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Agenda 07/26/2011 Item #16K27/26/2011 Item 16.K.2. COLLIER COUNTY Board of County Commissioners Item Number: 16.K.2. Item Summary: Request that the Board of County Commissioners direct the Collier County Health Facilities Authority to disburse grant funds to certain nonprofit health service agencies. Meeting Date: 7/26/2011 Prepared By Name: BrockMaryJo Title: Executive Secretary to County Manager, CMO 7/20/2011 11:08:15 AM Submitted by Title: Executive Secretary to County Manager, CMO Name: BrockMaryJo 7/20/2011 11:08:17 AM Approved By Name: KlatzkowJeff Title: County Attorney, Date: 7/20/2011 1:30:34 PM Name: IsacksonMark Title: Director -Corp Financial and Mgmt Svs,CMO Date: 7/20/2011 1:37:44 PM Packet Page -2704- 7/26/2011 Item 16.K.2. EXECUTIVE SUMMARY Request that the Board of County Commissioners direct the Collier County Health Facilities Authority to disburse grant funds to certain nonprofit health service agencies. Objective For the Board of County Commissioners to authorize the Collier County Health Facilities Authority (the "Authority") to disburse funds to certain health care agencies pursuant to the recommendations of the Authority and consideration by the Board. Backeround Chapter 154, Part III, Florida Statutes provides for the establishment of health facilities authorities by counties, which have the power to issue tax- exempt bonds for qualifying nonprofit health care facilities. Collier County established the Collier County Health Facilities Authority (the Authority") in 1979 by the adoption of Ordinance 79 -95. Section 154.209 authorizes an authority to levy fees for its services, and, after allowing for the administrative expenses of the authority, directs the authority to donate any surplus funds that remain in its account to the Board of County Commissioners, which is then required by the statute to disburse those funds to "nonprofit human health service agencies." The Authority has established a fee for its bond m issuance services, and has accumulated approximately $189,000 as a result of several bond issues it has authorized. The Authority has determined that $19,000 will cover its administrative expenses until further bond issuance revenues are received, and therefore desires to turn over its surplus funds, in the amount of $170,000 to the BCC, for the Board's further disbursal of the funds to qualifying agencies, or, alternatively, the Authority -rill disburse the funds directly to the agencies in accordance with the Board's direction. The process by which the Authority brings these recommendations to the Board has been as follows: 1. Several months ago, Authority staff discussed this matter with county management, and it was suggested that the Authority identify qualified agencies for grant funds and make recommendations with regard to disbursal. 2. After considering its fiscal needs, the Authority determined to donate $170, 000 in total grants. Accordingly, the Authority placed a notice in the Naples Daily News advising agencies of the opportunity to apply for grant funds, and providing instructions as to the filing of grant applications. A copy of the text of the notice is attached. 3. The Authority received grant applications from the following agencies, requesting funds for the purposes briefly described: a. CHS Healthcare. The grant purpose is to purchase Billicheck Systems, a noninvasive device that analyzes bilirubin in infants and neonates. The system Packet Page -2705- / P� :� f �� � y f i■ f� i T i "MWA eliminates the need for multiple heel sticks, which have proven to cause later medical complications in children. b. Physician Led Access Network of Collier County (PLAN). PLAN acts as a referral resource where uninsured patients who access the affordable primary care clinics, such as Collier Health Service's Mike Davis Clinic, the Neighborhood Health Clinic, etc. are referred to and receive specialty care. This is done through Patient Navigators, who conduct eligibility screening and obtain appointments with volunteer specialists. The grant is to fund the cost of an additional Patient Navigator to enable PLAN to continue to serve its expanding client base. Senior Friendship Centers' Friendship Health Clinic Collier. This facility allows retired professional volunteers- doctors, dentists, and nurses, to practice in partnership with the local county public health department, providing reduced fee services to low income seniors. Senior Friendship Center serves the elderly population, and provides specialty services not generally provided by other facilities, such as dental services. Grant funds would be used to help defray the costs of laboratory diagnostics. d. David Lawrence Mental Health Center, Inc. The grant request is to help with the cost of upgrading auxiliary power capability in several key buildings on the campus in the event of outages. This is a key need because in the event of a disaster, people receiving care are not able to be relocated to standard shelters. Copies of each of the applications are attached. 4. Pursuant to a public notice in the Naples Daily News, the Authority held a public hearing on April 22, 2011, heard presentations from each of the applicants and members of the public in support of the applications. After consideration, the Authority requested the applicants to refine their requests if possible, in view of the fact that the funds requested exceeded the funds available for grants. A copy of the text of the public notice is attached. 5. At the continuation of the April 22 meeting held on May 3, 2011, the Authority considered the refined requests, and adopted a motion to recommend that the Hoard of County Commissioners authorize grants as follows: a. That CHS Healthcare receive a grant in the amount of $25,000 for the purposes set forth in the application. b. That PLAN receive a grant in the amount of $35,000for the purposes set forth in the application. C. That Senior Friendship Center receive a grant in the amount of $60,000 for the purposes set forth in the application. d. That David Lawrence Mental Health Center, Inc. receive a grant in the amount of $50,000 for the purposes set forth in the application. Packet Page -2706- 7/26/2011 Item 16.K.2. Deciding among, and reducing some or the requests was a difficult decision, and a careful evaluation of each request was made. All the applicants have demonstrating success in serving the public health needs of the county over many years. There is a true public need and public health benefit to be obtained from each of the requests. Lesal Considerations: This item has been reviewed by the County Attorney and is legally sufficient for Board action. This item requires a majority vote for approval. In lieu of the recommendation the Board may accept these proceeds and later determine which nonprofit health service agencies it prefers to disburse these funds to. This Executive Summary, which was prepared by the Authoritv, is being placed on the County Attorney's consent portion of the agenda as a courtesy to the Authority. -JAK Recommendation: That the Board authorize the Authority to disburse grant funds in accordance with the above. All grants will be made pursuant to grant agreements that will require that the funds be used as indicated and provide for appropriate certifications as to compliance. Packet Page -2707- 7/26/2011 Item 16.K.2. TDAvID LAWRENCE CENTER Mental Health 6' .Substance Abuse Services Application for the Collier County Health Facilities Authority Grant Submitted March 15, 2011 COPY 7 of 7 Packet Page -2708- 7/26/2011 Item 16.K.2. N*rDAVID LAWRENCE CENTER Mental Healtb 6- Substance Abuse Services COVERPAGE Collier County Health Facilities Authority Grant Proposal Name: David Lawrence Mental Health Center Inc. Address: 6075 Bathev Lane Naples FL 34116 Phone: (239) 354 -1424 Email: DAVE(CDDLCMHC corn Contact Personrritle: David C. Schimmel Chief Executive Officer David Lawrence Center Page 1 Packet Page -2709- 7/26/2011 Item 16.K.2. Mission David Lawrence Center focuses on restoring and rebuilding lives by providing compassionate, highly skilled, affordable mental health and substance abuse services that are available to all. Current Operations David Lawrence Center has several locations in Collier County and provides 40 different programs designed to meet the diverse mental health and substance abuse needs of the community. The Center employs the following categories of staff: ➢ Medical and Nursing 43 ➢ Clinical 134 ➢ Clinical Support 28 ➢ Administrative 66 Total Staff 271 The Center operates acute care and residential programs at its Golden Gate /Bathey Lane location (see DLC Maps tab). The programs include mental health crisis stabilization units for adults and children, and substance abuse detoxification and residential care for adults. Bed Capacity - 51 Total Acute Care Beds — 35 Emergency Room Observation Beds - 3 Licensed Adult Crisis —16 Average Length of Stay - 6.48 Days Licensed Children's Crisis — 4 Average Length of Stay - 3.88 Days Licensed Adult Detoxification — 12 Average Length of Stay - 5.41 Days Adult Substance Abuse Residential Beds -16 Average Length of Stay - 24.51 Days Access and Urgent Care Services are provided on a walk in basis. In this traditional walk in clinic model, individuals can be seen and accessed by a qualified clinician on the same day services are requested. Clients are initially clinically triaged by a mental health counselor to determine the level of care (emergent, urgent or routine) and the appropriate services needed. In addition to providing the initial triage, the Access David Lawrence Center Packet Page -2710- Page 7 7/26/2011 Item 16.K.2. department conducts a clinical assessment, schedules appointments, makes referrals, completes the admissions paperwork and conducts a financial assessment for all new clients. Individuals can access services in Naples and Immokalee. Adult programs include resource coordination (case management); supported employment; supportive housing; a drop in center, and forensic services including competency restoration, drug court, and mental health court. Homeless outreach is provided through the Project for Assistance in Transition from Homelessness (PATH) as part of a Substance Abuse & Mental Health Services Administration grant. In addition, the Center sponsored the development of two affordable housing corporations in order to provide housing to people with mental illnesses and co- occurring disorders. Children's services include a juvenile assessment center, Title = /Behavioral Network services in Lee, Collier and Hendry counties, the Child's Path Preschool, substance abuse and suicide prevention programs. Group therapy includes programs such as Tough Times, designed to help adolescents 13 -17 years old who struggle with anxiety and depression. Breaking the Chains provides group therapy to the same age adolescents with co- occurring mental health and substance abuse problems. Outpatient Psychiatric Medical Services are administered by a board certified adult psychiatrists and the nursing staff. These services include an evaluation and assessment, medication management and ongoing consultation. These services are designed to help individuals achieve and maintain mental and emotional stability. Since July of 2010, David Lawrence Center has been providing psychiatric and counseling services at its Immokalee site via a telepsychiatry pilot project along with Value Options with whom the Center contracts for many of its Medicaid services. Through the program, a variety of clinicians based out of the Naples office provide convenient, accessible services to Immokalee residents. History The David Lawrence Center, previously known as the Collier County Mental Health Clinic, was the first mental health and substance abuse clinic in Collier County. The Clinic opened its doors on October 1969 with 3 staff members in a donated store front on Tamiami Trail in Naples. In the 1970's the Clinic had expanded to 35 staff members. In 1974, Doug and Mercy Bathey generously loaned and later donated $200,000 to acquire the 10 acre parcel of land needed to construct a new facility off Golden Gate Parkway, where the David Lawrence Center's main campus is currently located on the Bathey Lane access road. David Lawrence Center Page 8 Packet Page -2711- 7/26/2011 Item 16.K.2. To help garner financial support from the local community for the Clinic's work, a separate not - for - profit called the Foundation for Mental Health, Inc., now known as the David Lawrence Foundation, was formed in 1976. In the early 1980's, the Collier County Mental Health Clinic changed its name to the David Lawrence Center for Mental Health, Inc. in honor of significant donor's Doug and Mercy Bathey's son, David Lawrence Bathey, who died due to substance abuse and mental health issues. To meet the increasing demand in the rural farming community of Immokalee, the Center constructed a satellite location in 1986 on land donated by Collier County. For the first time in history mental health and substance abuse services were available to residents of that community. As Naples popularity and property values continued to rise, the Center realized that clients with a persistent mental illness who were on disability could not find affordable housing. As a result in 1996, the Center acquired a housing project with 20 units. In 1997, an additional housing project was acquired with 9 units and in 1998; a third housing project with 6 units was purchase Currently, a master site plan for the main campus renovations has been developed and continues to evolve. The plan currently includes an expansion of the adult crisis stabilization unit from a 20 bed to a 30 bed unit. Accomplishments In 1989, David Lawrence Center received its initial accreditation from the Joint Commission of Health Care Organizations, and has maintained the accreditation consistently since then. The Center has been successful securing many competitive grants. Currently, several million dollars in state and federal grant funds are awarded to David Lawrence Center. These include the Bureau of Justice Assistance for Drug Court, Housing and Urban Development Section 811 rental assistance, Community Development Block Grant, Florida Title XXI /Behavioral Network, Substance Abuse Services Administration (SAMHSA) Projects for Assistance in Transition from Homelessness (PATH). In 2010, the Center implemented an electronic prescribing technology. In addition to enhancing patient safety, the e- prescribe system improves efficiencies and staff productivity. In 2010, Value Options selected the David Lawrence Center's Immokalee satellite services location as a pilot site for Telemed Direct, the tele- psychiatry initiative that - Value Options is rolling out across the country. David Lawrence Center Page 9 Packet Page -2712- 7/26/2011 Item 16.K.2. In 2009, admissions to the overcrowded Adult Crisis Stabilization Unit were diverted and the Center's capacity was increased for triaging and observing individuals in crisis through the opening of the Emergency Services Assessment Center In 2010, David Lawrence Center for was awarded the Negley Associates Chairman's Award for Excellence in Risk Management for its use of the Profiler electronic medical record, and a methodology for minimizing medication errors. The primary purpose of the Negley Awards is to elicit information from behavioral health centers about extraordinary and quality practices with the ultimate goal of facilitating quality care improvement. David Lawrence Center Page 10 Packet Page -2713- David Lawrence Center Project Request Packet Page -2714- 7/26/2011 Item 16.K.2. Page 13 7/26/2011 Item 16.K.2. Project Request Summary. The David Lawrence Center is planning to significantly upgrade its ability to provide auxiliary power in several key buildings at its main campus in the event of outages. Need At any given time, the David Lawrence Center's Bathey Lane location houses over 50 adults and children in acute or serious mental health or substance abuse crisis situations in Building B (see page 7, Acute Care and Residential Bed Capacity). In addition dozens of people access medical and counseling outpatient care at the site each day in Building C. These services are provided to vulnerable people, 94% of whom are below poverty level. In the event of a disaster, people receiving care are unable to evacuate /relocate to a safe place due to a number of factors including those related to personal economic and emotional status, and lack of adequate transportation or social supports. Some may be legally required to be remanded to DLC under the Baker Act for psychiatric evaluation in the crisis stabilization unit (CSU) because they pose a danger to themselves or others. In addition, shelters generally will not accept a person in a psychiatric crisis, leaving them nowhere to go if the David Lawrence Center is inoperable. Current Emergency Power Capability The existing Emergency distribution system consists of a 100A panelboard connected to a manual transfer switch (MTS). The panelboard serves selective lighting in Building B, including the CSU bathrooms, exit signs, CRTC residence hall; and operates the freezer, cooler, refrigerator, ice machine, and sandwich cooler. In an extended power outage situation, David Lawrence Center rents a portable generator. The generator is set in place just outside Building B and the power cables are routed through the hallway to the MTS. Plan In order to provide optimum care and security during an extended period of power outage, David Lawrence Center will upgrade its current auxiliary power by purchasing equipment and connectivity that will provide the capacity to generate full power to acute care, residential and administrative offices. This includes purchasing a unit large enough and with sufficient fuel capacity to work for up to 120 hours. David Lawrence Center Page 14 Packet Page -2715- 7/26/2011 Item 16.K.2. Project Request Work Detail Generator Specifications Type: Single generator system is a 250 KW/288 kVA diesels stem Location: Installed in a concealed location at Building B Power: for 100% of the expected operating load for Buildings A, B, C Fuel: 1,500 gallon base- mounted diesel tank provides 72 hour operation Fuel Alternative: 2,500 gallon tank for 120 hour operation Site Preparation: Concrete slab and pad; automatic transfer switches; conduits to buildings Total Estimated Project Cost (including instal lation):$250,000 Requested Grant Funds: 30% of the total cost, $75,000 David Lawrence Center Page 15 Packet Page -2716- 7/26/2011 Item 16.K.2. + Collier County Health Facilities Authority Grant Proposal r March 16, 2011 Organization: Physician Led Access Network (PLAN) of Collier County 1012 Goodlette Road North, Suite 201 w Naples, FL 34102 239- 776 -3016 deb0plancc.ore r Contact: Deb Cecere Executive Director a Form: Corporation, Federal Tax Exempt #20- 0477556 + Officers: Margaret Eadington, Chair David Spellberg, M.D., Treasurer Collier County Medical Society Naples Urology Associates 1148 Goodlette Road North 1132 Goodlette Road North Naples, FL 34102 Naples, FL 34102 Betty Gamel, Secretary r Friendship Health Clinic 2171 Pine Ridge Rd Ste. Naples, FL 34109 The Physician Led Access Network (PLAN) of Collier County is a community -based referral network that coordinates volunteer medical care for eligible low- income, uninsured adults in need of health services in Collier County. Led by its physicians, it is a community partnership that brings together physicians, community clinics, hospitals, diagnostic and laboratory facilities, and other healthcare providers + through an integrated delivery system of volunteer care. Because PLAN encompasses a broad network of health care providers, the cost of providing free care is spread among many, rather than concentrated on a few. HISTORY In 2003, physician members of the Collier County Medical Society established PLAN (known as Collier • WeCare at that time) to create a program that would address the gaps in access to health care in this economically diverse community. Volunteer specialty care providers and facilities join PLAN's network and agree to see qualified residents in their own offices and facilities so there are no clinic overhead costs. PLAN Patient Navigators coordinate all of the donated specialty medical care and services by performing eligibility, setting appointments, coordinating surgeries, procedures and lab services and conducting follow -up. w w PLAN of Collier County Page 1 Packet Page -2717- Collier County Health Facilities Authority Grant Proposal March 16, 2011 7/26/2011 Item 16.K.2. MISSION STATEMENT r PLAN's mission is to improve the health care access and quality of care among low- income, uninsured adults in Collier County. _ SERVICES AND ACTIVITIES According to the 2009 Department of Health report, 33% of Collier County's residents under the age of 65 are uninsured. That represents about 80,000 year -round residents. r Thanks to affordable primary care clinics in our area such as Collier Health Services' Mike Davis Clinic, the Neighborhood Health Clinic, Friendship Health Clinic, and the Marion E. Fether Clinic in Immokalee, many low- income adults are receiving the basic health care they need. However, when a low- income patient needs to see a specialist, they face a medical bill that they simply cannot afford. Without PLAN, a low- income, uninsured patient has no financial access to needed specialty care, such as specialty consultation, surgery, or expensive tests such as an MRI or endoscopy. Some receive care in the emergency rooms. Others either live with debilitating pain or their condition continues to worsen to the extent that they can no longer work or care for their families. Because of PLAN, uninsured patients receive the specialty care they need. A Collier County primary care _ clinic (as mentioned above) refers uninsured patients to PLAN for all types of specialty care or tests required by the patient. PLAN's Patient Navigators conduct the eligibility process and make appointments with volunteer specialists who provide the needed care in their offices or facilities. With _ the support of many types of volunteer health care providers, patients receive necessary hospitalization, lab tests, and medication they need but cannot afford. 100% of patients seen through PLAN are uninsured and meet 200% of the Federal Poverty Guidelines. To date, PLAN has built a network of over 225 physicians, 2 hospitals, 4 community clinics and numerous other ancillary health care facilities who have provided approximately $13.5M in donated care to approximately 2,000 patients. In 2010 alone, PLAN served more than 500 residents during 2700 r medical appointments for a value of $3.4M in donated specialty care services. Criteria for Eligibility r • Treatment must be medically necessary • Collier County resident _ • 19 -64 years • Family income must not exceed 200% of federal poverty guidelines ($44,700 for a family of four) _ • Applicants must not have any medical insurance and cannot be eligible for Medicaid or Medicare, or have no access to a doctor who accepts Medicaid /Medicare. r PLAN of Collier County Page 2 Packet Page -2718- Collier County Health Facilities Authority Grant Proposal March 16, 2011 REQUEST 7/26/2011 Item 16.K.2. _ PLAN currently employs 2 Patient Navigators who coordinate all of the specialty care needs for over 500 patients annually. This number of residents served has held steadily over the last 3 years because we believe the navigators are coordinating at capacity. This year, PLAN intends to increase its volunteer base by adding at least 50 new physicians /facilities offering new primary care consultations and screenings. We are requesting $35,000 to partially cover the salary cost of an additional Patient Navigator. This position is responsible for: • receiving referrals from primary care clinics • conducting patient interviews to determine that eligibility requirements are met for new patients _ • collecting all patient documentation • referring patients to a volunteer health care provider who will accept the case • coordinating with volunteer's management to ensure the patient receives all needed care including procedures, lab work, tests such as MRIs, cancer treatments, radiology services, hospitalization and surgeries • Collecting documentation of the value of all volunteer services, e.g. consultations, procedures, surgeries /hospitalizations, lab tests. This candidate filling the position must be bi- lingual in order to effectively communicate with the program's participants. This will be a new position and will help increase not only the number of services given to patients but also increase the number of patients PLAN is able to serve. BUDGET For 2011, the PLAN Board of Directors approved a balanced budget of $303,854. Attachments: IRS Letter Patient Navigator Job Description 2009 Annual Report Brochure PLAN of Collier County Page 3 Packet Page -2719- Internal Revenue Service o,o. Box 2508 incinnati, OH 45201 Date: APR 12 2007 PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY INC % MARGARET WILLIAMS 1148 GOODLETTE RD N NAPLES FL 34102 7/26/2011 Item 16.K.2. Department of the Treasury Person to Contact: Barb Herald ID #31 -02637 Toll Free Telephone Number: 877 - 829 -5500 Employer Identification Number: 20- 0477556 Dear Sir or Madam: This is in response to your request of March 2, 2007, regarding your tax - exempt status. We have updated our records to change the name from COLLIER WECARE INC to PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY INC. Our records indicate that a determination letter was issued in July 2004 that recognized you as exempt from Federal income tax. Our records further indicate that you are currently exempt under section 501(c)(3) of the Internal Revenue Code. Jur records also indicate you are not a private foundation within the meaning of section 509(a) of the Code because you are described in section 509(a)(1) and 170(b)(1)(A)(vi). Donors may deduct contributions to you as provided in section 170 of the Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. _ If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely, Cinderestcott Man , Exempt Organizations Determinations y Packet Page -2720- 7/26/2011 Item 16.K.2. INTERNAL REVENUE SERVICE DEPARTMENT OF THE TREASUR° .. P. 0. BOX 2508 CINCINNATI, OH 45201 Dear Applicant: Based on information you supplied, and assuming your operations will be as stated in your application for recognition of exemption, we have determined yov are exempt from federal income tax under section 501(a) of the Internal Revenu Code as an organization described in section 501fc1r91 Because you are a newly created organization, we are not now making a final determination of your foundation status under section 509(a) of the Code. However, we have determined that you can reasonably expect to be a publicly supported organization described in sections 509(a)(1) and 170(b)(1)(A)(vi). Accordingly, during an advance ruling period you will be treated as a publicly supported organization, and not as a private foundation. This advance ruling period begins and ends on the dates shown above. Within 90 days after the end of your advance ruling period, you must send us the information needed to determine whether you have met the require- ments of the applicable support test during the advance ruling period. If you establish that you have been a publicly supported organization, we will classi- fy you as a section 509(a)(1) or 509(a)(2) organization as long as you continue to meet the requirements of the applicable support test. If you do not meet the public support requirements during the advance ruling period, we will classify you as a private foundation for future periods. Also, if we classify you as a private foundation, we will treat you as a private foundation from your beginning date for purposes of section 507(d) and 4940. Grantors and contributors may rely on our determination that you are not private foundation until 90 days after the end of your advance ruling period. If you send us the required information within the 90 days, grantors and contributors may continue to rely on the advance determination until we make Packet Page -2721- Letter 1045 (DO /CG. Employer Identification Number: Date: 20- 0477556 DLN: 17053006016044 COLLIER WE CARE INC Contact Person: 1148 GOODLETTE RD N DENNIS PHILLIPS ID# 52647 NAPLES, FL 34102 Contact Telephone Number: (877) 829 -5500 Accounting Period Ending: December 31 Foundation Status Classification: 509(a)(1) Advance Ruling Period Begins: September 15, 2003 Advance Ruling Period Ends: December 31, 2007 — Addendum Applies: No Dear Applicant: Based on information you supplied, and assuming your operations will be as stated in your application for recognition of exemption, we have determined yov are exempt from federal income tax under section 501(a) of the Internal Revenu Code as an organization described in section 501fc1r91 Because you are a newly created organization, we are not now making a final determination of your foundation status under section 509(a) of the Code. However, we have determined that you can reasonably expect to be a publicly supported organization described in sections 509(a)(1) and 170(b)(1)(A)(vi). Accordingly, during an advance ruling period you will be treated as a publicly supported organization, and not as a private foundation. This advance ruling period begins and ends on the dates shown above. Within 90 days after the end of your advance ruling period, you must send us the information needed to determine whether you have met the require- ments of the applicable support test during the advance ruling period. If you establish that you have been a publicly supported organization, we will classi- fy you as a section 509(a)(1) or 509(a)(2) organization as long as you continue to meet the requirements of the applicable support test. If you do not meet the public support requirements during the advance ruling period, we will classify you as a private foundation for future periods. Also, if we classify you as a private foundation, we will treat you as a private foundation from your beginning date for purposes of section 507(d) and 4940. Grantors and contributors may rely on our determination that you are not private foundation until 90 days after the end of your advance ruling period. If you send us the required information within the 90 days, grantors and contributors may continue to rely on the advance determination until we make Packet Page -2721- Letter 1045 (DO /CG. EPA! COLLIER WE CARE INC F7X:If GaI -,i�'Ti d:1:1" a final determination of your foundation status. If we publish a notice in the Internal Revenue Bulletin stating that we will no longer treat you as a publicly supported organization, grantors and contributors may not rely on this determination after the date we publish the notice. In addition, if you lose your status as a publicly supported organi- zation, and a grantor or contributor was responsible for, or was aware of, the act or failure to act, that resulted in your loss of such status, that person may not rely on this determination from the date of the act or failure to act. Also, if a grantor or contributor learned that we had given notice that you would be removed from classification as a publicly supported organization, then that person may not rely on this determination as of the date he or she acquired such knowledge. If you change your sources of support, your purposes, character, or method of operation, please let us know so we can consider the effect of the change on your exempt status and foundation status. If you amend your organizational document or bylaws, please send us a copy of the amended document or bylaws. Also, let us know all changes in your name or address. As of January 1, 1984, you are liable for social security taxes under the Federal Insurance Contributions Act on amounts of $100 or more you pay to each of your employees during a calendar year. You are not liable for the tax imposed under the Federal Unemployment Tax Act (FUTA). Organizations that are not private foundations are not subject to the pri- vate foundation excise taxes under Chapter 42 of the Internal Revenue Code. However, you are not automatically exempt from other federal excise taxes. If you have any questions about excise, employment, or other federal taxes, please let us know. Donors may deduct contributions to you as provided in section 170 of the Internal Revenue Code. Bequests, legacies, devises, transfers, or gifts to you or for your use are deductible for Federal estate and gift tax purposes if they meet the applicable provisions of sections 2055, 2106, and 2522 of the Code. Donors may deduct contributions to you only to the extent that their contributions are gifts, with no consideration received. Ticket purchases and similar payments in conjunction with fundraising events may not necessarily qualify as deductible contributions, depending on the circumstances. Revenue Ruling 67 -246, published in Cumulative Bulletin 1967 -2, on page 104, gives guidelines regarding when taxpayers may deduct payments for admission to, or other participation in, fundraising activities for charity. You are not required to file Form 990, Return of Organization Exempt From Income Tax, if your gross receipts each year are normally $25,000 or less. If you receive a Form 990 package in the mail, simply attach the label provided, check the box in the heading to indicate that your annual gross receipts are normally $25,000 or less, and sign the return. Because you will be treated as a public charity for return filing purposes during your entire advance ruling period, you should file Form 990 for each year in your advance ruling period Letter 1045 (DO /CG) Packet Page -2722- COLLIER WE CARE INC -3- 7/26/2011 Item 16.K.2. that you exceed the $25,000 filing threshold even if your sources of support do not satisfy the public support test specified in the heading of this letter. If a return is required, it must be filed by the 15th day of the fifth month after the end of your annual accounting period. A penalty of $20 a day is charged when a return is filed late, unless there is reasonable cause for the delay. However, the maximum penalty charged cannot exceed $10,000 or ,. 5 percent of your gross receipts for the year, whichever is less. For organizations with gross receipts exceeding $1,000,000 in any year, the penalty is $100 per day per return, unless there is reasonable cause for the delay. The maximum penalty for an organization with gross receipts exceeding $1,000,000 shall not exceed $50,000. This penalty may also be charged if a return is not complete. So, please be sure your return is complete before you file it. You are not required to file federal income tax returns unless you are subject to the tax on unrelated business income under section 511 of the Code. If you are subject to this tax, you must file an income tax return on Form 990 -T, Exempt Organization Business Income Tax Return. In this letter we are not determining whether any of your present or proposed activities are unre- lated trade or business as defined in section 513 of the Code. You are required to make your annual information return, Form 990 or Form 990 -EZ, available for public inspection for three years after the later of the due date of the return or the date the return is filed. You are also required to make available for public inspection your exemption application, any supporting documents, and your exemption letter. Copies of these documents are also required to be provided to any individual upon written or in person request without charge other than reasonable fees for copying and postage. You may fulfill this requirement by placing these documents on the Internet. Penalties may be imposed for failure to comply with these requirements. Additional information is available in Publication 557, Tax - Exempt Status for Your Organization, or you may call our toll free number shown above. + You need an identification If anemployeridentificationnumberwas not entered on you have no employees. your application, we will assign a number to you and advise you of it. Please use that number on all returns you file and in all correspondence with the .Internal Revenue Service. This determination is based on evidence that your funds are dedicated to the purposes listed in section 501(c)(3) of the Code. To assure your continued exemption, you should keep records to show that funds are spent only for those purposes. If you distribute funds to other organizations, your records should show whether they are exempt under section 501(c)(3). In cases where the recipient organization is not exempt under section 501(c)(3), you must have evidence that the funds will remain dedicated to the required purposes and that the recipient will use the funds for those purposes. If you distribute funds to individuals, you should keep case histories Packet Page -2723- Letter 1045 (DO /CG) COLLIER WE CARE INC -4- 7/26/2011 Item 16.K.2. showing the recipients' names, addresses, purposes of awards, manner of selec- tion, and relationship (if any) to members, officers, trustees or donors of funds to you, so that you can substantiate upon request by the Internal Revenue + Service any and all distributions you made to individuals. (Revenue Ruling 56 -304, C.B. 1956 -2, page 306.) If we said in the heading of this letter that an addendum applies, the addendum enclosed is an integral part of this letter. Because this letter could help us resolve any questions about your exempt + status and foundation status, you should keep it in your permanent records. We have sent a copy of this letter to your representative as indicated in your power of attorney. r If you have any questions, please contact the person whose name and telephone number are shown in the heading of this letter. Sincerely yours, 4t� Y. 4:�VP�0� Lois G. Lerner Director, Exempt Organizations + Rulings and Agreements Enclosure(s): Form 872 -C r a r + r Packet Page -2724- Letter 1045 (DO /CG) 7/26/2011 Item 16.K.2. PATIENT NAVIGATOR Reporting to Senior Patient Navigator, the position coordinates, administers and oversees all primary & specialty care medical services provided to qualified Collier County residents by the volunteer physician and facilities network. Specific Responsibilities Include: • Conducts patient pre - eligibility interviews via telephone • Conducts in- person patient eligibility interviews to determine eligibility based on qualification guidelines • Collects all required documentation • Refers and schedules appointments with PLAN's participating volunteer physicians and facilities for eligible patients. • Manages the coordination of all specialty care, diagnostics, lab work, hospitalization • Adheres to HIPAA requirements by ensuring the confidentiality of client records. • Reviews client care plans and client case records to assure completeness, accuracy and timeliness of all required paperwork • Researches compliance issues (i.e. missed appointments) with client and PLAN provider • Maintains all mandated client records; prepares reports. • Develops written correspondence to patients when necessary. • Records, maintains and updates patient, medical provider and appointment data in ClientTrack referral database tracking system. • Prepares utilization reports from database and other support programs upon request from Executive Director. • Communicates with and maintains positive working relationships with all PLAN providers and their staffs. Qualifications /Skills: ' • Bachelor's degree or any equivalent combination of education, training, or experience • Bi- lingual (English /Spanish) • Understanding of medical terminology • Excellent communication and organizational skills _ • Ability to multi -task and prioritize • Critical thinking necessary for troubleshooting • Strong office computer skills such as Microsoft Word, Excel and database • Previous customer service experience is strongly preferred PLAN of Collier County Page 1 of 1 Collier County Health Facilities Authority March 16. 2011 Packet Page -2725- 7/26/2011 Item 16.K.2. Collier County Health Facilities Authority Grant Proposal Senior Friendship Centers, Inc. Friendship Health Clinic Collier 2171 Pine Ridge Road Suite F, Naples, FL 34109 239 566 -7425 Email: bgamelPfriendshiocenters.org Contact Betty Gomel, Director Senior Friendship Centers Inc. is a non profit 501 (c) (3). Attached is a copy of IRS letter dated March 2007 designating status. Attached is a copy of the Board of Governors. Officers are: Alan Sloan, Chairman John Counsel, Vice Chair Dorrin Halsey, Treasurer Richard Beebe, M.D, Secretary The Mission of Senior Friendship Centers, Inc. is "Empowering individuals, families and communities through healthy and supportive aging services, activities, education and volunteerism." 1 Packet Page -2726- 7/26/2011 Item 16.K.2. Organization Information Since 1978 (in Sarasota), health service through Senior Friendship Centers has been considered a national model for volunteer engagement of health professionals. Through advocacy and education on the state level, sovereign immunity through a limited license was granted and has allowed retired professional volunteers — doctors, dentists, nurses — to practice in partnership with the local county Public Health Departments, providing reduced fee services to low income seniors. Sovereign immunity is provided by the State of Florida Division of Risk Management through our affiliation with the Collier County Public Health Department. The Naples Clinic was opened in 1985. In 1996, after years of advocacy with the Florida Board of Dentistry, dental services were added. The original business model addressed limited income seniors ages 60 and older, many enrolled in or approaching Medicare. As service demand grew, the eligibility age was reduced to age to 55 and then to 50, at the request of the local health department. Unfortunately, almost all individuals in this lower age group are uninsured altogether and many are unemployed. Most recently when the local real estate markets and associated economy collapsed, and unemployment rose above 9% and higher, the Friendship Health Clinic experienced a spike in non - reimbursable patient visits. Whether they represent the "working poor" or are retired, or attempting to qualify for disability, there are a great number of older adults throughout Collier County who have unmet health needs. Based on growth predictions for the State of Florida and the changing economics, this group will continue to increase proportionately with the longer life span. Nearly one third (30 %) of Collier County's 345,787 population (or 107,019 individuals) are age 60 or above (Florida Department of Elder Affairs, 2009). Of the 82,585 individuals age 65 and older, 18,250 are deemed medically underserved. The Naples Clinic was located at 811 Seventh Avenue South in downtown Naples from 1985 through 2010, directly adjacent to City Hall and Cambier Park in a converted church. Over the years, the aging structure required increasing maintenance — rotting subflooring, a leaking roof, mold and rodent infestation (raccoons in the attic /crawl space). As the anticipated costs to mitigate these issues mounted and serious health and safety issues arose, search began in earnest to relocate the operation to a newer, safer location, taking advantage of a weaker commercial real estate market. In October 2010, the Clinic operation moved to leased space on Pine Ridge Road that was formerly occupied by a medical practice. This location is accessible (on the bus route) to our targeted population and convenient to many retired physicians and dentists, upon whom we depend for their time and professional skills as volunteers. These professionals are especially effective in dealing with their peer group. The plan was to place the downtown property for sale and the resulting proceeds would help rebuild the Collier fund coffers housed within the Senior Friendship Center Foundation, and managed by Northern Trust Bank. 2 Packet Page -2727- 7/26/2011 Item 16.K.2. The Clinic provides primary care to eligible clients as well as several specialty services — cardiology, endocrinology, gynecology, ophthalmology, non - surgical orthopedics, rheumatology and dentistry. Dermatology and psychiatry have been provided until the retirements of those specialty physicians. Recruitment efforts continue to replace providers in these specialty areas. Client Eligibility Client eligibility is based on age, household income and insurance status. As stated above, clients must be a minimum of 50 years of age. Income levels are based on family size and Federal Poverty Guidelines. These guidelines are reviewed annually and changed periodically. New guidelines went into effect March 1, 2011. Clients have been eligible with incomes up to 200% of the Poverty Guidelines until March 9, 2011 when we were granted permission by the Director of Public Health in Collier County to increase eligibility to 300% of Federal Poverty Guidelines. Clients must produce documentation of residency in Collier; provide photo identification and income documentation. Medicare assignment is accepted. Currently several physicians and dentists are applying for Medicaid provider status. Primary, private insurance is not accepted at this time. Services Provided Ophthalmologists provide routine eye examinations, management of glaucoma, and other eye conditions as well as providing screenings in cooperation with local Lions Clubs to thousands of individuals throughout Collier County. The local LensCrafters provides eyeglasses free or at significant discounts. The Clinic partners with the Florida Breast and Cervical Cancer Screening Program to provide free mammograms and Pap Smears and follow up care to eligible women. Costs not covered by the above program for some diagnostic follow up are provided locally through Bosom Buddies. Local pathologists provide service at discounted fees. Pulmonologists currently provide low cost testing for lung capacity as well as manage chronic lung conditions. Orthopedics and rheumatology provide management of arthritis and are able to provide joint injections for pain relief. The Friendship Health Clinic is one of three health care facilities in Collier County providing primary care to low- income individuals who participate in PLAN (Physician Lead Access Network) - the Department of Health community group utilizing medical specialists in the area who volunteer their services in exchange for sovereign immunity. As a result of grants, we are now able to perform several basic diagnostic laboratory tests including blood chemistries and other tests allowing us to better monitor our patients with diabetes and those on Coumadin therapy. A state of the art EKG system allows us to perform diagnostic EKGs at the clinic. Through a grant from a local organization, the clinic last year provided 275 months worth of diabetic test strips and monitors to 45 clients. Medical patients are eligible to participate in a medication assistance program that has grown from $9,500 in 2004 when it was implemented to $118,046 in 2010. 3 Packet Page -2728- 7/26/2011 Item 16.K.2. The single overall busiest specialty is Dental. According to the Centers for Disease Control (2001), "Older Americans with the poorest oral health are those who are economically disadvantaged, lack insurance and are members of racial and ethnic minorities." While dental care is essential to good nutrition, the cost is often high and thus is often one of the last things people address. Periodontal disease or dental decay most often causes tooth loss. Older Americans continue to experience dental decay on the crowns of teeth and tooth roots because of gum recession. Severity increases with age and about 23% of 65 -74 year - olds have severe disease. People at the lowest socioeconomic level have the most intensive periodontal disease. Even fewer have dental insurance. Friendship Health Clinic is the major provider of primary dental care services to the uninsured population of adults 50 or older in Collier County. The Health Department provides primarily pediatric dental care. Adults must be at 100% of the Federal poverty level and generally only emergency dental care is provided for adults - -not preventive and health maintenance care. The Health Department refers adults over 50 years of age to us for primary and preventive dental care. The Veterans Administration does not have any dental program, so they also refer clients to us for care. Medicare and Medicaid do not cover primary or preventive dental services. In 2009 and 2010 the Clinic provided dental care to an annual average of 358 clients, accounting for 1,478 visits annually. Unfortunately, the need for care exceeds our available resources. There is a constant (12 -15 month) waiting list of 100 -125 uninsured individuals needing non - emergent dental services and a backlog of about 40 existing clients needing follow -up care. The Collier County Health Department is referring an increased number of eligible, emergent, and non - emergent clients over age 50 for treatment. The State of Florida Department of Health sliding scale fee schedule is now being utilized to determine payment for services. Patients with income less than 100% of Federal poverty guidelines pay $0. As we are seeing an increasing number of individuals on unemployment, food stamps, and homeless, we are seeing an increase in the numbers of individuals whose sliding scale is 0 %- 17% of charges. Historically, no one who met eligibility requirements has been turned away and funding was found to cover some who were unable to pay for laboratory fees. Because we are no longer able to charge many of these clients, we may not be able to provide dental prostheses unless funding is available. Rather than trying to "save" what natural teeth an individual has or supplement with a partial prosthetic, we will have to rely on extraction. Prosthetics can be measured for and fitted at the Friendship Health Clinic, but must be produced in a laboratory, which necessitates a cost of between $252 for a single full denture to $325 for a single partial denture. Local dental laboratories provide these devices at a discounted fee for our Clinic. Despite the discount, many clients have difficulty with payment. Thus, many uninsured clients, or those on Medicaid or Medicare, cannot afford these critical services. Many of our clients are living on minimal Social Security benefits and cannot even afford to pay Medicare Part B benefits. The scope of dental service includes providing dental hygiene, patient education, oral examination, laboratory and X -rays studies, diagnosis, dental treatment plan, and treatment 4 Packet Page -2729- 7/26/2011 Item 16.K.2. or referral for dental disease or injury. In addition to fillings, extractions are provided at our Clinic, as well as fitting and ordering needed dental prosthetics. Patients are referred for oral surgery, root canals or other conditions requiring further specialty when necessary. There are several types of clients who need our dental services: Clients from St. Matthew's House frequently are referred for dental care. Although they are required to work in order to stay at the shelter, they do not have an income sufficient to pay for prosthetics or other work needed and some are disabled. With the mandated sliding scale fee structure that includes payments of 0 -17 %, we may be unable to provide services to a large portion of these clients. Poor self- image is frequently either a result of choices made or a cause for choices made. Having money available to assist these individuals improves their health as well as self - image. Elderly individuals frequently lose their dental insurance when they retire. The situation may be worse for older women who generally have lower incomes and may never have had dental insurance. Medicaid funds some emergency dental care for the low- income and disabled elderly in Florida, but reimbursements are low. Medicare is not designed to reimburse for routine dental care. Individuals who have lost their jobs and no longer have dental insurance continue to have need for preventive and primary dental care. Service Statistics Summary • Between 2007 and 2010, there was an overall 55% increase in medical, dental and medication assistance provided and patient visits in 2010 exceeded 5,000 for the first time in the history of the Collier Clinic. The value of medication assistance in 2007 was $52,180 and in 2010, it peaked at $118,046. • Patient Demographics /Other information Of the 1052 clients served in 2010, 60% were female; 25% under the age of 60 and 35% over the age of 60. Forty percent of the clients were male; 17% under age 50 and 23% over age 60. Note: Currently, we are gathering information for Under 60 and Over 60 but we are in the midst of changing parameters in our new data management system, SAMS. Information on race and income was not being input. We have started to go back and enter the information in SAMS so will be able to pull information accurately in the future. • Medicare patients 98 Packet Page -2730- 7/26/2011 Item 16.K.2. • Medicare /Medicaid 22 • Medicaid 6 Eleven percent of patients are insured by Medicare; 89% are uninsured with incomes ranging from below poverty level to 200% of poverty level. Funding requested Amount to be Funded Through This Grant $100,000 for use in both medical and dental services. Financial Information Funding for Friendship Health Clinic comes primarily from private sources through grants, fundraising, private foundations, donations, patient fees, Medicare and secondary insurance. Grants /Fundraising Golf Tournament (Dr. Pastor Memorial) 2007 $8,724 net (staff chairing event) 2008 $7,852 net 2009 $33,758 net (Note: volunteer committee chairing the event) 2010 $27,274 net 2010 Annual Appeal (direct mailing) Results: $4,960: Based on 385 Letters Mailed with 24 Responses Grants & Organizational Donations 2007 -2010 $39,000 (rounded) Grants secured from the Community Foundation of Collier County, various faith - based groups and churches, a couple family foundations, and individual donors. $33,613 US Dept of Health and Human Services special Congressional Initiative Equipment purchased through Collier County Housing Department See Current Initiatives section below for anticipated grant revenue for 2011 Collier Fund - Senior Friendship Centers Foundation The Collier fund has been utilized to balance the budget for several years. The balance is affected by investment results, standard annual distributions, and transfers for additional operational shortages. Anticipated withdrawal of $135,417 to cover operational needs for 2011 will all but deplete this fund. 6 Packet Page -2731- 7/26/2011 Item 16.K.2. Staffing of the Friendship Health Clinic Staffing of the clinic is primarily provided by volunteer staff. Paid staff is at a minimum. To accommodate the increased number of clients, paid staff hours have been increased. Hours in dental will increase in 2011 to accommodate the increased dental work load. Recent Paid Staffing Proportional Share of Organizational Administrative Costs ($42K in 2010 /or 14% of overall expenses for Collier) Includes: Financial and Billing Services, Liability Insurance for officers and volunteers, External Audit services, IT, Human Resources, Executive Management No charges for any assistance from Communications, Development Volunteers FTEs Payroll 2008- 2.5 105,854 09 2010 3 136,737 Proportional Share of Organizational Administrative Costs ($42K in 2010 /or 14% of overall expenses for Collier) Includes: Financial and Billing Services, Liability Insurance for officers and volunteers, External Audit services, IT, Human Resources, Executive Management No charges for any assistance from Communications, Development Volunteers Unit Cost Summary 2009 Annual Average Rates Medical visit $48.74 Dental visit $70.05 Meds assist. $4.64 Recent Financial Results 2009 Total Expenses: $274K 2010 Annual Average Rates Medical visit $58.60 Dental visit $85.42 Meds assist. $6.25 Expenses exceeded Revenue by $25K Primary Reasons: Increased indigent care: $15K in write -offs, building maintenance costs — A/C repair, roof repair, etc.) 2010 Total Expenses: $361K Expenses exceeded Revenue by $120K Primary Reasons: Increased indigent care: $40K in write -offs; $29K in relocation expenses; additional staff for dental Capital Outlay (all computer and clinical equipment paid for by grant funding) Packet Page -2732- Total Volunteers In -kind Value 2010 83 $685,917 Unit Cost Summary 2009 Annual Average Rates Medical visit $48.74 Dental visit $70.05 Meds assist. $4.64 Recent Financial Results 2009 Total Expenses: $274K 2010 Annual Average Rates Medical visit $58.60 Dental visit $85.42 Meds assist. $6.25 Expenses exceeded Revenue by $25K Primary Reasons: Increased indigent care: $15K in write -offs, building maintenance costs — A/C repair, roof repair, etc.) 2010 Total Expenses: $361K Expenses exceeded Revenue by $120K Primary Reasons: Increased indigent care: $40K in write -offs; $29K in relocation expenses; additional staff for dental Capital Outlay (all computer and clinical equipment paid for by grant funding) Packet Page -2732- LDX Analyzer (Cholesterol) Spirometer and printer Piccolo Express Chemistry Analyzer EKG System and Cart (4) HP computers (4) 19in monitors (1) HP workstation (1) 24 in monitor (1) security appliance (1) Dell UPS tower / Server and $2,004 $1,644 $18,531 $4,483 $2,802 $724 $788 $440 $304 (just arrived) monitor $1,893 (Just arrived) 7/26/2011 Item 16.K.2. Nortel Phone System $4980 + $500 installation incl. voicemail (partially covered by grant from Moorings Presbyterian Church $4000) See Current Initiatives section below for anticipated grant revenue for 2011 Current Initiatives Electronic Health Records — Recently secured a federal LIP grant for $267,000; research under way to assure system purchased will serve long -term needs, network with area partner providers and work within a plan to transition the clinic via technology Relationship with Collier Public Health Department — increase eligibility to 300% Federal Poverty The $100,000 requested would be used for operational expenses in place of the Collier Fund from the Senior Friendship Foundation. This money would allow the Clinic to continue operation for one more year while awaiting sale of the property on 81h Avenue South and development of more community partners. Application has been made to the United Way of Collier County for funding in 2012. A new Advisory Council has been established. Packet Page -2733- Internal Revenue Service Date: March 2, 2007 SENIOR FRIENDSHIP CENTERS INC 2350 SCENIC DR VENICE FL 34293 -1510 Dear Sir or Madam: 7/26/2011 Item 16.K.2. Department of the Treasury P. O. Box 2508 Cincinnati, OH 45201 Person to Contact: Judy Simonson 31 -04016 Correspondence Specialist/Screener Toll Free Telephone Number: 877- 829 -5500 Federal Identification Number: 59- 1522614 This is in response to your request of March 2, 2007, regarding your organization's tax - exempt status. In May 1976 we issued a determination letter that recognized your organization as exempt from federal income tax. Our records indicate that your organization is currently exempt under section 501(c)(3) of the Internal Revenue Code. Our records indicate that your organization is also classified as a public charity under sections 509(a)(1) and 170(b)(1)(A)(vi) of the Internal Revenue Code. Our records indicate that contributions to your organization are deductible under section 170 of the Code, and that you are qualified to receive tax deductible bequests, devises, transfers or gifts under section 2055, 2106 or 2522 of the Internal Revenue Code. If you have any questions, please call us at the telephone number shown in the heading of this letter. Sincerely, Michele M. Sullivan, Oper. Mgr. Accounts Management Operations 1 Packet Page -2734- Door _ 7/26/2011 Item 16.K.2. Consumer's Cert'rficate of Exemption DR -14 \ R. 04/05 DEPARTMENT Issued Pursuant to Chapter 212, Florida Statutes 07/01/09 OF REVENUE 85- 8012643756C -1 07/31/2009 07/31/2014 501(C)(3) ORGANIZATION This certifies that SENIOR FRIENDSHIP CENTERS INC 1868 BROTHER GEENEN WAY SARASOTA FL 34236 -7118 is exempt from the payment of Florida sales and use tax on real property rented, transient rental property rented, tangible personal property purchased or rented, or services purchased. Important Information for Exempt Organizations °R -14 _ R. 04/05 DEPARTMENT OF REVENUE 1. You must provide all vendors and suppliers with an exemption certificate before making tax - exempt purchases. See Rule 12A- 1.038, Florida Administrative Code (FAC). 2. Your Consumer's Certificate of Exemption is to be used solely by your organization for your organization's customary nonprofit activities. 3. Purchases made by an individual on behalf of the organization are taxable, even if the individual will be reimbursed by the organization. 4. This exemption applies only to purchases your organization makes. The sale or lease to others by your organization of tangible personal property, sleeping accommodations or other real property is taxable. Your organization must register, and collect and remit sales and use tax on such taxable transactions. Note: Churches are exempt from this requirement except when they are the lessor of real property (Rule 12A- 1.070, FAC). . 5. It is a criminal offense to fraudulently present this certificate to evade the payment of sales tax. Under no circumstances should this certificate be used for the personal benefit of any individual. Violators will be liable for payment of the sales tax plus a penalty of 200% of the tax, and may be subject to conviction of a third degree felony. Any violation will necessitate the revocation of this certificate. 6. If you have questions regarding your exemption certificate, please contact the Exemption Unit of Central Registration at 850- 487 -4130. The mailing address is PO BOX 6480, Tallahassee, FL 32314 -6480. Packet Page -2735- 7/26/2011 Item 16.K.2. Senior Friendship Centers Board of Governors - 2011 *Alan Sloan Brother William J. Geenen, Albert Resnick, M.D. Chairman CSC 2nd term expires - 2012 2nd term - expires 2012 Lifelong Appointment 3240 Lake Pointe Blvd. #252 3746 Torrey Pines Boulevard Home: 1635 4" Street Sarasota, FL 34231 Sarasota, FL 34238 Sarasota, FL 34236 Phone: H (941) 927 -5166 Home: 941-926-2560 Phone W: 941- 957 -3949 villaslom(o ),comcast.net Phone H: 941 - 365 -0722 Colleen Reynolds 1st term expires 2012 *John Counsell Lars Hafner, PhD 18374 Fern Road Vice Chair 1st term - expires 2013 Ft. Myers, FL 33967 2nd term - expires 2011 3802 1" Avenue West Phone W: (239) 437 -0040 14917 American Eagle Court Bradenton, FL 34205 edgecommunications (cucomcast.net Fort Myers, FL 33912 Phone: W 941 -752 -5201 Cell (954) 294 -2871 hafnerlAscf.edu Joseph Sullivan, M.D. counsfl(atcomcast.net 1" term expires 2012 Hayden Lipp, PhD 375 Bowline Drive *Darrin Halsey 2nd term expires - 2012 Naples, FL 34102 Treasurer 7604 Bergamo Avenue Phone: H (239) 261 -3903 2nd term expires - 2012 Sarasota, FL 34238 wilsonsullivan comcast.net 9082 SW Liverpool Road Phone: H (941) 922 -0541 Arcadia, FL 34269 Phone: W (941) 586 -3959 Kathy Silverberg Phone: H (863) 993 -2700 Phone: Cell (901) 270 -6791 1" term - expires 2013 Phone: W 1- 888 - 726 -5556 FAX (941) 922 -0541 3589 Pennyroyal Rd. FAX: 1- 888 - 864 -8922 Hayden lippAcomcast net Port Charlotte, FL 33953 Phone Cell: (941) 465 -1005 Phone: H 941- 380 -2965 dhalsev(ahalsevcoadvisorv.com Jane Johnson Kathy. Silverbere(a-_)comcast.net I st term expires - 2013 *Richard J. Beebe, M.D. 4243 64" Dr. East Jane Smiley Secretary Sarasota, FL 34243 1" term - expires 2013 1' term expires 2011 Phone: 11941-309-3407 700 Ringling Blvd. H1,303 420 Bayshore Dr. iiohn75062(daol.com Sarasota, FL 34236 Venice, FL 34285 Phone: H 941 - 361 -7200 Phone: H (941)485 -8886 j [ smiley(q-),comcast.net ribeebe420Acomcast net Kevin W. O'Neil, M.D. 1" term expires - 2011 Dale L. Adler, MSW 3765 Beneva Oaks Blvd. Staff Contacts: I'term - expires 2013 Sarasota, FL 34238 14592 Jonathon Harbour Dr. Phone: 11 (941) 921 -6748 Bob Carter, CEO Fort Myers, FL 33908 Phone: Cell (941) 504 -9242 941- 556 -3246 Phone H: 239 - 466 -7812 KOncil a)brookdalelivine.com rcarter(a�friendshipeenters.ora spaeaele nearthlink.ne[ Molleen Pust Edward F. Banaszak, MD Lifelong Appointment Karen Bigner, Board Liaison 2 "a term -- expires 2011 1635 4"' Street 941 -556 -3253 7638 Mulberry Lane Sarasota, FL 34236 kbicnei(dfriendshtpcenters.org Naples, FL 34114 Phone: H (941) 365 -3052 Phone H:(239) 732 -5531 Phone Cell: (239) 682 -0416 *Denotes Executive Committee eeban(amac.com Packet Page -2736- m x 7/26/2011 Item 16.K.2. Z r Z C M m x w w p O m w U A < w O > A w c Z A m A z < m m 0 z 0 z G) m m A< ~ M A O M p O y Z m m A z C x m TA m A - w 0 rn m O O M p w Z O = N O y m z s 71 0 p A D Z z A O A O O m m z� m y A O G m v m m z Z O 3 m M Z w y- O w M Tzz T A MM O nW O? Omz L 30 yvy r2 O �0N TO py°e j�� zm0z S� pDZzy A O y D C y C C C r m p M w y� 0 m w D O O T m T� um C y z A* A Z m Z Z y O C Z C O= m m Z➢ 0 0 m r- m - 0 C) Z m m Mn y O Z M m Z T 0 0< O O p? p Z m T w A w w m A w 0 -� w w y r O w w w p 3 3 y Z A Z Z w m m m T w y y O w w w wwwwwwwwwwwwwwww w wwwww wwwww w Z M C A y < A n� w w wwwwwwwwwwwwwwww w wwwww wwwww w � w C C w m D m Az0 O m M mA pmyA w G O< y m M m D A mC„ M w w wwwwwwwwwwwwwwww w wwwww wwwww 2 Am w ➢ O z _ m y C O pT A �' < j - k p vM,Z c i. tD R JN aww �in rn N 0 cwii m mrn�p fpit> O y A pw A O Owi O v A N O O. O U O U O O O N ro IOi 01 U O . fD W �V N W2 z Z f O Tye w w wwwwwwwwwwwwwwww w wwwww wwwww O O M G) 0 G m C 6M Z m w -1 y y w w wwwwwwwwwwwwwwww w wwwww wwwww w A M A y GO py m w� r.v m wA �rp� m U °i a �rnip m� O U O O O N w W O V O U w w ............ w w w w w w .... w w w w w D Z D O T M m l0 O Q O N N N .p m O O Z y w w wwwwwwwwwwwwwwww w wwwww wwwww T C Z O N N O. A W, p. •� O N • W � � r i - U, • � � � i J • � � VI w Z O w w wwwwwwwwwwwwwwww w wwwww wwwww y O A A N O 1p Ip V tp O. U V p N � m Owi r • (O pN � N• N N U. O0 V N � .p W w W (O OWi U N O V 0 0� Ows W w w p A W V O U Packet Page -2737- 7/26/2011 Item 16.K.2. Application for Grant from The Collier County Health Facilities Authority Applicant CHS Healthcare PA. Box 0'77 Immokalee, FL 34143 (239) 658 -3111 cdillonPcoIlier.orQ Constance C. Dillon Executive Director, CHS Healthcare Foundation Applicant's form of organization Collier Health Services Inc. aka CHS Healthcare and CHS Healthcare Foundation, Inc. are both private, not - for - profit 501 ( c ) (3) organizations. CHS Healthcare Foundation was formed in 2008 and exists to raise funds to support CHS Healthcare programs and services. Both organizations have IRS letters of exempt status. Officers Richard Akin, President & CEO Steven Weinman, Executive Vice President and COO Sandra Steele, Chief Financial Officer Jerry Williamson, M.D., Chief Medical Officer Kelley Johnson, D.M.D., Dental Director Lesa Peterson, Director of Operations William J. Kuzbyt, Psy.D., JD, LEAP, CAP, Director of Professional Services Constance C. Dillon, Executive Director, CHS Healthcare Foundation Activities and History of CHS Healthcare CHS Healthcare was founded in 1977 to provide healthcare to the rural and migrant workers in Immokalee. Since that time, CHS Healthcare has grown to meet the expanding primary healthcare needs of the community and currently has twelve locations throughout Collier County. CHS provides primary medical and dental care, its mission being to provide quality medical and dental care targeting underserved children and adults in Collier County. CHS has six pediatric offices and a Ronald McDonald Care Mobile, three dental facilities and three adult care facilities. In 2010, CHS Healthcare sewed over 48,000 patients for close to 170,000 patient visits. Of those 48,000 patients, 69% or 33,000 were children through age eighteen. We serve all patients regardless of their insurance status or ability to pay. Uninsured patients pay on a sliding fee scale. The budget for CHS Healthcare was $23 million for fiscal year end 3/31/2010. Administrative costs were 12 %. CHS Healthcare employs 242 people. Packet Page -2738- 7/26/2011 Item 16.K.2. How grant monies would be used mould CHS receive grant monies from the Collier County Health Facilities Authority, we would purchase ten Bilicheck Systems. This equipment is used to analyze bilirubin in infants and neonates. The Bilicheck System is noninvasive so there is no pain, trauma or risk of infection to the patient. The Bilicheck cii ri linatci uic nccu lul InJti Nlc mcl s�iLns w`uGl lave piDVC ri i0 Ca uie ImedlCai l.0 ail pllcation5 Teter for the children. In addition., using the Bilichecl; gives the physician immediate results of infant's bilirubin levels without waiting for laboratory turnaround time. We would like to have a Bilicheck System in each of our ten offices with pediatric patients. The quote that we have received for this equipment is attached, indicating a discounted price of 55,878.17 each for a total of $58,781.70 for ten. We believe that this equipment will greatly benefit any of our 33,000 pediatric patients requiring a bilirubin analysis. Thank you for your consideration. Packet Page -2739- Lcn! v,F l-rcjjj 16 it Iti :CL 7/26/2011 Item 16.K.2. Yf stork 'W7, tt.ac Mj5t Ov wouec hr,rn the .9PM31 Or. U SWarate Order We follow at o later Cate. --i Jnl-' 0' '-�,h.jra .ten; Stalt's ox ice Iny 7 F- it produ= purchase History AK qljantinac ere Shove .1, the jo,•tsv unit of me..Sut, Fah Ma, 'I; May J,,T,5 ,::.a Sep[ Dct, N, 2C,1 17, b D Packet Page -2740- 1- tErnal Revenue D= strict !Director Date: SEP 2 4 1998 Collier Health Services Inc 1454 W Madison Ave Immokalee, FL 34142- 2200543 7/26/2011 Item 16.K.2. _ne __eases; �. B= 2ECS CLncinnatij 114 1C'J `ll �molcve_ Identification =9- 1741277 ?erscn to Contact,: David A Doeker - elephone Number: 213 - 684 -3863 Dear Sir or Madam: Based on the information which you have submitted, we have determined that you have terminated your private foundation status under the provisions o£ section 507(h)(1)(3) of the Internal Revenue Code of 1986 and that, as of Ppril 1, '_993, you are an or o£ he twe 'described in section(s) 509 (a) (1) and 170 (b) (i) (A) (vi) of 'the Code. C-ran-ors and contributors may rely on this determination until the internal Revenue Service publishes notice to the contrary. ary. Bowever, a grantor or a contributor may not rely ^n aeterm' ation _£ he or '-his - she was in part responsible for, or was aware of, the act or failure to act that resulted in your loss of section 509(a)(1) and (170(b)(1)(A)(vi) status, or accuired knowledge that the Internal Revenue Service had given notice that you would be removed from classification as a section SCi(c)(3) organization. This letter modifies our letter of June 3, 1960, which held you to he a private foundation. Because this letter could help resolve any questions zbcut your foundation status, you should keep it in your permanent records. you have any ciuestions, please contact the person whose name and telephone number are shown above. siricerely yours, /Ile C =shl _ Bullard District Director �n M R jI Str� ^ c 12- COLLIER PEALTH SERVICES Packet Page -2741- a APPERtikT, gEV �:.T*Q'n SERVI C3 P. 0. 3C: 2508 CI%C:2,jUT7, OH 45201 V _ L 0 T Date: THE COLLIER =%LTH 5ERYrT =S .......,... - +mom -.... C/o How= C!UMINGS k LOCF.'WOOD LLC 8000 HEALTH CENTER BLVD STE 300 BONITA SPRINGS, FL 34135 -0000 Dear Applicant: 7/26/2011 Item 16.K.2. DcPFRTN ,T OF Employe- :dent if iCat'_On N"umbsr: 26- 0229508 DLN: 17053247016037 COataCt parson! GREGORY % OLWZNE IDur 31382 Contact Telephone Number: (877) 829 -5500 Accounting Period Ending: December 31 public Charity Status: 170 (b) (1) (A) (vi) Form 990 Required: Yes Effective Date of Exemption: February 1, 2007 Contribution Deductibility: Yes Advance Ruling Ending Date: December 31, 2011 Addendum Applies: NO We are pleased to inform you that upon review of your application for tax exempt status we have determined that you are exempt from Federal income tax' under section 501(c) (3) of the Internal Revenue Code. Contributions to you are deductible under section 170 of tht_ande. you o u are also under qualified ato reCe2106 tax deductible bequests, devises, gifts or 2522 of the Code. Because this letter could help resolve any questions regarding your exempt status, you should keep. it in your permanent records: Organizations exempt under section 501(0)(3) of the Code are further classified as either public charities or private foundations.. buying your advance ruling period, you will be treated as a public charity. Your advance ruling period begins with the effective date' of your exemption and ends with advance ruling . and ng date shown in the heading ._of the letter. Shortly before the end of your advance ruling period, we will send you Form 8734, Support Schedule for Advance Ruling Period. You will have 90 days after . the end of your advance ruling period to return the completed form. We will then notify you, in writing, about your public charity status. please see enclosed Publication 4221 -PC, compliance Guide for 501(r) (3) Public Charities, for some helpful information about your responsibilities as an exempt organization. If you distribute funds to other organizations, your records must show whether Packet Page -2742- Letter 1045 (DO /CG) - 7/26/2011 Item 16.K.2. 501X1( =) =n cases where the recipient ;e exempt under section der s =ction 501(c) f') _ :m�__ ` ev- -de_nce the .Z C'an i5 MCI ena pt 'in _ _ - will be used for section 501(cl (1) p'=p:)ses. ..._---..... ...... . ... ...... ._. _.-- .---- --- --- indicated is your we have sent a copy of this letter to your representative as cower of attorney. Enclosures: Publication 4221 -Pe statute Extension Sincerely, Robert Choi Director, Bxemot Organisations Rulings and Agreements Packet Page -2743- Letter 1045 (DO /cc) 7/26/2011 Item 16.K.2. Collier County Health Facilities Authority Notice of Solicitation of Grant Proposals And Policies for Submission and Consideration of Requests The Collier County Health Facilities Authority (the "Authority ") is a governmental authority established pursuant to Florida Statutes to assist in the financing of qualifying health care facilities through the issuance of tax - exempt bonds. The Authority charges a bond issuance fee upon the issuance of bonds. Under Florida law, these surplus funds are required to be turned over to the Board of County Commissioners of Collier County which must appropriate and disburse such funds to "nonprofit human health service agencies ". Although the final decision on the disbursement of the funds will be made by the Board of County Commissioners, the County staff has requested the Authority to assist the county in selecting recipients of these funds. The Authority expects to recommend a maximum of $150,000 in total grants. The amount and number of grants recommended will be solely at the discretion of the Authority. By this Notice, the Authority is requesting nonprofit human health service agencies to submit requests for grants. Procedure for Submission of Applications I . Using the attached application request as a guide, applicant should submit original and 7 bound copies of the application to Authority Counsel at the address shown below not later than 5:00 p.m. on March 16, 2011. Applications received after that date will not be considered. 2. Applications will be considered by the Authority at a public hearing, and all applicants will be advised and should be prepared to orally present the application and respond to Authority questions. During Authority review period prior to hearing, Authority may request additional information Consideration of Applications and Recommendations to Board of County Commissioners Following presentations, the Authority will consider which, if any, applications will be recommended for funding. The Authority reserves the right, in its sole and absolute discretion, to select any, all, or none of the applications, and to recommend such amount of funding, if any, as the Authority shall determine. The Authority's recommendations will be forwarded to the Board of County Commissioners, and based on the Commission's decisions, funds will be disbursed to selected applicants in accordance with the terms and conditions of the award. Address for submissions: Donald A. Pickworth, Authority Counsel Packet Page -2744- Donald A. Pickworth, P.A. 5150 N. Tamiami Trail Suite 502 Naples, Florida 34103 Phone (239) 263 -8060 e -mail: picklaw &earthlink.net Packet Page -2745- 7/26/2011 Item 16.K.2.