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98-22745 RESO RESOLUTION NUMBER 98-22745 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 $327,983 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 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 A W ARD(S) FOR THE PERIOD OF JULY 1, 1998 TO JUNE 30,1999. WHEREAS, the State of Florida, Department of Children and Families Services (CFS) is desirous of having the City of Miami Beach apply for continued funding to provide independent living skills training, supported employment training, and transportation services for developmentally disabled adults; and WHEREAS, the City has been successfully operating these programs since 1983 and wishes to continue to provide these essential services; and WHEREAS, the City of Miami Beach Log Cabin Training Center is currently serving Medicaid-eligible clients, and the Log Cabin Training Center is a certified Medicaid provider; and WHEREAS, the City is desirous of submitting a Grant application for continued funding, in order to provide essential support and services to developmentally disabled adults in the estimated amount of$31O,523, for the period from July 1, 1998, through June 30, 1999; and WHEREAS, the City is desirous of receiving funding in order to continue to provide essential support and services to developmentally disabled adults in the estimated amount of $17,460, for the period from July 1, 1998, through June 30, 1999; and WHEREAS, the City will prepare the budget in accordance with the applicable Grant 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. Section 2. Section 3. That the Administration is authorized to prepare and submit an application to the Department of Children and Families Services (CFS), in accordance with the Grant period and the amount negotiated with CFS. That the Administration is authorized to appropriate funds for the final Grant award. That the Mayor and City Clerk are herein authorized and directed to execute, when awarded, the Grant Agreement in order to provide independent living skills training, supported employment training, transportation services, and supported independent living for up to fifty-three (53) developmentally disabled adults at the Miami Beach Log Cabin Training Center. PASSED AND ADOPTED THIS 20thday of May ,1998. ATTEST: CITY CLERK ~4 MAYOR ~ APPROVED AS TO FORM & LANGUAGE & FOR EXECUTION ~br!Ai,k- s.i!i~ Ity Afforney CITY OF MIAMI BEACH CllY HALL 1700 CONVENTION CENTER DRIVE MIAMI BEACH, FLORIDA 33139 http:\\cI.mlaml-beach.lI.ua TO: FROM: SUBJECT: COMMISSION MEMORANDUM NO. (So ( 9 g Mayor Neisen o. Kasdin and Members of the City C mmission DATE: May 20, 1998 Sergio Rodriguez City Manager A RESOL 'TION 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 $327,983 TO THE STATE OF FLORIDA, DEPARTMENT OF CHILDREN AND FAMILIES SERVICES (CFS), FOR CONTINUATION OF FUNDING OF THE LOG CABIN TRAINING CENTER, FROM THE STA TE 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 A W ARD(S) FOR THE PERIOD OF JULY 1, 1998 TO JUNE 30, 1999. ADMINISTRA TION RECOMMENDATION Adopt the Resolution. BACKGROUND This is an application for Grant Funding to the State of Florida, Department of Children and Families Services (CFS) designed to benefit up to fifty-three (53) developmentally disabled adults. The City's Log Cabin Training Center (LCTC), located at 8128 Collins Avenue, contiguous to the Log Cabin Plant Nursery since 1983, has operated a State of Florida, Department of Children and Families Services (CFS) program entitled Adult Day Training Program (ADT). The program is a training center for Independent Living Skills and Vocational Skills Training. It is administered by the City's Economic and Community Development Department. AGENDA ITEM C 16r DATE S-2o-~~ Clients participating in this program are referred from either the State of Florida, Department of Children and Families Services, or are sponsored by their own families. There is a limit of thirty-five (35) participants to this program. The program strives to teach clients basic living skills, such as such as housekeeping, cooking, horticulture, and interviewing techniques. It thus teaches participants to become self-reliant. Daily transportation is also provided to and from the site. The successful graduate of the program is then able to maintain a household and engage in meaningful employment. In 1989, the City's LCTC became involved in another CFS program for developmentally disabled adults entitled Supported Employment. There is a limit of fifteen (15) participants to this program. The program focuses exclusively on preparing and training clients to assume jobs utilizing the skills already learned under the Developmental Training Program detailed above. (Both of these programs, while funded separately, are intricately linked together.) A counselor makes the initial contact with a prospective employer to secure potential positions for graduates of the program and then matches a client's skills and abilities with the job duties and responsibilities required by the position. Follow-up and progress reviews are conducted by the counselor to ensure that the client is able to perform the job effectively. On July 1, 1993, the Log Cabin Training Center started to operate a program entitled Supported Independent Living (SIL) Services. The purpose of that program is to provide an independent living environment for three (3) clients currently served through the City's Program(s). The City of Miami Beach does not have to provide a direct match to qualify for and receive this grant. Matching funds are required for the Developmental Training Program and for the Supported Employment Program. Through this grant component clients are being provided with appropriate rental housing. Specific support services and supervision are being provided by present staff and a Supported Living Coach, in order to ensure the clients' health and safety in their new environment. ANALYSIS Presently, the City provides services for up to fifty-three (53) developmentally disabled adults of which all are funded through these CFS Grants. The City must apply annually to the State of Florida, Department of CFS for funding for the Developmental Training programs, as the grant awards are not guaranteed from year to year, nor are funds automatically allocated to the City. As such, a grant application has been prepared which includes narrative program descriptions and proposed operating budgets for each program: Independent Living Skills Training, Supported Employment Training, and Transportation Services. The City of Miami Beach Log Cabin Training Center is a Medicaid provider and is currently serving Medicaid eligible clients. The State of Florida, Department CFS has tentatively informed the City that it will consider the same grant requests under the Independent Living Skills Training (Developmental Training) Program (which include the Supported Employment Training Program and transportation services) and for the Supported Independent Living Program. Combining these programs results in a total grant request of $327,983 for Fiscal Year 1998-99 to fund the Log Cabin Training Center's Program(s). While over one-half of the Center's operating budget is provided by the State of Florida, Department of CFS, the balance is supported by the City's General Fund. Funding at this level will allow the City to continue providing services for up to fifty-three (53) developmentally disabled adults. The program period begins on July 1, 1998 and ends on June 30, 1999, in order to coincide with the State of Florida's fiscal year. The State of Florida, Department of CFS requires that the City adopt Resolutions which demonstrate the Commission's authorization to apply to the State of Florida -Department of CFS, for funding of these essential programs. CONCLUSION The Administration recommends adoption of the attached Resolution which authorizes the preparation and submission of a grant application in the amount of $327,983 to the State of Florida Department of Children and Families Services (CFS); authorizing the continuation of the Supported Independent Living Program; the appropriation of funds for the final grant awards; and authorization for the Mayor and City Clerk to execute the two (2) corresponding contracts. After the City's grant application has been negotiated and approved by State of Florida, Department of CFS, a final contract for each program, similar in form to the contract attached hereto, will be executed by the Mayor and City Clerk. S~AL/lk Attachments C:~J~~" ,- ...d I..; J -0 [::''') ". ~? I I L' V_ . I .~ FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES FY 1998/99 LOG CABIN TRAINING CENTER 8128 COLLINS AVENUE MIAMI BEACH, FLORIDA 33141 B. SERVICES TO BE PROVIDED The City of Miami Beach Log Cabin Training Center Program will provide habilitative progralLlming for up to 53 developmentally disabled adults. This program operates at the Miami Beach Log Cabin Training Center, Monday through Friday, from 8:30 A.M. to 4:30 P.M. The City's day training program (Independent Living Skills training) provides programs in areas that are considered to be critical to their independent functioning. We offer programs in the following areas: 1. Basic Academics - Remedial/Maintenance 1. Basic 2. Intermediate 3 . Advanced 2. Payroll The clients calculate their own payroll derived from services rendered in the Plant Nursery and other related areas. 3. Health Basic health practices and concerns are concentrated on in this' class. Self care skills are strengthened, as well as precautionary practices to common problems. 4. Survival Skills Instruction is offered to promote safety and independence in the community. 5. Cooking Clientele who are determined in need of these skills, are included in this class. 6. Cleaninq Our clientele are taught basic to advanced janitorial skills for their own personal use, and also as a precursor to job placement. 1. Basic 2. Intermediate -to 3 . Advanced 7. Communications This class offers skills in expressive/receptive communication skills training for those determined to require this instruction. 8. Exercise and Nutrition This class is offered to clientele who are determined to be in need of instruction regarding weight control. 9. Resource A general class offered to certain clients who requlre instruction in varying specific areas. 10. Film This class is offered as a "jumping off" point that encourages certain clients to discuss areas that concern them, while viewing certain selected films. 11. Recvclinq Intense instruction in the area of recycling skills for client's own personal use and also as a precursor for job placement. 12. Current Events Instruction and discussions regarding major events happening in our society and the world. 13. Job Placement This is done utilizing supported employment methodology. 14. Transportation Our clientele are transported to and from home, and/or are transported to various community site job sites, etc. as necessary. 15. Social Wor~ - .~ Our caseworker provides all related activities which include: 1. Reviewing referrals 2. Counseling clients 3. Counseling families 4. Developing behavior plans 5. Travel training 6. Client advocacy Our clientele all carry a primary diagnosis of mental retardation. In addition, some are also handicapped by epilepsy, cerebral palsy, mental illness, hearing impairments, and autism. Staffinq Our program is staffed with the following personnel: Program Administrator Education Coordinator Social Worker Employment Specialist Agricultural Instructor Instructor Driver/Instructor Aide Administrative Aide II -~ C. MANNER OF SERVICE PROVISION All programs listed in Section B take place at the Miami Beach Log Cabin Training Center, located at 8128 Collins Avenue, Miami Beach, Florida, 33141. The exceptions to this include: 1. Survival Skills This occurs in the surrounding neighborhood. 2. Job Placement Site specific. The remainder of our classes take place in classroom settings located at our site. Each client receives a schedule of classes twice per year. Clients are assigned specific classes based on their needs at the habilitation planning meeting (see attachment) . Classes are from 50 to 75 minutes long. Each instructor is responsible for implementing the client's program as specified in the Habilitation Plan. The Education Coordinator supervises the class content and evaluation. Upon entering the program all clientele are assessed using one or all of the following instruments: 1. Fundtional Livina Skills Assessment 2. Becomina Independent 3. Briaance 4. Critical Skills Assessment 5. Plant Nursery Assessment An individual Habilitation Plan (HAB) is developed for each client within 30 days of their admittance to the program. All clientele receive a quarterly review of their progress. The primary curriculum utilized in the program is "Becoming Independent." Additional curriculum include sex education materials, AIDS training materials, materials utilized for meditation/relaxation, counseling, and supplies for cooking and cleaning classes. -O! ELIGIBILITY All clientele must be referred by C.F.S. Following receipt of the referral packet, the following process occurs: 1. Review of referred by agency caseworker 2. Client3 must be Title XX eligible 3. Must be a Dade County resident 4. Client must have diagnosis of developmental disability (primary) 5. Interdisciplinary team review 6. Final determination INTAKE PROCEDURE 1. Referred from C.F.S. 2. If appropriate, client is accepted. 3. If space is unavailable, client is placed on waiting list. 4. At thirty days, a habilitation plan is developed with C.F.S. coordination. 5. Clients found to be inappropriate are referred back to C.F.S., with explanation. Also additional referrals may be given, such as to vocational rehabilitation. 6. All referrals are followed-up by an agency caseworker for a one-year period. ~~ D. EVALUATION The goals of the program ure all directed toward increasing the independence of the clientele that we serve. Listed below are the goals for FY 98-99 for our program. 1. GOAL: To provide Habilitative Services MEASURABLE OBJECTIVE: This contract will provide services for up to 35 clients for up to 230 days of service. See section B for description of services. STEPS: The program will comply with C.F.S., Developmental Training Program standards, and will implement programs. TIMETABLE: July 1, 1998 to June 30, 1999. 2. GOAL: Placement of Emplovrnent Individuals into Competitive MEASURABLE OBJECTIVE: Up to 15% of our population will be placed/retained into competitive employment for a minimum of 20 hours per week. STEPS: A. Apply to C. F. S. to grant funding for one additional position. B. Identify appropriate work dates. C. Present candidates to C.F.S./V.R. screening committee. D. Proceed with supported employment methodology. TIMETABLE: July 1, 1998 to June 30, 1999. -*!i 3 . GOAL: Increase the independent clientele served functioninq of the MEASURABLE OBJECTIVE: All clients will minimum of 50% of objectives on habilitation plans. meet a stated their STEPS: A. The program will implement the classes described in Section B, five days a week. B. Each client will be assessed at least annually. A new individual habilitation plan will be developed annually. C. Each client will receive a quarterly review of progress. D. The program will utilize "Becoming Independent" as the primary curriculum guide. TIMETABLE: July 1, 1998 to June 30, 1999. 4. GOAL: Increase independent transportation skills of the clientele served. MEASURABLE OBJECTIVE: Increase the number of clients by 20% traveling independently to and from the program. STEPS: A. Travel train and encourage clients taking public transportation and special transportation services. TIMETABLE: July 1, 1998 to June 30, 1999. 5. GOAL: Increase varies vocational skills of the clientele served. MEASURABLE OBJECTIVE: At least 20 clients will learn new vocational skills, besides nursery plant maintenance, in order to acquire jobs within the community. STEPS: A. The program will implement intensive training in cleaning, recycling and community awareness. . -i! TIMETABLE: July 1, 1998 to June 30, 1999. CLIENT POPULATION TO BE SERVED 30 adults (ages l8+) developmentally disabled adults. 6 CRT 24 IFL 30 Total Clients FY/98-99 DTP Services Equal: 6 CRT 24 IFL 30 Total Clients FY/98-99 Transportation Services Equal: 6 CRT 24 IFL 30 Total Clients FY/98-99 5 adults (ages 18+) developmentally disabled adults. 4 IFL 1 CRT 5 Total Clients FY/98-99 Number of clients served through this application: Per Month: 70 (35 DTP & 35 transporation) Per Year: 840 Number of units of service to be provided through this application: Per Month: 2,012.50 Per Year: 24,150 CRT = IFL = DTP = Community Residential Training Independent Family Living Developmental Training Program Skills training) (Independent Living DAYS OF SERVICE FY.2..a to 99 January February March April May June July August September October November December TOTAL = January February March April May June 20 --- July _15_ 20 --- August September 20 --- October 18 --- November 17 --- December 230 Days FY.2..a to 99 21 --- 18 --- 21 --- 19 --- 20 --- 21 --- -" CITY OF MIAMI BEACH LOG CABIN TRAINING CENTER SUPPORTED EMPLOYMENT PROGRAM 1. The City of Miami Beach will administer its supported employment program at the Miami Beach Log Cabin Training Center, which typically operates Monday through Friday from 8:30 A.M. to 4: 30 P. M. The program will provide up to fifteen (15) client placements utilizing one of the three supported employment models approved by the State of Florida and Developmental Services, District 11. We will provide services to developmentally disabled clients referred to the agency by CFS. Most of these clients have been vocationally trained by us under the Independent Living Skills training program and are ready to move on to Supported Employment. 2. The goals of this program are focused on increased independence and the achievement of self support for the persons served by providing employment opportunities and the necessary support services, utilizing the Supported Employment models approved by Developmental Services. A goal is placement of up to fifteen (15) individuals in the Supported Employment program increasing their chances of obtaining employment within the community. The measurable objective is that 85% of the clients enrolled in supported employment will obtain or retain community based employment for a minimum of 20 hours per week. STEPS: A. Assess consumer and review case files of potential candidates. B. Present appropriate candidates to CFS/VR screening committee. C. Proceed with Supported Employment methodology which includes job development, job site analysis, task analysis, training and follow up. A second goal is to increase independent functioning of the clients served. The measurable objective is that 85% of the clients enrolled in the Supported Employment program will have progressed to the next level if supervision which includes 20% of a job cqach intervention time per week within a twelve-month contract period. STEPS: A. The program will assess, trairl and provide support services described in section B. B. Each consumers progress will be reviewed monthly and quarterly. C. A reassessment of the hab';'li tation plan will be performed annually and will include an individual employment/follow-along plan. D. Consumers job-related skills will increase to an acceptable level, decreasing the need for job coach intervention. Another measurable objective is that 70% of the Supported Employment consumers will take public transportation to/from their work site and that 70% of Supported Employment consumers will reach employment/follow-along plan objectives within each consumers contract period. STEPS: A. Job coach, caseworker and employer will develop individual employment/follow-up plan objectives. B. Consumer obj ecti ves are presented at reassessment of habilitation plan annually. C. Implemented through Supported Employment guidelines. 3. Services provided include the following: individual asessmentsi training and career development (vocational and pre- vocational classes, career counseling, work adjustment classes and seminars) i job development (finding, creating, analyzing and identifying available positions in the competitive labor market, conducting a diagnostic interview to pre-determine consumers preferences, interests and motivation, matching candidates to specific jobs, teaching consumers to become acquainted with a variety of occupations and work demands) i follow-along/maintenance (assisting the placed worker during the initial phase of employment to adjust, meeting periodically with the worker to determine continued job progress and satisfaction) i additional services (counseling, client advocacy, coordination of services, follow up and trouble-shooting, documentation of systematic progression) . The services to be provided will be based at our site, 8128 Collins Avenue, Miami Beach, Florida, 33141. Each supported employment candidate will be assessed by using one or more of the following: work skil~s assessment, outside agency evaluations, becominq Independent curriculum/assessment, critical skills assessment, functional living skills assessment. Supported Employment consumers will receive individual counseling and support services. Eligible candidates receive pre-vocational and/or \rocational training, a tailor-made emplGyment/follow along plan which is supplemental to the individual habilitation plan. As required by Developmental Services, there will be a quarterly review of progress reports and monthly evaluations. A pre-placement service is also available as this service ensures a successful placement. Pre-placement may include the following: pre-interview counseling, job skills instruction, supervision and counseling. The position secured by each consumer will be evaluated according to location, work habits and abilities of specific candidates, and the needs and desires of each individual. Transportation and/or training on travel independence is provided for those eligible. Specific job skills training is provided at the work site. To date all clients who attended our program have retained their jobs a minimum of six (6) months and a maximum of three (3) years. Therefore, our success rates are extremely impressive. 4. The individual responsible for the daily operation of the Program is Agi Long, Program Administrator. -il! Staffing Program Administrator Education Coordinator Social Worker E~ployment Specialist Instructor/Job Coach Driver/Instructor Aide Administrative Aide II 11 DAYS OF SERVICE Not applicable CITY OF MIAMI BEACH LOG CABIN TRAINING CENTER DEVELOPMENTAL TRAINING PROGRAM 1. The Log Cabin Training Center Program will provide habilitative programming for up to 53 developmentally disabled adults who are referred by CFS. These clients must be Title XX eligible, must reside in Dade County, Florida and must have a diagnosis of developmental disability (primary). In addition, some are handicapped by elipepsy, cerebral palsy, mental illness, hearing impairments, and autism. The Training Program (Independent Living Skills training) provides programs in areas that are considered to be critical to the clients' independent functioning such as basic academics, money and budgeting skills, health, survival and travel skills, cooking, cleaning, communication, exercise and nutrition, and current events. 2. (a) Short Term: All clients will meet a minimum of 50% of stated objectives on their individual support plan. Each client will improve his/her independent travelling skills. Clients will learn new vocational skills in order to acquire jobs within the community. (b) Long Term: Up to 15% of the clients will be placed into competitive employment for a minumum of 20 hours per week. These clients will be able to be retained in their employment using skills developed/learned through the program. In addition, the clients will develop survival living skills that will enable them to live their lives as independently as possible. 3. Services provided include: basic academics, primarily reading and math - beginning, intermediate and advanced; vocational skills, i.e. punctuality, reliability, productivity, general good work habits; financial awareness (money skills) and payroll calculation; self care skills including health, cooking and cleaning; survival skills which promote safety and independence in the community i.e. expressive and receptive communication skills training and independent travel training. For personal enhancement and benefit of each client we provide classes in current events, recycling, exercise and nutrition. We also provide counseling in behavioral management, which includes sexua: awareness. Through t~ese services the clients will develop the skills necessary to live their lives as independently as possible and to obtain/retain CITY OF MIAMI BEACH LOG CABIN TRAINING CENTER SUPPORTED INDEPENDENT LIVING PROGRAM 1. The City of Miami Beach Log Cabin Training Center is helping to open the doors of community life for developmentally disabled clients from the Miami Beach area. Presently we are providing Supported Independent Living Services to two (2) - soon to be three (3) clients. Our objective is to make available homes in the community where our clients can feel accepted and valued by others around them and thus increase self-confidence, self-esteem and independence. 2. Our agency is committed to provide a long term supervised Supported Living Program for developmentally disabled adults who have been identified as being "at risk" due to poor quality of life. We provide training in community living skills which will enable the person to live independently in the community. 3. "Supported Living Services" means the provision of assistance and training to individuals in supported living, including teaching new skills, providing assistance in tasks the client cannot compete independently, and facilitating and coordinating the provision of such interventions through natural non-paid sources. A supportive Living Coach is assigned to each client. The coach provides assistance with tasks, training skills, or performance of activities with and on behalf of the person, which are necessary to maintain an autonomous household and participate in community life to the fullest extent. Coaching includes the coordination of generic resources and informal supports provided by community members and the individual's support team. The" Support Team" means the family coach, friends, neighbors, and significant others selected by the person participating in the Supported Living Services. We also ensure that the person lives within the neighborhood of the "Log Cabin Training Center", thus providing the extra support necessary. 4. The person responsible for the daily operation of the Program is Agi Long, Program Administrator. community based employment. Our program setting is very special. It is a plant nursery in which the clients learn through hands-on daily experience. They are ~onstantly monitored by their instructors in the areas of "on-task" skills, cooperativeness, self and equipment care in addition to other related vocational skills. 4. The individual respunsible for the daily operation of the Program is Agi Long, Program Administrator. -~ CITY OF MIAMI BEACH LOG CABIN TRAINING CENTER PROGRAM SUMMARY The City of Miami Beach Log Cabin Training Center serves developmentally disabled citizens throughout our community. We strive to equip these individuals with the job and life skills needed to live more independent and personally satisfying lives. Our comprehensive training programs are designed to provide marketable job skills to handicapped adults, as well as to enhance their personal self-esteem. Concepts such as punctuality, cooperativeness, and how to follow directions are taught in conjunction with practical plant nursery skills weeding, fertilizing, propagation and other tasks. The educational component includes money management, cooking skills, financial awareness, survival and safety skills, and other independent living skills. 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" >- x 1; .0 W 't:)'t:) m ~ ~ (5 ro 0 I- aT a. ....0. 1998-99 DEVELOPMENTAL SERVICES BUDGET REQUEST 1"""~,""""',"'r"m'TT"'~"''''TITTT11111~r'ml"r~--"'I""""""""n"f~""'-"''"'1 !llll_\_,.a~~____ A. AGENCY PROFILE: Executive Director: AG I LONG CITY OF MIAMI BEACH'S LOG CABIN TRAINING CENTER . Agency Name: Address: 8128 COLLINS AVE MIAMI" BEACH, FL 33141 Telephone: (305) 993-2008 AGENCY TYPE: X Governmental Agency Not-Far-Profit (Please provide documentation) For Profit '" SUD9S/99 1998-99 DEVELOPMENTAL SERVICES Proposal Form A: BUDGET REQUEST Agency Name: Service Name: HOW MANY NON-MEDICAID WAIVER CUSTOMERS WILL BE SERVED 7/1/98 - 6/30/997 8 HOW MANY MEDICAID WAIVER CUSTOMERS WILL BE SERVED 7/1/98 - 6/30/997 29 TOTAL NUM8ER OF CUSTOMERS TO BE SERVED 7/1/98 - 6/30/99 53 PROGRAM EXPANSION 711/98 - 6/30/99 YES IAttach Justification B.low I SE-15 SIL-3 NO WHAT ARE THE ESTIMATED AGES OF THE CUSTOMERS YOU WILL SERVE WHA T GEOGRAPHIC AREAISI IN DADE COUNTY WILL YOU SERVE7 BIRTH - 2 3-5 6-9 10 - 13 14 - 18 19+ ALL OF THE A80VE x NORTH CENTRAL SOUTH WEST ALL OF THE ABOVE COUNTY x HOW MANY TOTAL EMPLOYEES WILL YOUR PROGRAM HAVE7 FULL TIME PART TIME 7 4 HOW MANY EMPLOYEES WilL BE FUNDED BY D,S,7 FULL TIME PART TIME 7 4 . . ..... ......,. .... ......,. .. ...... :';:::';';';';';';';';';';':';';';';':;';" ...........;.;.;. :>:<:::: ':':':';';:;:::;:::;:;:::::;::;::;:;:';"" . ..... :::::;::::::::::;::::::::;::::;;::::;:::;::~;;:::::::;:;:;::.;. 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PR()GRAM:'EXPANSiOrJlfJUsnFicATION"':' .. . ................... .. .... ............ .... .. ..:.:.:.:.:...:.....:.:.:.::........:.:.:.. .........:......::.:....i!.ii.1i.il!!I!!!!i.i!I!.!i!.!!!ii'!i!!i',i',!i!ilili!iiiliiii!!;li,~iii:,!ilii,!i!i!,'iiiiili/i!ili/iiiliii/i!!/I!!!!!iic::::....:::::::: BU098/99 1998-99 DEVELOPMENTAL SERVICES BUDGET REQUEST ~~~\~~l?~~~~i~~i~, , ~...;~~"""'-~,.,.'" .. ';'''\'";'~~~~-:''''.~.;';:: :.. ~~~;:,~~~~\~~.-\, . ~.; ,~. ~:~~:~ :..~. ,..; " Please list all program locations, program names and person(s) in charge. 8. PROGRAM LOCA TION(S): Lead Person for The Program LESLI E REED CITY OF MIAMI BEACH'S LOG CABIN TRAINING CENTER Program Name: Address: 8128 COLLINS AVE MIAMI BEACH, FL 33141 Telephone: (305) 993-2008 (305) 993-2012 Fax Number: .~ ,- ..:~ - ~, ~. '1;;, 1998-99 DEVELOPMENTAL SERVICES Proposal Form B: BUDGET REQUEST Agency Name: Program Name: A. PERSONNEL 1 . Salaries 2. Fringe Benefits: Fica Florida Unemployment Worker's Compensation Insurance Retirement !1~/1..I.i..IIII!!lili!i!II!!liJil~~i{f!l!i..li.i'~i..I~/11I'!~iltll.~~!!il,~~1!81Iiq~~!!!i!' \ffm':':t'{}{BUOGET,::,:,::t}:?iftfJ!/mt///tF,FI()J\IIt01S~:@;\\. 75,950.95 75,950.95 7,481.95 o B. ,::=:::$",):/:,. ::Jl:3't#32:}9,(f{,}? :"!::::}$.tW}!:}7fii:~:9'J}1":gt,:{:t, TRA VEL 1. In-State 2. Out-of-State ,.. '.:{Sub{T(jtal}J)'i!\fiW:\{::'::{i{:.t BUILDING SPACE 1. Rent 2. Maintenance '/Sijt);,1'ottiCSqi/qiijgl$pace:t:/:}::?}}'i:.i:\',{/\/..,:ti,tifit:i?:tt::>ff'::'i"::':{}ifft}}' COMMUNICA TION & UTILITIES 1. Telephone 2. Postage 3. Electricity 4. Water/Sewer/Sanitation ,<'::sub{rotilr=:=:c(mjm#ni~~1:iQh$M~::'Utiltiest:,..tit{,'t:,:t::t}::t:{fi:::::f:::itt"fffiLi:i}Wt:"fi'fi)t't't::tzmntttJ.))):',J:},r:tJ::Jtfifit)iit(lmitJ.&,:t::t:: PRINTING & SUPPLIES 1. Printing 500.00 500.00 2. Office Supplies 0 0 3. Program Supplies 500.00 500.00 ':<Stibi"Ti)taIJ~,.Uitin9W&::=supplie~):.i.t{{tfi:tt:.,t.,tttUt:::ftt:wtftti{t::.tittt:::ft'..)ti!U:':iU:t::::!l::tQQ:fJ&QJttffri':'::f$.;it:ftiU'M::'~'iq:Q:A!M)9itt{:i: F. FOOD 0 0 :':Su~TQtal::t#H#JffiUI{!f::!{m:ft}fit.}t!:i!f':fr}::??f':'U,:)t::::{::'::}it}'}:(Wfff'(:f'!'(}::::}i ff,::::!!'it:!'i:!:!(//'!,it:tffft/:!oWfi}}t,{t G. INDIRECT EXPENSE 0 ,..,. ':'.::Sub~Toti1FI@jf~ct::E#lense:::.:t},"::if:,:tW?': ..,.............,.,.'........,. .",:'::::::.}i/:f::}'i?UU:'{:::: H. OTHER COSTS 1 . Audit 0 2. Legal 0 3. Consulting Fees 0 4. Insurance 0 5. COP0ng 0 6. Maintenance 0 7. Transportation 0 8. Staff Development 840.00 9. Miscellaneous 0 10. Office Equipment 0 Sti&{n~taFPthi.6t;j(pen$es.tt'fitit{'f!it.t)tj,'ii::,t::)/t:ff),:.t',::::::::"(:tt)'::(tt:ttt$.tt:t::.t{{:t:.::,fJ4D:l':O:(1.::'(:!} C. 435.00 o o D. o 200.00 o o o 200.00 o o E. o o o o o o o 840.00 o .~O ::f!/fft:/t}t8IfHJICt/;tf BUD98-99 ... lJl co u Q) a. V) ... l: Q) E >- o C. 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I- < >- < U ~ :r~ z < lJl a: :::l ~ :::l Z a: u: eft a.. lJl~ 0 3: :r (:I eft 0 a:I < . < 0 0 w cD .... a: <.J~ a: <.J t= 0 a: a: a: 0 eft W I- (:I W < W W w a. ::: 0 > Z 0 0 U l- X X lJl 0 -<'I 0 Z I- ~ ..J lJl ;:) W a: < 0 < W III 0 U a.. 0 > => 0 ~ <.J < ai c..i ci w u.: d :i 0 X I- W 1998-99 DEVELOPMENTAL SERVICES BUDGET REQUEST ~\;~j~Bfi Please list all program locations, program names and person(s) in charge. B. PROGRAM LOCA TION(S): Lead Person for The Program LAWRENCE ROTH CITY OF MIAMI BEACH'S LOG CABIN TRAINING CENTER Program Name: Address: 8128 COLLINS AVENUE MIAMI BEACH, FL 33141 Telephone: (305) 993-2008 Fax Number: (305) 993-2012 ,. - to >0, " Q It) lD Q Q M Q ::r ,.... lD ,... Q .... ::r ,... Q w .. .. Z z -! ,... ::r M 0 .. VI .. ~ ~ ~ a: en w a. ..( .r= .r= .r= u ~.B .. u ro L ro ro ~ 19~ 0 U L.r= e.r= 0) o u u U III ltI Q) ro l: .- Q) tI) Q) > >OJ III L Q) :::; Q).- o.E >.- .- E .. ;j ro .. ltI l: tI) .- ro._ Q) ~ Z~ 1J E.... .~ .... l: E 0 l: 0 Q) a. 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U U 0._ I: a.l:ro III to ~ I:.r. :J ro U (j) LQ)I: I-~- 00 00 00 Ol"l'l .....- 00 00 .0 o an o o an l"I'l l"I'l I"- or-- CO l"I'l CO M IJ'I IJ'I ~ IJ'I a\ l"I'l lD a\ ~ ,... ... ... 00 000 0 00 000 0 i:i M N 00 O.....l"I'l 0'1' a: w .... w (/l <( c.:J c.:J c.:J ~ Ol"l'l COl"l'lN .....w ~ <( <( <( (/l .....- CO l"I'l CO CO~ a.. a.. a.. 0 a: ..... ..... u a.. 0 -' IJ'I IJ'I IJ'I a\::t' <( <( <( a: 0..... ... ~ ~ ~ w l"I'l - .....< >- 0 0 0 J: ~ 0 a: ~ ~ ~ ~ a: a:l a:l al 0 ~ <( ::> ::> ::> al ::> U (/l (/l (/l (/l ::I' lD lD o 1"1 o 1"1 1"1 ... 1998-99 DEVELOPMENTAL SERVICES Proposal Form B: BUDGET REQUEST Agency Name: Program Name: ...'Wf;iii {;Wiiiilllril!E~~' PERSONNEL 1 . Salaries 2. Fringe Benefits: Fica Florida Unemployment Worker's Compensation Insurance Retirement 25,241.41 B. TRAVEL 1 . In-State 2. Out-of-State 290.00 o ):i$,t, ."t'290:taa. C. BUilDING SPACE 1 . Rent 2. Maintenance :':SilofT6t;al(i3#ili::fiijijl$pace),) ,..... ::}:(',(/::;:;:,:. :':. ...,.:.... D. COMMUN/CA TION & UTILITIES 1. Telephone 2. Postage 3. Electricity 4. Water/Sewer/Sanitation .,.:Sub'{T;atal\Co.,fumijnicBtiohs\&UtHties ........'...H,.... '.. :.:::...:::. "..... .... . .." PRINTING & SUPPLIES 1 . Printing 2. Office Supplies 3. Program Supplies . ,.:StJb"TQtaliP6ff.tiiil~f8t:SiJpplies' .. ...'.. ..... :.:.' :.:, ..... .. :::..,::,:/C',:???::;::: .., F. FOOD .,... ,SutHl):itat€~f,*:f}}}I}}}:t{{{t?i{:I:) . .... ...'. ,... G. INDIRECT EXPENSE ":":":"':SuD~TQt.aFJHaifect)~:Xpe,ris:e;:r?::;;/ ........' '.'.;.:.;.:.:.:.;.;.:.;.;.;.:.;.:.:.;.:.:; ;"::::;:":;:;:;::::::";::;:::.:;:::::;:;:::::::;:;:::::;:::::::;::.;.;....... OTHER COSTS 1 . Audit 2. Legal 3. Consulting Fees 4. Insurance 5. Copying 6. Maintenance 7. Transportation 8. Staff Development 9. Miscellaneous 10. uffice Equipment >Stib":Tot'ahPt~f:i::*penses.t?,)?),I;. E. o 100.00 o o .. ?({))1])Crtott: ,:,:.tL.. o o 320.00 /i}:32O:H)O', ....,.... ...... ._,-..",. o ,.....'.."....... . ................... ................... .... .. '.. ,...........................,...... ... ....,...... H. o 17,460.00 o o 290.00 o :;:::i/:t:;.':::::2!8ttU:OO:,.,:::{}::;::::",:: o o o 100.00 o o " ,. .:fr::;::::,:t:\tnt)iti(ltf",}/t,{{::: o o 320.00 ::"'{.:'.'",:\.$t:.!t:tit:'::::az:O::~::OO::::::::t{t::tt' , ,,' ,....- -...". o o '< BUD98-99 Proposal Form B: BUDGET REQUEST Agency Name: .!- Program Name: A. PERSONNEL 1 . Salaries 2. Fringe Benefits: Fica Florida Unemployment Worker's Compensation Insurance Retirement 248,930.00 !111\tJil~i; 220,206.64 c. 1,707.00 10,328.00 23 706.00 .. . .$~. n ~ .1' ... {}(48~}u7 <{OfF 435.00 o . ...."'/:.'5 0""'. ..... .. :(r!~{ir\(,,;~:. :,-J::, ,_;v){{)((}(; 1,707.00 10,328.00 5 926.50 ,.. ,:<)::::::$.2:38''::1::&31'1'4::;). " B. TRA VEL 1. In-State 2. Out-of-State 435.00 o .. '. '.43'5.00. ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ............ . - .." ". ......... ... .':':::::::\",,::::::. '< :.'::;;;::. . .::::::':;::;;:::::<;::::: ............ ..--......,,- .,............".. E. BUilDING SPACE 1 . Rent 2. Maintenance ::SutBTti~il\a#ildioglSpacE! :::::::::(::::::::::::):;::: .... ...., ....... ...... .. D. COMMUNICATION & UTILITIES 1. Telephone 2. Postage 3. Electricity 4. Water/Sewer/Sanitation ::;::Sf.tI:8Ttit~l'rc;-qi$m,ijnicati"ri$}&:lJtilties.::.:H:::;:::;::::::::::/:::\:t:\:/(}()\\:).. PRINTING & SUPPLIES 1. Printing 2. Office Supplies 3. Program Supplies . .:S:titlSl))taLfrI@og::&::Sup'plieii) ,..,. .,.. ,.>::::<:<::::,::. .,.. ..,........, FOOD 24,500.00 o ::::::~:::;;::"I:hr..::::::5.' ..0. :Q:.<o:n: ::::::~::::::~:~::;:::_ ,:, .:.." :l;f::: ...... ...... 200.00 0 1,200.00 1,200.00 10,000.00 3,000.00 2,000.00 0 <)::j('J4lUf1:taO::::((:=:}(Mi }\:'::/'::i::;;:t;ij:/::t-6:o:aUr{:}r::::} INDIRECT EXPENSE ,,:. .::'SUlj~T:()tat:ii1#itecfEj(periSer::::::::::::::::::"" .,.. .. OTHER COSTS 1. Audit 0 0 2. Legal 0 0 3. Consulting Fees 0 0 4. Insurance 3,323.00 0 5. Copying 0 0 6. Maintenance 9,337.00 9,337.00 7. Transportation 35,880.00 35,880.00 8. Staff Development 5, 130.00 5, 130.00 9 M'" 8,500.00 0 . .sce aneous 3 000 00 0 .::::~~bf.-rQ~:':~~;~f:~~~~~:$};:)):}::::::::)):;:):;::::}:::{{{::U)U)U:':::U::.:::::::rrr/)}::::::::UUU!$}:6:S':;':$70:~.ad:':::::::)//:;::::{::::::'::I!:)5b:::tj4WK':: 3,200.00 3,500.00 6,000.00 :;:(::::$::::l2/70Q;;:Oa::{t: 5,700.00 {:(} ::;:::::::/s.:f:7.])Q{Qf!: 3,200.00 3,500.00 6,000.00 :::::}$.tU::~l1(HnJ}O::;:Jr) 5,700.00 {}}:::;:J IJ:'}:: :';:::::::JiWf:Qg';i9.:f!:::}}::} ., H. BUD98-99 1998-99 DEVELOPMENTAL SERVICES BUDGET REQUEST Please list all program locations, program names and person(s) in charge. B. PROGRAM LOCA TION(S): Lead Person for The Program GLENNA H. KRETSCHMER CITY OF MIAMI BEACH'S LOG CABIN TRAINING CENTER Program Name: Address: 8128 COLLINS AVENUE MIAMI BEACH, FLORIDA 33141 Telephone: (305) 993-2008 Fax Number: (305) 993-2012 :- If, ;:~{;~:~:i{:~:~:~;i:~;~:?~:;;i:fi:~t ::;;::;::;}:::;;;::::::;;::;:;;::;:;;::::::::~:: ......................... .......................... ......................... ................................................... ..... ............... ...... I . ,. . .'. :.:.: .:. ~.:.;.:.:.:.:.:.:.:.:.;.:.:.:.;.:.:-:. ;:.\frHffrfI~titft ;;::~:::::::;:::;:::;:;::;~:::::::;:::;::::;;::: . .... ...... ............. ................................................ ..:.:.:.:.;.:.:.:.:.;.;.;.:.;.:.;.:.:.:.:.;.;.;. ........................ ............................................... {f1i~Jfffftffff~flfJ~ffftfJf!f~rfj ............................................... 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" .............. ::::~::::;:::.::~.::~::;:::: :::'.- ...,............. ...... .,.... .... .::::::::::;:::::::;::;::::::;::::' ................ .:.;.:.:.:.;.:.:-:.:.:-:;.:-:.:.; ..............,.. .................. ::::::::;:;::;;:;:;::::::;:;:::;:; .,............... ................................ ........... .... :;::::;:~::;;::::::;:;:;;::::::::. .;;:;::::.:;;::~;:;;;::::;::::;;:: ...'............................... :::;:::::::~::;:::::::;;:::;:::;:. 0 CO) N .,. ce w w w w < t-' t-' t-' l/) < < < en l- t-' ~ Q.. a.. a.. en l/) < ce -' -' -' cO 0 a.. 0 < < < en u -' ... l- I- I- 0 ce < >- 0 0 0 ::l w l- ce l- I- I- al J: 0 ce ell ell ell l- I- < ::l ::l :::l 0 ell U l/) l/) lJl ::l ci l/) Contract No. CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION CONTRACTSffiUBCONTRACTS This certif:cDtioil is required by the regulations implementing Executve Order 12549, Debarment and Suspension, signed February 18, 1986. The guidelines were published in the May 29, 1987 Federal Register (52 Fed, Reg., pages 20360 - 20369). INSTRUCTIONS 1, Each provider whose contract/subcontract equals or exceeds $25,000 in federal monies must sign this certification prior to execution of each contract/subcontract. Additionally, providers who audit federal programs must also sign, regardless of the contract amount. Children & Families cannot contract with these types of providers if they are debarred or suspended by the federal 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 knowingly rendered an erroneous certification, the Federal Government may pursue available remedies, including suspension and/or debarment. 3. The provider shall provide immediate written notice to the contract manager at any time the provider learns that its certification was erroneous when submitted or has become erroneous 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 manager for assistance in obtaining a copy of those regulations, 5, The provider agrees by submitting this certification that, it shall not knowingly enter into any subcontract with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from ,participation in this contract/subcontract unless authorized by the Federal 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 525,000 in federal monies, to submit a signed copy of this certification. 7. The Department of Children and Families may rely upon a certification of a provider that it is not debarred, suspended, ineligible, or voluntarily excluded from contracting/subcontracting unless it knows that the certification is erroneous. 8, This signed certification must be kept in the contract manager's contract file. Subcontractor's certifications must be ke t at the contractor's business location. (1) The prospective provider certifies, by signing this certification, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this contract/subcontract by any federal department or agency. (2) Where the prospective provider is unable to certify to any of the statements in this certification, such prospective provider shall attach an explanation to this certification. ~'~ 4/27/98 Date ,\Jame Agi Long Title Program Administrator JF 12/96 CERTIFICATION REGARDlNG LOBBYING CERTIFICATION FOR CONTRACTS, GRANTSr LOANS AND COOPERATIVE . AGREEMENTS Attachment 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 undersign~d, 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 member 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 agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan, or cooperative agreement. (2) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of congress, an officer or employee of congress, or an employee of a member of congress in connection with this federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 3nd not more than $100,000 for each such failure. Dr'; !L~ :ignature 04/27/98 Date Agi Long ame of Authorized Individual Application or Contract Number City of Miami Beachls Log Cabin Training Center 'me of Organization jress of Organization 8128 Collins Avenue, Miami Beach, FL 33141 Page _ =:t- o .... 0 0 CD &n ..... It) It) ~ .... It) CD .... ~ 0 l"Il =:t- .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... :; a: iii lfl < :; ...I X ,..: w < lfl w a. a: '" .- Z w >- a: w ::E ;:: Z 0 W ...I 0 W ~ 0 u.. 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Q. i ............................. lJl ....j :E z 0 0 J: Ii: Q. .:.:.:.:.::;::::::::::~;:::: a: < :5 0 ii .... ....j :;:::::::::::::::::~::::::::: W a: 0 ~ 0 < < u.. Q. .... ID U Q. u.. U .... 0 ;;=;::::;;:::::::;; 0 :;;;;:::;;:;:~:::;; .( cD U ci u.i u: c; Z .... tt ,- -,. ~l~H;Lr;REN (~ & FAMILIES"-" SECURl'TY AGREEMENT FORM " , , The Department of Children and Families has authorized you: o..'Ji L~ J C~9 ~ k, (2, ~ t..o~ C.o ~r ,,_ T'1.)~' ~ { Employee's lftlDcYOrganization (f to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's.disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of infonnation resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. · By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S., and have received any necessary clarification from my supervisor. r understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to lhe provisions in lhe Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. . Information is not to be obtained for my own or another person's personal use. (+ G; L 0 ~& Print Employee Name "'k. ~Of~ '-t /0/ 'f( . Date ~ ~ i\J d,().lr l 'fv\ArK.) Print Supervisor Name ~ y 'p-':/!~ '5J Signanuc of Supervisor Date ....I Cf 1l<C, Oee 116 (Repl~ces Oct lI6 eailion .IIIc:h nay be ,..,seal (Sloct Humber: 5740.o00.o114~1 Oistribution 01 Copies: WhIle _ Personnel Flle/CDftltad file Yellow. SecuriCy F~. ai-' -' PInk . Employee Copy - " - ~l~H 'LDrtEN ~ & FAMILIES ,- SECURITY AGREEMENT FORM " The Department of Children and Families has authorized you: [E?SI...I.E- (l&E0 evel.., of r(k~r 6~ b (N3'~ TItA-cNI'-<.& ~~-L tmployee's Name/Organization to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). ~ Computer crimes are a violation of the department's disciplinary standards and, in addition to departmental discipline, the commission ~f computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 8 I 5, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 8 I 5, F.S. · By my signature, I acknowledge that I have received, read and understand Chapter 8 I 5, F.S., and have received any necessary clarification from my supervisor. I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. ~UE <<-~o Print Employee Name ~'&dL ~ ~I q F' Date Signature ofEmployce Ac; l lo~ Print Supervisor Name ~ Ls-._/, , Sig of SuperYfsoru 41Fh f ~ Date CF 114, Dee lI' (Repla:es Cd 0. edition which nqy be used) (Stoclt Humber. 5740-000-0114-4) Distribution o( Copies: WhIte. PetsOMel FUeleonuad File VeUow . Security F!!!3, -. -.. Pink. Emoloyee Copy.. ~ , ~lORrDA DEPARTMENT Of CHILPREN , o & FAMILIES'- SECURITY AGREEMENT FORM The Department of Children and Families has authorized you: C ,W~ Employ. , Name/Organization to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's.disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. · By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S., and have received any necessary clarification from my supervisor. . r understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. )/e L Y1 1lJ'rt- Print Employee Name ~~/?L{ Signature of Employee ~ f1ld:;tNmnc Q~~ Sigua~O~ 1/e/7 rl' Date CF 1 1.c, Dee ra (Replaces Oct tl6 edilion which may be used) (Sloelt Humber: 57.cO..oOO..o1 1.c-6) Disltibulion n( Copies: Whlee . Personnel FUelConuad file Yellow. Security F~ ' A. .. -.. Pint . Employee Copy. . ' [f;G)] STATE OF FLORIDA DEPARTMENT OF HEALTH AND REHABILI'fAT/VE SERVICES CIVIL RIGHTS COMPLIANCE CHECKLIST Pro8'fm/Facility Name LOQ Cabir. Training CentE County D d I HAS Dis;e1t City Miami Beach's r a e Address Completed By 8128 Collins Avenue Nelson Padin City. State, Zip Code Date 03/31/98 ~ Telepyone Miami Beach Florida 3.1141 30:"_ 993-2008 READ THE REVERSE SIDE FOR ILLUSTRATIVE INFORMATION WHICH WILL HELP YOU IN THE COMPLETION OF THIS FORM. PART I. 1, Briefly describe the geographic area served by the program I facility and the type of service provided: ...D.is.trict X I. Dade County and the City of Miami Be~,::h. The services to ADA develonmentally disabl~d (1!lentally retarded) Center. 2. POPULATION OF AREA SERVED. Source of data: Total # % White % Black % Hispanic 92 000 42 4 53 proQram provides Day Training 3, % Female % Female 05 % Handicap 01 4. % Female 38 % Handicap 100 % Over 40 Yrs, 35 5. % Female PART II. USE A SEPARATE SHEET OF PAPER FOR ANY EXPLANATIONS REQUIRING MORE SPACE. 6. Is an Assurance of Compliance on file with HAS? If NA or NO, explain, NA YES NO o 00 0 7, Compare staff composition to the population, Are staff representative of the population? If NA or NO, explain. NA YES NO o ~ 0 8. Compare the client composition to the population, Are race and sex characteristics representative of the population? If NA or NO, explain, NA YES NO o rn 0 9, Are eligibility requirements for services applied to clients and applicants without regard to race, color, national origin, sex, age, religion or handicap? If NA or NO, explain. NA YES NO o ex 0 10, Are all benefits, services and facilities available to applicants and participants in an equally effective manner regardless of race, sex, color, age, national origin, religion or handicap? If NA or NO, explain, We are not a residential or intermediate care facility. However. all clients provided the services such as educational/vocational and ~O~~s~~ing without regard to race. sex. color. national origin re/igion;9 ndicap. NA ~ YES o NO o 11. For in-patient services, are room assignments made without regard to race, color, national origin or handicap? If NA or NO, explain, NA [SO YES o NO o We are not a residential facility. Distribution of Copies: White. District Program Office or OPLC Yellow. Facility HRS Form 946A, Jul8S (Obsoletes previous editions which may not be used) Stock Number: 574O.{)(JA.0946-O) Page 1 of 2 . ....., 'I. V;;)E;. M. w...nmM.1 t: ~nt:t: I U~ ....A....t:H FOR ANY EXPLANATIONS REQUIRING MORE SPACE. 12, Is the program / facility accessible te non-English speaking clients? If NA or NO. explain, NA o YES ~ NO o 13. Are employees. applicants and participants informed of their protection against discrimination? If YES. how? Verbal Written __ Poster If NA or NO, explain. NA o YES ~ NO o 14, Give the number and current status of any discrimination complaints regarding services or employment filed against the program/facility. NA ex NUMBER I I 15, Is the program / facility physically accessible to mobility. hearing and sight impaired individuals? If NA or NO. explain. NA KJ YES o NO o PART III. THE FOLLOWING QUESTIONS APPL Y TO PROGRAMS AND FACILITIES WITH 15 OR MORE EMPLOYEES 16, Has a self-evaluation been conducted to identify any barriers to serving handicapped YES NO individuals. and to make any necessary modifications? If NO. explain. 0 0 7. Is there an established grievance procedure that Incorporates due process into the resolution of complaints? If NO. explain, YES NO o 0 :> Has a person been designated to coordinate Section 504 compliance activities? If NO, explain, YES NO o 0 Du recruitment and notification materials advise applicants. employees and participants of nondiscrimination on the basis of handicap? If NO. explain. YES NO o 0 Are auxiliary aids available to assure acceSSibility of services to hearing a"d sight impaired ,ndivlduals? If NO. explain. YES NO o 0 ,RT IV. FOR PROGRAMS OR FACILITIES WITH 50 OR MORE EMPLOYEES AND FEDERAL CONTRACTS OF J,OOO OR MORE. Do you have a written affirmative action prog~am? If NO. exolain YES o NO o HRS USE ONLY viewed By YES 0 NO' D In Compliance: )gram Office -. . Notice of Corrective Action Sent 1 1 ~e I Telephone Response Due 1 1 Site 'I Desk Review 0 Response Received _1_'- ~ ; Form 9468, Feb 91 (Obsoletes ~revIOus eOrllons whiCh may nOI oe uSed) __ ~_ .......~ ........~ ii, PaQe 2 of 2 ~lORIDA DEPARTMENT OF ~H I LDREN . ~ & FAMILIES ,- .. SECURITY AGREEMENT FORM tLt(/-u.~ Employee's NamelOrganizat" n to have access to sensitive data through the use of computer..related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). ment of Children and Families has authorized you: 7 . 70k~' ~ Computer crimes are a violation of the department's disciplinary standards and, in addition to departmental discipline, the commission of comp*ter crimes may result in felony criminal charges. The Florida Computer Crimes Act, ~hapter 815, Florida Statutes, addresses the unauthorized modification, destructi09' disclosure, or taking of information resources. · r have read the above statements and have been provide~ a copy of the Computer Related Crimes Act, Chapter 815, F.S. · By my signature, r acknowledge that I have received, re,d and understand Chapter 8 I 5, F.5., and have received any necessary clarification ~om my supervisor. I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in discipliqary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. . Information is not to be obtained for my own or another person's personal use. ~-r/C.:i~E A, C;ll/lJKr)J/L't: Print Employee Name .~ I!~,t~~~ Signature of Employee & Date ---21 G; L 0 ~ (T Print Supervisor Name Dt'~ Signa of Supeo,isof If\ { \ [1 i '", ~ CF 'U. De-:: 1I11 (Replaces Celllll edilion which may be used) (Sloclt Humber: S7~O..oOO..o1 U~) Dislributicn of Copies: While. Personnel FllelConuac:t File Yellow. Security f~ . -' -' Pink. Employee Copy" J. , ~l(H 'LPREN ~ & FAMILIES'- SECURITY AGREEMENT FORM The Departm~ChiIdren a d Families has thorized you: ----.kov/~~ 6</A 'tl /~~ E ploy s NamelO anization to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). ,I' ~.#C Computer crimes are a violation of the department's .disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 8 I 5, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. · r have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 8 I 5, F.S. · By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S,~, and have received any necessary clarification from my supervisor. r understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. '/(ltl/~r A</1Y:J Print Employee Name A{;; Lor0~ Print Supervisor Name <2~~ Sig of Supervisq(- rf./fftJ> ate . Date CF ll.e, Dee 116 (Replaces Oct 116 edilion which may be used) (SIOClt Number: S7.eO-OOO-OU.e..ci) Dislribution of Copies: White. Personnel Flle/Conlnct File Yellow. Security F~ . -' -' Pink - Employee Copy - - · ' ~lOIUDA DEPARTMENT OF (;HILPREN , ~ & FAMILIES'- 0, SECURITY AGREEMENT FORM The Department of Children and Families has authorized you: L~fLIt LUINIVl/41J,- CIJ,16 Lf; Cth~ y~[- Employee's Name/Organizatio to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's.disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, 11lorida Statutes, addresses the unauthorized modification, destruction, disclosure; or taking of information resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. · By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S., and have received any necessary clarification from my supervisor. I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 8 15, F.S., and may also result in disciplinary action against me . according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. LAvP- ~ kLJ;;NIVI~tJ Print Employee Name ~LU~tL-: Signature of Employee ~ A b"\ L'U(0& Print Supervisor Name Q '~ Signa~OfSu~ ;~ CF ll~. Dee 96 (Replaces Oct 96 edition whic.'1 may be used) (Sloclt Humber: S7~O-OOO-O t 14-6) Dislribution of COpies: While. Peraonnel FUelConuad File Yellow - Security F&:i ' -, -.. PInk. Employee Co~ - . Ai . ~l~HILPREN 121 & FAMILIES.- SECURITY AGREEMENT FORM The Department of Children and Families has authorized you: iJA/AI HAl,,!.); <-Clq I/J~/,{/ I/k,(~cd Employee's Name/Organization I to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. . r have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. . By my signature, I acknowledge that I have received, read and understand Chapter 815, F~S., and have received any necessary clarification from my supervisor. I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: . Personal passwords are not to be disclosed. . Information is not to be obtained for my own or another person's personal use. 1l1llA! 1Jtf!&t.5 Print Employee Name ~'tf2. 4dD Date D~q \1f . Ibj hAlt Print supcrvi~ame G' ~ Q. ~---. Signae of Supcrvir Cf 114. Dee i6 (Replaces Oct 96 edition whiCh may lie used) (Slode Humbc:r: S7.cO.oOO.oII.c~) L'islribution of Copies: While _ Personnel Flle/Conlnc:l file Yellow. Security F~ . .. -' Pink . Employee Copy - . A. ' ~'~HiLPREN ~ & FM\ILIES'. SECURITY AGREEMENT FORM The Department of Children and Families has authorized you: ffip>>tM.\-\.kfe,\s~. ~~ J ~ fulct(s L~ldb~n . EmPIO,j. Namel rganlzalion --['Ve.<vi'>'\G) c.~4e.v to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). :..:. Computer crimes are a violation ofthe department's disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of infonnation resources. . [have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. . By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S., and have received any necessary clarification from my supervisor. [ understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F .S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: . Personal passwords are not to be disclosed. . Information is not to be obtained for my own or another person's personal use. !1tji UJAJb Print Supervisor Name hJ!)l/1U!~rr~ 11/8'/Qg .If}-< SignalweofEt;lJloyee ~ 1 f!1( (VIsor Oat e:,\~~. \4~G\uW Print Employee Name r.f' 11~, Dee 116 (Repl4lc:es Oct 1I~_ edition whiCh II\4IY be usedl Dislribution of Copies: White _ PersOftnel FUelconlf1lc:t file YelloW. securit1 F~- . pink - Employee Copy. . ' @:LORIDA DEPARTMENT OF ~H I LDREN ~ & FAMII.lES'- SECURITY AGREEMENT FORM The Department of Children and Families has authorized you: LAzJt:eJJce fLow - riIJl'v(. b '. Coi; )~1 ttL; t1 Ur,- {~ Employee' Name/Organization J to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 81 S, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of infonnation resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, P.S. · By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S.~ and have received any necessary clarification from my supervisor. I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. ~C-YmL~ ~~ ~ ~ ~!tig Date Print Employee Name Signature of Employee ~'Q,- . Signa of S;:Zor .' Date CF 114. Dee 116 (RepUlees Oct 06 edilion which m~ r be used) (Slock Humber: 5740-000-0 I U~) Oislribcllion of Copies: While. Personnel FUelContnd file Yellow - Security F~. - . Pink . Employee Copy - . A. , - ~lCH;LPnEN 12J & FAMILIES-. SECURITY AGREEMEN1' FORM The Department of Children and Families has authorized you: o~ ~L,11Yt~~1(- [~ Employ s Name/Organizati to have access to sensitive data through the use of computer-related media (e.g., printed reports, microfiche, system inquiry, on-line update, or any magnetic media). Computer crimes are a violation of the department's disciplinary standards and, in addition to departmental discipline, the commission of computer crimes may result in felony criminal charges. The Florida Computer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. · I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F.S. · By my signature, I acknowledge that I have received, read and understmtd Chapter 815, F.S." and have received any necessary clarification from my supervisor. r understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815, F.S., and may also result in disciplinary action against me according to the provisions in the Employee Handbook. The minimum security requirements are: · Personal passwords are not to be disclosed. · Information is not to be obtained for my own or another person's personal use. Print Employee Name .lLi(J!1.~~ Signature of Employee u..l t1 \~Vl ~ . (\1\ lutAeL- &16S~~ -l Lv V\. ? Print Supervisor N e ,-...., , . f\ 1i(I~- Sig' lure ~f Su rvisor ~' , Cj Cf ~ Date CF I U, Dee 116 (Repl~c:es Oct 116 edilbn which m.ay be used) (Sloa Number: S7~O-OOO-Ol14-6) Dislribution of Copies: While. Personnel FlIelConttac:1 file Yellow. Security F~ . -' -' Pink. Employee Copy' - ,~ , l~{('H ILDRETN &, FAMILIES Lawton Chiles Governor /17(; '-~:,,- J., (j k <;2 )/~'.-;I(). / t? - 2'("7 I~I r- _...---...--- Edward A. Feaver Secretary District 11 Dade & Monroe Counties Anita M, Bock District Administrator '~ " "COMMITTED TO EXCELLENCE" DOCUMENT A TION OF NEGOTIATION AGREEMENT THIS AGREEMENT, entered into between the State of Florida, Department of Children and Families, Division of Adult Care and Family Support, hereinafter referred to as the "Department" and City of Miami Beach, hereinafter referred to as "Provider," discuss the following points. This agreement is not binding until the resulting contract is reduced to writing and signed by the duly authorized officials of the Provider and the Department. AGREEMENT: The rate per unit of service as listed in this document, applies to the services specified below whether funded through this Agreement or Medicaid Waiver. ~. FY 98-99 FY 98-99 FY 98-99 FY 98-99 SERVICES TO BE PROVIDED FY 98-99 CONTRACTUAL TOTAL NEGOTIA TED CONSUMERS CALCULA TIONS G/R RATES TO BE SERVED FUNDING Adult Day Training $24.50 7 $24.50 x 7 x 230 $39,445.00 Supported Employment $426.00 2 $426.00 x 2 x 12 $10,224.00 $95.28 4 $95.28 x 4 x 12 $4,573.44 Transportation $485.00 x 2 x 12 $11,640.00 $485.00 2 I Supported Living TOTAL CONTRACT FUNDING $65.882.44 Provider Representative: Name:AgiLong ~, Department of Children and Families: Contract Supervisor: Don Gillette. OMC IkjdY . / Contract Man~ger:A/ex Perez. HSPS Y Date: 1)1':-:") .'1,/7 i \. Title: Program Administrator Date: ~ \ 0..).\ ~t , \ Working in partnership with local communities to help peoplt.: be self-sufficient and live in stable families and communities. 4/1/98 CFDA No. N/A Grants and Aids Client~ Non-Client 0 Mu/ti-DistrictD 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 "department," and CITY OF MIAMI BEACH hereinafter referred to as the "provider," I. THE PROVIDER AGREES: A. Attachment I To provide services in accordance with the conditions specified in Attachment I. B. 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 manager 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 1/" Paragraph 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-audit thereof. Where applicable, to subf11it bills for any travel expenses in accordance with section 112,061, FS, The department may, if specified in Attachment I, establish rates lower than the maximum provided in section 112,061, FS, To allow public access to all documents, papers, letters, or other materials subject to the provisions 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 comply with this provision shall constitute an immediate breach of contract. C. Governing Law 1. State of Florida Law a. That this contract is executed and entered into in the State of Florida, and shall be construed, performed, and enforced in all respects in accordance with the 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 contract. b. That it understands that the department and the Department of Labor and Employment Security have jointly implemented WAGES, an initiative to empower recipients in the Temporary Assistance To Needy Families Program to enter and remain in gainful employment. Employment of WAGES participants is a mutually beneficial goal for the provider and the department in that it provides qualified entry level employees needed by many providers and provides substantial savings to the citizens of Florida, 2. Federal Law a. That if this contract contains federal funds, the provider shall comply with the provisions of 45 CFR, Part 74, and/or 45 CFR, Part 92, and other applicable regulations as specified in Attachment I. b. That if this contract contains federal funds and is over $100,000, the provider shalf comply with all applicable standards, orders, or regulations issued 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 seq,), Executive Order 11738, and Environmental Protection Agency regulations (40 CFR Part 15), The provider shall report any violations of the above to the department. c. That no federal funds received in connection with this contract may be used by the provider, or agent acting for the provider, to influence legislation or appropriations pending before the Congress or any State legislature, If this contract contains federal funding in excess of $100,000, the provider must, prior to contract execution, complete the Certification Regarding Lobbying form, Attachment~, If a Disclosure of Lobbying Activities form, Standard Form LLL is required, it may be obtained from the contract manager. All disclosure forms as required by the Certification Regarding Lobbying form must be completed and returned to the contract manager, d. That unauthorized aliens shall not be employed. The department shall consider the employment of unauthorized aliens a violation of section 274A(e) of the Immigration and Nationalization Act. Such violation shall be cause for unilateral cancellation of this contract by the department. e. That if this contract contains $10,000 or more of federal funds, the provider shall comply with Executive Order 11246, Equal Employment Opportunity, as amended by Executive Order 11375, and as supplemented in Department of Labor regulation 41 CFR, Part 60, [45CFR, Part 92] F. That if this contract contains federal funds and provides services to childr.an up to age 18, the provider shall ;omply with the Pro-Children Act of 1994, Public Law 103-227. Failure to comply with the provisions of the law may oesult in the imposition of a civil monetary penalty of up to $1,000 for each violation and/or the imposition of an 3dministrative compliance order on the responsible entity. This clause is applicable to all approved subcontracts. CF STDCT JF 12/97 CONTRACT # KLB80 4/1/98 D. Audits, Records, and Records Retention 1. To establish and maintain books, records, and documents (including electronic storage media) in accordance with generally accepted accounting procedures and practices which sufficiently and properly reflect all revenues and expenditures of funds provided by the department under this contract. 2. To retain all client records, financial records, supporting documents, statistical records, and any other documents (including electronic storage media) pertinent to this contract for a period of five (5) years after termination of the contract, or if an audit has been initiated and audit findings have not been resolved at the end of five (5) years, the records shall be retained until resolution of the audit findings or any litigation which may be based on the terms of this contract. 3. Upon completion or termination of the contract and at the request of the department, the provider will cooperate with the department to facilitate the duplication and transfer of any said records or documents during the required retention period as specified in Section " Paragraph 0,2, above, 4. To assure that these records shall be subject at all reasonable times to inspection. review. copying, or audit by Federal, State, or other personnel duly authorized by the department. 5. At all reasonable times for as long as records are retained, persons duly authorized by the department and Federal auditors, pursuant to 45 CFR, Part 92,36(i)(10), shall be allowed full access to and the right to examine any of the provider's contract and related records and documents, regardless of the form in which kept. 6. To provide a financial and compliance audit to the department as specified in Attachment ~ and to ensure that all related party transactions are disclosed to the auditor, 7. To include the 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, goods, and services of the provider which are relevant to this contract, and to interview any clients and employees of the provider to assure the department of the satisfactory performance of the terms and conditions of this contract. Following such evaluation the department will deliver to the provider a written report of its findings and will include written recommendations with regard to the provider's performance of the terms and conditions of this contract. The provider will correct all noted deficiencies identified by the department within the specified period of time set forth in the recommendations, The provider's failure to correct noted deficiencies may, at the sole and exclusive discretion of the department, result in anyone or any combination of the following: (1) the provider being deemed in breach or default of this contract; (2) the withholding of payments to the provider by the department; and (3) the termination of this contract for cause, F. Indemnification NOTE: Paragraph J.F.1, and 2, are not applicable to contracts executed between state agencies or subdivisions. as defined in section 768,28, FS, 1. To be liable for and indemnify, defend, and hold the department and all of its officers, agents, and employees harmless from all claims, suits, judgments, or damages. including attorneys' fees and costs, arising out of any act, actions. neglect, or omissions by the provider. its agents, or employees during the performance or operation of this contract or any subsequent modifications thereof, whether direct or indirect, and whether to any person or tangible or intangible property, 2. That its inability to evaluate its liability or its evaluation of liability shall not excuse the provider's duty to defend and to indemnify within seven (7) days after notice by the department by certified mail. After the highest appeal taken is exhausted, only an adjudication or judgment specifically finding the provider not liable shall excuse performance of this provision, The provider shall pay all costs and fees, including attorneys' fees related to these obligations and their enforcement by the department. The department's failure to notify the provider of a claim shall not release the provider of these duties, The provider shall not be liable for the sole negligent acts of the department. 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 this contract and 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 768.28. FS. the provider accepts full responsibility for identifying and determining the type(s) and extent of liability insurance nesessary to provide reasonable 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 department written verification supporting both the determination and existence of such insurance coverage, Such coverage may be provided by a self-insurance program established and operating under the laws of the State of Florida. The department reserves the right to require additional insurance as specified in r,itachment I. 2 CONTRACT # KLB80 4/1/98 H. 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 regulations and Federal law or regulations (45 CFR, Part 205.50), except upon written consent of the recipient, or the responsible parent or guardian when authorized by law, I. Assignments and Subcontracts 1. To neither assign the responsibility for this contract to another party nor subcontract for any of the work contemplated under thIs contract without prior written approval of the department which shall not be unreasonably withheld, Any sublicense, assignment, or transfer otherwise occurring shall be null and void, 2. To be responsible for all work performed and all expenses incurred with the project. If the department permits the provider to subcontract all or part of the work contemplated under this contract, including entering into subcontracts with vendors for services and commodities, it is understood by the provider that all such subcontract arrangements shall be evidenced by a written document subject to prior review and comment by the department. Such review of the written subcontract document by the department will be limited to a determination of whether or not subcontracting is permissible, whether the offered subcontractor is acceptable to the department, and the inclusion of applicable terms and conditions of this contract. The provider further agrees that the department shall not be liable to the subcontractor for any expenses or liabilities incurred under the subcontract and the provider shall be solely liable to the subcontractor for all expenses and liabilities incurred under the subcontract. The provider, at its expense, will defend the department against such claims, 3. That the State of Florida shall at all times be entitled to assign or transfer its rights, duties, or obligations under this contract to another j10vernmental agency in the State of Florida, upon giving prior written notice to the provider, In the event the State of Florida approves transfer of the provider's obligations, the provider remains responsible for all work performed and all expenses incurred in connection with the contract. In addition, this contract shall bind the successors, assigns, and legal representatives of the provider and of any legal entity that succeeds to the obligations of the State of Florida, ' 4. To make payments to the subcontractor within seven (7) working days after receipt of full or partial payments from the department in accordance with section 287.0585, FS, unless otherwise stated in the contract between the provider and subcontractor, Failure to pay within 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 the amount 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 exceed fifteen (15) percent of the outstanding balance due, J. Return of Funds To return to the department any overpayments due to unearned funds or funds disallowed pursuant to the terms of this contract that were disbursed to the provider by the department. /n the event that the provider or its independent auditor discovers that an overpayment has been made, the provider shall repay said overpayment within 40 calendar days without prior notification from the department. In the event that the department first discovers an overpayment has been made, the department will notify the provider by letter of such a finding, Should repayment not be made in a timely manner, the department will charge interest of one (1) percent per month compounded on the outstanding balance after 40 calendar days after the date of notification or discovery, K. Client Risk Prevention and Incident Reporting 1. That if services to clients will be provided under this contract, the provider and any subcontractors shall, in accordance with the client risk prevention system, report those reportable situations listed in HRSR 215-6 in the manner prescribed in HRSR 215-6 or district operating procedures. 2. To immediately report know/edge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or disabled adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ABUSE). As required by Chapter 415, FS, this is binding upon both the provider and its employees, L. Transportation Disadvantaged To comply with the provisions of Chapter 427, FS, and Chapter 41-2, FAC, if clients are to be transported under this contract. The provider shall submit to the department the reports required pursuant to Volume 10, Chapter 27, HRS i.\ccounting Procedures Manual. VI. Purchasing I. To purchase articles which are the subject of or are required to carry out this contract from Prison Rehabilitative ndustries and Diversified Enterprises, lnc" (PRIDE) identified under Chapter 946, FS, in the same manner and under the Jrocedures set forth in subsections 946,515(2) and (4), FS, For purposes of this contract, the provider shall be deemed J be substituted for the department insofar as dealings with PRIDE. This clause is not applicable to subcontractors m/ess otherwise required by law. An abbreviated list of products/services available from PRIDE may be obtained by ;ontacting PRIDE, (850) 487-3774, ~. To procure any products or materials which are the subject of, or are required to carry out this contract, in :ccordance with the proviSions of sections 403.7065, and 287.045, FS, 3 CONTRACT # KLBSO 4/1/98 N. Civil Rights Requirements 1. Not to discriminate against any employee in the performance of this contract, or against any applicant for employment, because of age, race, creed, color, disability, national origin, or sex. The provider further assures that all contractors, subcontractors, subgrantees, or others with whom it arranges to provide services or benefits to participants or employees in connection with any of its programs and activities are not discriminating against those participants or employees because of age, race, creed, color, disability, national origin, or sex, This is binding upon the provider employing fifteen (15) or more individuals, 2. To complete the Civil Rights Compliance Questionnaire, HRS Forms 946 A and S, in accordance with HRSM 220-2, This is applicable if services are directly provided to clients and if 15 or more individuals are employed, O. Independent Capacity of the Contractor 1. To be solely liable for the performance of all tasks contemplated by this contract which are not the exclusive responsibility of the department. 2. To act in the capacity of an independent contractor and not as an officer, employee, or agent of the State of Florida, except where the provider is a state agency, The provider shall not represent to others that it has the authority to bind the department unless specifically authorized in writing to do so, In addition to the provider, this is also applicable to the provider's officers, agents, employees, subcontractors, or assignees, in performance of this contract. 3. Except where the provider is a state agency, neither the provider, its officers, agents, employees, subcontractors, nor assignees are entitled 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 contract. 4. To take such actions as may be necessary to ensure that each subcontractor of the provider will be deemed to be an independent contractor and will not be considered or permitted to be an agent, servant, joint venturer, or partner of the State of Florida, ; 5. The department will not furnish services of support (e.g., office space, office supplies, telephone service, secretarial or clerical support) to the provider, or its subcontractor or assignee, unless justified by the provider and agreed to in advance by the department in Attachment I. 6. All deductions for social security, withholding taxes, income taxes, contributions to unemployment compensation funds, and all necessary insurance for the provider, the provider's officers, employees, agents, subcontractors, or assignees shall be the responsibility of the provider. P. Sponsorship As required by section 286,25, FS, if the provider is a nongovernmental organization which sponsors a program financed wholly or in part by state funds, including any funds obtained through this contract, it shall, in publicizing, advertising, or describing the sJ:)onsqrship of the programh.state: "Spon~ored by (provide~s name) and the State of F.londa, Department of Children and Families,' If the sponsors Ip reference IS In wntten matenal, the words "State of Flonda, Department of Children and Families" shall appear in the same size letters or type as the name of the organization. Q. Final Invoice To submit the final invoice for payment to the department no more than 4_5_ days after the contract ends or is terminated, If the provider fails to do so, 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 this contract may be withheld until all reports due from the provider and necessary adjustments thereto have been approved by the department. R. Use Of Funds For Lobbying Prohibited To comply with the provisions of sections 11,062 and 216,347, FS, which prohibit the expenditure of contract funds for the purpose of lobbying the Legislature, judicial branch, or a state agency, S. Public Entity Crime Pursuant to section 287,133, FS, the following restrictions are placed on the ability of persons convicted of public entity crimes to transact business with the department: When a person or affiliate has been placed on the convicted vendor list following a conviction for a public entity crime, he/she may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or the repair of a public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transac..t business with any public entity in excess of the threshold 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. T. 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 undel this contract, or in anyway connected herewith, the provider shall refer the discovery or invention to the department to be referred to the Department of State to determine whether patent protection will be sought in the name of the State of Florida, Any and all patent rights accruing under or in connection with the performance of this contract are hereby reserved to the State of Florida. 4 rr.1\.T'T'D ..,........ u 1/1 00(\ 4/1/98 2. In the event that any books, manuals, films, or other copyrightable materials are produced, the provider shall notify the Department of State, Any and all copyrights accruing under or in connection with 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 or kind, including cost and expenses for or on account of any copyrighted, patented, or unpatented invention, process, or article manufactured by the provider. The provider 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 provide prompt 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, procure 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, device, or materials covered by letters, patent, or copyright, it is mutually agreed and understood without exception that the bid prices shall include all royalties or costs 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 I in an amount not to exceed N/A , subject to the availability of funds, The State of Florida's performance and obligation to pay under this contract is contingent upon an annual appropriation by the Legislature. Any costs or services paid for under any other contract or from any other source are not eligible for payment under this contract. B. Contract Payment Pursuant to section 215.422, FS, the department has five (5) working days to inspect and approve goods and services, unless the bid spes;ifications, purchase order, or this contract specifies otherwise, With the exception of payments to health care providers for hospital, medical, or other health care services, if payment is not available within 40 days, measured from the latter of the date a properly completed invoice is received by the department or the goods or services are received, inspected, and approved, a separate interest penalty set by the Comptroller pursuant to section 55,03, FS, will be due and payable in addition to the invoice amount. To obtain the applicable interest rate, contact the district fiscal office/contract administrator, Payments to health care providers for hospital, medical, or other health care services, shall be made not more than 35 days from the date eligibility for payment is determined, Financial penalties will be calculated at the daily interest rate of ,03333%, Invoices returned to a vendor due to preparation errors will result in a payment delay, Interest penalties less than one dollar will not be enforced unless the vendor requests payment. C. Vendor Ombudsman A Vendor Ombudsman has been established within the Department of Banking and Finance. The duties of this individual include acting as an advocate for vendors who may be experiencing problems in obtaining timely payment(s) from a state agency, The Vendor Ombudsman may be contacted at (850) 488-2924 or 1-800-848-3792, the State of Florida Comptroller's Hotline, III. THE PROVIDER AND DEPARTMENT MUTUALLY AGREE: A. Effective and Ending Dates This contract shall begin on July 1, 1998 or on the date on which the contract has been signed by both parties, whichever is later, It shall end on June 30, 1999 B. Termination: At Will, Because of Lack of Funds, or For Breach or Failure to Satisfactorily Perform Prior Agreement 1. This contract may be terminated by either party without cause upon no less than thirty (30) calendar days notice in writing to the otherJ'arty unless a lesser time is mutually agreed upon in writing by both parties, Said notice shall be delivered by certifie mail, return receipt requested, or in person with proof of delivery. 2. In the event funds to finance this contract become unavailable, the department may terminate the contract upon no less than twenty-four (24) hours notice in writing to the provider, Said notice shall be delivered by certified mail, return receipt requested, or in person with proof of delivery. The department shall be the final authority as to the availability and adequacy of funds, In the event of termination of this contract, the provider will be compensated for any work satisfactorily completed prior to notification of termination. 3. This contract may be terminated for the provider's non-performance upon no less than twenty-four (24) hours notice in writing to the provider, If applicable, the department may employ the default provisions in Chapter 60A-1.006 (3), FAC, Waiver of breach of any provisions of this contract shall not be deemed to be a waiver of any other breach and shall not be construed to be a modification of the terms of this contract. The provisions herein do not I:mit the department's right to remedies at law or in equity. 4. Failure to have performed any contractual obligations with the department in a manner satisfactory to the department will be a sufficient cause for termination. To be terminated as a provider under this provision, the provider llust have: (1) previously failed to satisfactorily perform in a contract with the department, been notified by the jepartment of the unsatisfactory performanre, and failed to correc~ the unsatisfactory performance to the sJtisfactJon of he department; or (2) had a contract terminated by the department for cause. 5 CO\ITRACT # KLB8~ 4/1/98 C. Renegotiation or Modification Modifications of provisions of this contract shall only be valid when they have been reduced to writing and duly signed by both parties. The rate of payment and the total dollar amount may be adjusted retroactively to reflect price level increases and changes in the rate of payment when these have been established through the appropriations process and subsequently identified in the department's operating budget. D. Official Payee and Representatives (Names, Addresses, and Telephone Numbers): 1. The provider name, as shown on page 1 of this 3. The name, address, and telephone number of the contract, and mailing address of the official payee to whom contract manager for the department for this contract is: the payment shall be made is: CITY OF MIAMI BEACH 8128 COLLINS AVENUE MIAMI BEACH, FLORIDA 33141 (305) 993-2008 PEREZ LUIS A 401 NW 2ND AVENUE MIAMI, FLORIDA 33128 (305) 577-6341 2. The name of the contact person and street address where financial and administrative records are maintained is: AGI LONG 8128 COLLINS AVENUE MIAMI BEACH, FLORIDA 33141' (305) 993-2008 4. The name, address, and telephone number of the representative of the provider responsible for administration of the program under this contract is: AGI LONG 8128 COLLINS AVENUE MIAMI BEACH, FLORIDA 33141 (305) 579-3400 5. Upon change of representatives (names, addresses, telephone numbers) by either party, notice shall be provided in writing to the other party and the notification attached to the originals of this contract. E. All Terms and Conditions Included This contract and its attachments as referenced, Attachments 1,la,lb,lc,ld,IJ,II/& Exhibits A,B,C,D,E,F,G,H,I,K, contain all the terms and conditions agreed upon by the parties, There are no provisions, terms, conditions, or obligations other than those contained herein, and this contract shall supersede all previous communications, representations, or agreements, either verbal or written between the parties, If any term or provision of the contract is found to be illegal or unenforceable, the remainder of the contract shall remain in full force and effect and such term or provision shall be stricken, The parties have read the entire contract inclusive of all its attachments, as referenced in Paragraph III.E. above, and understand each section and paragraph. IN WITNESS THEREOF, the parties hereto have caused this..IDL... page contract to be executed by their undersigned officials as duly authorized. PROVIDER: STATE OF FLORIDA CITY OF MIAMI BEACH DEPARTMENT OF CHILDREN AND FAMILIES SIGNED BY: , NAME: ANITA M, BOCK TITLE: DISTRICT ADMINISTRATOR SIGNED BY: NAME: TITLE: EST: MAYOR ~2;cIf.-~ERK DATE: STATE AGENt;Y 29 DIGIT SAMAS CODE: DATE: Federal EID # (or SSN): VF596000372001 ~ /\FPRO",'Eo.'AS T~C~C~~ A\u #~/@ A~i:; i.ci:.I;kt :'~:!1\ (,JOiscl / /' ~ro'/ider Fiscal Year Ending Date:....QL.J ~ APPROVED AS TO FORl'A & lANGUAGE & FOR EXECUTION 1tt !tti4/~ L/ ~~~...r-- CONTRACT # KLB80 FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES ATTACHMENT I PERFORMANCE CONTRACT 07/01/98 Contract Number KLB80 A. SERVICES TO BE PROVIDED 1. nefmition of Terms a. Contract Terms ,. (I) Contract period - is defined as the time period between the contract's effective date and end date, (2) Day: means calendar day. (3) Department - means the Florida Department of Children and Family Services (4) District: means a service district of the Department. (5) District Specific Services: services the Department negotiated with a Provider that are formulated according to specific need of the district. (6) Exhibit: An attachment to an Attachment I. The use of the word "exhibit" avoids confusion and allows for clearer referencing (7) Fiscal Year: means state fiscal year which begins July I and ends June 30 of every year. (8) Home and Community Based Waiver - provides necessary supports and services to people who have a developmental disability so that they may remain in the community and avoid placement in an institution, The waiver is funded by the Federal Health Care Financing Administration (RCF A) and matching state dollars, (9) H.P. 1.0, H.P. 2,0 - refers to Habilitation Programming Minimum Standards. 7 (10) Individual(s): means the customer/consumer served by the Department and the Provider, (11) Local match: is defined in current Appropriation Law and Chapter 65 B-4, F,A.C. (12) Provider: means a vendor, group or entity that has entered into a contract with the Department to provide one or more services, (13) Quality Improvement Plan: A plan of corrective action that specifies steps the Provider wiU take to bring cited areas deemed below standard by the Department or that are deemed not in conformity with the core assurances or Service Specific Attachment(s), District Specific Services, Quality improvement plans will be required as specified in a written monitoring report prepared by the Department. ,. (14) Reportable Events: means anyone of the eight reportable events defined in HRSR-215-6, Incident Reporting and Client Risk Prevention, July 1, 1994, version. (15) Self Assessment: means an evaluation completed by the Provider of its organizational policies and procedures, These policies and procedures win be described in the Provider's Management Plan and Service Specific Attachment(s), The Provider's self assessment survey win include a combination of a records review and individual satisfaction surveys to identify the extent to which the Provider's policies and procedures are consistent with the stated objectives in the Management Plan and Service Specific Attachment(s), (16) State - means the State of Florida. (17) Units of service: are defined as the unit of measure for biHing the Department for services, b. Program/Service Specific Terms (1) Adult Day Training: are those services intended to support the individual in daily valued routines of the community, which shall include work-like settings, but exclude services directed at teaching specific job skills or meeting employment objectives of non-supported, competitive, paid employment in the general work force, These services stress training in the areas of self-help, adaptive and social skills, and are age and culturally appropriate, The services are provided in a congregate, facility- based setting. in mobile crews, enclaves, entrepreneurial models, or off site 8 activities provided to groups of 4 or more persons, which do not meet the standards for supported employment. (2) Agency: means the Department. (3) Central Record of an Individual: means a file (or a series of continuation files) kept by the Provider in which the following documentation must be recorded, stored and made available for review: (I) Individual demographic data including emergency contact information, parental or guardian contact data, permission forms, as necessary and medical and medication information; (2) Legal data such as release forms and Medicaid Waiver Eligibility Worksheet; (3) Service delivery information including the current Support Plan, written authorization of services, and Implementation Plans; (4) Service delivery documentation in the form of progress reports or as specified in the Service Specific Attachment(s), and/or District Specific Services that are related to the service and support ;" activities identified in the Implementation Plan, (4) Client Satisfaction Survey: means a statewide survey designed to help determine how well the agency is fulfilling its vision of being client centered, community based, and results oriented. The primary objective of this survey is to obtain information from clients on a regular basis (twice a year), to aid in performance management and improvement. This generic tool will be used to look across all target groups at the state level. (5) Community Integrated Settings: means those settings which possess and are not limited to the following characteristics: (1) non-facility based; (2) generic community resources utilized by other people without disabilities; and (3) promote direct social interaction with others with or without developmental disabilities. (6) Core Assurances for Providers ofDevelopmentaI Services Medicaid Home and Community-Based Waiver Services Programs: Statewide document that specifies administrative and programmatic requirements that are applicable to all developmental services Medicaid waiver(s) Providers (hereinafter referred to as Core Assurances), (7) Cost plan: means an accurate list of the approved services and approved costs, The cost plan is to be completed according to the instructions provided with the Department's form, (8) Federal Poverty Guideline: A method to determine those individuals or groups who are at an economic level identified as at, above, or below the poverty level. This guideline is issued each year in the Federal Register by the Department of Health and Human Services. 9 (9) Functional Community Assessment: is the basis for identifying the types of training assistance and intensity of support rendered by the Provider. This assessment addresses all areas of daily life including relationships, medical and health concerns, personal care, household and money management, community mobility, recreation and leisure, The supported living Provider is responsible for helping the individual complete a functional community assessment prior to his or her move to a supported living arrangement. (10) Housing Survey: is the basis for surveying a prospective home to ensure that it is safe to inhabit. The supported living coach must forward a copy of the completed survey to the individual's support coordinator, and the Department's Supported Living Coordinator, must update it quarterly and have it available for review by the support coordinator at the time of the support coordinator's quarterly home visit. ,. (11) Implementation Plan: means an individualized document that specifies how the person will be assisted by the Provider(s) to achieve or maintain a specific support plan outcome, At a minimum, the plan will include the actions and tasks to be used by the Provider as required by the individual. This plan will also include any training objectives to be met by the individual, and the system of assessment used for measuring the progress of the individual in achieving the goal. (12) Management Plan: means a formal written plan submitted by the Provider that specifies how policies and procedures, scope of services and the specific services to be rendered will be implemented to ensure administrative compliance with state federal, and contract provisions as well as defining the service delivery methodology, (13) Minimum Wage: means the minimum rate of pay as defined by the United States Department of Labor, (14) Monitoring: means a Departmental review of the Provider's administrative and programmatic service delivery systems, (15) Non-residential support services: are training activities provided to an individual in community-integrated settings in order to achieve a specific support plan outcome, These services support the individual in valued roles in the community, are age and culturally appropriate, increase the individual's ability to control the environment, encourage the development of friendships with non-disabled persons and emphasize community inclusion, 10 (16) Personal Outcome Assessment Process: means the process by which the Provider will assist the Department, Human Services Counselors ITI, Support Coordinators and others in scheduling and arranging face-to-face interviews with the individuals served by the Provider in order to assess personal outcome measures, This assessment process may also involve records review, on-site visits and additional interviews with the Provider's staff if necessary, (17) Behavior Analysis: services include the analysis, development, modification and monitoring of behavior analysis service plans for the purpose of changing an individual's behavior. Training for parents, caregivers and staff is also part of the services when these persons are integral to the implementation or monitoring of a service plan. The services may also include a behavioral assessment, (18) Residential Habilitation: is supports and services in which supervision ;0 and/or specific training activities are provided that help the individual to acquire, maintain or improve daily living skills, in an approved setting. The services focus on personal hygiene skills such as bathing and oral hygiene; homemaking skills such as food preparation, vacuuming and laundry; and on social and adaptive skills that enable the individual to reside in the community, (19) Respite - means short-term, temporary care that is provided to a person with developmental disabilities to meet the planned or emergency needs of the person with developmental disabilities or the family or other caretaker, (20) Service Specific Attachment(s): means that portion of the Developmental Services Medicaid Waiver Services Agreement delineating the obligations of the Provider with regard to the provision of a specific . . . WaIver servtce or servtces, (21) Special Medical Home Care - means nursing services and the availability of physician services provided on a 24-hour-basis to customers with complex medical needs. (22) Statement of Work: means that part of the Provider's management plan which addresses and outlines the service(s) to be provided and defines the scope of those services, (23) Support Coordination: means activities that assist individuals in gaining access to needed waiver and other state plan services, as well as needed medical, social, educational anti other appropriate services, regardless of the funding source through which access is gained. 11 (24) Support Coordinator: means a state approved Provider of support coordination services who assists individuals and their families/guardians to identify and choose supports and services, (25) Human Services Counselor III: means a Department employed case manager providing support coordination services, who assists individuals and families/guardian to identify and choose support and services. (26) Supported Employment: services provide training and assistance in a variety of activities to support individuals in accessing and maintaining paid employment. The supported employment Provider assists with the acquisition, retention or improvement of skills related to such employment and the development of supportive relationships with coworkers, Supported employment is conducted in a variety of settings, particularly work sites in which persons without disabilities are employed. Individuals ,. rec'eiving supported employment are compensated at or above the nummum wage. (27) Supported Employment Individual Model: is defined as services in which one person is assisted to obtain competitive employment through the support of qualified Providers of supported employment services, (28) Supported Employment Group Models: are defined as one of the following approaches to supported employment: (a) Enclave: is defined as services for up to eight persons with disabilities working either as a group or dispersed through an integrated work setting with supervision furnished by the Provider. (b) Mobile crew: is defined as services in which a crew of up to eight persons with disabilities are in community businesses or other community settings with supervision furnished by the Provider, (c) Entrepreneurial: is defined as services in which up to eight people with disabilities work in a small business created specifically by or for the Individuals. (29) Supported Living Coaching: is a service that provides training of skills and assistance with tasks in a variety of activities with or on behalf of individuals who live in their own homes or apartments. The supported living coach provides assistance with the acquisition, retention or improvement of skills related to activities of daily living such as personal hygiene and grooming, household chores, meal preparation, shopping, 12 personal finances and the social and adaptive skills necessary to enable individuals to reside on their own. (30) Supported Living services: mean the provision of supports necessary for an adult who has a developmental disability to establish, live in and maintain a household of their choosing in the community. (31) Support Plan: means the document used to provide an accurate description of an individual's current outcomes and services. The support plan must be completed according to the instructions provided by the Department. (32) Transportation: services provide rides to and from home and community-based services to enable individuals to receive the supports and services identified on the support plan and approved cost plan when family or friends are unable to provide the support. " (33) Valued Social Roles: Those activities that are esteemed by the general public and that define the individual in relationships with others. Typical valued social roles include but are not limited to co-worker, employee, neighbor, volunteer, student, friend, family member, athlete, theater goer, church member, taxpayer, citizen, etc. 2. General Description a. General Statement: The Provider agrees to provide the following services in accordance with the guidelines specified in the Core Assurances and Service Specific Attachments which are hereby incorporated by reference: 1. Adult Day Training Services (Attach. Ia) 2. Supported Employment Services (Attach. Ib) 3. Supported Living Services (Attach. Ic) 4. Transportation Services (Attach. Id) 5. ~ 6. ~ b. District Specific Service: The Provider agrees to provide the following District Specific Services as described in Section B, Manner of Service, 1. Service Task, a. Task List: 1. ~ 2. ~ 13 3. .NLA 4. J::!.l.A 5. J::!.l.A 6. J::!.l.A c. Authority (1) Compliance With State Law and Regulations ;" (a) The Provider will comply with all applicable state statutes and rules of the Department, including Chapter 393, F.S., Chapter 409, F.S., Chapter 65B-8, F.A.C., Chapter 65B-ll, F.A.C., Chapter 65B-12, F.A.C., and with all regulations policies, procedures and directives pertaining to the implementation of the waiver as may be amended from time to time, including Department policy clarifications and procedures; district policies, policy clarifications and procedures; and all rates and fee schedules developed under such laws, rules, regulations, policies and directives. (b) The Provider will uphold the rights and privileges of individuals with developmental disabilities as specified in Chapter 393.13, F.S., "The Bill of Rights of Individuals Who Are Developmentally Disabled." (c) The Provider will comply with all federal, state and local laws and ordinances pertaining to the operation and requirements of the Provider's business. (2) Compliance With Federal Laws and Regulations (a) The Provider will comply with Title VI of the Civil Rights Act of 1964, as amended, 42 U.S.C. 2000d et seq., prohibiting discrimination on the basis of race, color or national origin in programs and activities receiving or benefiting from federal financial assistance (see HRS Manual 220-2, Method of Administration: Equal Opportunity In Service Delivety). (b) The Provider will comply with Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. 2000e, et seq., in regard to employees or applicants for employment (see HRS Manual 220-2, Method Of Administration: Equal opportunity In Service Delivety). (c) The Provider will comply with the Age Discrimination Act of 1975, as amended, 42 D.S.C. 6101 et seq., which prohibits discrimination on the basis of age in programs or activities receiving or benefiting from federal 14 financial assistance (see HRS Manual 220-2, Method Of Administration: Equal Opportunity In Service Deliver:y). (d) The Provider will comply with the Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, prohibiting discrimination on the basis of sex and religion in programs and activities receiving or benefiting from federal fmancial assistance (see HRS Manual 220-2, Method of Administration: Equal Opportunity In Service Deliver:y). (e) The Provider will comply with the Americans With Disabilities Act of 1990, P.L. 101-336, prohibiting discrimination based on disability in employment, public accommodations, transportation, state and local government services and telecommunications (see HRS Manual 220-2 Method of Administration: Equal Opportunity In Service DeIiver:y). ,," (3) ,The Provider will comply, within thirty (30) days of notification from the Department, with all other applicable state standards, Florida Statutes and Administrative Codes established by the Department or made known in writing to the Provider that are not included herein. (4) Pursuant to Section 20.19(19)(c)1., F.S., the Provider shall maintain data on the performance standards for the types of services provided under this contract and shall submit such data to the Department upon request. d. Scope of Service (1) Services shall be provided as described in Section C, Scope of Service, from the Service Specific Attachment for each service referenced in Section A, 2. General Description, a. General Statement, above. (2) The Provider also agrees to provide services as detailed in the Management Plan that will be maintained in the Developmental Services Program Office and is herein incorporated into this contract by reference. In the event of a conflict between the terms of the Core Assurances, and Service Specific Attachments, and the terms of the Provider's Management Plan, the terms of the Core Assurances and Service Specific Attachments shall prevail. (3) The Provider will not disclose or use any information concerning an individual receiving services for any purpose that is not in conformity with Chapter 393.13(4) and federal regulations, except upon written consent of the individual or the individual's legal guardian. (4) The Provider understands and agrees to provide and bill for only those services approved by the Contract Manager, Placement Coordinator and 15 when appropriate the Supported Living/Employment Coordinator and Senior Psychologist on the Client Services Authorization Form (Exhibit Ji.) for which the Provider is authorized to provide services. (5) The Provider agrees to participate in and support each individual's personal outcome assessment process and to use data from these assessments to enhance service delivery in a manner that supports the achievement of personal outcomes. (6) The Provider agrees within the mission and scope of the service(s) it will provide, to assist people in the achievement of personal outcomes in the areas of personal goals, choice, social inclusion, relationships, rights, dignity, and respect, health, environment, security and satisfaction. ,. (7) The Provider agrees to adhere to the guidelines contained in the HRSM 160-4 (Behavioral Programming)and HRSM 160-8, (Customer Programming). Manuals may obtained from the Department. (8) To comply with Florida Statutes 393. All Providers must comply with the requirements contained in Developmental Services form 2012, Habilitative Programming Minimum Standards, HRSM 160-4, Behavioral Management Guidelines, the Guide to Support Coordination, and all applicable Federal and State licensing standards, as well as all other applicable standards, criteria and guidelines of the Department, including the Long Term Residential Care minimum Standards, Developmental Training Program Standards, as well as Florida Department of Children and Family Services-Developmental Services form 2006,2014,2016, 2018. e. Major Program Goals: Mission Statement The mission of the Department is to enable developmentally disabled individuals and their families to receive supports and services that the individuals and their families believe are important to their lives. 3. Clients to be Served a. General Description The population receiving services funded by this contract are the Department's developmentally disabled consumers. 16 b. Customer Eligibility AIl persons meeting the target population descriptions and found categorically eligible are eligible for services based on the availability of funds. c. Customer Determination (1) The Department will determine categorical eligibility of each target population given in Chapter 393, F.S., Chapter 65B-II, F.A.C., Support Coordination Guidebook and proposed Chapter 65B-12, F,A.C. Should a dispute arise as to client eligibility, the Department makes final determinations. (2) The Provider will determine what services a person should receive in accordance with an approved support plan and the agency's contract as " appropriate. The Department will validate, at least once a year, a sample of the Provider's determinations to ensure accuracy. (3) Providers of day training services shall not be paid for non-residential support services when these services are provided as a component of day training service. Services are deemed a component of day training when the activity occurs in groups larger than three (3) persons with a developmental disability or in a setting that is primarily used to serve individuals with developmental disabilities. (4) Transportation: Separate payment for transportation services by the Provider will not be made when rendered as a component of the services, d. Contract Limits The number of clients served under this contract is limited by the availability of funds, B. MANNER OF SERVICE PROVISION 1. Service Tasks a. Task List (1) The Department will purchase units of services from the Provider by program and in the amounts as specified in Attachment II (Summary of Rates and Services), Services must be provided in compliance with all applicable rules and other service standards as approved by the Department or referenced in this contract. 17 (2) The task list is as described in Section C, Service Tasks from the Service Specific Attachment and or the District specific service description below for each service referenced in Section A, 2, General Description, a. General Statement, above, (3) Special Medical Home Care - means nursing services and the availability of physician services on a 24-hour-basis to customers with complex medical needs, b. Task Limits The task limits are as described in Section C, Service Limits section from the Service Specific Attachment, and District Specific Services for each service referenced in Section A, 2. General Description, a. & b above, 2. Staffing Requirements ,. a. Staffing Levels Staffing levels are as described in Section C, Staffing Ratio from the Service Specific Attachment and District Specific Services for each service referenced in Section A, 2. General Description, a. & b above. b. Professional Qualifications Professional qualifications are as described in Section C, Qualification section from the Service Specific Attachment, and District Specific Services for each service referenced in Section A, 2. General Description, a. & b above. c. Staffing Changes (1) The Department reserves the right to be notified of staffing changes in all positions funded by the Department. (2) The Provider agrees to notifY the Contract Manager in writing within thirty (30) days if any position becomes vacant. (3) If the number of staff hours for any full time position drops to thirty (30) hours per week or less, the Provider will notifY the Contract Manager in writing within thirty (30) days, d. Subcontractors It is anticipated that there will be NO subcontractors for the provision of this contract. If during this contract period, the need for subcontracted 18 services arises, the Provider agrees to notify the contract manager in writing and adhere to the provision as specified in Section I.I of the standard contract. 3. Service Location and Equipment a. Service Delivery Location Services shall be provided in the County(ies) of: Miami Dade. The location of services will be as described in Section C, Service Location from the Service Specific Attachment and District Specific Services for each service referenced in Section A, 2. General Description, a. & b above. b. Service Times ." (1), The times of services will be as described in Section C, Service Times from the Service Specific Attachment and District Specific Services for each service referenced in Section A, 2. General Description, a.& b. above. The exception is for Adult Day Training, and the service times will be as specified in the Provider's Management Plan. (2) The dates of service will be as specified in the Provider's Management Plan. (3) The Provider agrees to notify the Contract Manager in writing at least fourteen (14) days prior to any anticipated changes in dates and/or times specified in the Provider's Management Plan. Such changes are subject to Department approval. c. Changes in Location The Provider agrees to notify the Contract Manager in writing at least thirty (30) days prior to any anticipated changes in locations of services specified in the Provider's Management Plan. Such changes are subject to Department approval. d. Equipment The Provider is responsible for providing all appropriate equipment necessary for the effective delivery of the services purchased as described in the Provider's management plan. 19 4. Deliverables a. Service Units The Department agrees to pay for the service units at the unit price(s) and limits listed below: SERVICES UNIT OF MEASURE UNIT PRICE Adult Day Training Supported Employment Supported Living Transportation Daily Monthly Monthly Monthly $24.50 $426.00 $485.00 $95.28 b. Reports (1) The Provider agrees to submit to the Department Contract Manager, no later ,. than 'thirty (30) days after the sixth (6th) and twelfth (12th) month of this contract, a cost report reflecting Actual Revenue/Expenditures under this contract by line item following the format used in an approved line item budget (Exhibit .E,.). (2) The provider agrees to submit to the Department Contract Manager a completed Provider Inventory List (Exhibit J) which shall be attached to the final Actual Revenue/Expenditure report. This report shall be submitted no later than 30 days following the 12th month of this contract. (3) The Provider agrees to submit a copy of the annual Compliance Audit or a Letter of Attestation prepared by a Certified Public Accountant, as clarified in Attachment m.. This report shall be delivered to the Contract Manager no later than one hundred eighty (180) days after the effective date of this contract. (4) Documentation verifying the funding source and amount of twelve and one half(12Yz%) percent required local match for Adult Day Training (only) shall be submitted to the Contract Manager no later than December 31, 1998 and shall be subject to the approval ofthe Department. Please see instructions, Subpart G (Exhibit..E). (5) The Provider agrees to submit to the Contract Manager, a copy of the Emergency Plan, no later than five (5) days after the execution of this contract. Section D Special Provision, 8. Emergency Plan below. (6) The Provider agrees to submit to the Contract Manager, and the Supported Employment Coordinator, a Monthly Supported Employment Report, (Exhibit l!,.), no later than five (5) days following the close of each month. 20 (7) The Provider agrees to submit to the Contract Manager original signed Security Agreement Form(s) (CF 114) (Exhibit-I) for all required personnel no later than thirty (30) days following the execution of this contract or thirty (30) days from the date of employment. See Section D., Special Provision, 15 Security Data Integrity -CF operating Procedure No. 50-6. (8) Management Plan: The Provider agrees to submit a copy of the Management Plan to the Contract Manager no later than thirty (30) days following the execution of this contract. (9) The Provider will maintain documentation for each individual served in accordance with Section D Provider Responsibilities from the Service Specific Attachment, and District Specific Services for each service reference in Section A, 2. General Description, a. & b. above. ,. (10) Client Satisfaction Survey: The Provider agrees to submit a Client Satisfaction Survey (Exhibit K) for each customer served twice a year (every six (6) months). Surveys shall be received by the Department no later than December 31, 1998 and June 30, 1999. c. Records and Documentation (1) The Provider will maintain documentation in accordance with procedures specified in these contract documents including the Service Specific Attachments for each participant being served, as well as for each waiver service being provided. The Department retains the right to review an individual's record(s) at any time. (2) The Provider must maintain records for all contracted services, documenting the total number of customers and names (or unique identifiers) of customers to whom services were delivered so that an audit trail documenting service provision can be maintained. (3) The Provider must keep accurate records of expenses for the facility and provide an expenditure report when requested by the Department. (4) The Provider agrees to maintain a current record of each consumer served. All central records of an individual must pertain to the individual and not contain records or files of other individuals. (5) Documentation is required for all customers regardless of their billing status. 21 5. Performance Specifications a, Outcomes and Outputs Outcomes specific to this Provider are described in the Service Specific Attachment(s) or District Specific Services, By contracting for the services identified in Section A. 2. General Description, a. General Statement, the Department's mandate is to ensure that the customers derive such benefits as community inclusion, use of natural and generic supports, enhancement of their skills/abilities and promotion of maximum independence. Additionally, the Department requires assurance that funds expended for the provision of these services, are performed efficiently by identifying and reducing wasteful and unneeded services, Subsequently, ensuring the effectiveness of service delivery will enable the customer to meet their maximum level of ,. independent living, and ensure that the state has used its funds in the most cost effective manner, b. Standards Definition Refer to Section A, 1. a & b of this attachment. c. Monitoring and Evaluation Methodology (1) By execution of this contract, the Provider hereby acknowledges and agrees that its' performance under this contract must meet the standards set forth above and will be bound by the conditions set forth below, If the Provider fails to meet at least ninety percent (90%) of these standards, the Department, at its exclusive option, may allow up to six (6) months for the Provider to achieve compliance with the standards. If the Department affords the Provider an opportunity to achieve compliance, and the Provider fails to achieve compliance within the specified time frame, the Department will terminate the contract in the absence of any extenuating or mitigating circumstances, The determination of the extenuating or mitigating circumstances is the exclusive determination of the Department. (2) The Provider understands and agrees that it shall be subject to review by the Contract Manager and will be monitored at least annually by Department Contract Managers, and the Quality Management Administrative and Programmatic Monitoring Units to determine the extent to which it has provided services that meet or exceed performance standards, complied with state and federal requirements, the contract, and its own Management Plan, New Providers will be monitored within six (6)months of providing services, The Department will give written 22 notification to the Provider when the monitoring will be conducted. Unannounced monitoring will be conducted as determined by the Department. 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 which to submit a written response to the Department addressing any issues or areas of concerns identified in the monitoring report. (3) Within six (6) months of participation in the program, the Provider will obtain results from the Client Satisfaction Survey (ExhibitHJ in which each client is asked to determine hislher level of satisfaction with the services of the facility. It is the responsibility of the Provider to ensure that all Client Satisfaction Surveys are completed by either the consumer, families or legal guardian. At no time shall the Client Satisfaction Surveys be completed by the Provider. The Provider shall maintain the completed Client Satisfaction Survey on file for inspection by the Department. ;' (4) Provider must collect and maintain all data, statistics, reports, records, surveys and any other supporting documentation, relative to the performance standards identified in the Services Specific Attachments and or the District Specific Services Section B, Manner of Service Provision, I. service Task, a. task lists. This information must be maintained for review by the Department. (5) In the event the contract is terminated as a result of the Provider failing to achieve the standards set forth in the contract, the Provider may not contract for the same services within twelve (12) months of the date of termination as the result of a formal competitive procurement or as the result of a single source procurement. (6) The Provider understands and agrees that it shall be subject to review and monitoring at least once annually by the Department to determine the extent to which it has provided services that meet or exceed performance standards, complied with state and federal requirements, the contract, and its own management plan. The Provider further understands and agrees that review and monitoring may occur anytime the district believes it is necessary. d. Performance Definitions See Section A, l.a & b of this attachment. 23 6. Provider Responsibilities a. The Provider will submit a Management Plan to the Department Contract Manager for review and approval. The plan will include the following components: (I) Mission Statement; (2) The table of organization, including board of directors (when applicable), directors, supervisors, support staff, and all other employees; (3) Procedures for conducting Self-Assessments; (4) Policies and procedures that will protect the health, safety and welfare of every individual who receives services from the Provider; " (5) Procedures to assist the Department in the Personal Outcome Assessment Process; and (6) Written grievance procedures that will be used to resolve conflicts which may arise between the individual, family, and/or guardian and the Provider, These procedures do not preclude appropriate requests for a hearing in accordance with chapter 120, F,S., nor do they preempt the individual, family, and guardian's right to request a change in services and/or Provider, These procedures will specify: (a) That grievance procedures will be annually reviewed and signed by the individual, family, and/or guardian; (b) That grievance procedures will be communicated in clear, understandable language to the individual, his family or guardian, Responses to grievances will be provided verbally and in writing at the individual's level of comprehension and in the language understood by the individual; and (c) That a log of all grievances filed by individual's families or guardians will be maintained and will include the following infonnation: (I) The name of the individual making the complaint and his relationship to the individual receiving services; (2) The date the complaint is received; 24 (3) A clear description of the complaints, (Oral complaints will be documented in writing.) All complaints shall be retained in the individual's file and a copy retained with the grievance log; and (4) The date of the final disposition of each complaint. (7) Statement of Work. This document will include: (a) A description of the services to be provided in accordance with the needs of the individual( s) served to facilitate the outcomes supporting the services on the Support Plan, (b) A description of the population to be served including level of care criteria if applicable, (c) Admission and discharge criteria. ~. (d) A description of policies and procedures to ensure the smooth transition of the individual between Providers and other supports and services, (e) A description of a training plan that specifies how pre-service and in-service activities will be carried out. (8) The Provider will give written notification to the Contract Manager, the Placement Coordinator, the Waiver Support Coordinator or the Human Services Counselor III of any customer vacancies and/or anticipated customer vacancies, (9) In accordance with Section 414,1034, F,S., the Provider or any employee of the Provider who knows, or has reasonable cause to suspect, that an individual who receives services for Developmental Services is being or has been abused, neglected or exploited, will immediately report such knowledge or suspicion to the central abuse registry and tracking system of the Department on the statewide toll-free telephone number (1- 800-96 ABUSE). TIY users call 1-800-453-5145. (10) The Provider agrees to attend training as recommended and required by the Department. All staff will have a current certification in CPR, the Heimlich Maneuver and training in emergency procedures. All Providers, their staff and clients will complete IllV/AIDS training at least biannually, Documentation of training should be maintained on file for review, (11) The Provider agrees to have written admission and discharge criteria. Such criteria shall be made available to the Department upon request. 25 (12) The Provider agrees to conform to all local zoning ordinances and land restrictions, (13), The Provider shall establish and maintain communication with the surrounding neighborhood and community organization, and residents, AIl responses relative to concerns from the community, shall be maintained in a separate file and copies will be submitted to the Department upon request. (14) The Provider agrees to cooperate with the recruitment of personal advocates for each customer, providing them with the training needed to assure the protection of the customer's human, civil and legal rights, (15), The Provider will supply customer data as requested by the Department. ,. (16) The Provider shall ensure that prompt medical and/or dental attention will be obtained and coordinated with the Waiver Support Coordinator(s) and/or Human Services Counselor(s) ITI as warranted, for medical and/or dental injuries or illness, utilizing Medicaid, Medicare, and other insurance as appropriate. (17) The Provider will ensure that all customers will be assessed in accordance with the Department's HabiIitative Programming Minimum Standards (HRS-DS Form 2012, October 85), and Developmental Training Program Standards, HRS-DS Form 2006. Such assessment shall occur within thirty (30) days of placement. (18), Implementation Program Plans (IPP) will be developed and implemented, for all customers, based on the results of the assessments, Implementation Program Plans will be developed within 30 days of placement. (19) Based on a sampling of the Implementation Program Plan's by the Department, the Provider will meet a minimum of ninety percent (90%) of the identified goals on the customer's Implementation Program Plan's. (20), The Provider will ensure a minimum of ninety percent (90%) compliance with HP 1.0 (program guidelines) and H.P, 2,0, where applicable. (21) The Provider will ensure that all new admissions to the program shall have an approved Client Services Authorization Form (Exhibit.Q) . Authorization Form must be approved and signed by the Placement Coordinator, and the Contract Manager prior to enrollment for services 26 under this contract. The Provider will not be reimbursed for any services provided prior to such approval. (22) The Provider will share responsibility and assist the Department and others in the notification and resolution of the following issues and concerns for, or on behalf of each individual served by the Provider: (a) Notification to the district and the individual's support coordinator of issues concerning: 1) The individual's continued eligibility for services. 2) The possibility ofIosing eligibility 3) Plans to move out of the district or out of the state, 4) Plans to discontinue receiving services from the Provider, or the Department. ;' (b) Notification to the district of an emergency or of an unusual occurrence or circumstance in accordance with district operating procedures or protocols. Said notification of unusual occurrence or circumstance includes but is not limited to: 1) The hospitalization of the individual 2) The involvement ofIaw enforcement agencies 3) Concerns about abuse, neglect, or exploitation and reporting of abuse; (the Provider will report all suspected cases of abuse or neglect of children, disabled or elderly individuals to the Department's central abuse registry at 1-800-96-ABUSE). Reportable events as defined in HRSR 215-6, Incident Reporting and Individual Risk Prevention; and HRSR 210-1, Review of Suspicious Child Deaths, (23) The Provider agrees to adhere to the following sections of the Core Assurances for Providers of Developmental Services Medicaid Home and Community-Based Waiver Services Programs: 3,2 Personnel Policies, 3,3 Training Requirements, 3,4 Professional Business Practices, 3.5 Marketing Practices, and 3,6 Goods and Services Provided. b. Coordination With Other Providers/Entities The Provider agrees, with the individual's permission, to participate in the discussion of the individual's record, the individual's progress, the extent to which the individual's needs are being met or any need for modifications to the implementatic,n pian, if applicable, This discussion could involve the 27 Department, the support coordinator, the individual, the guardian, family and friends. 7. Department Responsibilities a. Department Obligations The Department and the Provider shall have joint responsibility for the selection of new clients in a program. b. Department Determinations ,. (I) The Provider understands and agrees that the Department is responsible for the expenditure of all funds appropriated to the Department by the Florida Legislature for individuals who receive services from Dev~lopmenta1 Services. Accordingly the District is ultimately responsible for determining the appropriateness of services purchased and the amount of developmental services funds available to purchase services and goods. (2) The Provider understands and agrees that the Department is the final authority on all matters pertaining to paid services or goods purchased with funds appropriated to the Department for individuals who receive servIces. (3) The Department reserves the right to make final determination as to the completeness and acceptability of all reports and deliverables. (4) The Department reserves the right to remove customers without notice upon allegations of abuse or neglect of customers in the facility/program. Confirmed cases of abuse or neglect of customers in the facility/program is grounds for termination of this contract in accordance with applicable Florida Statutes, rules and/or agency regulations. (5) The Department reserves the right to mediate any disputes that arise between the Provider and the Waiver Support Coordinator. The Department will have the final authority in all disputes. (6) The Department shall not be held liable for payment if the customer is admitted to the facility without a written Client Services Authorization form (ExhibitJi..) signed by the Placement Coordinator and the Contract Manager. (7) The Department shall have the right to determine what services shall be reimbursed under this contract. 28 (8) The Department shall make final determinations regarding any disputes concerning the retention of records and documents, C. METHOD OF PAYMENT 1. This is a fixed price (unit cost) contract. The Department shall pay the Provider for the delivery of service units provided in accordance with the terms of this contract for a total dollar amount not to exceed $ N/A. subject to the availability of funds 2. The Provider will provide match for Adult Day Training for this contract period in the amount of twelve and a half percent (12~%) of the total program cost as identified in Rule 45-CFR 74 ( Exhibit..!J which provides matching information, The Provider's contribution will be made in the form of cash and/or in-kind resources. If the Provider fails to meet match requirements, the final reimbursement will be adjusted accordingly, ,. 3. The Department agrees to pay the Provider for services at the unit price(s) and unites) of measure found in Section B Manner of Service Provision, 4. Deliverables, a. Service Units. 4. The Provider shall request payment on a monthly basis through the submission of a properly completed invoice (Exhibit A ) and back-up (Exhibit B.C & D) as required. Invoices must be submitted within 10 days following the end of the month of service. If a service is funded by more than one category, the Provider must submit a separate certification (Invoice) for each category. The Provider is responsible for ensuring the accuracy of unit count in each category. Upon receipt of a correct invoice, the Department will process an invoice in accordance with Florida Department of Children and Families Accounting Procedures Manual, Volume 2, Vouchering, Chapter 6,2 Developmental Services and the Developmental Services ABC System User's Guide, Invoice Module, 5, The Department's rates have been established based on the line item budgets contained in the Provider's Management Plan and negotiations between the Provider and the Department. 6. Vacation, holidays and in-service time is not reimbursable as a service day for computing units of service under this contract. Hours and days of service shall meet minimum standard requirements, shall be described and met as per agency proposal, and per any other special provision or other section of this contract. 29 ,,' 7. This contract provides payment to persons not eligible for payment from the Developmental Services Medicaid Home and Community-Based Waiver Services Programs. 8. Payment System a. The Provider will request payment for services delivered on a monthly basis through submission of a properly completed invoice within 15 days following the end of each month in which services were delivered. b. The Provider shall complete and submit an Invoice Request For Subsidies/Services Rendered form (Exhibit A) as their request for payment. Backup docwnentation (Daily Attendance and Enrollment Roster (Exhibit B) and/or (Daily Transportation Register (Exhibit ,C) shall be attached to the invoice request as docwnentation of service rendered, as required. c. Requests for payment approval shall be submitted to the Contract Manager, Contract Administration Office 401 NW 2nd Avenue, Room N-921, Miami, Florida 33128. d. The Department will issue an ABC generated invoice Form 3031, upon receipt of a correct Invoice Request For Subsidies/Services Rendered. e. The Department will issue invoices in accordance with HRS Accounting Procedures Manual, V olwne 2, V ouchering, Chapter 6.2, Developmental Services. f. The Provider's final invoice, which is due 45 days after the contract's end date, must reconcile actual units earned during the contract period with the nwnber paid for by the Department. g. In the case of a non-material breach, the Department retains the right to withhold payment of funds in total or in part, until such time as the breach is corrected. h. The Florida Department of Children and Family Services, Developmental Services shall not reimburse the Provider for any ineligible person served. i. Receipts are required for all expenses incurred, (e.g., office supplies, printing, long distance telephone calls, etc.) and must be 30 maintained on file by the Provider for audit and monitorin2 purposes. j. Travel: ;' 1, A Department of Children and Family Services travel voucher (State of Florida Voucher for Reimbursement of Traveling Expenses - Form C-676), (Exhibit.Kl must be completed and maintained on file by the Provider. Original receipts for expenses incurred during officially authorized travel; items such as car rental and air transportation, parking and lodging, tolls and fares; must be maintained on file by the Provider. Section 287,058 (1) (b), F.S" requires that bills for any travel expense shall be maintained in accordance with Section 112,061, F.S" governing payments by the state for traveling expenses. Florida Department of Children and Family Services 40-1 (Official Travel of Florida Department of Children and Family Services Employees and Non- Employees) provides further explanation, clarification and instruction regarding the reimbursement of traveling expenses necessarily incurred during the performance of official state business, 2. Prior approval is required in accordance with Section 112.061 F,S., for conference travel and must be certified on Form C-676C, (Exhibit.Kl ( State of Florida Authorization to Incur Travel Expense) with a copy of the program or agenda of the conference attached, Reimbursement is in accordance with "1" above. The Florida Department of Children and Family Services 40-1 provides further explanation, clarification and instruction. 3, The Provider must retain on file documentation of all travel expenses to include the following data elements: name of the traveler, dates of travel, travel destination purpose of travel, hours of departure and return, per diem or meals allowance, map mileage, incidental expenses, signature of payee and payee's supervisor, 9, INVOICE REQUIREMENTS: Home and Community Based Waiver Services (Medicaid Waiver) a. The services, units of service and rates found in section B, Manner of Service Provision, 4, Service Units, will be used to reimburse the Provider for services rendered for the DepartmentIHome and Community Based Services Waiver (Medicaid Waiver) eligible customers who are authorized to receive said services. 31 b. To receive reimbursement for services, the Provider shall submit a separate invoice for all eligible Medicaid Waiver customers on a monthly basis. Invoices will be sent to the appropriate Support Coordinator, for the appropriate customer services as found under Section B, Manner of Service Provision, 4, Deliverables a., Service Units. The Support Coordinator has the responsibility of approving and processing for payment all authorized invoices for Medicaid Waiver services within five (5) working days of receipt of an invoice. For General Revenue Payments, the Support Coordinator shall initial and approve the invoice indicating that these services are authorized to be paid, and forward the approved invoices to the Department for payment. c. During the life of this agreement, the required documents may change due to DepartmentIHome and Community Based Services Medicaid Waiver expansion requirements. Should documentation requirements be changed, the Department and the Provider agree to make changes through a memorandum of understanding or a formal amendment to this agreement at the discretion of the Department. ~. d. Vacation, holidays and in-service time is not reimbursable as a service day for computing units of service under this contract. Hours and days of service shall meet minimum standard requirements, shall be described and met as per Provider proposal, 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 of a properly completed invoice (Exhibit A) and back-up (Exhibit B.C & D) as 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 ofa correct invoice, the Support Coordinator will process an invoice in accordance with Florida Department of Children and Family Services Accounting Procedures Manual, Volume 2, Vouchering, Chapter 6.2 Developmental Services and the Developmental Services ABC System User's Guide, Invoice Module. f. Payments may be authorized only for service units on the invoice which are in 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, or cumulatively by totaling service units on previous invoices, exceed the total number of units authorized by this contract. g. F or the purpose of reimbursement, enrollment is related to continuing attendance. No day of absence will be reimbursed. The Provider shall maintain attendance records for each reimbursable service. 32 D. SPECIAL PROVISIONS ALL REFERENCE TO THE DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES AND THE DEPARTMENT OF CHILDREN AND FAMILIES, HERE AND THROUGHOUT THE CONTRACT, SHALL BE CONSTRUED AS THE DEPARTMENT OF CHILDREN AND FAMILY SERVICES 1. HUMAN RIGHTS ADVOCACY COMMITTEE (BRAC) ACCESS a. The Provider shall post in a readily accessible location visible to all customers either 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 any person who is developmentally disabled, staff or volunteers, in accordance with Sections 402.165 and 402.166 Florida Statutes, 2. COPYRIGHTS a. Where activities supported by this contract produce original writing, sound recordings, pictorial reproductions, drawings or other graphic representations and works of any similar nature, the Department has the right to use duplicate and disclose such materials in whole or in part, in any manner, for any purpose whatsoever and to have others acting on behalf of the Department to do so. If the materials so developed are subject to copyright, trademark, patent, legal title, then every right, interest, claim, or demand of any kind in and to any patent, trademark or copyright or application for the same, wiIl vest in the State of Florida, Department of State, for the exclusive use and benefit of the state. Pursuant to section 286.021, Florida Statutes, no person, firm or corporation, including parties to this contract shall be entitled to use the copyright, patent or trademark without the prior written consent of the Department of State, b. Any earnings realized by the Provider as a result of contract-related and supported activities, including royalties received from copyrights on publications or other works developed under this contract, interest income from fees, or sale of assets purchased with contract funds shaIl not be expended without the prior written approval of the Department. The Department reserves the right to require those funds to be used to reduce costs borne by Federal Government or the Department or both, 33 3. MORALS CLAUSE The Provider understands that performance under this contract involves the expenditure of public funds from both the state and federal governments, and that the acceptance of such funds obligates the Provider to perform its services in accordance with the very highest standards of ethical and moral conduct. Public funds may not be used for purposes of lobbying, or for political contributions, or for any expense related to such activities, pursuant to Section I R of the Standard Contract of this contract. The Provider understands that the Department is a public agency which is mandated to conduct business in the sunshine, pursuant to Florida Law, and that all issues relating to the business of the Department and the Provider are public record and subject to full disclosure. The Provider understands that attempting to exercise undue influence on the Department and its employees to allow deviation or variance from the terms of this contract other than negotiated, publicly disclosed amendment, is prohibited ;' by the State of Florida, pursuant to Section III C of the Standard Contract. The Provider's conduct is subject to all state and federal laws governing the conduct of entities engaged in the business of providing services to government. 4. MULTI-DISTRICT RATE AGREEMENT Other Florida Department of Children and Family Services districts may participate in this agreement at the rates specified in Section B, Manner of Service Provision, 4" Deliverables, a., Service Units, Each of the Florida Department of Children and Family Services districts is responsible for its own payment to the Provider for the services provided to customers of that district. The district that is financially responsible for the customer will prepare the invoice (Florida Department of Children and Family Services DS-3029A) and forward it to the Provider. The Provider will return the signed invoice with corrections noted to the responsible district for processmg. 5. ACCESS TO RECORDS All customers records including, but not limited to medical, psychiatric and psychological records, any and all other customers records shall be the sole property of the Department and shall remain at the Provider's facility upon termination of this contract. The Department shall have reasonable access to all manuals, policies, procedures, personal records, and other written materials produced or developed by the Provider pursuant to this contract at any time during the course of this contract, Upon termination ofthif: contract, said material shall remain at the Provider's facility until the 34 Department, or any subsequent Provider has had reasonable opportunity to reproduce and duplicate said materials, 6. RIGHT TO INSPECT The Provider agrees that the Department may enter the premises where services are provided, at any time deemed appropriate during the term of this contract. 7. USE OF FUNDS FOR LOBBYING PROHIBITED The Provider agrees to comply with the provisions of section 216,347, F.S., which prohibits the expenditure of contract funds for the purpose of lobbying the Legislature or a state agency. ,. 8. EMERGENCY PLAN The Provider shall be responsible for the care, maintenance and, if necessary, the relocation of customer during any natural disaster or period of civil unrest. The Provider shall submit its Emergency Plan to the Department Contract Manager for approval five (5) days following the execution of this contract and must be updated on a yearly basis. In case of evacuation, the emergency plan must identify the method of evacuation, the address of the emergency or shelter facility to be utilized and the method of notification of the Department of the evacuation. 9. NON-EXPENDABLE PROPERTY 3. Non-expendable property is defined as tangible personal property of a non consumable nature that has an acquisition cost of $500 or more per unit and an expected useful life of at least one year, and hardback bound books that are not circulated to students or the general public, the value or cost of which is $100 or more. Hardback books with a value or cost of $25 or more should be classified as an Other Cost Accumulator expenditure only if they are circulated to students or the general public. The Provider will use (Exhibit.1) to report all capital assets purchased through funding provided by the Department for prior and current year contract. b. All such property, purchased under this contract, shall be listed on the property records of the Provider. Said listing shall include a description of the property, model number, manufacturer's serial number, date of acquisition, unit cost, property inventory number and il1formation on the condition, transfer, replacement or disposition of the property. 35 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 the expenditure report for the period it was purchased. d. Title/ownership to all non-expendable property acquired with funds from this contract shall be vested in the Department upon completion or termination of this contract. e. At no time shall this Provider dispose of non-expendable property purchased under this contract except with permission of, and in accordance with instructions from the Department. f. A formal contract amendment is required prior to the purchase of ,. any item of non-expendable property not specifically listed in the approved contract budget. 10. TITLE TO VEHICLES: (TRANSPORTA TION DISADVANTAGED) 3. Procedures for acquisition of vehicles for transportation of Florida Department of Children and Family Services clients acquired directly by the Department or a contracted Provider are contained in Florida Department of Children and Family Services 40-5. The following clause must be used in all cost reimbursement contracts which provide for the purchase of vehicles for transportation of Florida Department of Children and Family Services clients (transportation disadvantaged), using Florida Department of Children and Family Services funds. b. Title (ownership) to all vehicles acquired with funds from this contract shall be vested in the Department upon completion or termination of the contract, The Provider will retain custody and control during the contract period, including extensions and renewals, 11. INSURANCE The Provider will obtain and maintain liability insurance on all motor vehicles owned and operated by the Provider, and used in conjunction with the operation of the group home or program, The Provider will also obtain and maintain liability insurance coverage of residents, staff, and visitors, as required by the Division of Risk Management, and Department of Insurance, Documentation of liability insurance should be submitted to the Department within thirty (30) days of executioll of this contract. 36 12. BOARD MEMBERS The Department encourages the Provider to develop and maintain a culturally diversified board, representative of the diverse population in Miami-Dade county, 13. BACKGROUND SCREENING The provider will implement background check requirements as set forth in Chapters 393 and 435 F.S, The provider also agrees to obtain three acceptable references prior to hiring any new employee, 14. IMPACT ZONE PLANNING The Provider will make available to the Florida Department of Children and Families, District 11, zip code data as to where customers reside as well as " certain other customer information as requested. This information will be used to facilitate the Florida Department of Children and Families 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 Chapter 815, Florida Statutes, "Florida Computer Crimes Act," all employees and contract employees with access to data through computer related media must read and sign the security agreement form (CF 114), as identified in (Exhibiti) Fulfillment of security responsibilities shall be mandatory and violations may be cause for civil penalties, or criminal penalties under chapters 119, 812, 815, 817, 839, or 877, Florida Statutes, or similar laws, The Provider will ensure that Security Agreement form (Exhibit.!.) will be signed by all required personnel within thirty (30 ) days from execution of this contract or thirty (30 )days from date of employment, and that a copy is retained in their personnel file, The signed original must be sent to the contract manager which will be retained in the contract file. A copy of the CF OPERATING PROCEDURE NO, 50-6 is available upon request 16. LOGO If the Provider is a non-governmental organization which sponsors a program financed wholly or in part by the state funds, including any funds obtained through this contract, it shall, in publicizing, advertising, or 37 describing the sponsorship of the program use one of the approved legends; which must be used in conjunction with the logo: 1. Sponsored/Funded by Florida Department of Children & Families, District 11, or Florida Department of Children & Families Sponsored/Funded Agency; 2. Partially sponsored/funded by Florida Department of Children & Families, District 11; 3. Operated under or sponsored/funded by a grant from the Florida Department of Children & Families, District II. 17. INFORMATION TECHNOLOGY RESOURCES: All Department contract. Providers must receive written approval from the ,. appropriate Department approving authority prior to the purchase of any Infonnation Technology Resource (ITR) made as part of this contract. The Provider agrees to secure prior written approval by means of an Infonnation Resources Request (IRR) fonn before the purchase of any ITR. The contract manager is responsible for serving as the liaison between the Provider and Infonnation Systems during the completion of the IRR/ITR process. ITR are data processing hardware, software, services, supplies, maintenance, training, personnel and facilities, The Provider will not be reimbursed for any ITR purchases made prior to obtaining the Department's written approval. 18. COMPETITIVE BIDDING/RELA TED PARTY TRANSACTIONS: In the purchase or procurement of all supplies and services relative to this contract (including the lease of space for use in the perfonnance of this contract), the Provider agrees to obtain such goods or services at the lowest practical cost, and to obtain such goods or services by means of a system of competitive bidding which includes at least three (3) bids. The Provider agrees that it will not purchase, lease, or otherwise procure goods, services, or leased space with any officer, agent or employee of the Provider or with any business entity which employs, uses or has substantial ownership by any officers, agent, or employees of the Provider, unless such purchases or other procurements are in compliance, with the competitive bidding provisions above. Further, regardless of the source of funding, the Provider agrees to comply with the provisions of all applicable state or federal cost principles, or the provisions of OMB Circular A-I22 where other cost principles do not 38 ATTACHMENT Ia ADULT DAY TRAINING SERVICES SERVICE SPECIFIC ATTACHMENT A. Waiver Services to be Provided: Definition of Terms: This attachment will encompass all applicable terms and definitions in the Developmental Services Medicaid Waiver Services Agreement and the following service specific definition: Adult Day Training are those services intended to support the Individual in daily valued routines of the community, which shall include work-like settings, but exclude services directed at teaching specific job skills or meeting employment objectives of non-supported, competitive, paid employment in the general work force, These services stress training in the areas of self-help, adaptive and social skills, and are age and culturally appropriate, The services are provided in a congregate, facility-based setting, in mobile crews, enclaves, entrepreneurial models, or off site activities provided to groups of 4 or more persons, which do not meet the standards for Supported Employment. B. Management Plans: If required by section 3,0 of the core assurances, the Provider will submit a Management Plan t<? the District for review and approval prior to provision of service. The Managertient Plan will contain all the required policy and procedural elements found in section 3,1 of the Core Assurances. C. Scope of Service: 1. Service Tasks: Adult Day Training services shall stress training in the areas of self-help, adaptive and social skills, and shall be age and culturally appropriate, a. Implementation Plan: The Implementation Plan shall be developed with input from the Individual and include information from the Individual's current Support Plan and other pertinent sources. The specific areas of training and strategies to meet Support Plan Outcomes for each Individual will be addressed in the Individual's Implementation Plan, At a minimum the Implementation Plan will include: 1) The name, address, and contact information of the Individual served, 2) The outcome from the Support Plan that the service will address, and 3) The strategies employed to assist the Individual in meeting Support Plan outcomes, 4) The system to be used for assessing the Individuals progress in achieving the Support Plan outcome, The information from this assessment will be used to update and adjust the plan as needed. b. The progress toward achieving outcomes from Implementation Plan shall be documented in the montWy progress notes, c. Timeframe: The Implementation Plan will be developed within 30 days of acceptance into the program or 30 days after receipt of the district approved Support Plan update. 41 SSA-l, Attachment to CFDS3064 July 1998 apply. The Provider recognizes that the above cost principles or Circular provide guidelines relative to competitive bidding and related party transactions. 19. YEAR 2000 COMPLIANCE WARRANTY The contractor warrants that each item of hardware, software and/or firmware delivered, developed or modified under this contract shall be able to accurately process date data including, but not limited to, calculating, comparing, and sequencing) from, into, and between the twentieth and twenty-first centuries, including leap year calculations, when used in accordance with the item documentation provided by the contractor, provided that all items (e.g. hardware, software, firmware) used in combination with other designated items properly exchange date data with it. The duration of this warranty and the remedies available to the State for breach of this warranty shall be as defined in, and subject to, the terms and " limitations of any general warranty provisions of this contract, provided that notwithstanding any provision to the contrary in such warranty provision(s), or in the absence of any such warranty provision(s), the remedies available to the State under this warranty shall include repair or replacement of any item whose non-compliance is discovered and made known to the contractor in writing within ninety (90) days after acceptance. Nothing in this warranty shall be construed to limit any rights or remedies the State may otherwise have under this contract with respect to defects other than Year 2000 performance. 20. YEAR 2000 COMPLIANCE (SOFfW ARE) The licensor represents and warrants that the software, which is licensed to licensee, hereunder, is designed to be used prior to, during, and after the calendar year 2000 AD and that the software will operated during each such time period without error relating to the, or the product of, date data which represents or references different centuries or more than one century. Without limiting the generality of the foregoing, Licensor further represents and warrants (1) that the software will not abnormally end or provide invalid or incorrect results as a result of date data, specifically including date data which represents or references different centuries or more than one century; (2) that the software has been designed to ensure year 2000 compatibility, including, but not limited to, date data century recognition, calculations which accommodate same century and muIti- century formulas and date values, and date data interface values that reflect the century; (3) that the software includes "year 2000 capabilities", which means the software (a) will manage and manipulate data involving dates, including single century formulas and multi-century formulas, and will not cause an abnormally ending scenario within the application or generate 39 incorrect values or invalid results involving such date; and (b) provides that all date-related user interface functionalities and date fields include the indication of century; and ( c) provides that all date-related data interface functionalities include the indication of century, 21. YEAR 2000 REMEDY CLAUSE In the event of any decrease in hardware or software program functionality related to time and date related codes and internal subroutines that impede the hardware or software programs from operating beyond the Millennium Date Change, Licensors and Vendors of Licensors products, agree to immediately make required corrections to restore hardware and software programs to the same level of functionality as warranted herein at no charge to the licensee, and without interruption to the ongoing business of the licensee, time being of the essence, ~. 22. INCIDENT REPORT All Providers will be required to document reportable incidents, as set forth by HRSR 215-6, paragraph 3, in the following manner: 1. The Provider must fill out an incident report for each incident occurring during the administration of its program. 2. A copy of the incident report must be placed in a central file marked "Incident Report", in each client's file involved in the incident and immediately forward a copy the incident report to the contract manager for the Department. The contract manager shall then be responsible for dissemination of the incident report to the program office, If the incident report is an emergency in that the Provider is aware that the health, safety or welfare of any person has been threatened or may be in imminent danger, the Provider shall make telephonic contact with the Department program office immediately, 23. FIDELITY BOND: The Provider shall obtain and maintain at all times during the terms of this contract, a fidelity bond covering the activities of designated employees as required by the Department in an amount acceptable for the Department. Documentation of validating insurance purchase will be furnished to the Department Contract Manager within thirty (30) days following execution of this contract. Said designated employees shall be any Provider employee that has direct access to program funds, Said amount of bond shall equal the amount of the Department's advance to the Provider and/or sum equal to two (2) months contracted cash flow, 40 Adult Day Training Sen'ices Sen'ice Specific Attachment, Cont. 2. Service Limits: Adult Day Training service shall be limited to the amount, duration and scope of the service described on the Individual's current approved cost plan. a. Exclusions: 1) Adult Day Training services specifically exclude supporting an Individual in competitive employment. 2) Transportation: Separate payment for transportation services by the Provider of Adult Day Training services will not be made when rendered as a component of the Adult Day Training services. b. Service Times: The Provider shall render Adult Day Training services for a minimum of 230 days per year. Hours of operation shall be 8:00 am to 5:00 p.m. for each day of service, 3. Service Location': 8. Service Delivery Location: Name of Facility: City of Miami Beach Address: 8128 Collins Ave, City: Miami Beach ZIP code: 33141 Phone: (305) 993-2009 b. Location Change: The Provider shall notify the department in writing of any change of facility location 30 working days prior to the effective date of such change. 4. Provider Requirements: a. Licensure: Not required. b. Staffing Ratio: The staffing ratio will not exceed ten consumers per direct care staff. c. Qualification: Providers of Adult Day Training services shall be designated by the district Developmental Services Program Office. Additionally, the following requirements must be met by the Provider unless waived in writing by the district. 1) Training and Experience: The Provider agrees to comply with the following minimum qualifications for staff. a) The manager or director will not be a full time instructor, b) The program director will posses at the minimum a bachelors degree from an accredited college or university and two years related experience, c) Instructors will possess at least an associates degree and two years experience in a related field, d) Related experience shall substitute on a year-for-year basis for the required college education, 42 SSA-I, Attachment to CFDS3064 July 1998 Adult Day Training Services Service Specific Attachment, Cont. 2) Training: Providers are required to attend 12 hours of pre service training and 12 hours of annual inservice training in accordance with the requirements of Section 3,3 of the Core Assurances, D. Provider Responsibilities: The Provider's performance is subject to the General Terms and Conditions in the Developmental Services Medicaid Waiver Services Agreement and the following: 1. Service Agreement Outcome: The Provider will report required data to the Department for the performance requirements, For Adult Day Training, the standard is: ~ percent of Individuals served moved to Supported Employment. 2. Service Delivery Documentation: The Provider will maintain the following documentation for each Individual served under this service agreement: a. An Individual Implementation Plan, , b. A copy of the daily attendance logs, c. Notes that include a monthly summary of the Individual's progress toward achieving the Support Plan outcomes. 3. Reimbursement: a. For reimbursement purposes, the Provider must submit an invoice and a daily attendance log, b. All required documentation shall be filed in the Individuals record prior to billing. 4. Payment: Providers of Adult Day Training services are paid by the day at a rate negotiated by the waiver support coordinator or district Program Office. The district office shall be the final authority over all rates negotiated, a. The Provider shall combine each unit of service in a month and bill at the end of the month, using the last day of the month as the date of services. b. If services terminate before the end of the month, the Provider shall combine each unit of service for the service period and bill at the end of the service period, using the last day of the service period as the date of service. 43 SSA-l, Attachment to CFDS3064 July 1998 ATTACHMENT Ib SUPPORTED EMPLOYMENT SERVICES SERVICE SPECIFIC ATTACHMENT A. Waiver Services to be Provided: 1. Definition of Terms: This attachment will encompass all applicable terms and definitions in the Developmental Services Medicaid Waiver Services Agreement and the following service specific definitions: Supported Employment services provide training and assistance in a variety of activities to support Individuals in accessing and maintaining paid employment. The Supported Employment Provider assists with the acquisition, retention or improvement of skills related to such employment and the development of supportive relationships with coworkers, Supported Employment is conducted in a variety of settings, particularly work sites in which persons without disabilities are employed, Individuals receiving supported employment are compensated at or above the minimum wage, Supported employment models include: a. Individual Model is defined as services in which one person is assisted to obtain competitive employment through the support of qualified Providers of supported employment services. ;" . b. Group Models are defined as one of the followmg approaches to Supported Employment: 1) Enclave is defined as services for up to eight persons with disabilities working either as a group or dispersed through an integrated work setting with supervision furnished by the Provider, 2) Mobile Crew is defined as services in which a crew of up to eight persons with disabilities are in community businesses or other community settings with supervision furnished by the Provider, 3) Entrepreneurial is defined as services in which up to eight people with disabilities work in a small business created specifically by or for the Individuals. B. Management Plans: If required by section 3.0 of the core assurances, the Provider will submit a Management Plan to the District for review and approval prior to provision of service, The Management Plan will contain all the required policy and procedural elements found in section 3,1 of the Core Assurances, C. Scope of Service: 1. Service Tasks: Supported Employment services shall provide assistance with the acquisition, retention or improvement of skills and supports related to accessing and maintaining employment, the development of supportive relationships with coworkers, and the following: a. Implementation Plan: The Implementation Plan shall be developed with input from the Individual and include information from the Individual's current Support Plan and other pertinent sources, The specific areas of training and strategies to meet Support Plan Outcomes for each Individual will be addressed in the Individual's Implementation Plan, At a minimum the Implementation Plan will include: 1) The name, address, and contact information of the Individual served, 44 SSA-IO. Attachmt'nt to CF-DS3064 Ju/v 199R Supported Employment Services Service Specific Attachment, Cont 2) The outcome(s) from the Support Plan that the service will address, and 3) The strategies employed to assist the Individual in meeting Support Plan Outcomes. 4) The system to be used for assessing the Individual' progress in achieving the Support Plan Outcome(s), The infonnation from this assessment will be used to update and adjust the plan as needed. b. Timeframe: The Implementation Plan will be developed within 30 days of acceptance into the program or 30 days after receipt of the district approved Support Plan update. c. The progress toward achieving outcomes from the Implementation Plan shall be documented in the monthly progress notes, d. Individuals working an average of less than 20 hours per week or who remain in job development status must have at least quarterly review and justification of attempts to increase wor~ hours or secure an appropriate job, .' e. The Provider will maximize funding through collaboration with Vocational Rehabilitation, the Social Security Administration Work Incentives and other alternative financial resources. f. Utilize the employer's nonnally occurring supervision, training and support to maintain employment. 2. Service Limits: a. Supported Employment services shall be limited to the amount, duration and scope of the service described on the Individual's Support Plan, current approved cost plan and the following: 1) Supported Employment services must be provided in an integrated setting, compensated at or above minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work perfonned by Individuals who are not disabled. 2) Payment will only be made for the adaptations, supervision, and training required by Individuals receiving waiver services as a result of their disabilities, and will not include payment for the supervisory activities rendered as a nonnal part of the business setting. b. Exclusions: 1) Supported Employment services furnished under the waiver for a given individual are not available under a program funded by either Vocational Rehabilitation or the Department of Education, Documentation will be maintained in the file of each Individual receiving this service to this effect. 2) Transportation: Separate payment for transportation services by the Provider of services will not be made when rendered as a component of the service, 45 SSA-lO. Aitachment to CF-DS3064 July 1998 Supported Employment Services Service Specific Attachment, Cont. c. Service Times: The Provider shall render services at a time mutually agreed to by the Individual, employer and Provider during the regularly scheduled work hours, Off hours support may occur as an alternative or supplement to the on-the-job contacts, 3. Service Location: a. Supported Employment services shall be provided in places mutually agreed to by the Individual and Provider such as the Individual's place of employment or various sites within the community as an alternative or supplement to the on-the-job contacts, b. Location Changes: Should the employment location of an Individual be changed the Provider will notifY the Individuals' Support Coordinator within 5 working days, 4. Provider Requirements: a. Licensure: Not required, ,. b. Qualifications: Providers of Supported Employment services shall be designated by the Developmental Services Program Office based on the following statewide standards: 1) Staffing Ratio: For group models the staffing ratio will not exceed eight consumers per coach, 2) Training and Experience: The Provider agrees to comply with the following minimum qualifications for staff a) A bachelor's degree from an accredited college or university with a major In business, education, or a social, behavioral, or rehabilitative science, b) In lieu of a bachelor's degree, a person rendering this service shall have an Associate's degree from an accredited college or university with a major in business, education or a social, behavioral or rehabilitative science and 2 years of experience, c) Experience in one of the previously mentioned fields shall substitute on a year-for- year basis for the required college education, 3) Training: Agency providers are required to attend 12 hours of preservice training and 8 hours of annual inservice training related to supported employment in addition to the requirements of Section 3,3 of the Core Assurances, Individual vendors must attend at least one Supported Employment related conference or workshop prior to certification and 8 hours of annual inservice training related to Supported Employment. 46 SSA-lO. Attachment to CF-DS3064 July 1998 Supported Employment Services Service Specific Attachment, Cont D. Provider Responsibilities: The Provider's performance is subject to the General Terms and Conditions in the Developmental Services Medicaid Waiver Services Agreement and the following: 1. Service Agreement Outcome: The Provider will report to the Department, as required, data for the performance requirements, For Providers of Supported Employment the requirements are: a. 100% of Individuals in supported employment are earning at or above minimum wage for ALL consecutive months, b. 25 % of Individuals in supported employment have annual income above federal poverty guidelines. c. 100 % of Individuals in supported employment do not need paid job coaching in excess of 20% of the Individual's average work hours, ;' d. Achieve a satisfactory or better rating on 90 % of client satisfaction surveys, 2. Service Delivery Documentation: The Provider will maintain the following documentation for each Individual served under this service agreement: a. An Implementation Plan, b. A monthly progress report that will include: 1) The name of the Individual being served, 2) A log of the services provided. 3) A summary of the progress toward achieving the outcomes from the Individual Support Plan. c. Reimbursement: For reimbursement purposes, the Provider must submit an invoice and a service log, All required documentation shall be filed in the Individuals record prior to billing. 3. Payment: Providers of Supported Employment services are paid a rate negotiated by the waiver support coordinator or district Developmental Services Program Office, The district office shall be the final authority over all rates negotiated. a. The Provider shall combine each unit of service in a month and bill at the end of the month, using the last day of the month as the date of services, b. If services terminate before the end of the month, the Provider shall combine each urJt of service for the service period and bill at the end of the service period, using the last day of the service period as the date of service, 47 SSA-lO, Attachment to CF-DS3064 July 1998 ATTACHMENT Ie SUPPORTED LIVING COACHING SERVICES SERVICE SPECIFIC ATTACHMENT A. Waiver Services to be Provided: 1. Definition of Terms: This attachment will encompass all applicable terms and definitions in the Developmental Services Medicaid Waiver Services Agreement and the following service specific definitions: a. Supported Living Coaching is a service that provides training of skills and assistance with tasks in a variety of activities with or on behalf of Individuals who live in their own homes or apartments. The supported living coach provides assistance with the acquisition, retention or improvement of skills related to activities of daily living such as personal hygiene and grooming, household chores, meal preparation, shopping, personal finances and the social and adaptive skills necessary to enable Individuals to reside on their own. b. Supported Living Services mean the provision of supports necessary for an adult who has a developmental disability to establish, live in and maintain a household of their choosing in the community. ;' c. Functional Community Assessment is the basis for identifying the types of training, assistance and intensity of support rendered by the Provider, This assessment addresses all areas of daily life including relationships, medical and health concerns, personal care, household and money management, community mobility, recreation and leisure, The supported living Provider is responsible for helping the Individual complete a functional community assessment prior to his or her move to a supported living arrangement, d. Housing Survey is the basis for surveying a prospective home to ensure that it is safe to inhabit. The supported living coach must forward a copy of the completed survey to the Individual's support coordinator, must update it quarterly and have it available for review by the support coordinator at the time of the support coordinator's quarterly home visit. 2. Authority: In addition to the authority cited in the core assurances, the Provider shall render services in accordance with The Guide to Supported Living in Florida. B. Management Plans: If required by section 3,0 of the Core Assurances, the Provider will submit a Management Plan to the District for review and approval prior to provision of service. The Management Plan will contain all the required policy and procedural elements found in section 3.1 of the Core Assurances, C. Scope of Service: 1. Service Tasks: Supported Living Coaching services shall provide assistance with the acquisition, retention or improvement of skills and with accomplishing various tasks on behalf of Individuals who live in their own homes, 48 SSA-ll, Attachment to CF-DS3064 July 1998 Supported Living Coaching Services Service Specific Attachment, Cont. a. Implementation Plan: The Implementation Plan shall be developed with input from the Individual and include information from the Individual's current Support Plan and other pertinent sources, The specific areas of training and strategies to meet Support Plan Outcomes for each Individual will be addressed in the Individual's Implementation Plan, The Implementation Plan will include: 1) The name, address, and contact information of the Individual served, 2) The Outcome from the Support Plan that the service will address, 3) The strategies employed to assist the Individual in meeting Support Plan Outcomes, 4) The system to be used for assessing the Individual's progress in achieving the Support Plan Outcome, The information from this assessment will be used to update and adjust the plan as needed, 5) How home and community safety needs will be addressed and the supports needed to meet these needs. 6) Method for accessing the Provider 24 hours per day, 7 days per week for emergency assistance, 7) Description of how natural and generic supports will be used to assist in supporting the Individual and reduce reliance on paid supports, and 8) A financial profile that includes strategies for assisting the person in money management, when requested. b. Timeframe: The Implementation Plan will be developed within 30 days of acceptance into the program or 30 days after receipt of the district approved Support Plan update. c. Quarterly Home Visit or Meeting: The Individual, the support coordinator, and the Provider will participate in the review of supported living services as arranged. The purpose of these visits is to update the housing survey to assure that the home continues to meet basic health and safety standards and to determine if Supported Living Coaching services identified on the Support Plan are being carried out. d. Satisfaction Surveys: At least annually, Individuals receiving supported living services will be asked to complete a survey that addresses satisfaction with supported living services. While it is the Provider's responsibility to assure this survey is completed, staff providing direct supported living services to an Individual may not be part of the survey activity for that Individual. 49 SSA-II, Attachment to CF-DS3064 July 1998 Supported Living Coaching Services Service Specific Attachment, Cont. 2. Service Limits: a. Supported Living Coaching service shall be limited to the amount, duration and scope of the service described on the Individual's Support Plan and current approved cost plan and the following: 1) Supported Living Coaching services shall be limited to adults who rent or own their own homes or apartments in the community. In order to be considered as a supported living arrangement, if renting, the name of the Individual receiving supported living services must appear on the lease either singularly, with a roommate or a guarantor. 2) Supported living encourages maximum physical integration in the community, In order to meet the density guidelines specified in Rule 65B-II F AC, Individuals in supported living may account for no more than ten percent of the residents in an identifiable area or ten percent of the apartment complex. Waivers of the density requirements can be made in writing by the district Developmental Services Program Office, .. 3) Individuals receiving Supported Living Coaching services shaH live where and with whom they choose, Individuals receiving supported living services shall live with no more than two other people who have developmental disabilities and shall have control over the household and its daily routines, 4) Within 90 days of the proposed move to a supported living arrangement and when approved on the cost plan, Supported Living Coaching services may be made available to Individuals who are in the process of looking for a place of their own, even though they reside in a family, foster, group home, residential habilitation center, or other licensed facility during the search process, b. Exclusions: 1) Supported Living Coaching services are not to be provided concurrently with residential habilitation services, except for the 90 days prior to moving into the supported living setting, 2) Individuals who live in family, foster, group home, residential habilitation center, or other licensed facility are not eligible for these services unless the Individuals are in the process of moving into their own homes, 3) The Provider shall not be the Individual's landlord, c. Service Times: The Provider shall have on call system in place that allows Individuals access to services for emergency assistance 24 hours per day, 7 days per week. The Provider shall render Supported Living Coaching services at the time and place mutually agreed to by the Individual and Provider, If an individual vendor, the Provider must specifY a backup 50 SSA-ll, Attachment to CF-DS3064 July 1998 Supported Living Coaching Services Service Specific Attachment, Cont. person to provide supports in the event he or she is unavailable, The specified backup Provider must be a certified and enrolled Medicaid Provider, 3. Service Location: a. Service Delivery Location: Supported Living Coaching services shall be provided in the Individual's place of residence or in the community, b. Location Changes: The Provider will notify the support coordinator 30 days prior to any non emergency change of the location of the Individuals residence, 4. Provider Requirements: a. Licensure: Not required. b. Qualifications: Providers of Supported Living Coaching services may be either individual yendors or agency vendors. Providers of this service shall meet the following minimum qualifications: 1) A bachelor's degree from an accredited college or university with a major in nursing, education or a social, behavioral or rehabilitative science, 2) In lieu of a bachelor's degree, a person rendering this service shall have an associate's degree from an accredited college or university with a major in nursing, education or a social, behavioral or rehabilitative science and 2 years of experience, 3) Experience in one of the previously mentioned fields shall substitute on a year-for-year basis for the required college education. c. Training: Providers are required to attend at least 12 hours of preservice training and 8 hours of annual in-service training. Providers shall maintain documentation of training attended, D. Provider Responsibilities: The Provider's performance is subject to the General Terms and Conditions in the Developmental Services Medicaid Waiver Services Agreement and the following: 1. Service Agreement Outcome: The report to the Department as required data for the performance requirements, For Supported Living Coaching, the standard is: a. 100% of Individuals in supported living are the lessor or owner of the home in which they reside, b. Achieve a satisfactory or better rating on ~% of client satisfaction surveys, 51 SSA-ll, Attachment to CF-DS3064 July 1998 Supported Living Coaching Services Service Specific Attachment, Cont. c. 100% of supported living clients live in homes in which persons with disabilities account for no more than 10% of the houses in an identifiable area or 10% of the units in an apartment complex. 2. Service Delivery Documentation: The Provider will maintain the following for each Individual served under this service agreement: a. Demographic information including health and medical information, emergency contact person. b. Current Support Plan authorizing supported living services, functional community assessment, implementation plans, housing survey, health and safety checklist and financial profile if appropriate. c. Notes of activities and contacts with the Individual, other Providers and agencies that provide pocumentation of service delivery including dates, times, as well as a summary of support provided during the contact, follow up needed and progress toward achieving outcomes, d. A monthly summary of activities or support log documenting support Provider activity during the month 3. Reimbursement: For reimbursement purposes the Provider must submit an invoice and support log or monthly summary, All required documentation shall be filed in the Individual's record prior to billing, 4. Payment: Providers of Supported Living Coaching services are paid at a rate negotiated by the waiver support coordinator or district Developmental Services Program Office, The district office shall be the final authority over all rates negotiated. a. The Provider shall submit an invoice for services at the end of the month. b. If services terminate before the end of the month, the Provider shall submit a prorated invoice for dates of services, c. Transportation shall be included as a component of the Supported Living Coaching services and shall not be paid separately, 52 SSA-ll. Attachment to CF-DS3064 Tuly 1998 ATTACHMENT Id TRANSPORTA nON SERVICES SERVICE SPECIFIC ATTACHMENT A. Waiver Services to be Provided: 1. Definition of Terms: This attachment will encompass all applicable terms and definitions in the Core Assurances and the following service specific definitions: a. Transportation services provide rides to and from home and community-based services to enable an Individual to receive the supports and services identified on the Support Plan and approved Cost Plan when family or friends are unable to provide this support. b. Major traffic violations are any at-fault accidents, speeding tickets for 15 or more miles over the posted limit, charges of careless or reckless driving or DUI/DWI, c. Alternative transportation provider is a provider of transportation services that is not part of the coordinated system of transportation disadvantaged, but meets the criteria for being used as an alternative to the coordinated system. d. Commercial transportation agencies are those transportation companies whose drivers are not in regular or continuous contact with the Individuals being transported, such as at- random taxi drivers who serve the general public and fixed route public transit bus drivers, e. Independent vendors are individuals and companies providing transportation services to Individuals, Such vendors may include neighbors, friends, group home operators, foster home parents, residential habilitation center operators, transportation operators, and alternative transportation providers, B. Management Plans: If required by section 3.0 of the Core Assurances, the Provider will submit a Management Plan to the District for review and approval prior to provision of service. The Management Plan will contain all the required policy and procedural elements found in section 3.1 of the Core Assurances, C. Scope of Service: 1. Service Tasks: Transportation services shall be used to provide rides to and from community- based services to enable an Individual to receive the supports and services identified on the Support Plan and approved Cost Plan when family or friends are unable to provide this support at no cost, To ensure the safety ofIndividuals being transported, the following minimum standards: a. A transportation disadvantaged coordinated system provider shall comply with their current Memorandum of Agreement and Transportation Service Plan, b. Alternative, commercial agency and independent vendor transportation service providers shall operate their vehicles at all times in compliance with applicable traffic regulation, ordinances and laws in the jurisdiction in which they are operating, 53 SSA-12. Attachment to CF-DS3064 July 1998 Transportation Services Service Specific Attachment, Cont. c. Vehicles shall be smoke-free, uncluttered, free of trash and vermin, regularly serviced and maintained in good operating condition. 2. Service Limits: a. Transportation services shall be limited to the amount, duration and scope of the service described on the Individual's Support Plan and current approved Cost Plan and the following: 1) Providers may charge for their service by the mile, the trip, or the month, as follows: (a) When a provider is reimbursed by the mile, an Individual shall receive no more than 200 miles per day of this service. (b) When the provider is reimbursed by the trip, an Individual shall receive no more than 4 one-way trips per day, or 80 per month of this service. " (c) Wh~m the provider is reimbursed by the month, the provider shall provide documentation of actual cost with the invoice for payment. b. Exclusions: 1) This service is not available to transport an individual to school. 2) Medicaid Home and Community-Based Services waiver funds shall not be used when Medicaid State Plan transportation services are available, c. Service Times: Transportation services shall be provided at times necessary for Individuals to access community supports and services. d. Service Location: Transportation services shall be provided anywhere in the community. 3. Provider Requirements: a. Licensure: 1) Drivers shall be at least 18 years of age and possess a current, valid driver's license appropriate to the vehicle and for the purpose it is being driven in accordance with Chapter 316, F.S, 2) Applicants shall provide the district Developmental Services Program Office with proof of license and insurance. b. Qualifications: Providers of transportation servIces shall be alternative, independent vendors or commercial transportation agencies, 54 SSA-12, Attachment to CF-DS3064 July 1998 Transportation Services Service Specific Attachment, Cont. 1) All drivers shall be licensed. 2) All drivers shall have a safe driving record as indicated by having no major traffic violation in the previous 3 years and having no more than 2 minor traffic violations in the previous 5 years. D. Provider Responsibilities: The providers performance is subject to the terms and conditions in the Developmental Services Medicaid Waiver Services Agreement, General Terms and Conditions and the following: 1. Service Delivery Documentation: The provider will maintain the following documentation for each individual served : a. Daily trip logs and b. For providers reimbursed by the month, the actual cost shall be fully documented, ,. 2. Reimbursement: For reimbursement purposes, the provider must submit an invoice and daily trip logs, 3. Payment: The provider of transportation services shall be paid at a rate negotiated by the waiver support coordinator or district Developmental Services Program Office. The district office shall be the final authority over all rates negotiated, a. Providers that are paid by the trip may combine all services during a month and bill at the end of the month, using the last day of the month as the date of service, b. If services terminate before the end of the month, providers may combine all trips during a service period and bill at the end of the service period, using the last day of the service period as the date of service. c. Providers that are paid by the mile are paid for each date of service and shall prepare their bills accordingly, d. Providers that are reimbursed by the month based on actual expenses shall bill at the end of the month, using the last day of the month as the date of service, e. If services terminate before the end of the month, providers that are paid by the month shall prorate the month's cost and bill at the end of the service period, using the last day of the service period as the date of service, 55 SSA-12. Attachment to CF-DS3064 July 1998 ATTACHMENT II Core Assurances for Providers of Developmental Services Medicaid Home and Community-Based Waiver Services Programs Chapter 393, Florida Statutes, charges the (Department) with providing services, particularly community-based services, to ensure the well-being and improve the quality of life of Individuals with developmental disabilities. Section 393.066, Florida Statutes, specifically directs the Department to purchase these services through contracts with private businesses, not-for-profit corporations, units of local government and other organizations capable of providing the services in a cost-efficient manner. The Department and the Agency for Health Care Administration (Agency) have agreed to jointly purchase necessary services for Individuals with developmental disabilities through the-Developmental Services Home and Community-Based Waiver and the Supported Living Waiver, which are both federally-approved Medicaid Waiver Services Programs authorized by Title XIX of the Social Security Act. These Core Assurances, and the Service Specific Attachment(s) that follow, provide the terms and conditions by which the Provider of waiver services to developmentally disabled Individuals served by the Departr:p.ent agree to be bound. Breach of the terms and conditions set forth in these Assurances will be considered by the Department as indicative of the Provider's failure to comply with the te~s and conditions set forth in this document and the Developmental Services Medicaid Waiver Services Agreement. The Assurances City of Miami Beach (name of individual or business), hereinafter referred to as the "Provider," assures compliance with the following stipulations. Programmatic Definition of Terms Agency means the Agency for Health Care Administration. Central Record of an Individual means a file (or a series of continuation files) kept by the Provider in which the following documentation must be recorded, stored and made available for review: (1) Individual demographic data including emergency contact information, parental or guardian contact data, permission forms, as necessary and medical and medication information; (2) Legal data such'as release forms and Medicaid Waiver Eligibility Worksheet; (3) Service delivery information including the current Support Plan or written authorization of services, and Implementation Plans (4) Service delivery documentation in the form of progress reports or as specified in the Service Specific Attachment(s) that are related to the service and support activities identified in the Implementation Plan. Community Integrated Settings means those settings which possess and are not limited to the following characteristics: (1) non-facility ba~ed; (2) generic community resources utilized by 56 July 1998 Core Assurances, Cont. other people without disabilities; and (3) promote direct social interaction with others with or without developmental disabilities. Core Assur~nces means this document that specifies administrative and programmatic requirements that are applicable to all developmental services waiver(s) Providers. Cost-efficient means productive of the desired effects or benefits without wasting financial resources and is economical in terms of the tangible benefits produced for the money spent. Cost Plan means an accurate list of the approved service and approved costs. The Cost Plan is to be completed according to the instructions provided with the Department's form. Cost Plan Year means the 365 days that correspond to the span of time covered by the individualized Support Plan. Department means the Department of Children and Family Services, also known as the Departme1'lt of Children and Families, Developmental Services. District means the District Developmental Services Program Office where the Provider IS certified to render waiver services. Florida Status Tracking Survey means an instrument for determining the level of need for Individuals receiving services. Implementation Plan means an individualized document that specifies how the person will be assisted by the Provider(s) to achieve or maintain a specific Support Plan outcome. At a minimum, the plan will include the actions and tasks to be used by the Provider as required by the Individual. This plan will also include any training objective to be met by the Individual, and the system of assessment used for measuring the progress of the Individual in achieving the goal. Incidental, Non-Reimbursed Transportation means any transportation of waiver Individuals that is provided during the course of and merely incidental to the provision of one or more other primary Waiver service(s) and that is not reimbursed separately. Individual(s) means an Individual(s) receiving services through the Developmental Services Home and Community-Based Services Waiver or Supported Living Waiver. When the Individual is not deemed legally competent, the legal guardian is to be notified of any changes in service and the delivery thereof. Licensed Professional means a Provider of services that is licensed and monitored through the Department of Professional Regulation and/or the Agency for Health Care Administration. This term is restricted to Providers of supports and services under the following services: Behavior Analysis and Assessment, Environmental Modification, Occupational Therapy, Personal Emergency Response System, Physical Therapy, Private Duty Nursing, Psychological 57 July 1998 Core Assurances, Cont. Assessment, Skilled Nursing, Special Medical Equipment and Supplies, Adaptive Equipment, Speech Therapy and Therapeutic Massage. A Provider who meets the aforementioned qualifications is only required to comply with the specific requirements identified on page 9, section 3.0, Administrative Plans, Policies, Procedures and Practices. Management Plan means a formal written plan submitted by the Provider that specifies how policies and procedures and scope of service outlined in these Assurances and the specific service to be rendered will be implemented to ensure administrative compliance with state, federal, and contract provisions as well as defining the service delivery methodology. Medicaid Home and Community-Based Waiver Services Programs means the federally- approved Medicaid programs authorized by Title XIX of the Social Security Act for the Developmental Services Home and Community-Based Services Waiver and the Supported Living Waiver. Medicaid Provider Agreement means the agreement between Providers and the Agency for Health Care Administration to render services under the Medicaid Program. Medicaid Waiver Services Agreement means the agreement between Developmental Services and Providers of services which consists of form CF-DS 3064, March 1998, the Core Assurances for Providers of Medicaid Home and Community-Based Waiver Services Programs, Service Specific Attachment(s), and Rate Structure documents. All eligible Medicaid Poviders must complete this agreement to provide services to Medicaid Home and Community-Based Waiver Services Program Individuals. Monitoring means a Departmental review of the Provider's administrative and programmatic service delivery systems. Personal Outcome Assessment Process means the process by which the Provider wiII assist the Department, support coordinators and others in scheduling and arranging face-to-face interviews with the Individuals served by the Provider in order to assess personal outcome measures. This assessment process may also involve records review, on-site visits and additional interviews with the Provider's staff if necessary. Provider means an individual vendor, group or agency that is an approved Medicaid waiver Provider and has entered into an agreement with the Department to provide one or more of the services in the Medicaid Home and Community-Based Waiver Services programs. Quality Improvement Plan means a plan of corrective action that specifies steps the Provider \viIl take to bring cited areas deemed below standard by the Department or that are deemed not in conformity with these Assurances or Service Specific Attachment(s). Quality Improvement Plans wiII be required as specified in a written monitoring report prepared by the Department. 58 July 1998 Core Assurances, Cont. Reportable Events means anyone of the eight reportable events defined In HRSR-215-6, Incident Reporting and Client Risk Prevention, July 1, 1994, version. Self-Assessment means an evaluation completed by the Provider of its organizational policies and procedures. These policies and procedures will be described in the Provider's Management Plan and Service Specific Attachment(s). The Provider's Self-Assessment survey will include a combination of a records review and individual satisfaction surveys to identify the extent to which the Provider's policies and procedures are consistent with the stated objectives in the Management Plan and Service Specific Attachment(s). Service Specific Attachment(s) means that portion of the Developmental Services Medicaid Waiver Services Agreement delineating the obligations of the Provider with regard to the provision of a specific waiver service or services. Statement of Work means that part of the Provider's Management Plan which addresses and outlines the service(s) to be provided and defines the scope of those services. ,. Support Coordination means activities that assist Individuals in gaining access to needed waiver and other State Plan services, as well as needed medical, social, educational and other appropriate services, regardless of the funding source through which access is gained. Support Coordinator means a state-approved Provider of support coordination services who assists Individuals and their families/guardians to identify and choose supports and services. Support Plan means the document used to provide an accurate description of an Individual's current outcomes and services. The Support Plan must be completed according to the instructions provided by the Department. Support Planning Information Gathering means the process of obtaining a thorough description of an Individual's capacities, current lifestyle and preferences for the future through structured interview processes and informal interactions. Transprofessional means a non-agency, sole Provider who provides services to fewer than five Individuals per week and provides services to these Individuals twenty hours or less per week per Provider. This term is restricted to Provider's of the following services: Chore, Respite, Companion, Homemaker, Personal Care Assistance, and Transportation. A Provider who meets the aforementioned qualifications is only required to comply with the specific requirements identified on page 9, section 3.0, Administrative Plans, Policies, Procedures and Practices. Valued Social Roles means those activities that are esteemed by the general public and that define the Individual in relationships with others. Typical valued social roles include but are not limited to, co-worker, employee, neighbor, volunteer, student, friend, family member, athlete, theater goer, church member, taxpayer, citizen, etc. 59 July 1998 Core Assurances, Cont. 1.0 Compliance with Laws and Regulations 1.1 Compliance with State Law and Regulations (A) The Provider will comply with all applicable state statutes and rules of the Department, including Chapter 393, F.S., Chapter 409, F.S., Chapter 65B- 8, F.A.C., Chapter Q5B-ll, F.A.C., Chapter 65B-12, F.A.C., and with all regulations, policies, procedures and directives pertaining to the implementation of the waiver as may be amended from time to time, including Department policy clarifications and procedures; District policies, policy clarifications and procedures; and all rates and fee schedules developed under such laws, rules, regulations, policies and directives. (B) The Provider will uphold the rights and privileges of Individuals with developmental disabilities as specified in s. 393.13, F.S., "The BiII of ,. Rights of Individuals Who are Developmentally Disabled." (C) The Provider will comply with all federal, state and local laws and ordinances pertaining to the operation and requirements of the Provider's business. 1.2 Compliance with Federal Laws and Regulation (A) The Provider will comply with Title VI of the Civil Rights Act of 1964, as amended, 42 V.S.C. 2000d et seq., prohibiting discrimination on the basis of race, color or national origin in programs and activities receiving or benefiting from federal financial assistance (see HRS manual 220-2, Method of Administration: Equal Opportunity In Service Delivery). (B) The Provider will comply with Section 504 of the Rehabilitation Act of 1973, as amended, 29 V.S.C. 2000e, et seq., in regard to employees or applicants for employment (see HRS manual 220-2, Method of Administration: Equal Opportunity in Service Delivery). (C) The Provider will comply with the Age Discrimination Act of 1975, as amended, 42 V.S.C. 6101 et seq., which prohibits discrimination on the basis of age in programs or activities receiving or benefiting from federal financial assistance (see HRS manual 220-2, Method of Administration: Equal Opportunity in Service Delivery). (D) The Provider will comply with the Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, prohibiting discrimination on the basis of sex and religion in programs and activities receiving or benefiting from federal 60 July 1998 Core Assurances, Cont. financial assistance (see HRS manual 220-2, Method of Administration: Equal Opportunity in Service Delivery). __ (E) The Provider will comply with the Americans with Disabilities Act of 1990, P.L. 101-336, prohibiting discrimination based on disability in employment, public accommodations, transportation, state and local government services and telecommunications (see HRS manual 220-2, Method of Administration: Equal Opportunity in Service Delivery). (F) The Provider will comply with Title 42, Code of Federal Regulations (CFR) 431.51, which states that each Individual served by the Provider will be afforded freedom of choice within the scope of available funding levels. Freedom of choice includes, but is not limited to: 1. Opportunities for the Individual to select non-funded supports available to the general community from among those activities or experiences that meet the Individual's needs and preferences; " '2. Opportunities for the Individual to select vendors of Medicaid State Plan services from among those enrolled in the Medicaid program, and that also meet the Individual's needs and expectations; 3. Opportunities for the Individual to select vendors of waiver services from among those certified to provide waiver services and enrolled in the Medicaid program, and that meet the Individual's needs and expectations; 4. Opportunities for the Individual to select vendors of non-Medicaid, non-waiver services from among those determined eligible to provide services by a District, and that also meet the Individual's needs and expectations; 5. Opportunities for the Individual to change Providers of supports and services; 6. Opportunities for the Individual to work with a Provider to identify mutually agreeable times and settings for the provision of supports or services; and 7. The opportunity for the Individual to end participation In the Waiver. 61 July 1998 Core Assurances, Cont. 2.0 Program Requirements 2.1 All Providers that render services under the waiver(s) must execute the Medicaid Waiver Services Agreement which incorporates Core Assurances and Service Specific Attachment(s) for the services they provide when applicable and must be enrolled in Medicaid as a waiver Provider prior to commencing service provision. 2.2 The Provider will not disclose or use any information concerning an Individual receiving services under the waiver for any purpose that is not in conformity with Chapter 393.13(4) and federal regulations, except upon written consent of the Individual or the Individual's legal guardian. 2.3 In accordance with section 415.1034, F.S., the Provider or any employee of the Provider who knows, or has reasonable cause to suspect, that an Individual who receives services from Developmental Services is being or has been abused, neglected or exploited, will immediately report such knowledge or suspicion to , the central abuse registry and tracking system of the Department on the statewide toll-free telephone number (l-800-96ABVSE). TTY users call 1-800-453-5145. 2.4 The Provider will maintain documentation in accordance with procedures specified in these contract documents including the Service Specific Attachment(s) for each participant being served, as well as for each waiver service being provided. The Department retains the right to review an Individual's record(s) at any time. 2.5 It is the responsibility of independent Medicaid Home and Community-Based Services Waiver Services Program Providers, and employees of agency Providers who transport Individuals in the process of and merely incidental to providing one or more other primary waiver service(s) and who are not reimbursed for such transportation, to comply with all applicable traffic and motor vehicle laws. 2.6 The Provider understands and agrees that the Department is responsible for the expenditure of all funds appropriated to the Department by the Florida Legislature for Individuals who receive services from Developmental Services and for the Medicaid Home and Community-Based Waiver Services Programs. Accordingly, the District is ultimately responsible for determining the appropriateness of services purchased and the amount of developmental services funds available to purchase services and goods. 2.7 The Provider understands and agrees that the Department is the final authority on all matters pertaining to paid services or goods purchased with funds appropriated to the Department for Individuals who receive services through the waiver. 62 July 1998 Core Assurances, Cont. 2.8 The Provider agrees, with the Individual's permISSIon, to partICIpate in the discussion of the Individual's record, the Individual's progress, the extent to which the Individual's needs are being met or any need for modifications to the Implementation Plan, if applicable. This discussion could involve the Department, the support coordinator, the Individual, the guardian, family and friends. 2.9 The Provider understands and agrees to provide and bill for only those services approved by the District on the Individual's Cost Plan for which the Provider is authorized to provide. 2.10 The Provider agrees to participate in and support each Individual's Personal Outcome Assessment Process and to use data from these assessments to enhance service delivery in a manner that supports the achievement of personal outcomes. 2.11 The Provider agrees within the mission and scope of the service(s) it will provide, ,. to assist people in the achievement of personal outcomes in the areas of Personal Goals, Choice, Social Inclusion, Relationships, Rights, Dignity and Respect, Health, Environment, Security and Satisfaction. 2.12 The Provider will share responsibility and assist the Department and others in the notification and resolution of the following issues and concerns for, or on behalf of, each Individual served by the Provider: (A) Notification to the District and the Individual's support coordinator of . . Issues concernmg: 1. The Individual's continued eligibility for waiver services; 2. The possibility of losing Medicaid eligibility; 3. Plans to move out of the District or out of the state; and 4. Plans to discontinue receiving services from the Provider, waiver or the Department. (B) Notification to the District of an emergency or of an unusual occurrence or circumstance in accordance with District operating procedures or protocols. Said notification of unusual occurrence or circumstance includes but is not limited to: I. The hospitalization of the Individual; 2. The involvement of law enforcement agencies; and 63 July 1998 Core Assurances, Cont. 3. Concerns about abuse, neglect, or exploitation and reporting of abuse; reportable events as defined in HRSR 215-6, Incident Reporting and Individual Risk Prevention; and HRSR 210-1, Review of Suspicious Child Deaths. 3.0 Administrative Plans, Policies, Procedures, and Practices The following types of Providers as defined by these Assurances are only required to comply with the following sections under 3.0: · Licensed Professional: 3.2 (B), 3.4, 3.5, 3.6, 3.7, 3.8. · Transprofessional: 3.2; 3.4, 3.5, 3.6 CA), CD); 3.7, 3.8. · Transportation providers within the Coordinated System: 3.1 (H), 3.4, 3.5, 3.6 (A), "(C), (D); 3.7, 3.8. 3.1 Man'agement Plan Prior to the Provider's initial determination of eligibility and or the provision of services, the Provider's Management Plan will be submitted to the District for review and approval. The plan will include the following components: (A) Mission statement; (B) The table of organization, including board of directors (when applicable), directors, supervisors, support staff, and all other employees; (C) Procedures for conducting Self-Assessments; CD) Policies and procedures that will protect the health, safety and welfare of every Individual who receives services from the Provider; (E) Procedures to assist the Department in the Personal Outcome Assessment Process; and (F) Written grievance procedures that will be used to resolve conflicts which may arise between the Individual, family, and/or guardian and the Provider. These procedures do not preclude appropriate requests for a hearing in accordance with Chapter 120, F.S., nor do they preempt the Individual, family, and guardian's right to request a change in services and/or Provider. 64 July 1998 Core Assurances, Cont. These procedures will specify: 1. That grievance procedures will be annually reviewed and signed by the Individual, family and/or guardian; 2. That grievance procedures will be communicated in clear, understandable language to the Individual, his family or guardian. Responses to grievances will be provided verbally and in writing at the Individual's level of comprehension and in the language understood by the Individual; and 3. That a log of all grievances filed by Individuals, families or guardians will be maintained and will include the following information: a. The name of the individual making the complaint and his relationship to the Individual receiving services; ,. b. The date the complaint is received; c. A clear description of the complaints. (Oral complaints will be documented in writing.) All complaints should be retained in the Individual's file and a copy retained with the grievance log; and d. The date of the final disposition of each complaint. (G) Statement of work. This document will include: 1. A description of the services to be provided in accordance with the needs of the Individual(s) served to facilitate the Outcomes supporting the services on the Support Plan. 2. A description of the population to be served including level of care criteria if applicable. 3. Admission and discharge criteria. 4. A description of policies and procedures to ensure the smooth transition of the Individual between Providers and other supports and services. 5. A description of a training plan that specifies how pre-service and in-service activities will be carried out. 65 July 1998 Core Assurances, Cont. (H) If the only service being provided is transportation services through the transportation disadvantaged program, the Community Transportation Coordinators' current Memorandum of Agreement and Transportation Disadvantaged Service Plan may be submitted in lieu of the Management Plan for this particular Provider. 3.2 Personnel Policies The agency Provider will develop and implement written personnel policies to ensure that: (A) Level Two background screening requirements are met in accordance with s. 393.0655, F.S.; (B) State and national criminal and history checks for any officer, director, billing agent, managing employee and any affiliated person, partner, or shareholder having ownership interest of 5 percent or greater in the agency, in accordance with 409.907, F.S. ,. 3.3 Training Requirements (A) The Provider will ensure that each employee receives pre-service training within 30 days of employment. Pre-service training will include: I. General concepts of the Core Assurances; 2. Emphasis on Individual choice and rights; 3. Recognition of abuse and neglect as well as District and Provider reporting procedures; 4. An explanation and review of the Provider's grievance procedures as set forth in section 3.1; 5. Self-Assessment procedures and Self-Assessment protocol; and 6. Training on the development and implementation of the Implementation Plan, when applicable. (B) The Provider will ensure that each employee receives annual in-service training based on requirements specified in the Provider's Service Specific Attachment( s). 66 July 1998 Core Assurances, Cont. (C) The Provider will maintain written documentation in each employee's personnel file, signed and dated by the employee, which indicates his participation in all required pre-service, and other ongoing training, as specified in the Service Specific Attachment(s) of this Agreement. Further, the Provider agrees to make said documentation available to authorized State and federal agents upon reque~t. (D) The Provider will ensure that each employee receives specific training required to successfully serve each Individual. 3.4 Professional Business Practices (A) The Provider will maintain all records, including information stored in electronic media, for at least five (5) years (or longer if under review), in accordance with generally accepted accounting procedures and practices and that accurately and properly reflect all revenues and expenditures of " funds provided under this Agreement. (B) The Provider understands and agrees that the Department and Individuals served will be notified of any change, sale or transfer of ownership and be given an opportunity to receive services from the new owner, purchaser, or transferee, or to select another vendor. (C) The Provider agrees that if all or part of the business is sold or transferred, the Provider will maintain and make available to the Department and the Agency those Medicaid-related records required to be kept unless the Provider enters into an agreement with a third party to do so and furnishes the Department with a copy of such agreement. Any such agreement will require the holder or custodian of the records to comply with the terms set forth in the Medicaid Waiver Services Agreement and the Core Assurances incorporated therein for retention and access to said records. (D) The Provider agrees to notify the Department in writing prior to any filing for bankruptcy protection. (E) The Provider agrees to maintain a separate checking account for any personal funds of any, and all Individual(s) in his care. If a single trust account is maintained for all Individuals' personal funds, a separate accounting must be maintained for each Individual's funds, which reconciles monthly to the account's total as noted on the bank statement and is retained for review by the Provider, the Department or Agency. The Provider further understands and agrees that at no time should any Individual's personal funds be commingled with the funds of the Provider or any of its employees. 67 July 1998 Core Assurances, Cont. (F) Neither the Provider nor its employees, in their official capacity, will receive any financial benefit as a result of being named the beneficiary of a life insurance policy on an Individual served by the Provider; and (G) Neither the Provider nor its employees, in their official capacity, will benefit financially hy borrowing or otherwise using the personal funds of an Individual served by the Provider. 3.5 Marketing Practices The Provider will market its services in a professional and ethical manner. The Provider agrees to NOT: (A) Possess or use for the purpose of solicitation, lists or other information ,. from any source that identifies Individuals receiving services from the Department; (B) Solicit Individuals directly or through an agent, through the use of fraud, intimidation, undue influence, or any form of overreaching or vexatious conduct, including offering discounts or special offers that include prizes, free services, or other incentives; or (C) Solicit or influence directly or through an agent, through the use of fraud, intimidation, undue influence, (or any form of overreaching or vexatious conduct), an Individual currently receiving services from another vendor for the purpose of inducing the Individual to switch vendors. 3.6 Goods and Services Provided The Provider will conduct or be responsible for the following administrative duties for or on behalf of each Individual served by the Provider. The Provider will: (A) Document all service provision clearly and legibly in accordance with the Waiver Services Directory in a manner that will describe the limits of service, units of service, payment of service, location of service, outcome achieved as a result of the service delivered and any other special consideration that will clearly document the rationale for the provision of the service; (B) Submit an annual summary of the Individual's accomplishment toward achieving the Support Plan outcomes; 68 July 1998 Core Assurances, Cont. (C) File all documentation in the Individual's record prior to submitting an invoice in accordance with policy and procedures specified herein; (D) Bill for only those services that have an approved service authorization or that have a Cost Plan authorizing those services at the approved rate, frequency and duration; (E) Provide information about the Individual to assist in the development of the Support Plan; (F) When invited by the Individual, family member or guardian, participate in the development of the Support Plan; (G) Within the realm and scope of the service(s) provided, expand the Individual's life experiences through opportunities to be part of the ,. c'ommunity through the provision of supports and services; (H)' Provide relevant training, experiences and opportunities that relate to the outcomes identified on the Individual's Support Plan; (I) Attend mandatory meetings and training scheduled by the District. 3.7 Payment for Services (A) The Provider understands and agrees that the Medicaid fiscal agent or the Office of the Comptroller will not pay a different rate for the same level of service from the same Provider and will only pay for those services authorized and directly related to the Individual's outcomes as identified in his current Support Plan and that are authorized on a current and approved Cost Plan. (B) The Provider understands and agrees that payment from the Medicaid fiscal agent is made to a Provider who is certified by a District and who has executed a Developmental Services Medicaid Waiver Services Agreement which includes these Core Assurances and applicable Service Specific Attachment(s). The Provider further understands that payment is contingent on enrollment in Medicaid as a waiver Provider for the particular service being invoiced. (C) The Provider understands that Medicaid payment will be payment in full for the services provided. The Provider understands that it may not bill the Individual or family for services covered by this agreement that are reimbursed by Medicaid. 69 July 1998 Core Assurances, Cont. (D) The Provider understands and agrees that payment from the Medicaid fiscal agent will be made only after services are rendered. (E) The Provider understands and agrees that payment for services for clients placed out-of-District will be made at the same rate for those Individuals being served by the Provider in the host District. (F) Payment shall not be made when no service is rendered. 3.8 Recoupment of Funds (A) The Provider understands and agrees that for any services for which the Provider received payment, but required documentation does not fully support that the services were rendered, the Department will recoup the funds paid to the Provider. ,. (B) The Provider understands that payment for services that are not authorized will result in recoupment of funds by the Department. 3.9 Self-Assessments and Monitoring The Provider agrees to conduct an annual Self-Assessment survey. Part of this assessment will be to determine, within the realm and scope of the service(s) that are provided, the extent to which the Provider is developing and maintaining person-centered processes that will assist Individuals in the achievement of personal outcomes, particularly in the areas of Personal Goals, Choice, Social Inclusion, Relationships, Rights, Dignity and Respect, Health, Environment, Security and Satisfaction. 70 July 1998 ATTACHMENT ill FINANCIAL AND COMPLIANCE AUDIT This attachment is applicable if the provider is any state or local government entity, nonprofit organization, or for-profit organization. An audit performed by the Auditor General shall satisfy the requirements ofthis attachment. Ifthe provider does not meet any of the requirement below, no audit is required by this attachment. PART I: FEDERAL AUDIT REQillREMENTS This part is applicable if the provider is a local government entity, or nonprofit organization, and expends a total of $300,000 or more in Federal Awards passed through the Department during its fiscal year. The determination of when a provider has "expended" Federal Awards is based on when the activity related to the award occurs. Local governments and nonprofit organizations shall comply with the audit requirements contained in OMB Circular A-113, Audits of State, Local Governments, and Non-profit Organizations, except as modified h~rein. Such audits shall cover the entire organization for the organization's fiscal year. The reporting package shall include a schedule that discloses the amount of expenditures by contract number for each contract with the Department in effect during the audit period. Compliance findings related to contracts with the Department shall be based on the contract requirements, 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 applicable contract. All questioned costs and liabilities due to the Department shall be fully disclosed in the audit report with reference to the Department contract involved. PART II: DEPARTMENT AUDIT REQillREMENTS This part is applicable if the provider is a non-profit organization that receives, during its fiscal year, a total of$100,000 or more in non-federal funds from the Department which was not paid from a rate contract based on a set state or area-wide fixed rate for service. 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 perfonned shall cover the financial statements and include a report on internal control and compliance. The reporting package shall include a schedule that disclose the amount of receipts by contact number for each contract with the Department in effect during the audit period. Compliance findings related to contracts with the Department shall be based on the contract requirements, including and rules, regulations, or statutes referenced in the contract. The fmancial statements shall disclose whether or not the matching requirement was met for each applicable contract. All questioned costs and liabilities due to the Department shall be fully disclosed in the audit report with reference to the Department contract involved. 71 03/01/98 If the provider receives funds from a grants and aids apprnpriatinn, the provider shall have an audit, or snbmit an attestation statement, in accordance with Section 2 16.349, Florida StaMes. The report shall COver the provider's fiscal Year. The andit report shall inclnde a schedule offmanciaI assistance which discloses each state contract hy number and indicates which contract funds are from state grants and aids appropriations. The provider has "received" funds when it has obtained cash from the Department. PART III: STATE AUDIT REQUIREMENTS For any of the above requirements, 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 days after the end of the provider's fiscal year directlx to each of the fOllOWing, unless otherwise required by Florida Statutes: PART IV: SUBMISSION OF REPORTS A. Office ofIntemal Audit 1317 Winewood Boulevard Building 1, Room 301 G Tallahassee, Florida 323990700 ,. B. Contract Manager for this contract C. Submit to this address only those reports required by OMB CirCUlar A-133: Federal Audit Clearinghouse Bureau of the Census 1201 E. 10th Street Jeffersonville, Indiana 47132 D. Submit to this address only those audits or attestation statements required by Section 216.349, Florida Statutes: The provider shall enSUre that audit Working papers are made available to the Department, or its designee, upon request for a period offive (5) years form the date the audit report is issued, unless extended in writing by the Department. Jim Dwyer Office of the Auditor General P. O. BOX 1735 Tallahassee, Florida 32302 03/01/98 a;l/trcalch 72 Financial & Compliance Audit Matrix (Applicable to Provider's fiscal year; use with Attachment dated 03/01/98) Contract with individual private oartnership or for-profit olVanization' Attestation &u1i1 &u1i1 Attachment Part(s) Fonn 1122 Code Note: Neither total non-federal funds received nor amount of Federal Awards expended considered here. Receives no grants and aids appropriation funding: N/A N/A N/A C, I, P Receives some grants and aids (G&A) appropriation funding: Total G&A funds received do not exceed S 25,000: CEO N/A III o Total G&A funds received exceed S 25,000: (CPA or AG) III B Contract With Non-profit Ore:anization Receives no grants and aids appropriation funding: Receives less that S100,000 in non-federal funds. from C&F and expends less than S 300,000 in Federal Awards; N/A ,. N/A N/A T Receives SI 00,000 or more in non-federal funds. from C&F and expends less that S300,000 in Federal Awards: N/A GAS II E Total expenditures include Federal Awards equal to or greater that S300,000, regardless of total amount non-federal funds receives: N/A A-I33 G Receives some grants and aids appropriation funding: A. Expends a total of S300,000 or more in Federal Awards: Note: Total amount of non-federal funds received not considered here. Total G&A funds received do not exceed S 25,000: CEO And A-133 I & III v Total G&A funds received exceed S 25,000: (CPA or AG)+A-133 I & HI y B. Expends less than S300,000 in Federal Awards: I. Receives S 100,000 or more in non-federal funds. from C&F: Total G&A funds received do not exceed S25,000: CEO And GAS II & 1Il S Total G&A funds received exceed S 25,000: (CPA or AG)+GAS II & III x 2. Receives less that SIOO,OOO in non-federal funds. from C&F: Total G&A funds received did not exceed S 25,000: CEO N/A III o Total G&A funds received exceed S 25,000: (CPA or AG) III B * Note: Receipts from fixed rate contracts based on set state or area-wide fixed rates for services should not be included in the caiculation of the SI 00,000 non-federal funds threshold. 73 Attestation Awlli Form 1122 A.IlII.it Attachment Part(s) ~ Contract with Local Governmental Entity: Form 1122 ~ C,I,P, T B D E G S v x y .:Utrcalch.doc Receives no grants and aids appropriation funding: Expends less that $300,000 from C&F in Federal Awards: N/A N/A N/A T Total funds expended include $300,000 or more in Federal Awards: N/A A-133 G Receives some grants and aids appropriation funding: A. Expends a total of $300,000 or more in Federal Awards: Total G&A funds received do not exceed $25,000: CEO And A-I33 I&I1I v Total G&A funds received exceed $ 25,000: (CPA or AG)+A-133 1&I1I y B. Expends a total ofless than $300,000 in Federal Awards: Total G&A funds received do not exceed $25,000: CEO N/A III D Total G&A funds received exceed $25,000: (CPA or AG) III B ,. Types of attestations/audits N/ A - Not Applicable CPA or AG - Attestation statement prepared by independent CPA or audit as required by Chapter 10.600, rule of the Auditor General. CEO - Attestation statement by head of organization as required by Section 216.349, Florida Statutes. GAS - Organization wide financial and compliance audit in accordance with Government Auditine: Standards. A-133 - Organization wide fmancial and compliance audit in accordance with OMB Circular A-I33. CEO & GAS - Organization wide fmancial and compliance audit in accordance with Government Auditine: Standards and attestation statement by head of organization as required by Section 216.349, Florida Statute. CEO & A-133 - Organization wide fmancial and compliance in accordance with OMB Circular A-I33 and Attestation Statement by head of organization as required by Section 216.349, Florida Statute. (CPA or AG)+GAS - Organization wide fmancial and compliance audit in accordance with Government Auditin~ Standards and either an audit or an attestation statement prepared by an independent CPA as required by Chapter 10.600, Rules if the Auditor General. (CPA or AG)+A-133 - Organization wide fmancial and compliance audit in accordance with OMB Circular A-133 and either an audit or an attestation statement prepared by independent CPA as required by Chapter 10.600, Rules of the Auditor General. 74 ATTESTATION STATEMENT CONTRACT NUMBER (S): I, (Executive Director) , hereby attest, under the penalties of perjury, that (provider Name) has complied with all provisions of the contract listed above during the fiscal year ended (Month, day, year) (Signature) , (Title) (Date One copy of this Attestation Statement shall be submitted within one hundred eighty (180) days after the 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. Jim Dwyer Office of the Auditor General P.O. Box 1735 Tallahassee, Florida 32302 3. Contract Manager for this contract This document does not need to be notarized. 75 Vendor Name: Address: DISTRICT ELEVEN DEPARTMENT OF CHILDREN AND FAMIL Y SERVICES DIVISION OF ADULT CARE & FAMIL Y SuPPORT INVOICE REQUEsT FOR SUBSIDIES/SERVICES RENDERD EXHIBIT A Contract Number: Month of Service: Service Provided: Funding Catergory: IES Vendor ID #: CLIENT NAME SOCIAL SECURITY RA TE PER NUMBER OF AMOUNT NUMBER UNIT UNITS REQUESTED 1 2 ,. 3 4 5 6 7 8 9 10 1 2 ; TOTAL 'RTIFY THAT GOODS AND SERVICES ITEMIZED ON TIIIS AUTHOR/ZA TION INVOICE, HAVE BEEN RECIEVES ,D ARE A PROPER CHARGE AGINST THE STATE FliNDS APPROPR/A TED FOR TIIIS PROGRAM. SUPPORT EVED FOR IN HOME SUBSIDY OR SUPPORTED LIVING STIPEND WILL BE USE FOR THE PURPOSE PREVrOUSL Y BED uPON IN WRITING. 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These rulc:s apply whether the cost shuing or matching is required by Feder.Jl statUte or by other terms oC !.be grant. (b) HHS aod a grantee may enter into ao insticu- uonal cost-sharing agreement covering all ot HHS's research project grants to th:lt grantee in the aggregate. Except as provided by the insticutional cost-sharing agreement, this subpart applies to tbe satisfaction of the grantee's obligatioo under the agreement, as well as to the satisfactioa oC cost-sharing or matching require- meots that apply only 10 a single grant. . .. S 7-l.51 . Definitions. ,. For purposes ot this subpart: WCost sharing Or matching" means tbe value of third-party in-kind contributions ~nd that portioo ot the costs ot a grant-supported project or program not borne by the Federal Government. "Equipment" has the same meaning given to that term in S 74.132, except that instead of "acquisitioll COSt," the words "market value at the time of donatioo" shall be substituted. "Supplies" means all tangible persollJ.1 properry other thao "cquipment" as defined in this section. "Third-party in-kind contrioutions" meao.s ~i' .2! s~rvi~ which benefit a grant-supported project or program aod which arc contributed by noo-Federal third parties withOut charge to the grantee, the sub- gr3ntce, or a COSl-t;:pe con:r:lctOr uncer the gnnt or subgr3.H. 37.J.52 B:lsic rule: Costs :Ind contriburions accept- able. Wi:., th~' qU31i!ications Jod ace?tions listed :0 .i 7.1.5:;. a (os:-sharing or :112tcn::1g reql!::e~ent .m:1j' ~ be: satisfied by either or both of the following: .. (a) Allowable costs incurred by the graotee, sub- grantee, or :1 COst-type con~r;Jc[or undc:r the grant or subgranl. This includes :llJowable costs borne by non- Federal grants or by Other cash dooations from OOn- Federal third panies. (b) The value of third-party in-kiad contributions applicable 10 the period to which the COSt-sbaring or matching requirement applies. ~ 74.53 Qualifiotions and exce-ptioa5... (a) Costs born~ by otna FcdaaJ gran.l.S. (1) Ex- cept as provided by Federal statute, a cost-sbariog or matchi.cg requirement may not b<: met by costs borne by Another Federal graaL Th~ prohibition does oat apply to costs borne by general program income cuned (rom a coo trace awarded under another Federal grant. (2) For the purposes of this part, general revenue shariog fuods under J 1 U.S.C. 1221 are not cOllSidered a Federal graot. Therefore, in the absence of any pro- visioll oC Federal statute to the contrary, aUow2.ble costs borne by these funds may couot towards satisfying a cose-shariog or matching requ iremen.L (b) COSlS or contributiolls COunted lowards owr Fe dual cas I-sharing requiremenrs. Neic.her cosu nor the values of third-party in-kind cootributions may couot towards satisfying a cost-sharLgg or matching requirement of an HHS graot i1 [hey have been or will be counted towards satisfying J. cosHharing or match. iog requiremeat of another Federal grant, a Federal procureme:H .:ootrJCt, or any other a.....ard of Federal iucds. (c) COSlS .~n(lnad b.v yu:ua{ pror;ram income. COSts fin:uiced by scnccJI ?rogTJm income, as ~~5.0ed in ~ i~..J2, ih311 not .:ounc towards ~atisf'ilOg a .:ost- sha~ing or mJtcJing ,cq;Jiremcot at :hc HHS gr~Dt sup-˜porting the Jctivity giving rise :0 t~e income unless !I::e ter~~ -;,{ the grant c:.<prc:ssly f><:r~i~ :hf-iocoCl~ ,0 be 83 ( used (or cost sharing Or matching. (This is the alterna. tive (or us(: o( geoeral progr:lm income described io i i':,.12(d).) (J) R~corC$. Costs aod third-parry in-kind contri- butioos couoting towards satisfying a cost-;hari::lg or m3lc~iog requiremc:ll must ~ \'erifi:lble from tbe rec- urds of recipieots or cOst-type Cootractors. These rec- ords must show how the value placed on third-party in-k.ind contributioos was arrived at. To the <:.tleot iCJ.sible. volunteer services shaU be supponed hy the .ame methods that the organiuuon uses to support the allocability of its regular personnel COSts. (e) Special standards for third-parry in-kind contri- butions. (I) Third-party in-kind coorrib.u.ti.Q.05 shall count towards satisfyin~ a cos~-sharioe- or matching reQuirement only where, if the party re~iving rhl': con- lributions were to pay for them, tbe "p'ayrr.en~ould Ix: allowable costs. (2) 6....Jhirrl-p:.!rry in \-inn /"nntributioQ sbaU not count as direct cost sharin~ or matching where, i{ the 2-anv receivin'! ~t:: cnntrihurioo were to pay for J~_We paymeot would ~. an indirect cost. Cost-sharing or matc~ing credit (or such contributions shall be given only if the' recipient or contractOr has establisbed, along with its regular il?direct 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 obtained (rom the Division of Cost Allocation in any IDiS regional office's Regional Adminislrative Suppon Center.) (J) The values placed on thlrd-party in-kind con- tributions [or cOSl-sharing or matching purposes shall conform to the rules in the succeeding sections of this subpan. Ii a third-parry in-kiDd contribueion is oC a type ooe lreaeed in those sectioas, the value placed upon it shall be {air aDd reasonable. ~ 74.54 ValWltion of dona fed seo'ices. (a) Voluntur !Crvi,,!. Unpaid services provided 10 a recipient by individuals shall be valued at rates constsCeDe with those ordinarily paid (or similar work in tbe recipient's. organizati<<;>D. Ii the recipient does Dot ha....: employees performing similar work, the rates shall be coosisteot with those ordinarily paid by other employers for similar work: in the same labor market. In either case, a reasonable :lmounc [or fringe benefits ~ay be included in the valuation. (b) Employas of otha OrgOJli::,ations. When :In :r.Jploycr other thJO a recipiene or Cost-type .:ontractor turnis!1es Cre: oC c~:lrse the services oC an emplo)"e:: :::1 the employee's normal line of work, the services shall be valued ae c~e employee's regular rate of pay exclusive of the emplo}'er's Cringe bene6es and over- ,~~?,~" com. Ii ilie scrvic::~ are i1;1 a differeDt liOe ~ol ,. :N?f~' ?a.!'agra?c \ a) oC this section shall appLY~ t;Xhibit~cont. ~ 74.55 Valuation o[ donated supplies and IOllJJed equipment Or space. (a) Ii a third p:lny donates supplies, the contribu- tioo shall be valued at tbe market value o( the supplies at the time of donatioo. (b) Ii a tbird parry don:lIes the 'use of equipmeot or space in a building bue retains title, the Coatribu- tion sball be valued at the (air rental rate o( tbe equip- meat or space. ~ 74.56 Valuation of donated equipment, buildiogs, and land. U a third party donates equipmeot, buildings, or l3lld, and title passes to a recipient, the treatment of the dooated property sball depend upon the purp~e of tbe grant or subgrant, as (ollows: (a) A. wards lor capital t:xpt:nditures. U the pUI1>Qse of the grant or subgranc is to assist .the recipient in the acquisition of property, the marlcct value of that property at the time of donation may be cOUDted as cost shariog or matching. (b) Olhu awards. Ii assisting in the acquisition of properr)' is not the purpose of the grant or subgranc, the (ollowing rules apply: (1) U approval is obtained from the awardiog parry, the market value at the time of dooation of the donated equipmeot or. buildings and the (air rental rate of the docated land may co: couoted as COSt shar- i..og or matching. Ln the case of a subgrant, the terms of the HEW gI3llt may require that the approval be obuined from the granting agency as well as the grant~e. In aU cases, th:: approval may be given ooJy if a purchase oC the equipmeQt or rental oC the land would be approved as an allowable direct cost. (2) Ii approval is not obtained under paragrapb (b) (1) of this section, no amount may be counted (or docated land, and only depreciation or us.e allow- ances may be counted (or donated. equipment anq . buildings. The depreciation or use allowanc.c:.s for this property are not treated as tillrd-pany in-kind con- tributions. Instead, tbey are crcated as costs iocurred by the recipient. They are compUlCd and allocated (usually as indirect costs) in accord~nce with the cost principles specified in subpart Q of-this pan. in the sarrie way as depreciation- or use allowances (or ?ur- cbased equipment and buildings. The amount of de- preciation or use allowances (or donated equipc=ot and buildings is based on the ?roperty's mari:et value at the time it was doo:lted. . . 84 S 7~.57 Appr.llsal of real p~opert).. .In some cases under ~ ~ 74.55 and i J.:5 6, it will be Decessary to wi'lbl.ish the market valuc ot land or a building or the ("it rental (lte of land or ':Jl space i.c. a .building. In thc:se .,:ases, the gr:lOd..ag agency cay EXHIBIT G (1) CUSTOMER NAME: (4) CURRENT PLACEMENT: (6) CURRENT D.T.P.: (8) VENDOR NUMBER: (9) REASON FOR SERVICES: (10) L.T.R.C. REPLACEMENT NAME: (12) REASON FOR D.T.P.IL.T.R.C. REPLACEMENT: (2) D.O.B:_'_'_ (3) SS#: (5) PROPOSED PLACEMENT: (7) PORPOSED D.T.P,: (11) D.T.P. PLACEMENT NAME: FUNDING SOURCES MEDiWAIVER PARTICIPANT S.S.1. RECIPIENT S.S.A RECIPIENT OTHER THIRD PARTY SECTION 8 FINANCIAL INFORMATION YES NO AMOUNT REPRESENTATIVE PAYEE OTHER PARTICIPATING AGENCY - - - _...~ ~-~'--'-- - -<. '" . - , SECTION C SERVICES RATES AND UNIT ONGOING CONTRACT ONE TIME ANTICIPATED EFFECTIVE OF MEASURE CATEGORY EXPENSE EXPENSE PLACEMENT PLACEMENT DATE DATE RESIDENTIAL I ROOM AND BOARD I I I I L.T.R.C. I I. F. S. MEDiWAIVER I I I D.T.P. I I. F. S. MEDiWAIVER I I I , TRANS. I I. F. S. MEDiWAIVER I ! i I MEDICAL I I. F. S. MEDiWAIVER I I I RESPITE I I. F. S. MEDiWAIVER I I I RES.HA8 I I. F. S. MEDiWAIVER I I I OTHER I S.8. I.F.S MEDiWAIVER I I I SECTION D (1) SUBMITTED BY (2) HSPS PLACEMENT (3) CONTRACT MANAGER (4) OMC I BUDGET NEW CUSTOMER/ONE TIME ONLY EXP.) DATE DATE DATE DATE I SECTION E 1 cc: HSPS II (BUDGET) HSPS II (PLACEMENT) (1) CONTRACT MANAGER: (2) FIELD UNIT INPUT INTO ASS IMMEDIATELY AGENCY (3) WS.C INPUT INTO ABC IMMEDIATELY - '1 OPOS (EFF 10109190) REVISED 02126/92 REVISED 10/22/92 REVISED 10/14194 85 Exhibit G INSTRUCTIONS FOR COMPLETING CUSTOMER AUTHORIZATION FORM 1. 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 PLACEMENT COORDINATOR DEPARTMENT OF CHILDREN & FAMILY SERVICES 401 NW 2ND AVE - S518 MIAMI, FL 33128 II. IF PLACEMENT COORDINATOR INITIATES AUTHORIZATION REQUEST FOR SERVICES OTHER THAN SUPPORTED LIVING AND SUPPORTED EMPLOYMENT: COMPLETE: 1. Section A - Question 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 III. 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 expo 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/Contracts section will complete signature line #3 for individuals who receive services through CSLA, Medicaid Waiver or General Revenue 86 -...................L n Instructions for Administering the Client Satisfaction Sun.ey The purpose of this st2.te\\ide client satisfaction Slli""\'ey is to help determine bow well L~e agen'cy i?Ju!filling its vision of being client centered, co:nrmmity based, and results ori~nt;:d. Tne pri m 2.:.'")' objective of t.his Slh""\'ey is to obtai.n iriormation from clients on a regula: basis (r.\i~e a yea:) to aid in pCrf0:Ti12..1Ce ma.1agement a.'1d improvement. This generic su:n~y \\ill be use': to look acr:,.oss all t2.rge~ groups r.t t!:.:: S~2.te level. The iruo:mation from L~e SLLrycy \\ill not be used to c\'alU2.te i.ndividU2.1 sr.::..ft members. AdmirUstcring the instrument is L~e most critical step in the survey process. \Ve appreciate your participation in administering this survey. You ere JlQ.t expected to sit while the client fills out the survey. Use the guidelines below to Gdministcr the survey properly. . Ask the client to fill out the Slh"'vey. . Explain the purpose of the survey. . Ex)'!ain to t~e .client that L~C info:rnation from L~e slL""\'e)' \"ill assist the agency in making i...np"rovements. . Give the client specific instructions on retu:.u.ing the completed fOml. Instruct them to use black in..~ if possible and completely fill in circles. Tney can write comrnents in the space provided but shoul<i not \"nte elsewhere on the form (except the back). . Explain that they should respond in terms of their most recent experiences with the services provided for L~e identified target group. Help them focus, if needed, on the servoices Lf}ey should rate. Hopefully, their responses will reflect their sreneral percep:io:1 of L~ese seryices, not a single encounter. . Instruct the client to use the "Not Applicable" category as needed. For exarnple, if services were provided in the home, #10 should be marked "Not Applicable". . Assure the client that the information from hisrner slL.-vey \\i11 be confidential. . If admirjstering the SlL-vey in the office, give the client a plain white envelope and ask Lf}e client to place L~e survey in the drop box provided. If administering the survey out of the office, gi....e the client 2. stamped, addressed en....elope pro....ided by the district coordinator. Forms should be carefully tri-folded to'go into the envelopes. . Provide appropriate assistance to the client to complete and return the survey -- but only as requested. . Do nnt re\'iew the client's responses. . DCI TInt staple anything to the form. . Thm..: tne client for participating in the sun.ey. Your participatio/l in the sun'ey administration is ver)' much appreciated. Thank youfor your time and effort. CSSnscr.do: 5/6/97 ... 87 ~ & FAMILIES ..,C\......--J 1317 ....i,-.c....ooc DIve!. T~I.1.".,:.~~. F1. 32399~iC.J EXHIBIT H (co:: t. \ / " -, Dear Client: The Depar.men: of Children and Fam11ies is conducting 2. stater..-ide cEent satisf2.ction survey \vhich \\ill help us find out what parents thin." about their cxpenence \\ith . Departmen: of CrJldren and Families counselors. Your answers "..ill help us improve what we do. Your name was selected at random,.from a list of thous!I1ds who have had some contact with th~' depari.meni \\itrun the past year. This is a cOiU'identiaJ survey so please do not put your name'do the form. Your answers \\i11 be compared to what other parents tell us. Your name \~ill r:ot be used 2J1d no on~ \'..ill kno"..... which cho:ces are yours. Please fill in the appropriate circle across from each statement on the survey form ana write any comments or suggestions you may ha.....e at this time. A staii1ped, self-addressed em'elope is enclosed for your convenience. Than-I..: you for your help. Sincerely, Jd'Y:C!o- {l~,.) Linda Radigan Assistant Secretary Family Safety & Presei\'ation Working in pa,-tner.ship witJ: local communities to help people be self-sufficient and live in stable families and communities 88 ~ '- . I . ...,..,. . ... ..... , Ed.....2~d A. Fe2'1a; Se:rc:a~ & FAMI LI ES EXHIBIT H (cont) Muy estimado c!iente: EI Departamento de Asistencia F'amilia:- ha iniciado un sondeo ofic!21 a 10 larao del eslado de la Florida, con el p~op6sito de determinar el grado de satisfacci6n con los servicios ofrecidos y con respedo a la calidad del trabajo de los ase- sores profesionales que oo;an bajo el rubrico de la agencia. Ud. ha side seleccionado[a) para participar en esla encuesta, a: obtener su nombre al aZ2r de una lisla de personas que han tenido conlacto con el depar- tamento durante este pasado ano. Su co!aboraci6n con esle sand eo nos asis- tire en la planific2ci6n y posible mejoramiento de los servicios prestados al pu- blico, ya que se realizara una evaluaci6n comparativa de las respueslas someli- das.- " '.~ . Este es un informe confidencial; por 10 tanto, no es necesario que se identifique en el formulario adjunlo. Ni su nombre ni su direcci6n apareceran en ningun do- cumento, y nadie podra indentificarlo par sus respuestas. Haga el favor de marcar el circulo apropriado en cada una de las piOpueslas del formul,ario, Y anole en el margen cualquier comentario 0 sugerencia adicional que desee ofrecer. . . Se Ie agradece de antemano su cooperaci6n con esla encuesta. Cordialmente, . ~~~d!~~~ Secretaria-Asistente Seccion de Seguridad y Prevencion de I:: Fa;nilia Departamento de Asistenda Familiar 1317 V't'i:1:','''::lod BO'Jlevarc, T2aa~assee, Floiida 32393.0700 ~'/ort:ing in parlnf::ship \'Ir~h loea: comm:.mi:ies to help pe?pfe be sel/-s'.Jfii-;ien: 2nd live b s,!ab/e families end commumt/~s. 89 lsi\' ....., I LVI~J:,I~ &, FAMILIES Ec!W2:d A. Fca'/e: Se::retary EXHIBIT H (cont) 1317 Winewood Blvd T2.llahass::, r.L 32399.1)iOO .. '. Che Kliyan: Depatmen Timoun ek Fanmiy-yo (Department of Children end Families) ep fa yon evaliasyon atrave tout Florid-Ie pou ede nou konnen kisa paren yo pense de.xe eksperians yo eves. konseye Depetman Timoun ak Fanmiy-yo. Repol1s ou 2P ede nou fE~ travay-Ia pi byen. . Yo te chwazi non-ou nan yon lis de miliye moun ki fa kon~ak avek Depatman-a:1 nan denye ana pase yo. Evaliasyon sa-a konfidansyel, konsa pa mete non-w sou f6m-nan. Nou pral ~onpare repons ou yo avek sa lot paran yo di nou. Yo pap Hilize non-','! e pes6n pap konnen ki chwa ou fe. Tanpri ranpli ti'bou! yo dapre sa yo k~responn pou chak kesyon, e ekri nenpot komante aubyen sigjesyon au genyen. Ou-ap j'o'/enn yon anvlop, adrese ak tout tena pO'J-W itilize. t'liesi anpil pou ed-ou. Sensemsn, d7if~~ Assistant Secretary Family Safety and Preservatio:1 Wor'r:ing in partn~rship with loca! communiti~s to h~!p people be se/f-sufiicient and liw: in stable (amifies and c'Jr;,(jjunities. 90 ~ 9. 2 (~;. ~ :::: r. t: < !:: C. o ... o '1 () o I c: " C) t) o ~ o , .... -::::: ~~ n t: .. ... ~ $ c:;- n ... r o n tJ g (') o c. o :j ~ D :::: ::J ~ g '" g. g /5 0' ""t /, i l i' I ~ I, c.o I ~ I -. ~ I c: =< Q '=' ~r p, I R ....- "'< c., ~ ~ ~ n - o' 0' ::1 n l:J n ~, ~ 0' 1:S l.:) r:; :;:- nC. ;:.,.:: c5 0 c ::: ~, ::; == g --0 n, e. o I () :..: = Co .;; ~r l;f I-3 I o 010/ o 0/0 o 0 0 0 0 0/0 I ~ 0 0 0 0 '0 I 0 '0/0 0 0/0/0/0 o I 0 I 0 /0/ 0/ 0 I 0 I I ' I ..- .... n - - CJ n 3 -c -< n n e. ... '< ::; n n e. ~ o <: n ., t.: ~. t.J ., g ~ 3 o' 'C ~ ~ E ~ c. _ g 2.' 0 ~ .., ... ".- ~ Q ~ ~ ., Q 2 R ~ 1 ~'I '[ ~ ~ ~. g ~ i I (,'1 r: n . n c., Cj - c. C' n ~ I .c. ~ 010 010 o 000 I I I I I I I ! I I I I ~gl~~ -:i1 Qt") ~:: . n o !? c.: ~i'l ~ :J !;!. E: ~ c.. n po. 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The Florida Gomputer Crimes Act, Chapter 815, Florida Statutes, addresses the unauthorized modification, destruction, disclosure, or taking of information resources. . I have read the above statements and have been provided a copy of the Computer Related Crimes Act, Chapter 815, F. S. . By my signature, I acknowledge that I have received, read and understand Chapter 815, F.S., and have received any necessary clarification from my supervisor, I understand that a security violation may result in criminal prosecution according to the provisions of Chapter 815. F. S., and may also result in disciplinary action against me according to the provisions in the Department of Children and Family Services Employee Handbook( ). The minimum security requirements are: . Personal passwords are not to be disclosed, except as provided in paragraph 4,d., HRSOP 50-6. . 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