Backup Documents 06/23/2020 Item #16D13ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 160 13
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines # 1 through #2 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 a line through routing lines # 1 through #2, complete the checklist and forward to the Coun Attorney Office.
Route to Addressees (List in routing order)
Office
Initials
Date
1. Wendy Klopf
Community and Human
Services
Wk
06/23/20
2. Minutes and Records
Clerk of Court's Office
-P(n
b/A(20
y=apl)
PRIMARY CONTACT INFORMATION
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, may need to contact staff for additional or missing information.
Name of Primary Staff
Wendy Klopf/CHS
Phone Number
252-2901
Contact / Department
Agenda Date Item was
06/23/20
Agenda Item Number
16D (W ?
Approved b the BCC
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Type of Document
Amendment ADI 203.19.003
Number of Original
1
Attached
Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark "N/A" in the Not Applicable column, whichever is
Yes
N/A (Not
a ro riate.
Initial
Applicable)
1.
Does the document require the chairman's original signature?
NA
2.
Does the document need to be sent to another agency for additional signatures? If yes,
NA
provide the Contact Information(Name; Agency; Address; Phone on an attached sheet.
3.
Original document has been signed/initialed for legal sufficiency. (All documents to be
WK
signed by the Chairman, with the exception of most letters, must be reviewed and signed
by the Office of the County Attorney.
4.
All handwritten strike -through and revisions have been initialed by the County Attorney's
NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5.
The Chairman's signature line date has been entered as the date of BCC approval of the
NA
document or the final negotiated contract date whichever is applicable.
6.
"Sign here" tabs are placed on the appropriate pages indicating where the Chairman's
WK
sip -nature and initials are required.
7.
In most cases (some contracts are an exception), the original document and this routing slip
NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
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!
8.
The document was approved by the BCC on 06.23.20 and all changes made during
WK
the meeting have been incorporated in the attached document. The County
Attorne 's Office has reviewed the changes, if applicable.
1
VAJIF_
9.
Initials of attorney verifying that the attached document is the version approved by the
WK
i
BCC, all changes directed by the BCC have been made, and the document is ready for the
an option_,..
Chairman's signature.
this line.
I: Forms/ County Forms/ BCC Forms/ Original Documents Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.05; Revised 11/30/12
1u1y 2019 to I,,,.c `?0}0 AD[ 203,19.003
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA, INC.
ALZHEIAIER'S DISEASE INITIATIVE PROGRAM STANDARD
COLLIER COUNTY BOARD OF COUNTY COMMISSIOiNERS
THIS AMLI'lliNjEN I' is entered into betiveen the Area Agency on Aging for Southwest Florida, Inc. ("Agency") and Collier
County Board of County Coniniissioners ("Contractor"), amends agreement AD4 203.19.
The purpose , f this amendment is to add Shopping Assistance and Telephone Reassurance services; revise
ATTACH,IMENT I and ATTACHMENT XV SERVICE RATE RE, PORT.
L ATTACHMENT I, Section ILE.I.a. 13-14, is hereby added:
13) Shopping Assistance — COVID-I 9
14) Telephone Reassurance---COVID-t 9
2. Client Call Tracker Spreadsheet provided by the Area Agency will be used for maintaining records for
Telephone Reassurance.
All provisions in the contract and anv attachments thereto in conflict With this Amendment shall be and are
hereby changed to conform to 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 contract.
Tliis Amendment and all its attachments are hereby made pats of the contract
IN WITNESS THEREOF, the Parties hereto have caused this amendment, to be executed by their undersigned
officials as duly authorized; and agree to abide by the terms, conditions and provisions of this AD] contract as
amended. The Telephone Assurance and Shopping Assistance is effective as of April 1, 2020.
IN WITNESS WHEREOF, the Parties hereto have caused this amendment to be executed by their undersigned officials
as duly authorized.
CONTRACTOR: COLLIER COUNTY
BOARD OF COON Y OMMI S
SIGNED BY: ( 1
NAME: STEPHEN Y CARNELL
TITLE:PUBLIC SERVICE DEPARTMENT 14EAD
DA,rE: O,F/ 1 /2020
Federal Tay. ID: 59-6000558
Fiscal Year Ending Date: 09/30
Duns: 076997790
AREA AGENCY ON AGING FOR
SOUTHWEST FLORIDA, INC.
SIGNED BY:i2�1�u:�.
NAME: MARIANNE G LORINI
TITLE: PRESIDENT/CEO
DATE: c .S
Approved as to Form anti l+;gulity
Assi utt Caunly A it ney
16013
July 2019 to June 2020
ATTACHMENT XV
SERVICE RATE REPORT
Collier
DELIVERABLES
Case Aide:
Case Management:
Respite In -Facility:
Respite In -Home:
Shopping Assistanec—. COVID-19**
Telephone Reassurance—COVID-19**
Specialized Medical Equipment, Services and
Supplies
Transportation
ADI 203.19,003
HIGHEST
REIMBURSEMENT METHOD OF
UNIT RATE PAYMENTS
$33.88 Fixed Fee / Unit Rate
$60.00 Fixed Fee / Unit Rate
$11.44 Fixed Fee / Unit Rate
$25.02 Fixed Fee / Unit Rate
$34.12 Fixed Fee/Unit Rate
Per ONE-WAY
$13.40 Fixed Fee/Unit Rate
Per EPISODE
Cost Reimbursement
Cost Reimbursement
**Effective April 1, 2020. Please note these two services are temporary and will be reevaluated once the
Governor's Executive Order has been lifted.
2
16013
Revind August 2007
Attestation Statement
Agreement/Contract Nmnber All] 203.19
Amendment Number .003
1, Stephen Y Carnell , attest that no changes or revisions have been made to the
(Recipient/Contractor representative)
content of the above referenced agreentent!cmit•act or amendment between the Area Agency on Agiag for
Southwest Florida and
_Collier County Board of County Commissioners
(Itccipicnt/Contractor name)
The only exception to this statement would be for changes in page formatting, (tile to the differences in
electronic data processing media, which has no affect on the agreement/contract content.
1z,
Signature of ecipient/ . itractor representative Date
Ahhrowd�as-,to titrni and Icl;ality
Assistant County ttzmlly
Revised August 2007
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