABC IMMEDIATELY
11DPDS (EFF 10/09/90\ REVISED 02/26/92 REVISED 10/22/92 REVISED 2/2/95
48
lTE
AC
CI
--------..,- --
~
_.---_..-.
-..---
CUSTOMEF
~D IN
(.ITV
--".-- -
-.-- -
---. - --
~---
----
-- - -_..-
---......-
~-
--.--
- ONLY EXP
_.__..~-
1M
INSTRUCTIONS FOR COMPLETING CUSTOMER AUTHORIZATION FORM
L IF PROVIDER INITIATES AUTHORIZATION REQUEST FOR SERVICES OTHER THAN
SUPPORTED LIVING AND SUPPORTED EMPLOYMENT:
COMPLETE
MAIL COMPLETED FORM TO
1. Section A - Questions 1 - 12
2. Section B - Complete as Appropriate
3. Section C - Not Applicable
4. Section D - Signature Line #1
5. Section E - Not Applicable
PLACEMENT COORDINATOR
DEVELOPMENTAL SERVICES
401 N.W. 2ND AVE - S518
MIAMI, FLORIDA 33128
ll. IF PLACEMENT COORDINATOR INITIATES AUTHORIZATION REQUEST FOR SERVICES
OTHER THAN SUPPORTED LIVING AND SUPPORTED EMPLOYMENT
COMPLETE:
1. Section A - Question(s) 1-12
2. Section B - Complete as Appropriate
3. Section C - Complete as Appropriate
4. Section D - Signature Lines #1 and #3
5. Section E - Lines 1,2 and 3
Ill. CONTRACT MANAGER COMPLETES FOR ALL SERVICES:
1. Section C - Complete As Appropriate
2. Section D - Signature Line #3
IV. BUDGET MANAGER COMPLETES:
1. Section D - Signature #4 (for one time expense and new customers)
V. FOR SUPPORTED LIVING AND SUPPORTED EMPLOYMENT
1. SECTION A - Special Projects completes section A items 1-5 &9
2. SECTION B - Special Projects will complete as appropriate
3. SECTION C - Special Projects will complete as appropriate
4. SECTION D - Special Projects will complete signature line #1 and # 5, and Budget/~ontracts
section will complete signature line #3 for individuals who receive services
through Medicaid Waiver or General Revenue.
49
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IIBl STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES
~ ...__....._..~.._.... ....U .._._u..._.._. -...-----.... -..
CIVIL RIGHTS COMPLIANCE CHECKLIST
Program/Facility Name . -."."'"TCOunty''' .""-"."--.'-THRSDlstrlc,"""
. City of Miami Beac..h'..~..12.9.....<:9..q.in TC(jill!ng .(.~n~L. ...J)~l<J.~_..__.._.l_-....-.X.L..
Addr~ I cOrQQIElleeJ 8y. .
8128 collins Avenue ~ Ne son Padln, Social Worker
Mi~i"lf::a~~Co<\!lorida 33141 ~~~~-r~~;;~oo; J
READ THE REVERSE SIDE FOR ILLUSTRATIVE INFORMATION WHICH WILL HELP YOU IN THE COMI"LETION Of
THIS FORM.
PART I. 1.
Brlelly describe the geqgraphlc ar8a served by the pr~raml facility and the !ype of service ..Qrovlded: .. -:-r::r- ...-
District X I, Dade CoullJ.Y~n.c1.<:::J!L....9!_~~i9-l!'i t5eac.h.....:__I..b.~r~C.~rT}_.P1 ?V~LJes
. services to ADA dev~men_!.5~!J.Y._c.lLsa. b.l~dj..0.1~nJ.9J-'-Y_Jet~ded) Da Y.....I. ~!:l0!.i 'l~
Center.
2. POPULATION OF AREA S~VED. Source 0' data:
I 91o:~tf8 l % '1)'~I:'3 ~~ % HIW~~
3. STAFF CURRENTLY EMPLOVEO. Effective date:
Total /I % White 0;. Blael< % Hispanic
10 6 2 2
-----
ror~3 ..~~~ble_.J==~'~~-
[= =~~-~~-=":
4.
Female
33
0;, Handicap
100
0/0 CNer 4f) -;~i~-I
_?..L_-
5. ADVISORY OR GOVERNING BOARD~ APPLICABLE. ;aTei r-'. .----. .
Total /I % White % Black- ,/;HispanlC/';;-Olher }'/' F~.~ _ ______'
PART II. USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE SPACE
6. Is an Assurance at Compliance on file with HRS? I! NA or r~o. eXPlain r-, A YES hi
[J CZ
r-,A
C.,
.I
YES
[.'l
.0
N,.
'.'
I
-. ----~
7. Compare staff composition to the population. Are staff representative of the population?
If NA or NO, explain.
------.------
---
8. Compare the client composition to the population Are race and sex characteristics
representative of the population? If NA or NO. explail1
r-,A
[J
YES
[II
NO
_._------~---~
t-A
[]
YES
Q\]
NO
9 Are eligibility requirements for se(\llces applied to clients and applicants without regard to race.
color, national origin, sex, age. religion or handlUlP? II NA or NO. explain
---------------
-------
-..
~IA
n
YES
[]
Nt'
10. Are all benefits, services and facilities lIvailable to applicants and participants In an eQualiy
effective manner regardl~ ot race. sex. color. aoe. national origin. religion or handlcar.?
If NA or NO. explain.
We are not a residential or i[1terr.n,g.dii3te care_fa.clIl1~-..l:i.frWe..Y.er.
all clients are QIovided seryices such as edu9l1l9J1<;llJ...Y..Q.<;.9.1lQ.r.\pl coun.s.eli.ng
wit h 0 u t r e q a r d tor ace. sex ,._Q2\.Q.L.......oni..Qllilu.rJ.g.in~.r: e I i g ion. rl g 1" 0 r h a r d i = a p .
rIA
I):
I'ES
o
NO
11. For In-patient semces, are room asslgrHTl8f1t6 made wl1hout regard to race. color. Mtlonal
or1~~,:, Ol handicap? If NA or NO. eKplalr).
We are not a residential faci1it:i..:-.
-.----
DIstribUtion of CopIes:
While. District Program Office or oPlC
YelloW' Facility
HRS Form G46A, Jul85 (Ot>~lete5 prfJ'lloos editions which may not be used)
Paoe 1 at I
PART III. THE FOllOWING QUESTIONS APPLY TO PROGRAMS AND FACILITIES WITH 1S OR MOFIE IIi~MPlOYEES
16. Has a self-evaluallon been conducleo to .dentlty any barflers to serving nandICil~)Dec YES N'
Individuals. and to make any necessary modifications? II NO. e.pla'" [j [-'
,
PART II. USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE SPACE.
12. Is the program / facility accessible to non.En91Is" speak'G9 cl,enls.' II NA or NO. e.p,ar i.,j,I,
------
------- ----------
13. Are employees. applicants and part,cipants Informed of llle" prOI.Kt'On agalflst dls<;Tlm,naI1nn?
" YES. hOw? Verbal Written ___ Poster ___ If NA or NO. explain
\". Give the number and currenl status 01 any discriminatIon complaints regarding services or
employment filed againslthe program/facility
--.--..------.--.-.
. -.----
15. Is the program / facility physically acceSSible to rTlotillll "eaclng and sighllmp8"ed ,,.,d:vlduals?
If NAor NO. explain.
--...---
------------...------
t 7. Is there an established 9roevance procedure lhat .ncorrorales due process Into the resol'JI.on
ot complaints? If NO. explain
18. Has a person been designated to coordinate SectIon 504 compliance actIvities?
It NO. explain
--------_..._~..
19. Do recruitment and notification maleflals adVise apOllcants employees and par1IC1panlS of
nondiscrlminatlon on the basiS ot handicap? If NO. explal11
20 Are aUKot,ary aids available to assure access.botity of SIHVlces 10 hearing ar'd s'ghllmpa.,()(j
inolvlljuals? If NO. uplaln
--.----- ----.--..
IJ
YE ~,
[]
'.
I~A
[]
YES
ex
NO
[=-1
rIA
!'9
N~EP
[-.--
NA
[]
YES
54
NO
[~
YES NO
o 0
YES NO
o 0
YES NO
o 0
YES NO
[l [l
----r-
PART IV. FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONT'R.A,CTS OF
$50,000 OR MORE. .~
2'. Do you have a wrollen afflrmat,ve action program? Il NO. eKpla.n
I
- --8
In CQmpliance: YES 0 NC' I]
. NOtl~ of Cofr~tlve Action Sent _ -=-'-'-
~sponse Due -= -' -'-...;::-
-~=-I
-----.
.-------.-----.-.--.--
-----
HRS USE ONLY
Reviewed By
Program Office
Date
I Telephone
Desk Revtew 0
-----.-----
J Res~nse Received
On.Slte 0
.,." ""(1 "Of,""'"
NO
o
YES
o
Paoe'( of 2
1997-98 DEVELOPMENTAL SERVICES BUDGET REQUEST
I
BUDGET REQUEST - COVER PAGE
---_._._._-------------_..~_. "---
A.
AGENCY PROFILE:
Executive Direotor:
Agi Long
. -------------------
Agency Name:
___ <t~9' etJf~a'ira~~r8SC~D.t~-L
Address:
8128 Collins Avenue
Miami Beach, Florida 33141
Telephone:
(305) 993-2008
------- -------.-------
AGENCY TYPE:
x Governmental Agency
Not-for-Profit (Provide Documentation)
For Profit
1997-98 DEVELOPMENTAL SERVICES
Proposal Form A: BUDGET REQUEST
Agency Name: City of Miami Beach's Log Cabin Training Center
Program Name: City of Mia mi Beach's Log Cabin Training Center
""""'.,".::..:::-::<<'::::,;.'
P6~~8~M>.. .
lNFORN~fJON
OUT OF DISTRICT
CUSTOMI:R5
--'--' --.---.....---.-.-------
HOW MANY NON-MEDICAID WAIVER CUSTOMEltS WILL BE SERVED 7/1/97 - 6/30/98 ----~------
HOW MANY MEDICAID WAIVER CUSTOMERS WILL BE SERVED 7/1/97 - 6/30/98
____~!L_______
TOTAL NUMBER OF CUSTOMERS TO BE SERVEQ 7/1/97 - 6/30/98
53 SE - 16 (7 med v\iaiver):
------------- SIL - 3 (1 med waiver)
YES____~____(Attach Justification Below) "0_ ._______
PROGRAM EXPANSION 7/1/97 - 8/30/98
WHAT ARE THE ESTIMATED AGES OF THE
CUSTOMERS YOU WILL SERVE
WHAT GEOGRAPHIC AREA(S) IN
DADE COUNTY WILL YOU SERVE?
BIRTH - 2
3 - 5
0-9
10 - 13
14 - 18
19+
ALL OF THE ABOVE
x
NORTH
CENTRAL
SOUTH
WEST
ALL OF THE ABOVE
COUNTY
x
HOW MANY TOTAL EMPLOYEES WILL YOUR PROGRAM HAVE?
FULL TIME
PART TIME
8
..T--
HOW MANY EMPLOYEES WILL BE FUNDED BY D.S.?
FULL TIME
PART TIME
8
3
FY97'--;98 . ..,
PROSRAMIEXPANSION.. (JUSTIFICATION)
We have customers ready to be placed into jobs. However, all available slots in our
Supported Employment prog;ram are full. Therefore, we need to increase our SE
program by one slot.
Also, there are jobs available for the customers once the slot is available and the;'
have been placed into SE.
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PROGRAMS, LOCATIONS, LEAD PERSON
Please list all program locations, program names and person(s) in charge.
B. PROGRAM LOCATION(S):
Lead Person for
The Program
Program Name:
Leslie Reed
-_.._~._--_.~----"'_..._._. ~-_.._--_._._-~-----_..
City of Miami Beach's Log Cabin Training :enter
___~ u pp_c:~~ed__~~p~y~e n t _~~<I~_~~____
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Address:
8128 Collins Avenue
--.-..-----.----.-----.-..-----.......-.....-..--..-----...".-------.-
Miami Beach, Florida 33141
-----.---.---- -----------
Telephone:
(305) 993-2008
Fax Number:
(305) 993-2012
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PROGRAMS, LOCATIONS, LEAD PERSON
. ..-..-....---.----....-..-.-..---. .......----- "--
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Please list all program locations, program names and person(s) in charge.
B. ~ROGRAM LOCATION~.:_
Lead Person for
The Program
_.. --- .---.-...--. -.....-.-..-.------.-..----..---.-.... ----------..------
Lawrence Roth
Program Name:
C. it.:y. o. f.t.M.l'a.midB. each's Loa.. C..3b. in Training Ce 1ter
suppor. ed In epen'denr L1VI~g nl~!ogram
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._ __ J~92L.~9}-=~.2-~~.
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(305) 993-2012
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1997-98 DEVELOPMENTAL SERVICES BUDGET REQUEST
------
---1
[
PROGRAMS. LOCATIONS. LEAD PERSON
------.-------------------.-------.--------- ._- - -...-.,.---
Please list all program locations, program names and person(s) in charge.
8. PROGRAM LOCATIOm?l
Lead Person for
The Program
---~---_..,_._-------------- ----..---------
Glenna H. Kretschmer
Program Name:
City of Miami Beach's Log Cabin Training Center
.____~_gu I CQ_~y- _T rQ.illlD--9-frggrarrL----
Add res's:
__ _.___u.__ ____.." ------.. ,,'-'-- -' -..--..----...-- - .-.. -------------
8128 Collins Avenue
___.___~i..9mJ.J1~9s::.!l....XLor.id'l. 331 ~1_.__...
Telephone:
(305) 993-2008
... ,...--.-.---- "...... ...--....---..-.---.---......
Fax Number:
... --..------..-.--.--.--------------- ."-
(305) 993-2012
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CERDElCAI10N REGARD1NG LOBBY1NG
CERTIFICATION FOR CONTRACTS, GRANTS, LOAttS-AND COOPERATIVE.
AGREEMEN.TS
/'..ltad,nl :)nt
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the unclersigned,
to any person for influencing or attempting to influence an officer or an employee of any agency,
a member of congress, an officer or employee of congress, or an employee of a mer1b~r of
congress in connection with the awarding of any federal contract, the making of any federal
grant, the making of any federal loan, the entering into of any cooperative agreemert,md the
extension, continuation, renewal, amendment, or modification of any federal contracl, flrant,
loan, or cooperative agreement.
(2) If any funds other than federal appropriated funds have been paid or will be paid to ciln~! person
for influencing or attempting to influence an officer or employee of any agency, a memt er of
congress. an officer or employee of congress, or an employee of a member of congri~s; in
connection with this federal contract, grant, loan, or cooperative agreement, the undE!rs gned
shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying." n
accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in thE a ,yard
documents for all subawards at all tiers (including subcontracts, subgrants, and conti acts
under grants, loans and cooperative agreements) and that all subrecipients shall cer1lf~ and
disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when t~is
transaction was made or entered into. Submission of this certification is a prerequisite for m3king
or enteri into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who
fails t II. the required certification shall be subject to a civil penalty of not less than $10,:>0)
and ot more than $100,000 f ach such failure.
~(i:) 7~) /~ 97
Date
~ Pwck-
Application or Contract Number
City of Miami Beach Log Cabin Training Center
Name of Organization
APPROVED AS TO
FORM & lANGUAGE:
~ FOR EXECUTION
,
8128 Collins Avneue Miami Beach, Florida 33141
.
~
ity Attorney
u~~..L,~1
~ZJ:age
Dl,..
Address of Organization
.IF 03196
Contract No.
CERTIFICATION BEGARDlNG
DEBARMENI.._SUSPENSION, I(IlELlGIBILlTY ANDJLOL.UNTARYEXCLUS1ON
CQNTRACr~S_UBCQNlRACIS
This certification is required by the regulations implementing Executive Order 12549, Debarment
and Suspension, signed February 18, 1986. The guidelines were published in the May 2E. 1987
Federal Register (52 Fed. Reg., pages 20360 - 20369).
Lt-lSTRUCTIOHS
1. Each provider whose contract/subcontract equals or exceeds $25,000 in federal me nies must
sign this certification prior to execution of each contract/subcontract. Additionally, pro\'iders
who audit federal programs must also sign, regardless of the contract amount. DOH C~3nnot
contract with these types of providers if they are debarred or suspended by the fede-ra
government.
2. This certification is a material representation of fact upon which reliance is placed when this
contract/subcontract is entered into. If it is later determined that the signer knowingl{ r,~ndered
an erroneous certification, the Federal Government may pursue available remedies. in,:luding
suspension and/or debarment.
3. The provider shall provide immediate written notice to the contract manager at any lime the
provider learns that its certification was erroneous when submitted or has become e TO 1eous
by reason of changed circumstances.
4. The terms "debarred", "suspended", "ineligible", "person", "principal", and "voluntarily
excluded", as used in this certification, have the meanings set out in the Definitions and
Coverage sections of rules implementing Executive Order 12549. You may contact the
contract maJ:1ager for assistance in obtaining a copy of those regulations.
5. The provider agrees by submitting this certification that, it shall not knowingly enter nt,,> any
subcontract with a person who is debarred, suspended, declared ineligible, or voluntar, y
excluded from participation in thiS contract/subcontract unless authorized by the Feder 11
Government. .'
6. The provider further agrees by submitting this certification that it will require each subcontractor
of this contract/subcontract. whose payment will equal or exceed $25,000 in federal T1( nies
to submit a signed copy of this certification. I
I
I
I
Subcol1tr3ctor's I
7. The Department of Health may rely upon a certification of a provider that it is not debarred,
suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it <nows
that the certification is erroneous
8
--i
(1) The prospective provider certifies, by signing this certification, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineli~ible, or
luntarily excluded from participation in this contract/subcontract by any federal d'?'p 3rtment
r agency.
able to certify to any of the statements in thi~j, I
r shall attach an explanation to this certification '
)J~ ~ If9 2 I
Date I
APPROVED l\S TO J
FORM & LANC:~::AGe
. m!cm-
AJj~' I-
( f~~ Aa-. /) ~(!
JF 1 2J96