Backup Documents 03/11/2025 Item #16D 3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 3
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 3.11.25 BCC MTG
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 County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Carolyn Noble Community and Human CN 3.4.2025
Services
2. County Attorney Office— County Attorney Office
bi25
3. BCC Office Board of County
Commissioners ,S ky ;)0(z.5
4. Minutes and Records Clerk of Court's Office `
a
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepare 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 inf ation.
Name of Primary Staff Carolyn Noble Phone Number 239-450-5186
Contact/ Department
Agenda Date Item was 3.11.25 BCC Mtg Agenda Item Number 16.D.(3
Approved by the BCC
Type of Document 3 DLC STATE MANDATED MOU Number of Original 3 DOCUM NTS
Attached Documents Attached (GGUPIe
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
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature STAMP OK CN
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
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 Yes
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 N/A
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 N/A
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 YES
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip N/A
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 above date and all changes made during ( N/A is not
the meeting have been incorporated in the attached document. The County 9L"i lnh an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the /A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the 90 option for
Chairman's signature. is line.
16D3
MEMORANDUM OF UNDERSTANDING BETWEEN COLLIER COUNTY
AND
DAVID LAWRENCE MENTAL HEALTH CENTER,INC.
THIS MEMORANDUM OF UNDERSTANDING (MOU) is made and entered into on
this CIfI' day of jLcrdl, 2025; by and between Collier County, a political subdivision of
the State of Florida(COUNTY), having its principal address as 3339 E.Tamiami Trail,Naples,FL
34112, and David Lawrence Mental Health Center, Inc, (RECIPIENT) a private not-for-profit
corporation under agreement with the State of Florida, Department of Children and Families,
through the Central Florida Behavioral Health Network, Inc. contract,having its principal address
at 16075 Bathey Lane, Naples, FL 34116;.
WHEREAS, Section 125.01(1)(e), Florida Statutes, authorizes the COUNTY to provide
health welfare programs for the residents of Collier County to the extent not inconsistent with
general or special law; and
WHEREAS, the establishment and maintenance of such programs are in the common
interest of the people of Collier County; and
WHEREAS,The COUNTY desires the RECIPIENT to become a community health partner
to assist in providing services for substance use and mental health to eligible residents of the
COUNTY; and
NOW THEREFORE,in consideration of the mutual benefits contained herein,it is agreed
by the Parties as follows:
PART I
SCOPE OF SERVICES
1.1. The RECIPIENT shall in a satisfactory and proper manner and consistent with any standards
required as a condition of providing services as provided herein and as determined by Collier
County Community and Human Services (CHS) Division, perform the tasks necessary to
provide mental health and substance use services to residents of Collier County.
1.2. Provision of substance use and mental health services programs shall be provided to serve
residents of Collier County, in accordance with Chapters 394 and 397. Florida Statutes, and
all exhibits hereto.
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25 CAO
1-6 D---3
1.3. The RECIPIENT and/or its subcontractor shall provide timely responses to requirements.
1.4. Performance Deliverables
A. Clients Served
RECIPIENT will serve a minimum of 6,500 non-duplicated Collier County
residents/clients with at least one(1)unit of service, as defined by F.A.C. 65E-14 during
the MOU period. Clients may receive duplicated services; only one unit of service will
be applied to minimum number of clients served.
B. Performance Deliverables
Program Deliverable Supporting Documentation Submission Schedule
Insurance Proof of coverage in Within 30 days following
accordance with Exhibit B MOU execution and
annually within 30 days
after renewal
Quarterly Performance Exhibit C Quarterly by 30th of the
Report month following quarter
end.
Quarterly Match Obligation CARISK Match Report Quarterly by the 30th of the
month following quarter end
DCF/CFBHN/ Final Audit/Monitoring Within 30 days of receipt
Accreditation Agencies Report including any plans
Audit Reports of corrective action
Single Audit Audit report and Within 9 months of end of
management letter fiscal year
PART II
PAYMENTS
The COUNTY shall make intergovernmental transfers (IGT) on behalf of the RECIPIENT, in
connection with the Low Income Pool (LIP) program, to the State of Florida(State) in accordance with
the Letter of Agreement between the COUNTY and the Agency for Health Care Administration
(AHCA).
2.1. The COUNTY will remit to AHCA an amount not to exceed $1,719,499.44. The COUNTY
will transfer payment to the AHCA in the following manner:
2
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25
C:AO j
16D3
a. The payments for the months July 2024 —June 2025 are subject CMS approval of the
LIP reimbursement and funding methodology document. Once approved, AHCA sends
an IGT invoice to the COUNTY. Upon receipt of the IGT invoice from AHCA, the
COUNTY will remit payment to AHCA. AHCA subsequently provides LIP payment to
RECIPIENT. This timeframe has not yet been determined.
2.2. The COUNTY'S IGT payment in the amount of$1,719,499.44 shall serve as local match for
eligible mental health and substance use services. Should the RECIPIENT'S match obligation
decrease by 25%or more of the required local match amount of$ 1,719,499.44 over the term
of the MOU, the COUNTY may withhold future match funding in the following fiscal year.
2.3. The following document is hereby incorporated by reference as Exhibit A to this MOU.
a. Low Income Pool Agreement (LIP) with the State of Florida Agency for Healthcare
Administration (AHCA) reflecting the anticipated annual distributions for State Fiscal
Year t024-2025
PART III
TERMS OF MOU AND TERMINATION
3.1. The term of this MOU shall be October 1, 2024, through September 30, 2025. with no
renewal.
3.2. Either party may terminate this MOU thirty (30) calendar days after receipt of written notice
of intent to terminate from the other party and should the RECEIPIENT choose to terminate
the RECIPIENT is obligated to return the pro-rated share of the COUNTY'S funds paid on
the RECIPIENT'S behalf to AHCA.
3.3. Upon breach of this MOU, the aggrieved party may, by written notice of breach to the
breaching party, terminate the whole or any part of this MOU. Termination shall be upon no
less than 24 hours' notice, in writing, delivered by certified mail, or in person. Waiver by
either party of breach of any provisions of this MOU shall not be deemed to be a waiver of
any other or subsequent breach and shall not be construed to be a modification of the terms
of this MOU.
3.4. It is further agreed that in the event general funds to finance all or part of the AHCA LIP
agreement do not become available, the obligations of each party hereunder may be
terminated upon no less than 24 hours' notice in writing to the other party. Said notice shall
be delivered by certified mail, or in person.
3
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25 r—
(t.b4;l
16D3
PART IV
NOTICES
Notices required by this MOU shall be in writing and delivered via mail (postage prepaid),
commercial courier, personal delivery, or sent by facsimile or other electronic means. Either
party may change the address to which notices are to be sent to it by giving written notice of
such change to the other party in the manner herein provided for giving notice. Any notice,
request, instruction, or other document delivered or sent as aforesaid shall be effective on the
date of delivery or sending. All notices and other written communications under this MOU shall
be addressed to the individuals in the capacities indicated below, unless otherwise modified by
subsequent written notice.
COLLIER COUNTY ATTENTION:'Carolyn Noble, Grant Coordinator
Collier County Government
Community and Human Services Division
2671 Airport Pulling Road, Suite 202
Naples, Florida 34112
Email:Icarolyn.noble@colliercountyfl.gov
Telephone: (239) 450-5186
RECIPIENT ATTENTION: Scott Burgess,CEO & President
David Lawrence Mental Health Center, Inc.
6075 Bathey Lane
Naples, Florida 34116
Email: ,scottb@dlcenters.org
Telephone: (239)354-1425
PART V
ASSIGNMENT
The RECIPIENT and/or its subcontractors shall not assign or transfer this MOU, or any interest,
right, or duty herein, without the prior written consent of the COUNTY.
PART VI
SUBCONTRACTING
The parties agree that, upon approval of the COUNTY, the RECIPIENT shall be permitted to
execute subcontracts for the purchase of such services, articles, supplies, and equipment that are
both necessary and incidental to the performance of the work required under this MOU. However,
the RECIPIENT expressly understands that it shall assume the primary responsibility for
performing the services outlined in Part I of this MOU.
4
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25 (Let.^tom.
16D3
PART VII
INSURANCE, SAFETY, AND INDEMNIFICATION
7.1. Indemnity. To the maximum extent permitted by Florida law, the RECIPIENT and/or its
subcontractors shall indemnify and hold harmless the COUNTY against any claims,
damages, losses,and expenses, including reasonable attorney's fees and costs,arising out of
or resulting from the RECIPIENT'S failure to pay for services or performance under this
MOU. This indemnification obligation shall not be construed to negate, abridge, or reduce
any other rights or remedies which otherwise may be available to an indemnified party or
person described in this paragraph.
The RECIPIENT shall jointly and severally indemnify and hold harmless the COUNTY for
all claims demands, actions, suits, losses, costs, charges, expenses, damages, and liabilities
whatsoever which the COUNTY may pay, sustain, suffer, or incur by reason of or in
connection with this MOU, including payment of all legal costs, including but not limited to
attorney's fees paid by the COUNTY.
7.2. Insurance Required: RECIPIENT shall not commence any work and/or services pursuant to
this MOU, until all required insurance, as outlined in Exhibit B has been obtained. Said
insurance shall be carried continuously during RECIPIENT's performance under this MOU.
PART VIII
RECORDS
The RECIPIENT and/or its subcontractors shall keep orderly and complete records of its accounts
and operations related to the services provided under this MOU for the entire term of the MOU plus
six(6)years. The RECIPIENT and/or its subcontractors shall keep these records open to inspection
by COUNTY personnel at reasonable hours during the entire term of this MOU. If any litigation,
claim, or audit is commenced prior to the expiration of the six (6) year period and extends beyond
this period,the records must remain available until any litigation,claim,or audit has been resolved.
Any person duly authorized by the COUNTY shall have full access to, and the right to examine any
of said records during said period. Access to Protected Health Information (PI II) shall comply with
federal laws and the Health Insurance Portability and Accountability Act (HIPAA).
PART IX
CIVIL RIGHTS
9.1. In the performance of this MOU, there will be no discrimination against any employee or
person served based on race, color, sex, age, religion, ancestry, national origin, handicap, or
marital status.
5
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25
trig
16D3
9.2. It is expressly understood that, upon receipt of evidence of such discrimination, the
COUNTY shall have the right to terminate this MOU for breach of MOU.
9.3. The RECIPIENT and/or its subcontractors shall comply with Title VI of the Civil Rights
Act of 1964 (42 USC 2000(d))regarding persons served.
9.4. The RECIPIENT and/or its subcontractors shall comply with Title VII of the Civil Rights
Act of 1964 (42 USC 2000(c)) regarding employees or applicants for employment.
9.5. The RECIPIENT and/or its subcontractors shall comply with Section 504 of the
Rehabilitation Act of 1973 regarding employees or applicants for employment and clients
served.
PART X
OTHER CONDITIONS
10.1. The COUNTY or RECIPIENT may amend this MOU at any time, provided that such
amendments make specific reference to this MOU, are executed in writing, signed by a duly
authorized representative of each organization, and approved by the COUNTY'S Board.
Such amendments shall not invalidate this MOU, nor relieve or release the COUNTY or
RECIPIENT from its obligations under this MOU.
The COUNTY may, in its discretion, amend this MOU to conform with Federal, State, or
Local governmental guidelines, policies, available funding amounts, or other reasons. If
such amendments result in a change in the funding, scope of services, or schedule of the
activities to be undertaken as part of this MOU,such modifications will be incorporated only
by written amendment, signed by both COUNTY and RECIPIENT.
10.2. This MOU contains all the terms and conditions agreed upon by the parties. All items
incorporated by reference are as though physically attached. No other agreements, oral or
otherwise,regarding the subject matter of this MOU, shall be deemed to exist or to bind any
of the parties hereto.
10.3. The RECIPIENT and/or its subcontractors shall obtain and possess throughout the term of
this MOU all licenses and permits applicable to its operations under federal, state, and local
laws, and shall comply with all fire, health, and other applicable regulatory codes.
10.4. The RECIPIENT and/or its subcontractors agree to comply with all applicable requirements
and guidelines prescribed by the COUNTY for recipients of funds.
6
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25 (//�
1 6 D 3
10.5. The RECIPIENT and/or its subcontractors agree to safeguard the privacy of information
pursuant to HIPAA regulations.
10.6. If RECIPIENT provides services to clients under this MOU, RECIPENT and any
subcontractors shall report knowledge or reasonable suspicion of abuse, neglect, or
exploitation of a child, aged person, or disabled person to the COUNTY. During the term
of this MOU,RECIPIENT must report to the COUNTY in writing, within one business day
of occurrence, any substantial, controversial, or newsworthy incidents. The RECEIPIENT
shall use the standard CFBHN, DCF or Collier County Incident Report Form to report all
such incidents.
Signature Page to Follow
7
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25
16D3
IN WITNESS WHEREOF, the RECIPIENT and COUNTY have each respectively, by an authorized
person or agent, hereunder set their hands and seals on the date first written above.
ATTEST: AS TO COUNTY:
CRYSTAL�`, 44EL, CLERK
BOARD OF COUNTY COMMISSIONERS OF
/ p, '� COLLIER COUNTY, FLORIDA
` e
Attest a•;• i , '1r4:'Dept4ly Clerk
sig r=, ly : . By:
a. " VA B R L. SA S, CHAIRPERSON
fp• t,i�. KEY ,,,'‘
� ...
Dated: . lf, .i.
.(st L"} Date: 3/ 02,5
AS TO'RECIPIENT:
WITNESS :
'DAVID LAWRENCE MENTAL HEALTH
r 9V CENTER, INC.
Witness ignature
_`1}IVLH z- lite-}i 11.PA6 By:
itn ss#1 Printed Name 'SC T URGESS, CE & PRESIDENT
es #2 Sig ature
Date: -Z IB ___
t7'W Pi-t2MStc [Please provide evidence of signing authority]
Witness#2 Printed Name
Appro '• s t• ft rm and legality:
: ..itlifi A
Ili liall-4
Jeff A. •tzkt w
County tto y
Date: 1 li t/1 (
I
8
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool 24-25
i (CA.O
I
16D3
EXHIBIT A
LOW INCOME POOL AGREEMENT
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool
CAO
16D3
Low Income Pool Letter of Agreement
THIS LE-TER OF AGREE'vtEN1 tLOA;• s made and entered into in duplicate on th Zy '.
day of Sept. 2024, by a .: cetweer Collier County tune`iGT Provider")on behalf of
David Lawrence Behaviors,Health and the State a'F crida.Agency for Health Care
Administration;the`Agency') for good and valuable cons.derat,on. the receipt and
suft c ency of wn.ch is a7.4nowledgec.
DEFINITIONS
'Charity care' Of'unCOmpensateo Chanty care means that cannon of hospital charges reporter
to the Agency for which there is no compensation,other than restricted or unrestricted revenues
provided to a hospital by local governments or tax districts regardless of the method o' payr'e-t
L ncompensated care includes charity care for the uninsured but does not include
uncompensated care for insured •ndiyrduals.bad debt.or Medicaid arc Children a Hee th
nsurarce Program(CHIP)shortfall The state and prov oers hat are participating..n Low
rcome Poo!(LIP)wr t provide assurance that L'claims int ude any costs associated with
uncompensated care that is fjri;shcc through a charity care program and that adheres to the
principles of the Healthcare F;rancial Management Association (HFMA)operated by the
provider
'intergoverrmental Transfers(IGTey means transfers of funds from a non-Meorca d
governmental ent`ty(e g.counties Hospital taxing districts. providers operated by state or wcai
government)to trio Medicare agency GTs must be compliant with 42 CFR Part 433 Suepart e
'Low Income Pool(LIP)'mans providing gove•nreht support for safety-rot providers f:.' the
costs a'.,ncorpensated charity care for tow-income individual who are uninsu'er,
Uncompensated care includes charity care for the uninsured but does not include
uncompensated care for rsured indviduais.'bad dent,'or Medicaid and C!•+n siiortfa'I
'Med card'means the mecical assistance program authahred by Tale XIX c'tne Soc al Security
Act.42 U S C.§§ 1396 of see .and regulations thereunder as acmir stored n Florida by the
Agency
A. GENERAL PROVISIONS
1. Per House Bill 5001.the General ApprooriatioriS Act of State'isca+Fear 202a-2025,
passed by the 2C24 Florida Leg s;ature.the GT Prev'dPr and the Agency agree that the
IGT Provider will rorrit!GT funds to the Agency r an amount not to exceed he total of
S1,719,499.44 if me entire State Fiscal Year(SFY)24-25 eistrrbut'Or is paid using the
enhanced Feoeral Medical Assistance Percentage‘FMAP; per the Ferries First
Coronavirus Response Act or if a port or.of the SCV2d.25 distributor is paid after the
expiration o'the end of the enhanced FMAP
a The IGT Provider and the Agency have agreed that these;GT funds wilt only he
used to increase the provision of neatth services for the charity care of the °aT
Provider and the State of Florida at large
b 1 he increased provis:en of chanty care health services v:r'!DO accomplished
through the following Medicaid programs
i LIP payr'ner.ts to hosp:tats•federally quaff free health renters l/edncal
Scncol physician Practices community tehaviorat health providers an t
Jigdeiry t1ned
J� /f��by CAO
CoiK'Csunty.,Oav,,i Law'en H fe 8■•avirai .a=r'JP t04 srY 702t.7r C AV pale
2024.09.12
104906 04'00'
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool t
(CAO
16D3
rural heath centers pursuant:o tie approved Centers for Medicare&
Voarca.d Services Special Terns and Conditions
1 The IGT Provider wel return the signed LOA to the Agency nc later than October 1,
2024
2 The IGT Provider wilt pay IGT ti,nds to the Agency in an amount rot to exceed Sr•e total
of S1,719,499.44 if the entire SI=Y24-25 distribution is pad pr or to me end of the pubic
nea:tn emergency or if a portion of the SrV24-25 d str hrt•on is oa d aver the c,^•d of the
public^ealth emergency
a Per Ficnda Statute 409 9C8, annual payr•ents fcr the months of.:u:y 2024 through
.une 2325 are clue to the Agency ro later teee October 31, 2C24 unless an
aterna,:ve plan is spec fica.ly anprovec by the agency
b The Agency wi;hill the ICI'Provider when payrrert is due
3 The IGT Provider aria the Agency agree etas the Agency wtil maintain necessary records
and supporting documentation applicable to health services covered by this LOA
a Audits and Records
Tne t01 Prnv.dcr agrees to maintain books.records.and documents
(including e'.eclronic storage media)pertinent to performance under this L
0 A in accordance with generally accepted accounting procedures and
tract ces.which sufficiently and properly reflect ar revenues and
experd'tures Of funds prcv ded.
i T^e G T Prov der agrees to assure mat these recorca shai oe suoiect at
all reasonable times to inspection 'ev`ew,or and t t y state perso'inel and
otho.personrei duly authorised by the Agency.as wet! as by federal
oersonnei
Tne'GT Provider agrees to comply with public record taws as cuthred in
section 11907C1,Florida Statutes
b Retention of Records
Inc IGT Provider agrees to retain aft financial records, supporting
documents.statistical records.and any other documents(including
electronic storage media)pertinent to performance under Iris LCA for a
period n'six(6)years after term nation of this t.OA. or if an audit has
cecn initiated and eat t f rdings have rot beer resolved at the end of
six (6)years.tee records si-a''be retained.:ntr!resolution or the audit
findings
r. Persons duly autnor'zed by the Agency and fece•a auditors sr-all have'.:I
access to And the right to examine any pr saic reccrds and oocumonts
Car•;e•Cunty_Da,a Lawence Henavva r eat:n +P LOA SFr 2C24-25
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool
(CA 0
16D3
The rrgrts of access in tn.s sec:ron must not be aTree to tro rettuired
retention.pcirwd but sal ast as'ono as the records are retained
c. Morilor rng
The IGT Prouder agrees to oerrrr.t be:sors duly authorized Cy the
Agency to inspect any records oacors. aro documents of the 'GT
P'ovrdcr which are re'evant to this _CA
d Assignment and Subcontracts
i The IGT Prouder agrees to norther assign the resporsibrlly of this LCA
to another party nor subcontract for any of the work contemp'ateo under
this LOA without onor written approval of the Agency No such approval
by the Agency Of any assignment or subcontract shall be deemed in any
evert c' n any manner to provide fo•the incurrence of any oNigation of
the Agency in additor to the total no tar amount agreed Jpon r tha
LCA Al'sucn assignments or subcontracts snarl be subject to the
conditions of this LOA an::tc any condrt ons of aporaval that the Agency
shalt deem necessary.
4 This LOA may on:y be amended upon written agreement s tined by both oar es
The:GT Provider and the Agency agree that any modifications to this LOA shal be .n
the sane term. ameiy tie exchange of s fined copies of a rev'sed LOA
5. The tGT Provider confirms that there we no pie-arranged agreements Icontractuat or
otherwise)betweon the respective coJ'Yres,taxing drsthcts. a'c'er the providers to re-
direct any portion of these aforementioned charity care supp'omental payments,r order
to satisfy nor•Medica d.non•uninsured,and ran•urce'rnsored activities
6 The IGT Provider agrees the for owing provision snail to included r-n any agreements
between the IGT Provider and locar prov,ders where:u, funding is provided pursuant
to;n-s LOA `Funding provided in this Agreement shall be priont'red so that cosrgnated
IGT funding shad fist to used to fund the Mecca'ti program(-ncluding LIP or OShI;and
used secondar'ty for ctner purposes:
7 This I OA cove's the period of July / 2024,through June 30.2025,and shag,
be term-rated Senterrber 30,2026..which includes t re states certified forward
period
This LOA may be executed in muttipte courterpals.each or which shall constitute an
orig-nal and each of which shad be rely rind rg on any party signing at+east one
counterpart
Coale-Ccu^t't..Javd;uwir••ce Ha'sna•a hea"•_ LOA SrY 2024.25
David Lawrence Mental Health
MOD-State Mandated/Low Income Pool
I 6 D 3
LIP Local Intergovernmental Transfers (IGTsj_
Program/Amount State Fiscal Year 2024-2025
Estimated IGTs $1,719,499.44
Total Funding Not to Exceed
$1,719,499.44
WITNESSETH:
IN WITNESS WHEREOF,tie parties have caused this(4)page..etter of Agreement
to be executed by their undersigned or cials as duly authorized.
COLLIER COUNTY STATE OF FLORIDA,AGENCY FOR
HEALTH CARE ADMINISTRATION
::.... ) _.
SIGNED SIGNED ,l --
BY: BY:
r
NAME: St a
Chris Hall,Chairman
TITLE: Acting Chief-Medicaid Program
Finance
DATE; /ZY/2 Li DATE: `\\ O,-L 1.... u'\
All LST '
CRYSTAL ' hit'
BY: - . -
Attest a I Cr,aah,ana
',.signature only
I A
i
Approved ma..;se form and legality
} u, is
Jeffrey A.lfla zkow,County Attorney
I'
t
Conroe Ce:.rty_nav d LaNrc'1:e nehav ors 'I.azh_LIP LCA Sr v 2024.25
Da%id Laorence Mental Health
MOH-State Mandated/Low Income Pool •
�.
r( rc;,
1-6 Ira
EXHIBIT B
INSURANCE REQUIREMENTS
The CONTRACTOR shall furnish to Collier County, c/o Community and Human Services
Division, 3339 Tamiami Trail East, Suite 213, Naples, Florida 34112, Certificate(s) of Insurance
evidencing insurance coverage that meets the requirements as outlined below:
1. Workers' Compensation as required by Chapter 440, Florida Statutes.
2. Commercial General Liability, including products and completed operations insurance,
in the amount of$1,000,000 per occurrence and $2,000,000 aggregate. Collier County
must be shown as an additional insured with respect to this coverage.
3. Automobile Liability Insurance covering all owned, non-owned and hired vehicles used
in connection with this MOU, in an amount not less than $1,000,000 combined single
limit for combined Bodily Injury and Property Damage.
DESIGN STAGE (IF APPLICABLE)
In addition to the insurance required in 1 —3 above, a Certificate of Insurance must be provided as
follows:
4. Professional Liability Insurance, in the name of the CONTRACTOR or the licensed
design professional employed by the CONTRACTOR, in an amount not less than
$1,000,000 per occurrence/$1,000,000 aggregate providing for all sums which the
CONTRACTOR and/or the design professional shall become legally obligated to pay as
damages for claims arising out of the services performed by the CONTRACTOR or any
person employed by the CONTRACTOR in connection with this MOU. This insurance
shall be maintained for a period of two (2) years after the Certificate of Occupancy is
issued.
CONSTRUCTION PHASE (IF APPLICABLE)
In addition to the insurance required in 1 —4 above, the CONTRACTOR shall provide, or cause its
Subcontractors to provide,original certificates indicating the following types of insurance coverage
prior to any construction:
5. Completed Value Builder's Risk Insurance on an"All Risk"basis, in an amount not less
than 100 percent of the insurable value of the building(s)or structure(s). The policy shall
be in the name of Collier County and the CONTRACTOR.
6. In accordance with the requirements of the Flood Disaster Protection Act of 1973 (42
U.S.C. 4001), the CONTRACTOR shall assure that for activities located in an area
identified by the Federal Emergency Management Agency (FEMA) as having special
flood hazards, flood insurance under the National Flood Insurance Program is obtained
and maintained, as a condition of financial assistance for acquisition or construction
purposes (including rehabilitation).
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool
16 D3
OPERATION/MANAGEMENT PHASE (IF APPLICABLE)
After the Construction Phase is completed and occupancy begins, the following insurance must be
kept in force throughout the duration of the loan and/or MOU:
7. Workers' Compensation as required by Chapter 440, Florida Statutes.
8. Commercial General Liability including products and completed operations insurance
in the amount of$1,000,000 per occurrence and $2,000,000 aggregate. Collier County
must be shown as an additional insured with respect to this coverage.
9. Automobile Liability Insurance covering all owned, non-owned and hired vehicles used
in connection with this MOU in an amount not less than $1,000,000 combined single
limit for combined Bodily Injury and Property Damage.
10. Property Insurance coverage on an "All Risk" basis, in an amount not less than 100
percent of the replacement cost of the property. Collier County must be shown as a Loss
payee, with respect to this coverage A.T.I.M.A.
11. Flood Insurance coverage for those properties found to be within a flood hazard zone,
for the full replacement values of the structure(s) or the maximum amount of coverage
available through the National Flood Insurance Program (NFIP). The policy must show
Collier County as a Loss Payee A.T.I.M.A.
David Lawrence Mental Health
MOU-State Mandated/l.ow income Pool
16D3
EXHIBIT C
PROGRESS REPORT
Subrecipient Name: David Lawrence Mental Health Center
Report Period:
Fiscal Year: —_--- - - _---- - -----
— — — —
Organization/s:
Program:
Contact Name:
I Contact Number:
1st 2nd 3rd 4th Cumulative Total
Quarter Quarter Quarter Quarter To Number to
Performance Measures 10/1- 1/1-3/31 4/1-6/30 �/1 Date be served
9/3 0
12/31 Annually
# of nonduplicated Collier
County residents/clients 6500
who received at least one
unit of service
# Service Units delivered `n
the Quarter to eligible
Collier County residents
State Mandated Match
Obligation per CFBHN
Agreement
Total Collection of other
local match sources (client
fees, donation,volunteers.
other municipalities etc.)
Signature Date
Title
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool (;
1603
EXHIBIT D
INCIDENT REPORT FORM
Organization Name:
Organization Address:
Project No:
Grant Coordinator:
Date of Incident Time of Incident:
Report Submitted By:
(Name& Phone)
Description of Incident:
Location/Address of Incident:
Was Police Report Filed? ❑ Yes ❑ No
If Yes, Police Report Number: Jurisdiction:
Were there any warning signs that this type of Incident could occur? ❑ Yes ❑ No
If Yes, Explain:
What actions will be taken to prevent a recurrence of a similar incident?
I certify under penalty of pet:jury under F.S. 837.06 that the contents of this affidavit are true and correct.
Signature of Person Making Report Date
Printed Name Title
David Lawrence Mental Health
MOU-State Mandated/Low Income Pool
L:ii}