Backup Documents 09/11-12/2012 Item #16D14ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
16014
ROUTING SLIP
Complete routing lines # 1 through #4 as appropriate for additional signatures, dates, and/or information needed. If the document is already complete with the
exception of the Chairman's signature, draw aline through routing lines #1 through #4, complete the checklist, and forward to Ian Mitchell (line #5).
Route to Addressee(s)
(List in routing order)
Office
Initials
Date
1. Louise Pelletier
HHVS
(Initial)
Please call or e-mail
2.Ian Mitchell, Executive Manager
Board of County Commissioners
LP
3. Minutes & Records
Clerk of Courts
Agenda Item Number
ct of
Approved by the BCC
by the Office of the County Attorney. This includes signature pages from ordinances,
Type of Document
Amendment to contract agreement
Number of
4 documents 2 copies
Attached
an original signature from the
Chairman needed on each copy
Documents Attached
of each
Total: 12 documents
PRIMARY CONTACT INFORMATION
(The primary contact is the holder of the original document pending BCC approval. Normally the primary contact is the person who created/prepared the executive
summary. Primary contact information is needed in the event one of the addressees above, including Ian Mitchell needs to contact staff for additional or missing
information. All original documents needing the BCC Chairman's signature are to be delivered to the BCC office only after the BCC has acted to approve the
item.)
Name of Primary Staff
Louise Pelletier / Housing, Human and
Phone Number
252 -2696
Contact
Veteran Services
(Initial)
Please call or e-mail
for pick u
Original document has been signed/ initialed for legal sufficiency. (All documents to be
LP
Agenda Date Item was
September 11, 2012
Agenda Item Number
16 D 14
Approved by the BCC
by the Office of the County Attorney. This includes signature pages from ordinances,
Type of Document
Amendment to contract agreement
Number of
4 documents 2 copies
Attached
an original signature from the
Chairman needed on each copy
Documents Attached
of each
Total: 12 documents
INSTRUCTIONS & CHECKLIST
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
Initial the Yes column or mark "N /A" in the Not Applicable column, whichever is
Yes
N/A (Not
appropriate.
(Initial)
Applicable)
1.
Original document has been signed/ initialed for legal sufficiency. (All documents to be
LP
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney's Office and signature pages from
contracts, agreements, etc. that have been fully executed by all parties except the BCC
Chairman and Clerk to the Board and possibly State Officials.)
2.
All handwritten strike - through and revisions have been initialed by the County Attorney's
LP
Office and all other parties except the BCC Chairman and the Clerk to the Board
3.
The Chairman's signature line date has been entered as the date of BCC approval of the
LP
document or the final negotiated contract date whichever is applicable.
4.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
LP
signature and initials are required.
5.
In most cases (some contracts are an exception), the original document and this routing slip
LP
should be provided to Ian Mitchell in the BCC office within 24 hours of BCC approval.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
6.
The document was approved by the BCC on 09/11/12 (enter date) and all changes
LP
made during the meeting have been incorporated in the attached document. The
County Attorney's Office has reviewed the changes, if applicable.
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05
16p14
MEMORANDUM
Date: September 14, 2012
To: Louise Pelletier, Case Management
Housing, Human &Veteran Services
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Amendment to Contract Agreement CCE 203.12.001
Attached are twelve (12) originals referenced above, (Item #16D14) approved by
Board of County Commissioners on September 11, 2012.
After forwarding for signature and subsequent return, please send an executed
original to the Minutes and Records Department for the Board's Official Record.
If you have any questions, please contact me at 252 -8411.
Thank you.
Attachment
0 Ter C;014ftty
Public Services Division
Housing, Human & Veteran Services
Date: September 27, 2012
To: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
From: Louise Pelletier, Case Management Supervisor
Housing, Human & Veteran Services
Re: Area Agency on Aging of SW FL for
Amendment ADI 203.12.001
Amendment CCE 203.12.001
Amendment NSIP 203.12.001
Amendment HCE 203.12.001
BCC Meeting 09/11/2012
Item: 16.D.14
16014
Enclosed are the originals of the signed documents referenced above being forwarded to
the Minutes and Records Department for the Board's Official Record.
If you have any questions, please contact me at 239 - 252 -2696.
Thank you.
Humani an d
Vel ern 1�services .
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Amendment 001 CCE 203.12.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA 16014
STANDARD CONTRACT
COMMUNITY CARE FOR THE ELDERLY PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ( "Agency ") and Collier County Board of County Commissioners, ( "Recipient "), amends agreement
CCE 203.12.
The purpose of this amendment is to revise Attachment VIII, Rate Summary to increase Case Management services rate
and to add Respite Facility service.
This amendment shall be effective on July 1, 2012. All provisions in the agreement and any attachments thereto in
conflict with this amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF
COUNTY COMMISSIONERS
SIGNED BY: -L �,j c",j
NAME: Fie. V_.0 W. C oy L
TITLE: C ku .r4 I e- /tl_n A)
DATE:
C,I It I I t2
Federal Tax ID: 59- 6000588
Fiscal Year Ending Date: 09/30
4Mved as to form & legal Sufftj"cy
AREA AGENCY ON AGING FOR SOUTHWEST
FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: 4ei A,4 --,k
NAME: LEIGH ANNA NOWAK
TITLE: BOARD PRESIDENT A
DATE: '/ tz-
As3istant County Attorney
3'_ ry N I -f-i-,Q (3.,,4,\ �-T �F
.a�1 *7_1T
UV ,fl 'IT E. BROOK, ciaxl:
' �t
to Cha,i rpw ak
�,t�ri� bier'! get •. ,� ,
Amendment 001
COMMUNITY CARE FOR THE ELDERLY PROGRAM
BUDGET SUMMARY
for
Collier County Board of Commissioners
Collier County
1. CCE Spending Authority $589,107.00
2. Case Management and 72 250.00
Case Aide '
Total $661,357.00
RATE SUMMARY
for
Collier County Board of Commissioners
Collier County
CCE 203.12.001
16014
ATTACHMENT VIII
Collier County
Total Unit Cost
Reimbursement Rate- 90%
Case Management
$55.56
$50.00
Case Aide
$30.00
$27.00
Adult Day Care
$12.22
$11.00
Chore
$22.22
$20.00
Enhanced Chore
$28.89
$26.00
Companion
$22.22
$20.00
Skilled Nursing
$40.00
$36.00
EARS
$ 1.24
$ 1.12
Homemaking
$21.11
$19.00
Personal Care
$24.44
$22.00
Respite -in Home
$24.44
$22.00
Respite Facility
$12.22
$11.00
Specialized Medical Equipment,
Services & Supplies
$ Cost Reimbursement
$90% Cost Reimbursement
Transportation
$ Cost Reimbursement
$90% Cost Reimbursement
2
16D14
Attestation Statement
Agreement /Contract Number CCE 203.12
Amendment Number 001
I, Fred W. Coyle , attest that no changes or revisions have been made to the
(Recipient /Contractor representative)
content of the above referenced agreement /contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement /contract content.
Fred W. Coyle, Chairman
Collier County Board of Commissioners
Approval as to form & legal Sufficiency:
Jennifer B. White
Assistant County Attorney
09/11/2012
Date
YN
A""*
Amendment 001 ADI 203.12.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC. D
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
STANDARD CONTRACT s
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ( "Agency ") and Collier County Board of County Commissioners, ( "Recipient "), amends agreement
ADI 203.12.
The purpose of this amendment is to revise Attachment VIII, Rate Summary, to increase Case Management services rate.
This amendment shall be effective on July 1, 2012. All provisions in the agreement and any attachments thereto in
conflict with this amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF
COUNTY COMMISSIONERS
SIGNED BY:
NAME: F2�C) J • c o y L �. \
TITLE: C"'k, N (k, M-A t)
DATE: Cl \ N't \ `-Z-
Federal Tax ID: 59- 6000588
Fiscal Year Ending Date: 09/30
APPMVW U to form & legal SUfftl•ncy
ASSIstant County ,attorney
AREA AGENCY ON AGING FOR SOUTHWEST
FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: - , � 24, "),
NAME: LEIGH ANNA NOWAK
TITLE: BOARD PRESIDENT
q
DATE: / 1�S - r)^
ATTE=ST'
DWI T E. BROOK lark
A"ftst t0 CMIMM -1
Amendment 001
ALZHEIMER'S DISEASE INITIATIVE PROGRAM
BUDGET SUMMARY
for
Collier County Board of County Commissioners
1. Respite
2. Case Management and Case Aide Allocation
3. Total
RATE SUMMARY
for
Collier County Board of County Commissioners
SERVICES
Case Management
Case Aide
In -Home Respite
Respite Facility
Specialized Medical Equipment,
Services and Supplies
PA
ID�6'fl� "4
ATTACHMENT VIII
$93,969.00
750.00
$94,719.00
UNIT RATE
$55.56
$30.00
$24.44
$12.22
100% Reimbursement
16D14
Attestation Statement
Agreement /Contract Number ADI 203.12
Amendment Number 001
I, Fred W. Coyle , attest that no changes or revisions have been made to the
(Recipient /Contractor representative)
content of the above referenced agreement /contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Recipient/Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement /contract content.
Fred W. Coyle, Chairman
Collier County Board of 1
Approval as to form & legal Sufficiency:
Jennifer B. White
Assistant County Attorney
09/11/2012
Date
,;
;,NT 1;
Mtw
'.
V,j .
Amendment 001 - Revised HCE 203.12.001- Revised
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
dba SENIOR CHOICES OF SOUTHWEST FLORIDA 16014
STANDARD CONTRACT
HOME CARE FOR THE ELDERLY PROGRAM
COLLIER COUNTY BOARD OF COUNTY COMMISSIONERS
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ( "Agency ") and Collier County Board of County Commissioners, ( "Recipient "), amends agreement
HCE 203.12.
The purpose of this amendment is to revise Attachment VIII, Budget Summary to switch HCE basic subsidies amount and
HCE special Subsidies amount and Rate Summary to increase Case Management services rate.
This amendment shall be effective on July 1, 2012. All provisions in the agreement and any attachments thereto in
conflict with this amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment to be executed by their officials there
unto duly authorized.
Recipient: COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: SIGNED BY:
NAME: X 2£ 0 (.j, C a 4 L_ E NAME
TITLE: C4-1.A i 2 M A N-)
DATE: 9 1' ` i \Z-
Federal Tax ID: 59- 6000588
Fiscal Year Ending Date: 09/30
1ppmed as to form & legal Sut'iclenCY
As atant County Attorn &Y
SFt-3►.).F£Q r3. -.kaA'-"'5,
TITLE
LEIGH ANNA NOWAK
BOARD PRESIDENT
DATE: T - 6 • /°>
ATTEST
D I T E. BROCIC, C�erk,,,
t
to t�q irk
tk
W;
Amendment 001- Revised
HOME CARE FOR THE ELDERLY PROGRAM
BUDGET SUMMARY
Collier County Board of Commissioners
HCE Case Management $ 4,601.00
HCE Basic Subsidies 13 -27 -HCE Clients 40,680.00
HCE Special Subsidies 16,428.00
Total $61,709.00
HOME CARE FOR THE ELDERLY PROGRAM
SERVICES
Case Management
Case Aide
RATE SUMMARY
2
HCE 203.12.001- Revised
16D14
ATTACHMENT VIII
REIMBURSEMENT RATE
$55.56
$30.00
16D14
Attestation Statement
Agreement /Contract Number HCE 203.12
Amendment Number 001
I, Fred W. Coyle , attest that no changes or revisions have been made to the
(Recipient /Contractor representative)
content of the above referenced agreement /contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Recipient /Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement /contract content.
Fred W. Coyle, Chairman
Collier County Board of 1
Approval as to form & legal Sufficiency:
Jennifer B. White
Assistant County Attorney
1 `'
09/11/2012
Date
Amendment 001 NSIP 203.001
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC. 16014
dba SENIOR CHOICES OF SOUTHWEST FLORIDA
STANDARD CONTRACT
NUTRITION SERVICES INCENTIVE PROGRAM
THIS AMENDMENT is entered into between the Area Agency on Aging for Southwest Florida, Inc. dba Senior Choices
of Southwest Florida ( "Agency ") and Collier County Board of County Commissioners (Contractor), amends agreement
NSIP 203.12.
The purpose of this amendment is to decrease allocation by $9,000, revise Attachment I- SECTION III, 3.1 Statement of
Method of Payment and ATTACHMENT III Exhibit -1, 1. Federal Resources Awarded to the Subrecipient.
This amendment shall be effective on August 9, 2012. All provisions in the agreement and any attachments thereto in
conflict with this amendment shall be and are hereby changed to conform with this amendment.
All provisions not in conflict with this amendment are still in effect and are to be performed at the level specified in the
agreement.
This amendment and all of its attachments are hereby made a part of this agreement.
IN WITNESS WHEREOF, the parties hereto have caused this 3 page amendment to be executed by their officials there
unto duly authorized.
Contractor COLLIER COUNTY BOARD OF AREA AGENCY ON AGING FOR SOUTHWEST
COUNTY COMMISSIONERS FLORIDA, INC. DBA SENIOR CHOICES OF
SOUTHWEST FLORIDA
SIGNED BY: C"'t SIGNED BY: Aj_��
0 _��
NAME: Fa-F- £ 0 1n) , Co y L g NAME:
TITLE: L -0 ► 2 M.A rJ
DATE: 9 \ %-% \-%"2._
Federal Tax ID: 59- 6000558
Fiscal Year Ending Date: 09/30
PMV6d as to Iorrn & logai Sufficiency
A ssis ant County Attorney
TITLE:
LEIGH ANNA NOWAK
BOARD PRESIDENT
DATE: T. a G , /',.,;L-
ATTEST:
I; WIG T E. BROCK Cl f'k;,,
to Cho I rim
Amendment 001
NSIP 203.001
AT AC EIT 6U SECTION III: METHOD OF PAYMENT
4
3.1 STATEMENT OF METHOD OF PAYMENT
This is a fixed rate contract. The Agency shall make payment to the Contractor for provision
of services up to a maximum number of units of service and at the prospective rate stated
below:
Service to be Provided
Unit of Service
Unit Rate
Eligible Congregate and
Home Delivered Meals
1 unit = 1 meal
$0.68
The prospective rate is based on the estimated OAA grant award.
COLLIER
Service to be
Provided
Unit of Service
Unit Rate
Maximum
Units
Allocation
Eligible Congregate
I unit= I meal
$0.68
50,886
$ 34,602.00
and Home Delivered
Meals (Under OAA
and ARRA
0
Amendment 001
16014 NSIP 203.001
ATTACHMENT III
EXHIBIT —1
1. FEDERAL RESOURCES AWARDED TO THE SUBRECIPIENT PURSUANT TO THIS
AGREEMENT CONSIST OF THE FOLLOWING:
PROGRAM TITLE
FUNDING SOURCE
CFDA
AMOUNT
Nutrition Services Incentive Program
Older Americans Act
93.053
$34,602.00
TOTAL FEDERAL AWARD
$ 34,602.00
TOTAL FEDERAL AWARD
$34,602.00
COLLIER
PROGRAM TITLE
FUNDING SOURCE
CFDA
AMOUNT
Nutrition Services Incentive Program
Older Americans Act
93.053
$ 34,602.00
TOTAL FEDERAL AWARD
$ 34,602.00
3
16D14
Attestation Statement
Agreement /Contract Number NS1P 203.12
Amendment Number 001
1, Fred W. Coyle , attest that no changes or revisions have been made to the
(Recipient /Contractor representative)
content of the above referenced agreement /contract or amendment between the Area Agency on Aging for
Southwest Florida dba as Senior Choices of Southwest Florida and
Collier County Board of Commissioners
(Recipient /Contractor name)
The only exception to this statement would be for changes in page formatting, due to the differences in
electronic data processing media, which has no affect on the agreement /contract content.
Fred W. Coyle, Chairman
Collier County Board of Commissioners
Approval as to form & legal Sufficiency:
Jennifer B. White
Assistant County Attorney
09/11/2012
Date
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