Agenda 01/08/2019 Item #16D 601/08/2019
EXECUTIVE SUMMARY
Recommendation to approve an Agreement with Omega Health Services, LLC d/b/a Omega Care
Services pursuant to the Board of County Commissioner’s (Board) previous award under Request
for Proposal (RFP) #18-7470, Services for Seniors.
OBJECTIVE: To approve an Agreement allowing for the provision of comprehensive in-home and out of
home services to the elderly in Collier County.
CONSIDERATION: Collier County’s Services for Seniors Program has been providing support services
to Collier County’s frail elderly for the past thirty (30) years through the Community Care for the Elderly
(CCE), Home Care for the Elderly (HCE) and the Alzheimer’s Disease Initiative (ADI) programs. The
Collier County Services for Seniors Program is a comprehensive program offered to qualified seniors age
sixty (60) and older, who need services to prevent, decrease, or delay premature or inappropriate expensive
placement in nursing homes or other institutions.
Collier County, as the lead agency, is required to enter into contractual agreements with area service
providers to administer homemaking, personal care, respite, chore adult day care, nursing, escort,
companion, shopping assistant, and emergency alert response services. Annually, services provided to
program participants have cost approximately $550,000. The cost of services is reimbursed through
agreements between Collier County and the Area Agency on Aging for Southwest Florida, Inc. d/b/a
Senior Choices of Southwest Florida.
At its December 11, 2018 meeting, the Board approved the award of RFP #18-7470, Services for Seniors,
to eight (8) vendors, including Omega Health Services, LLC d/b/a Omega Care Services (See Agenda Item
#16D13, attached). Omega Health Services was unable to produce the requisite Certificate of Insurance in
time for the December 2018 meeting, so staff informed the Board it would bring back the Agreement with
Omega separately when it became available. The insurance requirements have now been satisfied and staff
is asking that the Board approve and authorize the Chair to execute the attached Agreement.
The attached agreement is the same as the agreements the Board approved at its December 11, 2018
meeting; and provides for an initial three (3) year contract period, with the option of three (3) additional
one (1) year renewal periods, consistent with the period of the grant funds awarded.
FISCAL IMPACT: Funds for vendor services and supplies are available in Human Services Grant fund
(707) for the CCE, ADI, and HCE projects 33560, 33558, and 33562.
GROWTH MANAGEMENT IMPACT: There is no Growth Management Impact associated with this
Executive Summary.
LEGAL CONSIDERATIONS: This item is approved as to form and legality and requires majority vote
for Board approval. -SRT
RECOMMENDATION: To approve and authorize the Chair to execute the attached Agreement with
Omega Health Services, LLC d/b/a Omega Care Services under RFP #18-7470, Services for Services.
Prepared By: Wendy Klopf, Grant Coordinator, Community & Human Services Division
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01/08/2019
ATTACHMENT(S)
1. 18-7470 OmegaHealth-dba-OmegaCare_Contract_VendorSigned (PDF)
2. 18-7470 Omega Health Services Insurance (PDF)
3. 18-7470 Solicitation (PDF)
4. (linked) 18-7470 Omega Health Proposal (PDF)
5. 18-7470 Final Ranking (PDF)
6. 18-7470 Addendum #1 (DOC)
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COLLIER COUNTY
Board of County Commissioners
Item Number: 16.D.6
Doc ID: 7591
Item Summary: Recommendation to approve an Agreement with Omega Health Services, LLC
d/b/a Omega Care Services pursuant to the Board of County Commissioner’s (Board) previous award
under Request for Proposal (RFP) #18-7470, Services for Seniors.
Meeting Date: 01/08/2019
Prepared by:
Title: Operations Coordinator – Community & Human Services
Name: Wendy Klopf
12/17/2018 10:41 AM
Submitted by:
Title: Manager - Federal/State Grants Operation – Community & Human Services
Name: Kristi Sonntag
12/17/2018 10:41 AM
Approved By:
Review:
Community & Human Services Kristi Sonntag CHS Review Completed 12/17/2018 12:09 PM
Procurement Services Opal Vann Level 1 Purchasing Gatekeeper Completed 12/17/2018 12:56 PM
Procurement Services Sandra Herrera Additional Reviewer Completed 12/17/2018 1:58 PM
Procurement Services Swainson Hall Additional Reviewer Completed 12/17/2018 4:04 PM
Procurement Services Ted Coyman Additional Reviewer Completed 12/17/2018 5:26 PM
Community & Human Services Maggie Lopez Additional Reviewer Completed 12/18/2018 5:15 PM
Public Services Department Kimberley Grant Level 1 Reviewer Completed 12/18/2018 5:19 PM
Procurement Services Viviana Giarimoustas Additional Reviewer Completed 12/19/2018 9:14 AM
Public Services Department Todd Henry Level 1 Division Reviewer Completed 12/19/2018 10:05 AM
Public Services Department Steve Carnell Level 2 Division Administrator Review Completed 12/19/2018 11:33 AM
County Attorney's Office Scott Teach Level 2 Attorney Review Completed 12/20/2018 2:24 PM
Grants Erica Robinson Level 2 Grants Review Completed 12/20/2018 2:34 PM
Office of Management and Budget Laura Wells Level 3 OMB Gatekeeper Review Completed 12/20/2018 4:25 PM
County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 12/21/2018 8:51 AM
County Attorney's Office Emily Pepin CAO Preview Completed 12/21/2018 3:50 PM
Budget and Management Office Ed Finn Additional Reviewer Completed 12/26/2018 12:21 PM
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Grants Therese Stanley Additional Reviewer Completed 12/27/2018 8:39 AM
County Manager's Office Nick Casalanguida Level 4 County Manager Review Completed 12/27/2018 3:23 PM
Board of County Commissioners MaryJo Brock Meeting Pending 01/08/2019 9:00 AM
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16.D.6.aPacket Pg. 1407Attachment: 18-7470 OmegaHealth-dba-OmegaCare_Contract_VendorSigned (7591 : RFP-7470 Omega)
121031201A
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICiES
BELOW THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSIJRED provisions or be endorsed
lf SUBROGATION lS WAIVEO, subject lo the terms and conditions oI the policy, certain policies may requi.e an endorsement A statement on
this certiticate does not confer righls to the certiricate holder in lieu of such endorsement(s).
lnsuranceHubAgency, LLC
1720 Lakes Parkway
GA 30043
AshLey Hemphil
(77O) 497-1240 \774) 814-7187
ahemphili@insurancehub.com
IN SURER(S) A FFOROING COVERAGE
tNsuRERA. Certain lJndeMriters at Lloyds of London
INSURED
Omega Heallh Serv ces
592Mhshiag10n 51
FL 33321
rNsuRER B. Progressive Express lns Co 10193
CERTIFICATE OF LIABILITY INSURANCE
CERTIFICATE NUMBER: CL18T 2310068COVERAGES REVISION NUMBER:
THIS IS"TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEO EELOW HAVE BEEN ISSUED TO THE INSURED NAMEO AEOVE FOR THE POLICY PERIOD
INDICATED, NOTWTHSTANDING ANY REQI.]IREIVIENT, TERI'I OR CONDLTJON OF ANY CONTRACT OR OTHER DOCUi,IENT WTH RESPECT TO \A,tI]CH THIS
CERTIFICATE MAY AE ISSUED OR IVIAY PERTAIN, THE INSURANCE AFFOROEO BY THE POLICIES OESCR]BEO HEREIN IS SUBJECT TOALL THE TERMS,
EXCLUSIONSANO CONDITIONS OF SUCH POLICIES. LIMITS SHOVIIiIMAY HAVE EEEN REOUCED BY PA]O CLAIMS
COMMERCIAL GENERAL LIABIL]TY
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$3 000,000
DESCRIPTION OF OPERATICN S / LOCATIOiIS / VEHICLES (ACORD 101, Addtion.l Reoarls Sch.dule, hay bo .nached if hoe spac. is EquirEd )
Collier County Eoard of Count Commissioners, OR, Board ofCounty Commlssioners in Collier County, OR, Collier County Govemment, OR, Collier County
incllded as an additional insured under the caplioned Commercia GeneralLiablity andAutofirobile Liablity Policies on a primary and non'contributory bass
if and to the extent requred by wrltten contract
CERTIFICATE HOLDER CANCELLATION
Collier County Board of County Commissioners
3295 TamiamiTrall E.
Nap es FL 34112
SHOTJLOANYOF THEABOVE OESCRIBEO POLICIES BE CANCELLED BEFORE
THE EXPIRAT]ON DATE THEREOF, NOTICE WLL BE OELIVERED IN
ACCOROANCE WITH THE POLICY PROVISIONS,
AUTHORiZED REPRFSENTATiVF
Auyaal
O 1988-2015 ACORD CORPORATION. A righrs reserved.
The ACORD name and logo are registered marks ofACORDACORD 25 (2016/03)
1113412018
16.D.6.b
Packet Pg. 1408 Attachment: 18-7470 Omega Health Services Insurance (7591 : RFP-7470 Omega)
COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
REQUEST FOR PROPOSAL (RFP)
FOR
Services for Seniors
SOLICITATION NO.: 18-7470
VIVIANA GIARIMOUSTAS, PROCUREMENT STRATEGIST
PROCUREMENT SERVICES DIVISION
3295 TAMIAMI TRAIL EAST, BLDG C-2
NAPLES, FLORIDA 34112
TELEPHONE: (239) 252-8375
Viviana.Giarimoustas@colliercountyfl.gov (Email)
This solicitation document is prepared in a Microsoft Word format (Rev 8/7/2017). Any alterations
to this document made by the Vendor may be grounds for rejection of proposal, cancellation of any
subsequent award, or any other legal remedies available to the Collier County Government.
16.D.6.c
Packet Pg. 1409 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
SOLICITATION PUBLIC NOTICE
REQUEST FOR PROPOSAL (RFP)
NUMBER:
18-7470
PROJECT TITLE: SERVICES FOR SENIORS
DUE DATE: 11/7/2018 10:00 AM EST
PLACE OF RFP OPENING: PROCUREMENT SERVICES DIVISION
3295 TAMIAMI TRAIL EAST, BLDG C-2
NAPLES, FL 34112
All proposals shall be submitted online via the Collier County Procurement Services Division Online Bidding System:
https://www.bidsync.com/bidsync-cas/
INTRODUCTION
As requested by the Community and Human Services Division (hereinafter, the “Division”), the Collier County Board of County
Commissioners Procurement Services Division (hereinafter, “County”) has issued this Request for Proposal (hereinafter, “RFP”)
with the intent of obtaining proposals from interested and qualified vendors in accordance with the terms, conditions and
specifications stated or attached. The vendor, at a minimum, must achieve the requirements of the Specifications or Scope of Work
stated.
The results of this solicitation may be used by other County departments once awarded according to the Board of County
Commissioners Procurement Ordinance.
Historically, County departments have spent approximately $11 million dollars over five (5) years; however, this may not be
indicative of future buying patterns.
BACKGROUND
The purpose of this solicitation is to secure vendors for the provision of home and community-based services, to be delivered to
persons sixty years and older under Older American’s Act (OAA), Community Care for the Elderly (CCE) and Health Care for the
Elderly (HCE), and to qualified persons eighteen years or older under Alzheimer’s Disease Initiative (ADI), within the geographic
area of Collier County. Unless otherwise stated, minimum hours of availability are 7:00 am to 5:00 p.m. Monday through Saturday,
with the exception of federal and state holidays. Respite services and emergency services must be available 24 hours/day, 365
days/year if needed.
Definitions, standards, and requirements of these services are included in the Department of Elder Affairs’ Home and Community-
Based Services Handbook (DOEA Handbook) link below:
http://elderaffairs.state.fl.us/doea/nois.php
TERM OF CONTRACT
The contract term, if an award(s) is/are made is intended to be for three (3) years with three (3) one (1) year renewal options. Prices
shall remain firm for the initial term of this contract.
Surcharges will not be accepted in conjunction with this contract, and such charges should be incorporated into the pricing structure.
The County Manager, or designee, may, at his discretion, extend the Agreement under all of the terms and conditions contained in
this Agreement for up to one hundred eighty (180) days. The County Manager, or designee, shall give the Contractor written notice
of the County's intention to extend the Agreement term not less than ten (10) days prior to the end of the Agreement term then in
effect.
DETAILED SCOPE OF WORK
Those interested in providing the services detailed below must adhere to all requirements in this RFP, in addition to maintaining
adherence with the guidelines set forth by the current DOEA Handbook. Lack of knowledge of all requirements of a service
listed in the proposal SHALL NOT relieve the provider of liability and obligations under the agreement.
Collier County Community & Human Services (CHS) shall lead all service authorization and coordination. In an effort to comply
with the requirements of the OAA, ADI, CCE and HCE Programs, clients entering the service system will be assessed and
prioritized by CHS. Upon determination of the service level to be provided, the CHS will offer the client a listing of service
vendors for the specific service(s) outlined within their care plan.
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Packet Pg. 1410 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
The client will be encouraged to pick a service provider of their choice and have the option of interviewing potential service
providers. Should the client not have a preference, CHS will select a service provider from the centralized provider list, using a
rotation basis (rotating to the next vendor on the list). In this manner, all service providers will be equally treated unless the client
has a preference. CHS shall not endorse one service provider over another.
Upon the determination of the service, the service levels, and the selected vendor, CHS will contact the vendor agency, and
authorize the service, number of hours, and frequency. In keeping with the state policy of client choice of service providers, Collier
County does not guarantee a minimum or maximum number of clients that will be referred, nor a minimum or maximum number of
service hours that will be requested during the contract period.
Should a client later indicate dissatisfaction with the chosen service provider, they will again be offered their choice of provider.
CHS shall send the agreed-upon Service Authorization to the chosen provider. These “service authorizations” or “service orders”
must contain necessary client information, such as street address, telephone number, and services or items needed, as well as the
name and telephone number of the CHS case manager authorizing the service. In order to meet client needs, some services may be
required outside of normal office hours (8:00 AM to 5:00 PM, Monday - Friday).
CHS reserves the right to request adding additional service providers throughout the resultant agreement period. The County may
do so through a competitive and publicly announced selection process, which shall be coordinated through the County’s
Procurement Department. Services shall be provided in the manner described in the most current DOEA manual and outlined
herein. Should funding for additional Senior Services be identified the County reserves the right to add to the resultant agreements
the services, descriptions, rates, etc. by way of a contract addendum.
Services covered by this agreement include, but are not limited to:
1. Adult Day Care: A program of therapeutic social and health activities and services provided to adults who have functional
impairments, in a protective environment that provides as non-institutional an environment as possible.
2. Chore: Performance of routine house or yard tasks including such jobs as seasonal cleaning, yard work, lifting and moving
furniture, appliances, or heavy objects, household repairs which do not require a permit or specialist, and household maintenance.
3. Enhanced Chore: This service is beyond the scope of chore due to the level of service needed. The service includes a more
intensified, thorough cleaning to address more demanding circumstances.
4. Homemaking: Specific home management duties including housekeeping, laundry, cleaning refrigerators, clothing repair, minor
home repairs, assistance with budgeting and paying bills, client transportation, meal planning and preparation, shopping assistance,
and routine house-hold activities by a trained homemaker.
5. Personal Care: Assistance with eating, dressing, personal hygiene and other activities of daily living. This service may include
assistance with meal preparation, housekeeping chores such as bed making, dusting, and vacuuming incidental to the care furnished
or essential to the health and welfare of the individual. Personal care can include accompanying the client to clinics, physician
office visits, or trips for the purpose of health care provided that the client does not require special medical transportation. Personal
care can also include shopping assistance to purchase food, clothing, and other items needed for the client’s personal care needs.
6. In Home Respite: Relief or rest for a primary caregiver from the constant/continued supervision, companionship, therapeutic
and/or personal care, of a functionally impaired older person for a specified period of time.
7. Skilled Nursing: Part-time or intermittent nursing care administered to an individual by a licensed practical nurse, registered
nurse, or advanced registered nurse practitioner, in the client’s place of residence, pursuant to a care plan approved by a licensed
physician.
8. Emergency Alert Response Services: Emergency alert/response service is defined as a community based electronic
surveillance service which monitors the frail homebound elder by means of an electronic communication link with a response
center.
9. Specialized Medical Equipment, Services, and Supplies: Adaptive devices, controls, appliances, or services, which enable
individuals to increase their ability to perform activities of daily living and repair of such services which may include: dentures,
walkers, reaching devices, bedside commodes, telephone amplifiers, touch lamps, adaptive eating equipment, glasses, hearing aids,
and other mechanical or non-mechanical, electronic, and non-electronic adaptive devices. Supplies may include such things as adult
briefs, bed pads, oxygen or nutritional supplements.
10. Facility Respite: 24-hour care in a State of Florida Licensed Nursing home.
11. Establish protocols for contacting CHS Case Managers in emergency or unusual circumstances and include the
documentation requirements (oral and written) in the Service Provider Application.
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Packet Pg. 1411 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
12. Provide disaster response protocols, plans and services: In the event of a natural disaster (hurricane, tropical storm, tornado,
flood, heat wave, etc.), the provider will have staff available to serve those clients in critical need of services, as designated by the
CHS Case Managers.
13. Establish a client grievance process: Each service provider agency must have a policy addressing client grievances and/or
complaints.
14. Establish and provide staff training: All services provided with funding from DOEA require service delivery personnel to
have general pre-service orientation and training specific to the service being provided. Lead Agencies are responsible for provision
of the pre-service training (on program and billing requirements, in particular) for all paid staff, volunteer staff and assigned staff of
service providers.
Pre-service orientation also must include:
• An overview of the aging process
• An overview of the aging network
• Communication techniques with the elderly
• Observation of abuse, neglect, exploitation and incident reporting
• Local agency service procedures and protocol
• Client confidentiality.
NOTE: All “hands-on” service personnel must receive training emphasizing the necessity of Universal Precautions. Home Health
Aides must have documentation of successful completion of 40 hours required training, and CNAs must have on file a copy of their
State of Florida certification. In-service training hours and topics are to be provided at the discretion of the service provider agency
and shall meet state requirements.
15. Compile and report program service delivery statistics and other data as identified by CHS. This may be required to be
provided in an electronic format at the choosing of CHS. These are reported to the Area Agency on Aging and Department of
Elder Affairs in accordance with the reporting requirements developed by the Department. Lead agencies are responsible for entry
of data in the Client Information and Registration Tracking System (CIRTS), which generates payment to the service provider
agency. Therefore, service provider agencies are required to provide Lead Agencies with correct and timely service data to
comply with these requirements. Timely submission is no later than noon on Wednesday of the week following the week
services are performed (service week defined as Monday through Sunday).
16. Maintain complete and accurate records: Service delivery logs, at a minimum, must be legible and contain the name of
client, type/s of services and date/s and hour/s of delivery. The client/caregiver must sign the log at the time of each service visit.
The service worker must sign and date the log upon completion, and submit it to the service provider agency.
Provide complete, clear and accurate invoices: Weekly invoices, which may be required to be provided electronically in a
system provided by CHS, must be submitted by noon on the Wednesday following the week that the service was provided and shall
include service provided. The service week is defined as Monday through Sunday. Monthly reporting requirements for CIRTS
dictate that all client and service data for the previous month to be entered into CIRTS by the 10th day of the month. Collier
County “Services for Seniors” will coordinate with vendors to determine due dates for invoices. This will insure compliance
with DOEA reporting requirements. Failure to record or report units of service will result in nonpayment (or delayed
payment) for such services.
Data required on weekly invoices and weekly timesheets include:
• Vendor name
• Vendor address
• Vendor telephone number
• Client name
• Service Provider employee who delivered the service(s)
• Services ordered and services delivered date
• Number of service hours, cost per hour and total cost
• Person preparing the report and the date it was prepared
• Weekly timesheets signed and dated by the client and Service Provider employee
• Additional information as determined by CHS
17. Prepare for annual on-site compliance audits by CHS or members of the Collier County staff as directed by the CHS or grant
requirements
REQUEST FOR PROPOSAL (RFP) PROCESS
1.1 The Proposers will submit a qualifications proposal which will be scored based on the criteria in Evaluation Criteria for
Development of Shortlist, which will be the basis for short-listing firms.
The Proposers will need to meet the minimum requirements outlined herein in order for their proposal to be evaluated and
scored by the COUNTY. The COUNTY will then score rank the firms and enter into negotiations with the top ranked firm
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to establish cost for the services needed. The COUNTY reserves the right to issue an invitation for oral presentations to
obtain additional information after scoring and before the final ranking. With successful negotiations, a contract will be
developed with the selected firm(s), based on the negotiated price and scope of services and submitted for approval by the
Board of County Commissioners.
1.2 The COUNTY will use a Selection Committee in the Request for Proposal selection process.
1.3 The intent of the scoring of the proposal is for respondents to indicate their interest, relevant experience, financial capability,
staffing and organizational structure.
1.4 The intent of the oral presentations, if deemed necessary, is to provide the vendors with a venue where they can conduct
discussions with the Selection Committee to clarify questions and concerns before providing a final rank.
1.5 Based upon a review of these proposals, the COUNTY will rank the Proposers based on the discussion and clarifying
questions on their approach and related criteria, and then negotiate in good faith an Agreement with the top ranked Proposer.
1.6 If, in the sole judgment of the COUNTY, a contract cannot be successfully negotiated with the top-ranked firm(s),
negotiations with that firm will be formally terminated and negotiations shall begin with the firm ranked second. If a contract
cannot be successfully negotiated with the firm ranked second, negotiations with that firm will be formally terminated and
negotiations shall begin with the third ranked firm, and so on. The COUNTY reserves the right to negotiate any element of
the proposals in the best interest of the COUNTY.
RESPONSE FORMAT AND EVALUATION CRITERIA FOR DEVELOPMENT OF SHORTLIST:
1.7 For the development of a shortlist, this evaluation criterion will be utilized by the COUNTY’S Selection Committee to score
each proposal. Proposers are encouraged to keep their submittals concise and to include a minimum of marketing
materials. Proposals must address the following criteria:
Evaluation Criteria Maximum Points
1. Cover Letter / Management Summary 5 Points
2. Certified Minority Business Enterprise 5 Points
3. Organizational Capabilities 20 Points
4. Financial and Human Resources Capabilities 20 Points
5. General Service Delivery 20 Points
6. Acceptance of Cost 20 Points
7. Cost of Services to the County 10 Points
TOTAL POSSIBLE POINTS 100 Points
Tie Breaker: In the event of a tie at final ranking, award shall be made to the proposer with the lower volume of work
previously awarded. Volume of work shall be calculated based upon total dollars paid to the proposer in the twenty-four
(24) months prior to the RFP submittal deadline. Payment information will be retrieved from the County’s financial system
of record. The tie breaking procedure is only applied in the final ranking step of the selection process and is invoked by the
Procurement Services Division Director or designee. In the event a tie still exists, selection will be determined based on
random selection by the Procurement Services Director before at least three (3) witnesses.
----------------------------------------------------------------------------------------------------------------------------------------------------------
Each criterion and methodology for scoring is further described below.
***Proposals must be assembled, at minimum, in the order of the Evaluation Criteria listed or your
proposal may be deemed non-responsive***
EVALUATION CRITERIA NO. 1: COVER LETTER/MANAGEMENT SUMMARY (5 Total Points)
Provide a cover letter, signed by an authorized officer of the firm, indicating the underlying philosophy of the firm in providing the
services stated herein. Include the name(s), telephone number(s) and email(s) of the authorized contact person(s) concerning
proposal. Submission of a signed Proposal is Vendor's certification that the Vendor will accept any awards as a result of this RFP.
Submit proposer’s Agency for Health Card Administration (AHCA) Certification: If certification is not provided at time of
proposal submission, the firm will be deemed non-responsive.
Indicate by selecting any one, or multiple services which the proposer is interested in providing to the County (descriptive
information is outlined in the above scope of work.
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Packet Pg. 1413 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
Interested in Providing
Service (Place X)
Not Interested in Providing
Service (Place X)
Item Services
1 Adult Day Care
2 Chore
3 Chore (Enhanced)
4 Homemaking
5 Personal Care
6 Respite (In-home)
7 Skilled Nursing
8 Emergency Alert Response
Services EARS
9 Specialized Medical
Equipment, Services, and
10 Respite (Facility Based)
EVALUATION CRITERIA NO. 2: CERTIFIED MINORITY BUSINESS ENTERPRISE (5 Total Points)
Submit certification with the Florida Department of Management Service, Office of Supplier Diversity as a Certified Minority
Business Enterprise.
EVALUATION CRITERIA NO. 3: ORGANIZATIONAL CAPABILITIES (20 Total Points)
In this tab, include five (5) References Questionnaires from clients of similar scope of services. Please include name, contact name,
phone number, address and years performing.
1. The proposer has received license from Agency for Health Care
Administration (AHCA). Provide evidence of license.
Yes/No
2. The proposer has by-laws which describe how business will be
conducted.
3. The proposer has the appropriate license for the services it
intends to provide to Collier County. Provide license evidence.
4. Board members are required to sign a conflict of interest
statement.
5. The proposer has a written business plan that is updated
regularly.
6. Organizational Chart: Proposer has to provide a copy of the
organizational chart indicating lines of authority and permanent and
full-time positions. Provide evidence.
7. Total number of years that the proposer has been in business.
8. Proposer has supervisory staff on call 24 hours per day/ 365 days
per year.
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Packet Pg. 1414 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
9. Proposer’s Owner/Operator license has never been denied, suspended
or revoked by Medicare, Medicaid, any Federal and/or any State
Agency. If yes, please attach a letter or explanation.
EVALUATION CRITERIA NO 4: FINANCIAL AND HUMAN RESOURCES CAPABILITIES (20 Total Points)
Complete each of the items below in the format requested, and calculate the totals as indicated. Submit evidence of
documentations where indicated. Proposers who do not complete in the format indicated below may be deemed non-responsive.
1. Proposer maintains daily, monthly and annual financial records of
payroll, benefits, operating and capital equipment.
Yes/No
2. Proposer prepares annual 1099 forms for all employees.
3. Proposer has a certified public accountant or an independent
accounting/auditing firm to prepare financial records.
4. Proposer uses an accounting software product.
5. Proposer has an accounting staff produce monthly financial
statements.
6. Proposer has annual audit completed. Provide copy recently completed.
7. Proposer has written recruitment policy.
8. Proposer provides criminal background check for employees on this
contract.
9. Proposer conducts formal orientation for all new staff.
10. Proposer distributes written personnel policies to staff.
11. Proposer distributes written personnel policies.
12. Workman's Compensation Policy information clearly posted for staff.
13. Proposer maintains written, signed Job Descriptions.
14. Proposer’s employees are evaluated at least annually in writing.
15. Proposer has written hiring practices.
16. Proposer has written retention policies.
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Packet Pg. 1415 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
17. Proposer has formal progressive disciplinary procedures.
18. Proposer has written policies regarding theft and falsification of time
sheets
19. Proposer has policy to prevent fraud and formalized methods to report
suspected incidents.
20. Agency has written disaster plan.
21. Proposer agrees to utilize electronic means to submit documentation, as
determined by CHS, to include invoices
EVALUATION CRITERIA NO 5: GENERAL SERVICE DELIVERY (20 total points)
1. Proposer maintains a formal record of in-services, available
for review.
Yes/No
2. Proposer maintains copies of training schedule for last year,
available for review.
3. Proposer maintains sign in sheets for in-service training, available for
review.
4. Proposer maintains evidence of attendance and completion
in employee files.
5. Proposer has copies on file of training materials.
6. Proposer has written Quality Assurance plan.
Provide plan.
7. Proposer surveys clients for satisfaction in writing at least once per
year. Provide sample.
8. Proposer analyzes surveys and uses reports for transmission
to administration and to employees.
9. Proposer incorporates results of Quality Assurance activities to
annual plan.
10. Proposer has Quality Assurance Committee as standing
subcommittee of Board
11. Proposer has written policy for reporting incidents.
Provide copy and a sample of the incident report
12. Proposer has formal training for staff regarding reporting of suspected
cases of abuse or neglect.
13. Proposer maintains anti-discrimination policies related to service
consumer
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Packet Pg. 1416 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
14. Proposer has written policy regarding consumers rights.
15. Proposer has written system for registering consumer’s complaints.
16. Proposer has written policy to follow up on consumers complaints.
17. Proposer has written description of how service is delivered from point
of request through provision and termination.
Provide copy.
18. Proposer has written procedures for assuring confidentiality of consumer
records.
EVALUATION CRITERIA NO. 6: ACCEPTANCE OF COST (20 Total Points)
In this tab you will be provided a list of services needed by the County. Those services with rates, In-kind match and Cost already
completed are standard rates in which you will be required to accept.
Please sign as an acceptance to the rates if you deem these standard rates to be acceptable.
______________________________________ I accept the standard contract rates listed below.
Item
Services
Grant Service
Unit
Cost Per Service
Unit (Cost your
company charges
for the service)
In-kind 10%
Match (Grant
Amount your
company will be
paying)
Reimbursement
Rate Per Unit
(Amount the
County will
reimburse your
company for a
given service)
1. Skilled
Nursing
CCE Per Hour $40.00 $4.00 $36.00
2. Enhance Chore ADI, CCE, OAA Per Hour $40.00 $4.00 $36.00
3. Respite (In-Home) ADI, CCE, OAA Per Hour $24.11 $2.41 $21.70
4. Respite (Facility
Based)
ADI, CCE, OAA Daily Rate $200.00 0 $200.00
5. Personal Care ADI, CCE, OAA Per Hour $24.11 $2.41 $21.70
6. Chore ADI, CCE, OAA Per Hour $24.00 $2.40 $21.60
7. Homemaking ADI, CCE, OAA Per Hour $23.33 $2.33 $21.00
8. Adult Day Care ADI, CCE, OAA Per Hour $13.89 $1.39 $12.50
9. Emergency Alert
Response
ADI, CCE, OAA Per Day $1.09 $0.11
$0.98
EVALUATION CRITERIA NO. 7: COST OF SERVICES TO THE COUNTY (10 Total Points)
In this tab, insert your cost for the services listed below.
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Packet Pg. 1417 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
Item
Services
Grant Service
Unit
Cost Per Service
Unit (Cost your
company charges
for the service)
In-kind 10%
Match (Grant
Amount your
company will be
paying)
Reimbursement
Rate Per Unit
(Amount the
County will
reimburse your
company for a
given service)
10.
Specialized Medical
Equipment, Services,
and Supplies
ADI, CCE, OAA Per Episode
VENDOR CHECKLIST
***Vendor should check off each of the following items as the necessary action is completed (please see, Form 2: Vendor Check
List):
The Solicitation Submittal has been signed.
The Solicitation Pricing Document (Bid Schedule/Quote Schedule/Proposal Pricing/etc.) has been completed and attached.
All applicable forms have been signed and included, along with licenses to complete the requirements of the project.
Any addenda have been signed and included.
Affidavit for Claiming Status as a Local Business, if applicable.
Division of Corporations - Florida Department of State – http://dos.myflorida.com/sunbiz/ (If work performed in the State).
E-Verify/Immigration Affidavit (Memorandum of Understanding).
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Packet Pg. 1418 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
FCP-1
FEDERAL UNITED STATE DEPARTMENT OF AGING
AND
FLORIDA DEPARTMENT OF ELDER AFFAIRS
The supplemental conditions contained in this section are intended to cooperate with, to supplement, and
to modify the general conditions and other specifications. In cases of disagreement with any other section
of this contract, the Supplemental Conditions shall govern.
Contractor means an entity that receives a contract.
The services performed by the awarded Contractor shall be in compliance with the provisions of 45 Code
of Federal Regulations (CFR) 75 and/or 45 CFR Part 92, 2 CFR Part 200 and other applicable regulations.
It shall be the awarded Contractor’s responsibility to acquire and utilize the necessary manuals and
guidelines that apply to the work required to complete this project. In general,
1) The contractor (including all subcontractors) must insert these contract provisions in each lower
tier contracts ( e.g. subcontract or sub-agreement);
2) The contractor (or subcontractor) must incorporate the applicable requirements of these contract
provisions by reference for work done under any purchase orders, rental agreements and other
agreements for supplies or services;
3) The prime contractor is responsible for compliance with these contract provisions by any
subcontractor, lower-tier subcontractor or service provider.
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Packet Pg. 1419 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
FCP-2
FEDERAL CONTRACT PROVISIONS
Administrative, contractual, or legal remedies (Ref. 41 U.S.C. 1908, 2 CFR § 200 Appendix II (A)
Unless otherwise provided in this contract, all claims, counter-claims, disputes and other matters in
question between the local government and the contractor, arising out of or relating to this contract, or the
breach of it, will be decided by arbitration, if the parties mutually agree, or in a Florida court of competent
jurisdiction.
Access to Records and Reports (Reference: 2 CFR § 200.333, 2 CFR § 200.336)
The contractor/vendor agrees to maintain all books, records, accounts and reports required under this
contract for a period of not less than three years after the date of termination or expiration of this contract,
except in the event of litigation or settlement of claims arising from the performance of this contract, in which
case the Contractor agrees to maintain same until the Purchaser, the Grantor Administrator, the Comptroller
General, or any of their duly authorized representatives, have disposed of all such litigation, appeals, claims
or exceptions related thereto. Furthermore, the County shall maintain written policies and procedures for
computer system backup and recovery and shall have the same requirement of its Contractors.
No Government Obligation to Third Parties - The Federal Government is not a party to this contract and
is not subject to any obligations or liabilities to the non-Federal entity, contractor, or any other party
pertaining to any matter resulting from the contract.”
Program Fraud and False or Fraudulent Statements of Related Acts The contractor acknowledges that
31 U.S.C. Chap. 38 (Administrative Remedies for False Claims and Statements) applies to the contractor’s
actions pertaining to this contract.”
Clean Air and Federal Water Pollution Control Acts (Reference: 2 CFR § 200 Appendix II (G))
Contracts and subgrants of amounts in excess of $150,000 shall contain a provision that requires the
Contractor or recipient to comply with all applicable standards, orders, or requirements issued pursuant to
the Clean Air Act (42 U.S.C. 7401–7671q) and the Federal Water Pollution Control Act as amended (33
U.S.C. 1251–1387). Violations must be reported to the Federal awarding agency and the Regional Office
of the Environmental Protection Agency (EPA).
Energy Policy and Conservation Act - (Reference 2 CFR § 200 Appendix II (H)
The contractor shall comply with any mandatory standards and policies relating to energy efficiency which
are contained in the F l o r i d a state energy conservation plan issued in compliance with the Energy
Policy and Conservation Act (Pub. L. 94-163, 89 Stat. 871, 42 U.S.C Section 6201)
Debarment and Suspension (Reference 2 CFR § 200 Appendix II (I)
Contract awards that exceed the small purchase threshold and certain other contract awards shall not be
made to parties listed on the government wide Excluded Parties List System in the System for Award
Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders
12549 (3 CFR Part 1986 Comp., p. 189) and 12689 (3 CFR Part 1989 Comp., p. 235), ‘‘Debarment and
Suspension.’’ The Excluded Parties List System in SAM contains the names of parties debarred,
suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or
regulatory authority other than Executive Order 12549. The successful bidder, by administering each lower
tier subcontract that exceeds $25,000 as a “covered transaction”, must verify each lower tier participant of
a “covered transaction” under the project is not presently debarred or otherwise disqualified from
participation in this federally assisted project.
Byrd Anti-Lobbying Amendment (31 U.S.C. 1352) (Reference 2 CFR § 200 Appendix II (J)
Vendors must certify it will not and has not used Federal appropriated funds have been paid or will be paid,
by or to any person or organization for influencing or attempting to influence an officer or employee of an
agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the
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Packet Pg. 1420 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
FCP-3
making of any Federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative
agreement. The certification includes any lobbying with non-Federal funds that takes place in connection
with obtaining any Federal award.
Procurement of Recovered Materials (Reference 2 CFR § 200.322)
Contractor and subcontractor agree to comply with Section 6002 of the Solid Waste Disposal Act, as
amended by the Resource Conservation and Recovery Act, and the regulatory provisions of 40 CFR Part
247. (1) In the performance of this contract, the Contractor shall make maximum use of products containing
recovered materials that are EPA designated items unless the product cannot be acquired (i) Competitively
within a timeframe providing for compliance with the contract performance schedule; (ii) Meeting contract
performance requirements; or (iii) At a reasonable price. (2) Information about this requirement is available
at EPA's Comprehensive Procurement Guidelines web site, http://www.epa.gov/. The list of EPA-designate
items is available at https://www.epa.gov/smm/comprehensive‐procurement‐guideline‐cpg‐program.
Diversity (Reference 2 CFR § 200.321)
The County is dedicated to fostering the continued development and economic growth of small, minority-,
women-, and service-disabled veteran business enterprises. All contracting and subcontracting
opportunities afforded by this solicitation/contract are strongly encouraged to contribute as both Contractors
and Sub-Contractors. Firms may be required to submit documentation addressing diversity and describing
the efforts being made to encourage the participation of small, minority-, women-, and service-disabled
veteran business enterprises. Information on Certified Minority Business Enterprises (CMBE) and Certified
Service-Disabled Veteran Business Enterprises (CSDVBE) is available from the Office of Supplier Diversity
at:
http://dms.myflorida.com/other_programs/office_of_supplier_diversity_osd/
Termination for Cause and Convenience
See County’s Standard Terms and Conditions.
Nondiscrimination-Civil Rights Compliance
The Contractor will 1. not discriminate against any person in the provision of services or benefits under this
contract or in employment because of age, race, religion, color, disability, national origin, marital status or
sex in compliance with state and federal law and regulations. 2. Assumes others with whom it arranges to
provide services or benefits in connection with any of its programs and activities are not discriminating
against clients or employees because of age, race, religion, color, disability, national origin, marital status
or sex. And 3. Assures others with whom it arranges to provide services or benefits to participants or
employees in connection with any of its programs and activities are not discriminating against those
participants or employees in violation of the above statutes, regulations, guidelines, and standards.
Computer Use and Social Media Policy
The Florida Department of Elder Affairs has implemented a Social Media Policy, in addition to its Computer
Use Policy, which applies to all employees, contracted employees, consultants, OPS and volunteers,
including all personnel affiliated with third parties, such as, but not limited to, contractors and
subcontractors. Any entity that uses the Department’s computer resource systems must comply with the
Department’s policy regarding social media. Social Media includes, but is not limited to blogs, podcasts,
discussion forums, Wikis, RSS feeds, video sharing, social networks like MySpace, Facebook and Twitter,
as well as content sharing networks such as flickr and YouTube. This policy is available on the Department’s
website at: http://elderaffairs.state.fl.us/doea/financial.php
STATE CONTRACT PROVISIONS
Discriminatory Vendors List
In accordance with Section 287.134, Florida Statutes, an entity or affiliate who has been placed on the
discriminatory vendor list may not submit a bid on a contract to provide any goods or services to a public
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Packet Pg. 1421 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.A FEDERAL CONTRACT PROVISIONS
FCP-4
entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building
or public work, may not submit bids on leases of real property to a public entity, may not be awarded or
perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity,
and may not transact business with any public entity.
Inspector General Cooperation
The Parties agree to comply with Section 20.055(5), Florida Statutes, for the inspector general to have
access to any records, data and other information deemed necessary to carry out his or her duties and
incorporate into all subcontracts the obligation to comply with Section 20.055(5), Florida Statutes.
Equal Employment Opportunity
The Contractor shall not discriminate against any employee or applicant for employment because of race,
age, creed, color, sex or national origin. The Agency will take affirmative action to ensure that applicants
are employed, and that employees are treated during employment, without regard to their race, age, creed,
color, sex, or national origin. Such action shall include, but not be limited to, the following: Employment
upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay
or other forms of compensation; and selection for training, including apprenticeship. Contractors must insert
a similar provision in all subcontracts, except subcontracts for standard commercial supplies or raw
materials.
Interest of Members of Congress
No member of or delegate to the Congress of the United States shall be admitted to any share or part of
this contract or to any benefit arising therefrom.
Interest of Public Officials
No member, officer, or employee of the public body or of a local public body during his tenure or for two
years thereafter shall have any interest, direct or indirect, in this contract or the proceeds thereof. For
purposes of this provision, public body shall include municipalities and other political subdivisions of States;
and public corporations, boards, and commissions established under the laws of any State.
Interest of Public Officials
No member, officer, or employee of the MPO or of a local public body during his tenure or for two years
thereafter shall have any interest, direct or indirect, in this contract or the proceeds thereof.
Lobbying
No funds received pursuant to this Agreement may be expended for lobbying the Legislature, the judicial
branch or a state agency.
EVerify
Vendors/Contractors/Subcontractors: 1. shall utilize the U.S. Department of Homeland Security's E-Verify
system to verity the employment eligibility of all new employees hired by the Vendor/Contractor during the
term of the contract; and 2. shall expressly require any subcontractors performing work or providing services
pursuant to the state contract to likewise utilize the U.S. Department of Homeland Security's E-Verify system
to verify the employment eligibility of all new employees hired by the subcontractor during the contract term.
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Packet Pg. 1422 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 1
GRANT CERTIFICATIONS AND ASSURANCES
THE FOLLOWING DOCUMENTS NEED TO BE RETURNED WITH SOLICIATION DOCUMENTS
BY DEADLINE TO BE CONSIDERED RESPONSIVE
1. Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered
Transactions
2. Certification regarding Lobbying
3. Conflict of Interest
4. Anticipated DBE, M/WBE or VETERAN Participation Statement
5. Opportunity List for Commodities and Contractual Services and Professional Consultant Services
6. Acknowledgement of Grant Terms and Conditions
7. Scrutinized Companies Certification
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Packet Pg. 1423 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 2
COLLIER COUNTY
Certification Regarding Debarment, Suspension, and Other Responsibility Matters
Primary Covered Transactions
(1) The prospective primary participant certifies to the best of its knowledge and belief, that it and its principals:
(a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a
public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft,
forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen
property;
(c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(Federal, State or local) with commission of any of the offenses enumerated in paragraph (l)(b) of this
certification; and
(d) Have not within a three-year period preceding this application/proposal had one or more public
transactions (Federal, State or local) terminated for cause or default.
(2) Where the prospective primary participant is unable to certify to any of the statements in this certification,
such prospective participant shall attach an explanation to this proposal.
__________________________ ________________________________________
Name Project Name
__________________________ ________________________________________
Title Project Number
__________________________ ________________________________________
Firm Tax ID Number
________________________________________
DUNS Number
_________________________________________________________________________
Street Address, City, State, Zip
__________________________________
Signature
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Packet Pg. 1424 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 3
COLLIER COUNTY
Certification Regarding Lobbying
The undersigned certifies, to the best of his or her knowledge, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of an agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with
the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the
entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or
modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal
contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-
LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents
for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and
cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any
person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000
and not more than $100,000 for each such failure.
The Contractor, __________________________, certifies or affirms the truthfulness and accuracy of each
statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that
the provisions of 31 U.S.C. § 3801 et seq., apply to this certification and disclosure, if any.
In addition, the Contractor understands and agrees that the provisions of 11.062, Florida Statutes., apply to
this certification and disclosure, if any.
Signature of Contractor's Authorized Official
Name of Authorized Official and Title
Date
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Packet Pg. 1425 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 4
COLLIER COUNTY
Conflict of Interest Certification
_______________________
Collier County Solicitation No.
I, ________________________________________, hereby certify that to the best of my knowledge, neither I
nor my spouse, dependent child, general partner, or any organization for which I am serving as an officer,
director, trustee, general partner or employee, or any person or organization with whom I am negotiating or have
an arrangement concerning prospective employment has a financial interest in this matter.
I further certify to the best of my knowledge that this matter will not affect the financial interests of any member
of my household. Also, to the best of my knowledge, no member of my household; no relative with whom I
have a close relationship; no one with whom my spouse, parent or dependent child has or seeks employment;
and no organization with which I am seeking a business relationship nor which I now serve actively or have
served within the last year are parties or represent a party to the matter.
I also acknowledge my responsibility to disclose the acquisition of any financial or personal interest as described
above that would be affected by the matter, and to disclose any interest I, or anyone noted above, has in any
person or organization that does become involved in, or is affected at a later date by, the conduct of this matter.
Name Signature
Position Date
Privacy Act Statement
Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 and 5 CFR Part 2634,
Subpart I require the reporting of this information. The primary use of the information on this form is for review
by officials of The Justice Department to determine compliance with applicable federal conflict of interest laws
and regulations. Additional disclosures of the information on this report may be made: (1) to a federal, state or
local law enforcement agency if the Justice Department becomes aware of a violation or potential violation of
law or regulations; (2) to a court or party in a court or federal administrative proceeding if the government is a
party or in order to comply with a judge-issued subpoena; (3) to a source when necessary to obtain information
relevant to a conflict of interest investigation or decision; (4) to the National Archives and Records
Administration or the General Services Administration in records management inspections; (5) to the Office of
Management and Budget during legislative coordination on private relief legislation; and (6) in response to a
request for discovery or for the appearance of a witness in a judicial or administrative proceeding, if the
information is relevant to the subject matter. This confidential certification will not be disclosed to any
requesting person unless authorized by law. See also the OGE/GOVT-2 executive branch-wide Privacy Act
system of records.
16.D.6.c
Packet Pg. 1426 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 5
16.D.6.c
Packet Pg. 1427 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 6
16.D.6.c
Packet Pg. 1428 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 7
COLLIER COUNTY
Acknowledgement of Terms, Conditions and Grant Clauses
Flow Down of Terms and Conditions from the Grant Agreement
Subcontracts: If the vendor subcontracts any of the work required under this Agreement, a copy of the
signed subcontract must be available to the Department for review and approval. The vendor agrees to
include in the subcontract that (1) the subcontractor is bound by the terms of this Agreement, (ii) the
subcontractor is bound by all applicable state and federal laws and regulations, and (iii) the subcontractor
shall hold the Department and Recipient harmless against all claims of whatever nature arising out of the
subcontractor’s performance of work under this Agreement, to the extent allowed and required by law. The
recipient shall document in the quarterly report the subcontractor’s progress in performing its work under
this agreement. For each subcontract, the Recipient shall provide a written statement to the Department as to
whether the subcontractor is a minority vendor as defined in Section 288.703, Fla. Stat.
Certification
On behalf of my firm, I acknowledge, and agree to perform all of the specifications and grant requirements
identified in this solicitation document(s).
Vendor/Contractor Name ______________________________
Date __________________
Authorized Signature ___________________________________________________________
Address _____________________________________________________________________
Solicitation/Contract # ____________________________
16.D.6.c
Packet Pg. 1429 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES
GCA - 8
COLLIER COUNTY
Scrutinized Companies Certification
The undersigned (Vendor/ Contractor) certifies, to the best of his
or her knowledge and belief, that it is not listed on the
Scrutinized Companies with Activities in Sudan List,
Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, and/or
Scrutinized Companies with Activities in Israel List (eff. 10.1.2016), pursuant to Section 215.473,
F.S.
The subcontractor further agrees the County may immediately terminate this contract for cause if the
vendor/contractor is found to have submitted a false certification or is placed on the Scrutinized Companies list
during the term of the contract.
Name of Authorized Official
Title
Signature of Vendor/Contractor's Authorized Official
Date
16.D.6.c
Packet Pg. 1430 Attachment: 18-7470 Solicitation (7591 : RFP-7470 Omega)
www.omegahealthservices.org Ph: 786-304-8483
E: info@omegahealthservices.org 7130 W McNab Rd, Tamarac FL, 33321
NPI: 1265920094 Tax ID: 82-5284470
November 1st,, 2018
Cover Letter
RE: Collier County Board of Commissioners
RFP- Services for Seniors
Solicitation NO: 18-7470
Dear Sir/ Madam:
Omega Health Services LLC, is pleased to submit its proposal to the Collier County Board of
Commissioners in response to the above-referenced Request for Proposal (RFP) to provide care
to seniors of home and community-based services.
Omega Health Services (dba: Omega Care Services) is a licensed Homemaker and Companion
agency within Tamarac FL. As a new start-up company, OHS provides care to a diverse client
population, who are seniors 55 yrs and older, individuals with disabilities, including those
diagnosed with autism, Spina Bifida, cerebral palsy, and more. Our team is composed of
qualified and experienced staff, who are bilingual in English, Spanish and Creole. Each staff
member on our team has been in the field for over four years; they are competent and passionate
about making a difference in the lives of others. Lastly, our management team’ primary goal is to
provide the finest coordinated care possible. OHS recognizes the need for HCBS in the state of
Florida, as it is estimated that total population aged 65 and over is forecast to represent 24.1
percent by 2030; and that 51 of Florida’s 67 counties has exceeded the US percent of population
65 years and older; this includes Collier County.
Our mission is to provide high quality, client-centered and affordable Home Care services to
seniors; which will assist them to lead dignified and independent lives. Their needs are carefully
assessed, understood and met through the selective assignment of a qualified, trustworthy and
compassionate personnel. Omega Health Services LLC, seeks to improve the overall well-being
of seniors in Collier County by:
●Assistance with daily tasks- helping clients with everything from cooking, cleaning,
feeding, and more
●Open Lines of Communication- by having a confidant, they can share their thoughts,
feelings, and opinions
● Sense of Security- We will give every individual and family members a peace of mind
knowing that someone is always there.
● General Comfort- Our companions offer general comfort and friendship that can lift our
clients’ spirits.
●Homemaker - takes the responsibility for how the household runs, how it is organized,
daily routines and chores and the health and well-being of the family.
We have seen measurable success by performing client surveys, safety and functional housing
assessments, client centered care, and performance effectiveness. We believe in the integrated
model approach to care, and understand the importance of home and community based
programs, which should be cost effective, culturally responsive, and have familiarity.
We appreciate you for taking an interest in reviewing our application, and can certainly vouch
that OHS will be the chosen provider to assist ALL clients we serve to Live their Best Lives. On
behalf of Omega Health Services, thank you for giving us the opportunity to respond to this RFP
and we look forward to a mutually rewarding partnership.
Sincerely,
Agnes Saint Preux
_______________________________
Agnes Saint Preux, MHSA
Administrator
Executive Summary
I.Our Mission
Omega Health Services LLc offers high quality, client-centered and affordable home care
services to seniors and adults with disabilities; which will assist them to lead dignified and
independent lives. It is our utmost goal that all clients served live their best lives possible. We
ensure this philosophy of care by :
●Making accessible a range of direct service providers who are culturally diverse,
experienced, and compassionate about the needs of their clients
●Providing good communication and a effective care plan transitions between providers
●Focusing on the total health care needs of the consumer
●Communicating clear and simple information that patients can understand
II. The Company and Management
Omega Health Services LLC is located the City of Tamarac, in Broward County Florida. The
company formed from a volunteer service to seniors at their church who required daily living
assistance. During that time, the owners witnessed and researched the need for home and
community based services to those affected by disabilities and age. The company is owned by
Agnes Saint Preux and Mirline Omega, both owners have an extensive knowledge in Long Term
care management, and nursing
1. Agnes Saint Preux - MHSA | Administrator
Ms. Saint Preux is a current graduate student at Florida International University with a focus in
Health Service Administration, and a certificate in Healthcare Risk Management & Patient
Safety. She is in charge of the administrative aspect of the company along with the creation of
work and shift schedules for direct care providers, keeping and organizing records of the
facility’s services, managing , controlling, coordinating, and supervising the fiscal activities of
the agency, payroll, contract preparation, and client intake.
2. Mirline Omega, BSN, RN | Clinical Director / Co-Owner
Mrs. Omega-Richard oversees all of our non-medical operations within the organization, along
with, delivery and client outcomes, to ensure that care meets the patients needs, monitor and take
reasonable steps to ensure: a. Patient rights are exercised. b. compliance with applicable
Federal, State and Local laws and training. c. Compliance with established policies and
procedures. d. Compliance with the patient’s plan of care. She has been practicing as a licensed
healthcare professional for over 5 years and will oversee all of our skilled nursing services in
2019.
3. Direct Service Providers - Contracted Staff
Provide utmost respect for all persons and their families in all interactions. Have knowledge of
senior care, and developmental disabilities. Participate in the development & implementation of
Individual Treatment Plan. Provide in home & community support. 1. Adherence to the
objectives & methods in the Plan of Care (POC). 2. Adherence to the safety plan. 4. Maintain
accurate up-to-date daily progress notes and reports in a timely manner. 5. Provide transportation
as needed, as indicated in the POC, ensuring safety at all times. 6. Carry out all other duties and
responsibilities as assigned.
III. Our Services
Our senior companion care and homemaker
services include, but are not limited to:
●Caring companionship and conversation
●Help with hobbies
○Scrapbooking
○Artistic pursuits
○Playing games
○Gardening
○Sports & news
○General shopping and errand
●Transportation
○Doctor visits
○Religious services
○Community events
○Visiting family and friends
●Assistance with pet care
●Reminder services (medications, dates,
routines, etc.)
●Meal preparation
●Light housekeeping
●Errands
○Prescription pickup
○Dry cleaning
●Grocery shopping
●Home safety evaluation
Chore Services include:
Deep Cleaning Services
●Kitchens
●Bathrooms
●Floors
●Any hard to reach area
Assistance with Transitions
●Downsizing
●Packing and unpacking
●Organizing before and after a move
Home Organizing
●Kitchens and pantries
●Closets
●Basements and garages
●Bedrooms and bathrooms
Window Washing
●First floor inside and out
●Inside
● on any floor
Flexible Care - Our companion/homemaker care service options are flexible and customizable
according to your specific situation, whether you are traveling, or will remain at home, we
provide the exact services that will give your family member the companionship they require.
We work with you to determine a personal, customized care plan, whether you need assistance
24/7 or just a few hours a day, our office is here to help.
IV. The Market
Research shows that global home care services market is expected to record a year-over-year
growth rate of 9.9%.Some factors driving the growth of the global home care services market
are the increase in healthcare expenditures,increase in adoption of home care services,
government/private/public funding for home care services,and well-developed infrastructure
with wide-ranging services.Also,the rising number of elderly and individuals suffering from
disabilities,and the high dependency ratio of elderly over the younger population is likely to fuel
the home care services market over 2018–2026.
V. Our Competitive Advantages
While there are currently many businesses offering Homemaker and Companion Services in
Florida, Omega Health Services marketing strategy is to emphasize the quality of care we
provide (“Living Your Best Life”) and the availability of our services. Families who we have
serviced in the past can guarantee that they will come home to find happy, friendly and
experienced companions. Some of our other competitive advantages are :
1.Caregiver Quality
2.Exceptional Customer Experiences
3.Personal Relationships
4.Organizational Relationships
5.Relationship Selling
6.Branding
7.Specialized Programs and Services
8.Telemedicine Video Calls
View current license information at: Floridahealthfinder.gov REGISTRATION #: 235520
CERTIFICATE #: 25307
State of Florida
AGENCY FOR HEALTH CARE ADMINISTRATION
DIVISION OF HEALTH QUALITY ASSURANCE
Homemaker And Companion Services
REGISTERED
This is to confirm that OMEGA HEALTH SERVICES LLC has complied with Chapter 400, Part III, rules of the State of Florida and
is authorized to operate the following:
OMEGA CARE SERVICES
7130 W Mcnab Rd
Tamarac, FL 33321
in the following counties:
BROWARD
Homemaker & Companion Services are prohibited from providing any hands-on personal care services.
EFFECTIVE DATE: 08/08/2018
EXPIRATION DATE: 08/07/2020 Deputy Secretary, Division of Health Quality Assurance
RICK SCOTT
GOVERNOR
JUSTIN M. SENIOR
SECRETARY
Facebook.com/AHCAFlorida
Youtube.com/AHCAFlorida
Twitter.com/AHCA_FL
SlideShare.net/AHCAFlorida
2727 Mahan Drive MS#33
Tallahassee, FL 32308
AHCA.MyFlorida.com
August 8, 2018
Agnes Saint-Preux, Administrator File Number: 39970485
Omega Care Services License Number: 235520
5921 Washington St #120
Hollywood, FL 33023
Provider Type: Homemaker And Companion
Services
RE: 7130 W Mcnab Rd, Tamarac
Dear Administrator:
The enclosed Homemaker And Companion Services license with license number 235520 and
certificate number 25307 is issued for the above provider effective August 8, 2018 through
August 7, 2020. The license is being issued for: approval of the initial application.
Review your certificate thoroughly to ensure that all information is correct and consistent with
your records. If errors are noted, please contact the Home Care Unit.
If we may be of further assistance, please contact me by phone at (850) 412 -4316 or by email at
Jerome.Preston@ahca.myflorida.com.
Sincerely,
Jerome Preston
Home Care Unit
Division of Health Quality Assurance
AGNES SAINT-PREUX, MSHSA
asain032@fiu.edu
5921 Washington St. Apt 120
Hollywood, FL 33023
7863048483
Goal-driven, experienced, and dedicated Healthcare professional soon to complete a Master of Science
degree with an emphasis in Healthcare administration and holds a B.S. degree in Public Administration.
With more than 2-years related, hands-on experience in a fast-paced and time sensitive healthcare
industry. Adaptable leader and administrator accustomed to managing numerous employees, and
training initiatives. Keeping abreast of increasingly complex regulatory environments, provides quality
customer service initiatives for clients, and staff
CORE STRENGTHS : Foster Teamwork, Interpersonal Awareness, Personnel Development Strategic
Guidance, Decisive Thoroughness, Quality-Oriented, Insurance/ Billing, Dispute Resolution, Policy
Management, Contract Management
Employment Experiences
Omega Health Services LLC. | Administrator / Director
June 2018 - PRESENT| Tamarac, FL
●Monitor budgets and prepare reports
●Maintain medical and staff records
●Track medical and office supplies stock
●Update patient health records, including admissions and insurance data
●Create work schedules for staff members
●Keep records of expenses and suggest ways to minimize costs
●Answer queries from doctors, nurses and patients
●Liaise with medical staff to identify efficiencies in the facility’s operations
●Ensure compliance with current healthcare regulations
Omega Behavioral Consulting Inc. | Executive Assistant / Behavior Assistant
April 2017 - PRESENT| Tamarac, FL
●Insurance Eligibility/Verification
●General Administrative Duties (scheduling, inventory, payroll, office management)
●Hiring Manager
●Marketing
●Procurement ( office supplies, supplier research and selection )
●Research (Programs for children with Autism, ADHD, Aspergers, office functionality)
●Data collection procedures for Applied Behavior Analysis
●Implementation of skill acquisition and behavior reduction interventions
●Managed day-to-day office activities: establishing priorities, troubleshooting, patient scheduling,
and insurance filing
●Supervised and delegated responsibilities, as appropriate, to office personnel/volunteers
●Provided strong communication serving as key point of contact and facilitated responses for
inquiries and data requested from both internal and external customers.
●Created policy and procedures to be distributed to the department and new hires.
●Strong business management, technical, human resource, problem solving and decision making
skills
●Build work teams, collaboration, and accountability that consistently exceed goals for
productivity, efficiency, and quality of operations. Make recommendations to business
associations, staff personnel, and management on identified opportunities for policy, procedure
and process improvement
●Implemented training and incentive programs to enhance performance, quality and efficiency to
improve morale, satisfaction, customer service and profitability.
●
South Florida CARES Mentoring Movement | Recruitment Director & Executive Assistant
June 2014 - June 2017| Miami FL
●Compliance Administrator for Kellogg Grant Funding
●Public speaking events
●Event Planning (Philanthrofest, Recruitment Mixers, Art Basel Annual Youth Brunch)
●Volunteer recruitment
●Social Media Coordinator
●Management
●Group Mentoring to at-risk youth in Miami-Dade & Broward County Public Schools
Law Office of Criminal Conflict & Civil Regional Counsel | Legal Assistant / Clerk | Miami, FL
November 2010 – February 2014
●Prepare correspondence and type legal documents
●Maintain complex docket systems to track legal filing deadlines,
●Create spreadsheets; index and update pleadings and discovery binders
●Schedule depositions
●Communicate with attorneys, experts, opposing counsel, vendors, etc
Department of Children & Families | Clerk Typist Specialist
June 2008 - January 2009 | Miami, FL
●Compile and compute data
●Organizes and updates computer files and databases
●Prepares office and departmental reports
●Furnishes the public with general information and advice in regards to the Department’s policies,
procedures and services.
Education
Florida International University
Master of Science- Health Service Administration | Present
Florida International University
Bachelors of Arts- Public Administration, Degree completed Aug 2017
Miami Dade College
Associate of Arts, Degree completed, May 2015
Dr. Michael Krop Senior High
High School Diploma
Skills
●Bilingual (Haitian Creole)
●Excellent interpersonal skills
●Team player
●Proactive, solution seeker
●Performs well under pressure
●Proficient computer skills
●Geographic Information Systems
●Mind Mapping
●Management
Volunteer/ Fellowship Experiences
Tabernacle of Glory | Children’s Ministry Sunday School Teacher
March 2016 - Present | North Miami, FL
Starbucks In-Store Recruitment | Recruitment Director
March 2016 - June 2017 | Miami, FL
Superfriends CARES Youth Program @ Williams Park
October 2015 - June 2017 | Miami, FL
Sant La Haitian Neighborhood Center | Fellowship Program for Haitian Professionals
June 2015 - April 2016 | North Miami, FL
His House Children’s Home| Tutor
June 2007 - January 2008 | Miami, FL
Certifications:
CPR and AED
Grant Writer - Certificate of Completion | November 2018
References
Available upon request
AGNES SAINT-PREUX
asain032@fiu.edu
5921 Washington St. Apt 120
Hollywood, FL 33023
7863048483
Greetings Sir or Madame:
My name is Agnes Saint-Preux and I am writing to express interest for the applied position within your
company/organization. I possess over three years of experience in clerical/administrative work. I hold
strong interpersonal skills that have helped me form relationships with many community members. My
communication, management and organization skills in event planning have prepared me both
personally and professionally for my next employment endeavor. I have a solid reputation as an
independent worker who takes initiative to get the job done. I believe that my experience and skills
makes me a top candidate for the position you are hoping to fill.
I look forward to hearing from you to further discuss this exciting opportunity. I am available for an
interview at your earliest convenience, please contact me via phone or email to arrange a suitable time.
Thank you for your consideration!
Sincerely
Agnes Saint Preux
JOB DESCRIPTION- Caregiver
(Homemaker/Companion/Housekeeper/Shopper)
Position Description:
A Caregiver is a non-licensed member of the home care team who assists the client with the
tasks of daily living as outlined in a written care plan that is established by a Supervisor and is
kept in the client's home. The Administrator and Client Service Supervisor supervise
caregivers.
Qualifications:
1. A Caregiver must have a satisfactory work record, with experience as a caregiver
preferred. Aventas must be able to verify three work or personal references, and
caregiver must complete the agency’s employment process.
2. Must be at least 18 years of age.
3. High School diploma or equivalent preferred.
4. Must be physically able to perform the duties of the position.
5. Must exhibit mature, responsible behavior, and understand the need for patient
confidentiality. Must be able to communicate with client and carry out instructions.
6. Must be able to read, write, understand and speak English.
7. Must be able to follow direction and accurately report to the Administrator any
change in client’s condition.
8. Must maintain current credentials, including CPR, 1st Aide, TB Test, Physical and
Fingerprint Clearance Card. Must attend ongoing training when offered.
9. Must have available reliable transportation to and from assignments. May be
approved to drive client and/or run errands.
Duties:
The duties of a Caregiver may include, but are not limited to the following:
1. Planning and preparing meals and snacks according to specific dietary
requirements of the client. Wash dishes and clean kitchen.
2. Maintaining a safe, clean and healthy environment through light housekeeping
including changing bed linens, dusting and vacuuming, cleaning bathroom, and
doing laundry.
3. Providing companionship and stimulation for the client including reading, walks,
etc.; accompanying the client to doctors or other appointments.
4. Grocery shopping or other errands when needed.
5. Performing other housekeeping tasks as indicated in the care plan.
6. Participating in in-service education programs.
Employee May Not:
1. Administer or pour medication as mandated by law.
2. Cut the fingernails or toenails of any patient.
3. Perform any personal care for the patient including toileting, hair care, oral
hygiene, bathing and grooming.
4. Assist with ambulation when patient uses mechanical aids such as a walker.
DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
CINCINNATI OH 45999-0023
Date of this notice: 04-23-2018
Employer Identification Number:
82-5284470
Form: SS-4
Number of this notice: CP 575 B
OMEGA HEALTH SERVICES LLC
AGNES SAINT PREUX MBR
5921 WASHINGTON ST APT 120 For assistance you may call us at:
HOLLYWOOD, FL 33023 1-800-829-4933
IF YOU WRITE, ATTACH THE
STUB AT THE END OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN). We assigned you
EIN 82-5284470. This EIN will identify you, your business accounts, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, payments, and related correspondence, it is very important
that you use your EIN and complete name and address exactly as shown above. Any variation
may cause a delay in processing, result in incorrect information in your account, or even
cause you to be assigned more than one EIN. If the information is not correct as shown
above, please make the correction using the attached tear off stub and return it to us.
Based on the information received from you or your representative, you must file
the following form(s) by the date(s) shown.
Form 1065 03/15/2019
If you have questions about the form(s) or the due date(s) shown, you can call us at
the phone number or write to us at the address shown at the top of this notice. If you
need help in determining your annual accounting period (tax year), see Publication 538,
Accounting Periods and Methods.
We assigned you a tax classification based on information obtained from you or your
representative. It is not a legal determination of your tax classification, and is not
binding on the IRS. If you want a legal determination of your tax classification, you may
request a private letter ruling from the IRS under the guidelines in Revenue Procedure
2004-1, 2004-1 I.R.B. 1 (or superseding Revenue Procedure for the year at issue). Note:
Certain tax classification elections can be requested by filing Form 8832, Entity
Classification Election. See Form 8832 and its instructions for additional information.
A limited liability company (LLC) may file Form 8832, Entity Classification
Election, and elect to be classified as an association taxable as a corporation. If
the LLC is eligible to be treated as a corporation that meets certain tests and it
will be electing S corporation status, it must timely file Form 2553, Election by a
Small Business Corporation. The LLC will be treated as a corporation as of the
effective date of the S corporation election and does not need to file Form 8832.
To obtain tax forms and publications, including those referenced in this notice,
visit our Web site at www.irs.gov. If you do not have access to the Internet, call
1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office.
(IRS USE ONLY) 575B 04-23-2018 OMEG B 9999999999 SS-4
IMPORTANT REMINDERS:
* Keep a copy of this notice in your permanent records. This notice is issued only
one time and the IRS will not be able to generate a duplicate copy for you. You
may give a copy of this document to anyone asking for proof of your EIN.
* Use this EIN and your name exactly as they appear at the top of this notice on all
your federal tax forms.
* Refer to this EIN on your tax-related correspondence and documents.
If you have questions about your EIN, you can call us at the phone number or write to
us at the address shown at the top of this notice. If you write, please tear off the stub
at the bottom of this notice and send it along with your letter. If you do not need to
write us, do not complete and return the stub.
Your name control associated with this EIN is OMEG. You will need to provide this
information, along with your EIN, if you file your returns electronically.
Thank you for your cooperation.
Keep this part for your records. CP 575 B (Rev. 7-2007)
----------------------------------------------------------------------------------------------
Return this part with any correspondence
so we may identify your account. Please CP 575 B
correct any errors in your name or address.
9999999999
Your Telephone Number Best Time to Call DATE OF THIS NOTICE: 04-23-2018
( ) - EMPLOYER IDENTIFICATION NUMBER: 82-5284470
_____________________ _________________ FORM: SS-4 NOBOD
INTERNAL REVENUE SERVICE OMEGA HEALTH SERVICES LLC
CINCINNATI OH 45999-0023 AGNES SAINT PREUX MBR
5921 WASHINGTON ST APT 120
HOLLYWOOD, FL 33023
INCIDENT REPORT
EMPLOYEE: Return this COMPLETED FORM to your SUPERVISOR as soon as
possible.
Name of Person Involved: __________________________________________
Address: ______________________________________________________________
Phone Number: ____________________ Age: ___ DOB: _______ Sex: M ____ F ____
Patient#: _________________________ Date of Incident: ___ Time: ___ am/pm
Exact Location of Incident: __________________________________________
Check Type of Accident:Check:
●Clerical/Data Entry _____Patient
●Communications _____ Employee
x Transfer (Non ambulatory)_____ Visitor
●Result reporting _____ Volunteer
●Safety _____ Other
●Medical Device Failure
●Policy/Procedural Violations
●Adverse Drug Reaction
●Vehicle Accident
●Needlestick
●Exposure to Hazardous Substance
●Medication Error (Wrong: Route, Dosage, Medication, Schedule)
EMPLOYEE: Stephanie Moore
Involved ___ yes _____ no
Were they doing their regular job duties: ____ yes _____ no Observed by employee:
yes___ no __
Hire Date: _____ Position: _ Situation observed only by employee: yes__ no ___
Employee Classification: ______________________________
Protective Equipment being used: ____ yes _____ no
If not used, Why: _______
Description of Incident/Complaint (Who, What, Where, How, Why, Include sequence of events,
personnel involved, body part injured, reason incident occurred) (If medication error include
brand name, manufacturer, dosage) (Use additional form if necessary)
Actions Taken by Staff Members:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Witness Name: _________________________ Phone Number: _______________
Address: ___________________________________
Witness Name: ___________________Phone Number: _________________
Address: _____________________________________________________
MEDICAL FOLLOW-UP: Was Medical Attention Sought: ____ yes _____ no
Treatment Refused: _____ yes ____ no First Treatment Date: ______________
Treating Physician: ___________________ _ Phone Number: ____________________
Address: ___ _____________________________________________
First Day Off Work: ______________________ Return to Work Date: _______________
Duties Restricted: _____ yes ___ no Explain:________________________________________
INCIDENT/COMPLAINT REPORT
Incident Reported By: _ _______ Date: _________
Supervisor Notified: ___ yes _____ no Date: ______ Time: ____
Name of Supervisor: _____________________________________
Signature and Title of Person Preparing Report: __________________ Date: _________
Supervisor Comments: _____________________________________________________
Corrective Action Taken/Follow-Up: (Things that have been or will be taken to prevent
recurrence)
______________________________________________________________________________
_____________________________________________________________________________
Administrator Signature: ________________________________ Date: ______
Supervisor Signature: _______________________________Date: _____
I understand the information above will be used by my employer to help determine liability for
injury. I acknowledge that the above statements are true and accurate representation of the
requested information.
Employee Signature: ____________________________ Date: ________
Minority Business Certification
Omega Health Services LLC
11/01/2018 11/01/2020
[42]
Omega Health Services LLC
Direct Care Provider
Companion
Direct Care provider
Homemaker
Direct Care Provider
Chore
Mirline Omega
Clinical Director
Agnes Saint Preux
Owner/Administrator
Mirline Omega
Owner/ Chief Financial
Officer
Personal Disaster Plan
Name: ________________________ Address: ____________________________________________
Ph#: ______________________ Roommate(s): ___________________________________________
Emergency Contact/Relationship/Ph.# ________________________
This Personal Disaster Plan should be updated annually, or as living situations change.
Most recent update: ________________________
Copies of Disaster plan to be provided to:
______ Consumer ______ Provider
______ Case Worker/Manager ______Other
____________________________
PLAN A: My Personal Plan to Shelter in Place: My first choice will always be to shelter in my own home
unless County Emergency Management mandates evacuation, or the emergency situation makes me
feel that I may not be safe if I remain in my home. This is my plan to shelter in place:
●I have the following supplies reserved in my home for emergencies:
●3-day supply of water (1 gal/day for each person in my home; water replaced every 6 mos.)
●3-day supply of nonperishable food that requires little/no cooking and little/no water to
prepare.
● Battery-operated radio and extra batteries.
●Flashlight for each person in the home and extra batteries.
●First aid kit with bandages, cleansing agent, antiseptic, gloves, sunscreen, over-the-counter
meds, etc.
●Sanitary supplies including toilet paper, hand sanitizer, bleach, personal hygiene items,
garbage bags.
●Duct tape, pre-cut plastic sheeting to cover ducts and all openings in interior room
designated for shelter in event of a chemical or biological threat.
●Other tools/supplies: disposable cups, plates and utensils; multipurpose utility tool; hand
held can-opener; whistle; matches/lighter; rain gear; complete change of clean dry clothing;
bedding/sleeping bag; charged cell phone and charger; cash; pet supplies; games, books,
entertainment supplies.
●In the event of a potential disaster, the contact information of the person who will help me
fill my prescriptions to obtain at least a two-week supply is:
Name: ______________________________ Phone: ___________________
●I have a waterproof container that has copies of my identification, emergency contact
information, insurance papers, list/proof of valuables; evacuation communicator, disaster
plan, updated medical and prescription information, bank and credit card information,
Social Security information and other important documents.
●I will notify my employer about where I am.
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________________
____________________________________________________________________
1 | Page
Personal Disaster Plan
●I will use the following interior space in my home to shelter in the event of a tornado, chemical
or biological threat or similar emergency: ____________________________
●I have a generator. _____Yes. _____ No. It will run the following in my home (appliances, etc.):
_____________________________________________________________________________
●The contact information of the person who helps me to ensure that all the above has been
completed, all equipment is in working order, and that all personal information is current on a
quarterly basis is:
Name: ____________________ Phone: ___________________
●If I need assistance as I shelter in my home, this person(s) will remain with me in my home:
Name: ____________________ Phone: ___________________
PLAN B: My Personal Plan When I Must Evacuate My Home: If I must evacuate my home during an
emergency or disaster, I am prepared to follow this plan:
●Please see “Go Kit” on page 3.
●Please see “Pets” on page 4.
●I will evacuate to one of these locations if I can evacuate within the area:
●First Choice
Name: _______________ Address: ________________ Phone Number: _____________
●Second Choice: If circumstances prevent me from evacuating to my first choice, I will
evacuate to
Name: _______________ Address: ________________ Phone Number: _____________
●I have transportation arranged to get to both my first and second choices for both of my
in-area and out-of-area evacuation destinations. The contact information for the person
who has committed to assisting me in evacuating is:
Name: ______________________________ Phone: ___________________
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
● If I need assistance when I evacuate, this person(s) will remain with me for
the duration of my evacuation:
Name: ______________________________ Phone: ___________________
PLAN C: My Personal Plan If I Must Go to a Shelter or Medical Facility: I understand that shelters
operated by County Emergency Management and the Health Department are available but should only
be used as a last resort and as a back-up to My Personal Sheltering Plans A and B. Note: Shelters may be
crowded, noisy, lack privacy and may be especially challenging for persons with behavioral health needs.
However, if circumstances make it necessary for me to go to a shelter or medical facility; this is my plan:
●I have determined what type of shelter or medical facility that I will need to go to (a general
population shelter, a special needs shelter, or a medical facility.)
●This person helped me determine where l need to go:
2 | Page
Personal Disaster Plan
Name: ______________________________ Phone: ___________________
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
●Transportation: I have identified how I will get to my designated shelter.
●I will need to use transportation arranged and provided by County Emergency
Management and have confirmed this with them.
●I will be transported by this person/company:
Name: _______________ Address: ________________ Phone Number: _____________
General Population Shelter
●I will be able to go to a general population shelter because I do not need the type of care and
supervision that is provided in a special needs shelter.
●The name and location of the general population shelter that I will go to is:
Name: _______________ Address: ________________ Phone Number: _____________
Special Needs Shelter
●I will need to go to a special needs shelter because I need electricity for life supporting medical
equipment, or basic nursing care, or oxygen therapy, or observation/monitoring by a healthcare
professional, or assistance with medication and no one to assist me, or a chronic condition that
requires assistance from a healthcare professional, or special medical requirements that do not
require hospitalization or another special need that cannot be accommodated in a general
population shelter.
●I understand that there are eligibility criteria that I must meet to have access to a special
needs shelter. I have submitted pre-registration to my County Emergency Management
if I need or suspect I may need to shelter in either a special needs shelter or a medical
facility or if I need transportation to evacuate to a shelter.
●This person submitted my pre-registration on this date:
Name: _____________________Phone: __________________Date: ____/____/______
●I received confirmation from my County Emergency Management regarding my
pre-registration shelter assignment. Yes ____ or No____
●The County Emergency Management has assigned the following special needs
shelter or medical facility address as follows:
Name: ________________ Address: ___________________
Phone Number: _________________
●I will need to use transportation arranged and provided by County Emergency
Management and have confirmed this with them.
●I will be transported by this person/company:
Name: _______________ Address: ________________ Phone Number: _____________
3 | Page
Personal Disaster Plan
●If I evacuate to a special needs shelter, this person(s) will remain with me for the
duration of my evacuation:
Name: ___________________ Phone Number: _____________
Medical Facility
●I will need to go to a medical facility because my special medical requirements exceed what can
be provided in a special needs shelter. The contact information of the facility is:
●Name: ___________________ Address: ___________________ Phone Number: _____________
“Go Kit”
●I have an easy-to-carry "Go Kit" prepared that contains or can be readily packed to contain the
following supplies that I have reserved in my home and will take with me to the shelter: at least
a two week supply of meds; Items required for special diet; a 3-day supply of water and
non-perishable food and snacks; personal hygiene essentials; first aid kit; battery-operated radio
and extra batteries; flashlight and extra batteries; cash; cell phone and charger;
bedding/sleeping bag; at least one complete change of clean dry clothing; glasses; hearing aids;
durable and consumable medical supplies; waterproof container that has copies of all of my
important documents; multipurpose utility tool; whistle; matches/lighter; rain gear; games,
books, entertainment supplies.
●This person will help make sure my "Go Kit" is readied if I need to go to
a shelter:
Name: _______________ Phone Number: _____________
Pets/Service Animals
●I have a plan for my pet(s). My pet will either go to the designated pet shelter in my county or I
have arranged for this person/veterinarian to take care of my pet(s) for me:
Name: ___________________ Address: ___________________ Phone Number: _____________
● My pet(s)'s supplies and papers will be sent along with my pets.
●I have a Service Animal. It is this kind of an animal ______________________ and it performs
the following services for me: _____________________________________________________.
My personal Commitment to Disaster Preparedness:
●I understand that I have a personal responsibility for disaster preparedness and I am committed
to working in a proactive manner with County Emergency Management and the people who
support me to follow my Personal Plan for Disaster Preparedness.
●I have received information about my personal responsibility for preparing for all types of
disasters including hurricanes, tornadoes, wildfires, earthquakes, floods, chemical and biological
spills/ attacks, nuclear power accidents, terrorist attacks, etc.
●I review/practice/drill on this plan with this person _________________ on at least an annual
basis.
●I will contact: Name_______ ____________________ at one of these numbers:
___________________ or __________________ about my location in any type of emergency,
4 | Page
Personal Disaster Plan
within 2 hours or as soon as possible to report on my location and health/safety status and
needs.
______________________________
Consumer Signature/Date
_____________________________
Case Manager Signature/Date
___________________________________________________________
Legal Representative Signature/Date Provider Signature/Date
5 | Page
Personal Disaster Plan
Name: ________________________ Address: ____________________________________________
Ph#: ______________________ Roommate(s): ___________________________________________
Emergency Contact/Relationship/Ph.# ________________________
This Personal Disaster Plan should be updated annually, or as living situations change.
Most recent update: ________________________
Copies of Disaster plan to be provided to:
______ Consumer ______ Provider
______ Case Worker/Manager ______Other
____________________________
PLAN A: My Personal Plan to Shelter in Place: My first choice will always be to shelter in my own home
unless County Emergency Management mandates evacuation, or the emergency situation makes me
feel that I may not be safe if I remain in my home. This is my plan to shelter in place:
●I have the following supplies reserved in my home for emergencies:
●3-day supply of water (1 gal/day for each person in my home; water replaced every 6 mos.)
●3-day supply of nonperishable food that requires little/no cooking and little/no water to
prepare.
● Battery-operated radio and extra batteries.
●Flashlight for each person in the home and extra batteries.
●First aid kit with bandages, cleansing agent, antiseptic, gloves, sunscreen, over-the-counter
meds, etc.
●Sanitary supplies including toilet paper, hand sanitizer, bleach, personal hygiene items,
garbage bags.
●Duct tape, pre-cut plastic sheeting to cover ducts and all openings in interior room
designated for shelter in event of a chemical or biological threat.
●Other tools/supplies: disposable cups, plates and utensils; multipurpose utility tool; hand
held can-opener; whistle; matches/lighter; rain gear; complete change of clean dry clothing;
bedding/sleeping bag; charged cell phone and charger; cash; pet supplies; games, books,
entertainment supplies.
●In the event of a potential disaster, the contact information of the person who will help me
fill my prescriptions to obtain at least a two-week supply is:
Name: ______________________________ Phone: ___________________
●I have a waterproof container that has copies of my identification, emergency contact
information, insurance papers, list/proof of valuables; evacuation communicator, disaster
plan, updated medical and prescription information, bank and credit card information,
Social Security information and other important documents.
●I will notify my employer about where I am.
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________________
____________________________________________________________________
1 | Page
Personal Disaster Plan
●I will use the following interior space in my home to shelter in the event of a tornado, chemical
or biological threat or similar emergency: ____________________________
●I have a generator. _____Yes. _____ No. It will run the following in my home (appliances, etc.):
_____________________________________________________________________________
●The contact information of the person who helps me to ensure that all the above has been
completed, all equipment is in working order, and that all personal information is current on a
quarterly basis is:
Name: ____________________ Phone: ___________________
●If I need assistance as I shelter in my home, this person(s) will remain with me in my home:
Name: ____________________ Phone: ___________________
PLAN B: My Personal Plan When I Must Evacuate My Home: If I must evacuate my home during an
emergency or disaster, I am prepared to follow this plan:
●Please see “Go Kit” on page 3.
●Please see “Pets” on page 4.
●I will evacuate to one of these locations if I can evacuate within the area:
●First Choice
Name: _______________ Address: ________________ Phone Number: _____________
●Second Choice: If circumstances prevent me from evacuating to my first choice, I will
evacuate to
Name: _______________ Address: ________________ Phone Number: _____________
●I have transportation arranged to get to both my first and second choices for both of my
in-area and out-of-area evacuation destinations. The contact information for the person
who has committed to assisting me in evacuating is:
Name: ______________________________ Phone: ___________________
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
● If I need assistance when I evacuate, this person(s) will remain with me for
the duration of my evacuation:
Name: ______________________________ Phone: ___________________
PLAN C: My Personal Plan If I Must Go to a Shelter or Medical Facility: I understand that shelters
operated by County Emergency Management and the Health Department are available but should only
be used as a last resort and as a back-up to My Personal Sheltering Plans A and B. Note: Shelters may be
crowded, noisy, lack privacy and may be especially challenging for persons with behavioral health needs.
However, if circumstances make it necessary for me to go to a shelter or medical facility; this is my plan:
●I have determined what type of shelter or medical facility that I will need to go to (a general
population shelter, a special needs shelter, or a medical facility.)
●This person helped me determine where l need to go:
2 | Page
Personal Disaster Plan
Name: ______________________________ Phone: ___________________
●I am dependent on the following special dietary supplies, durable medical equipment and/or
consumable medical supplies:
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________________
_______________________________________________________________________
●Transportation: I have identified how I will get to my designated shelter.
●I will need to use transportation arranged and provided by County Emergency
Management and have confirmed this with them.
●I will be transported by this person/company:
Name: _______________ Address: ________________ Phone Number: _____________
General Population Shelter
●I will be able to go to a general population shelter because I do not need the type of care and
supervision that is provided in a special needs shelter.
●The name and location of the general population shelter that I will go to is:
Name: _______________ Address: ________________ Phone Number: _____________
Special Needs Shelter
●I will need to go to a special needs shelter because I need electricity for life supporting medical
equipment, or basic nursing care, or oxygen therapy, or observation/monitoring by a healthcare
professional, or assistance with medication and no one to assist me, or a chronic condition that
requires assistance from a healthcare professional, or special medical requirements that do not
require hospitalization or another special need that cannot be accommodated in a general
population shelter.
●I understand that there are eligibility criteria that I must meet to have access to a special
needs shelter. I have submitted pre-registration to my County Emergency Management
if I need or suspect I may need to shelter in either a special needs shelter or a medical
facility or if I need transportation to evacuate to a shelter.
●This person submitted my pre-registration on this date:
Name: _____________________Phone: __________________Date: ____/____/______
●I received confirmation from my County Emergency Management regarding my
pre-registration shelter assignment. Yes ____ or No____
●The County Emergency Management has assigned the following special needs
shelter or medical facility address as follows:
Name: ________________ Address: ___________________
Phone Number: _________________
●I will need to use transportation arranged and provided by County Emergency
Management and have confirmed this with them.
●I will be transported by this person/company:
Name: _______________ Address: ________________ Phone Number: _____________
3 | Page
Personal Disaster Plan
●If I evacuate to a special needs shelter, this person(s) will remain with me for the
duration of my evacuation:
Name: ___________________ Phone Number: _____________
Medical Facility
●I will need to go to a medical facility because my special medical requirements exceed what can
be provided in a special needs shelter. The contact information of the facility is:
●Name: ___________________ Address: ___________________ Phone Number: _____________
“Go Kit”
●I have an easy-to-carry "Go Kit" prepared that contains or can be readily packed to contain the
following supplies that I have reserved in my home and will take with me to the shelter: at least
a two week supply of meds; Items required for special diet; a 3-day supply of water and
non-perishable food and snacks; personal hygiene essentials; first aid kit; battery-operated radio
and extra batteries; flashlight and extra batteries; cash; cell phone and charger;
bedding/sleeping bag; at least one complete change of clean dry clothing; glasses; hearing aids;
durable and consumable medical supplies; waterproof container that has copies of all of my
important documents; multipurpose utility tool; whistle; matches/lighter; rain gear; games,
books, entertainment supplies.
●This person will help make sure my "Go Kit" is readied if I need to go to
a shelter:
Name: _______________ Phone Number: _____________
Pets/Service Animals
●I have a plan for my pet(s). My pet will either go to the designated pet shelter in my county or I
have arranged for this person/veterinarian to take care of my pet(s) for me:
Name: ___________________ Address: ___________________ Phone Number: _____________
● My pet(s)'s supplies and papers will be sent along with my pets.
●I have a Service Animal. It is this kind of an animal ______________________ and it performs
the following services for me: _____________________________________________________.
My personal Commitment to Disaster Preparedness:
●I understand that I have a personal responsibility for disaster preparedness and I am committed
to working in a proactive manner with County Emergency Management and the people who
support me to follow my Personal Plan for Disaster Preparedness.
●I have received information about my personal responsibility for preparing for all types of
disasters including hurricanes, tornadoes, wildfires, earthquakes, floods, chemical and biological
spills/ attacks, nuclear power accidents, terrorist attacks, etc.
●I review/practice/drill on this plan with this person _________________ on at least an annual
basis.
●I will contact: Name_______ ____________________ at one of these numbers:
___________________ or __________________ about my location in any type of emergency,
4 | Page
Personal Disaster Plan
within 2 hours or as soon as possible to report on my location and health/safety status and
needs.
______________________________
Consumer Signature/Date
_____________________________
Case Manager Signature/Date
___________________________________________________________
Legal Representative Signature/Date Provider Signature/Date
5 | Page
Table of Contents
Quality Management
POLICIES
Quality Management Plan 4.1
Incident Reports 4.2
Patient/Family Perception of Care 4.3
Conducting the Quality Management Program 4.4
Compliance Program 4.5
FORMS/ATTACHMENTS
Client /Family Perception of Care Survey Tool 4.3A
Client Family Perception of Care QM Data Collection and Analysis Summary 4.3B
Client Record Audit 4.4A
Quarterly Patient Record Audit 4.4B
Quarterly Audit Corrective Action Plan 4.4C
Omega Health Services LLC
THIS PAGE WAS LEFT BLANK INTENTIONALLY
PARTS OF THIS PLAN WILL BE IMPLEMENTED IN MARCH OF 2019
Omega Health Services LLC
Quality Management (QM) Plan
______________________
POLICY
Omega Health Services develops implements and maintains an effective, ongoing, organization
wide quality assessment and performance management program. OHS measures, analyzes and
track quality indicators, including adverse client events, and other aspects of performance that
enables the organization to assess processes of care, efforts to address priorities for improved
quality of care and patient safety, and that all improvement actions are evaluated for
effectiveness.
______________________
PURPOSE
To continuously collect and analyze data to improve the OHS performance of consumer care and
other processes, specifically as follows:
●Continuously improve processes of client care/services as well as outcomes of care.
●Communicate information to all staff members.
●Use a systematic approach to problem identification and resolution.
●Conform to all applicable federal/state rules/regulations as well as home care standards.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
Registration Requirements for Homemaker & Companion Services Providers, Chapter
59A-8.025
Health Care Licensing Procedures Chapter 59A-35
______________________
DEFINITION
Omega Health Services shall establish a quality management program appropriate to the size and
type of agency that evaluates the quality of patient services, care and safety, and that complies
with the requirements set forth in 6 CCR 1011, Chapter II, and section 3.1.
______________________
GOALS/OBJECTIVES
●To collect and analyze data to improve identified processes within the Agency.
Omega Health Services LLC
●To educate and involve appropriate staff in quality management (QM) activities.
●To collect and analyze data to improve identified processes of patient care/services as
well as outcomes of patient care, leadership and managerial processes, as indicated.
●To establish mechanisms to reprioritize QM activities in response to unusual and/or
urgent events.
●To allocate adequate resources for QM.
●To create and maintain information systems (manual and/or computer) to support the
collecting, managing and analyzing of data needed to facilitate ongoing QM.
●To endeavor to meet the needs/expectations of staff, patients, families, and caregivers,
physicians, referral sources, third party providers, community agencies, federal and state
agencies.
●To apply principles and tools of QM to all aspects of the organization.
______________________
SCOPE OF CARE
1.Types of clients served: all seniors and individuals with disabilities regardless of race,
sex, [age], religion, disability, national origin, sexual preference or whether the patient
has an advance directive; patients residing in Agency’s service area.
2.Services provided: The Agency primarily serves clients that live within the geographic
area requiring the following care:
●Homemaker, Companion and Chore Services
●Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy and
Medical Social Services. (effective 2019)
●All skilled services are provided under the orders of a licensed physician.
●Service limitations: (effective 2019)
o The Agency does not provide the following services at this time: geriatric or
hospice services.(effective 2019)
3.Types of practitioners providing care:(effective 2019)
●Skilled Nurses
●Physical Therapists
●Occupational Therapists
●Speech Therapists
●Therapy assistants
●Medical Social Workers, Licensed Clinical Social Workers
●Home Health Aids
●Direct Service Providers
4.Sites and times of care provision: Administrative office hours are from 9:00 am to 6:00
pm, Monday through Friday. Services can be rendered 24 hours a day/every day.
Omega Health Services LLC
Service is rendered as agreed upon by the Agency representative and the client and or the
client representative, at the client’s place of residence.
5.Ongoing: Continuous and periodic collection and assessment of data. Assessment of
such data enables areas of potential problems to be identified and indicates data that
should be collected and assessed in order to identify whether a problem exists
The following areas should be considered within the plan:
●Program objectives.
●All consumer care disciplines.
●Description of how the plan of care will be administered and coordinated.
●Methodology for monitoring and evaluating the quality of care.
●Priorities for resolution of problems.
●Monitoring to determine effectiveness of action.
●Oversight responsibility report to governing body.
●Documentation of the review of its own program.
______________________
CONFIDENTIALITY
Confidentiality will be maintained in all QM activities and meetings. Client or staff data
contained in QM reports will be identified by client initials, member ID or staff identification
numbers only. QM reports will not be available to unauthorized persons and will be maintained
in strict confidence in the Agency’s office.
__________________________________
RESPONSIBILITY/ACCOUNTABILITY
1.The Management Team is ultimately responsible for QM and implementation of the QM
plan.
2.Administrative responsibility for the QM plan is delegated to the Administrator, who, in
turn, assigns certain QM activities to other staff members. The Administrator will be
responsible for: ensuring adequate resources are available, assigning adequate number of
staff, allowing staff sufficient time to participate in QM activities and instituting
appropriate information systems (manual and/or computer) for collecting and analyzing
data.
3.The Administrator is responsible for appointing the Quality Improvement (QI) Coordinator
and assigning staff to the QM team. The role of QI Coordinator will be the responsibility of
the Director of Clinical Services, unless the Administrator designates an alternate staff
member. The QM team will be responsible for coordinating all QM activities, reviewing
collection of data, analyzing data, assisting staff in developing QM design or improvement
Omega Health Services LLC
activities, planning actions, collecting data and analyzing the effectiveness of action and
implementing effective actions.
4.The QM team will meet bi-annually and will share in reporting to the Administrator and
Clinical Director. Results will also be communicated by the QM team to staff, including
contract staff. The QM team will meet at least quarterly to aggregate data and will prepare
and the action plans for improvement.
___________________________________
PROBLEM SOLVING METHODOLOGY
OHS will utilize the PDCA (Plan-Do-Check-Act) model for problem solving methodology and
QM.
______________________
DESIGN/REDESIGN
The Agency will strive to design new processes and redesign old processes as needed.
Design/redesign will be based on:
●Omega Health Service’s mission, vision and plan.
●Needs/expectations of client staff and others.
●Up-to-date sources of information (i.e., publications, practice guidelines or trainings).
●Performance of processes and outcomes in other organizations, e.g., reference databases.
______________________
DATA COLLECTION
1.Data collection will include established priorities for improvement, including:
●Referral/intake
●Insurance verification, as applicable
●Scheduling
●Service delivery process: Consumer care and compliance
●Satisfaction surveys
●Grievance and complaint reporting/resolution
●Medication errors (effective 2019)
●Infection control (effective 2019)
●Clinical Record and Utilization review
●Medical records: documentation, timely filing
●Personnel recruitment
●Staff orientation, training and competency evaluation
●Staff in-servicing
Omega Health Services LLC
●Annual Performance Evaluations
●Payroll
●Billing and Collection
●Review of ethical issues
●Monitor all service/care provided under a contract or agreement
2.Data collection may include:
●High risk processes: patients are placed at risk of serious consequences or deprived of
care if care is not provided correctly, not provided when indicated or provided when
not indicated.
●High volume processes: care/service/process occurs frequently or affects large
numbers of patients/staff.
●Problem prone processes: care/service/process tends to produce problems for patients
or staff.
3.Data collection asks these questions in prioritizing process:
●Is the process, function or service consistent with the Agency's mission, vision and
plan?
●Has our Agency listened to customer and staff ideas about a well-designed process,
function or service?
●What industry information is available to assist us in decision making and
comparative analysis?
4.Data collection includes developing QM indicators, criteria or performance levels for
each major function or process determined to be improved. Data collection will be
ongoing and frequency will be determined by the process improvement activity and the
QM team.
5.Sources of information from which data may be collected include (but are not limited to):
●Home visits.
●Client records.
●Client/caregiver interviews.
●Staff interviews.
●Policies/procedures.
●Incident/Grievance/Complaint/Infection reports.
●Staffing patterns.
●Supervisory visit observation.
●Peer review.
●Client perception of care surveys.
●Review of ethical issues
Omega Health Services LLC
●Staff, physician, referral source and Home Health Care CAHPS satisfaction surveys,
if applicable (effective 2019)
6.The Agency will consider data collection about the following activities:
●Staff opinions and needs.
●Staff perceptions of risks to individuals and suggestions for improving patient safety.
●Staff willingness to report unanticipated adverse events.
●Conditions in the patient and organization environment.
_____________________________
AGGREGATION AND ANALYSIS
1.The QM team will aggregate and analyze collected data, which may include detection of
trends, patterns of behavior, and for an action plan to decrease occurrences. OHS will
monitor at least one important aspect of the service/care provided by the Agency, at least
one important administrative/operational aspect of function
2.Statistical techniques will be utilized, as appropriate, to analyze data. Such techniques
help to focus the Omega Health Services attention and resources on those processes and
outcomes for which more intensive analysis will be most beneficial.
3.When findings during the analysis of data are relevant to an individual staff member's
performance, the individual is given not only sufficient opportunity to improve his/her
performance, but also education to bring his/her performance to the desired level. If staff
member's performance does not improve, other appropriate actions are taken. Whatever
action is taken, the individual's personnel file will contain such documentation. When
relevant, this information is used in evaluating the individual’s performance.
_____________________________
PERFORMANCE EXPECTATION
1.For each process identified to be improved, mechanisms to identify levels, patterns or
trends in that process that will trigger further evaluation of the process will be identified.
2.For each established process to be improved, the performance expectation will be
determined. The frequency of data collection and analysis will be specified for each
process. The QM team will analyze the data collected to pursue opportunities for
improvement and identify important problems.
3.A summary of data collection, analysis, recommendations for improvement and report of
cumulative findings will be prepared by the QM team. The reports are provided to the
Management Team. Failure to achieve expected levels of performance will be
documented and an explanation delineated to identify opportunities for improvement.
Omega Health Services LLC
_________________________________________
ACHIEVED AND SUSTAINED IMPROVEMENT
1.The QM team is responsible for taking appropriate action, If the performance expectation
is not met, the findings will be evaluated by the QM team to determine the systematic
approach for making improvement. The systematic approach will include:
●Identification of potential improvement.
●Implement identified improvement strategy.
●Analyze whether the strategy was effective.
2. OHS will conduct monitoring of a least one important aspect of the service/care provided.
An important aspect of service/care reflects a dimension of activity that may be high
volume (occurs frequently or affects a large number of patients), high risk (causes a risk
of serious consequences if the service/care is not provided correctly), or problem-prone
(has tended to cause problems for staff or clients in the past).
3. OHS will conduct monitoring of at least one important administrative/operational aspect
of function or service/care of the agency. (Examples of QM activities may include, but
are not limited to, monitoring compliance of conducting performance evaluations,
in-service hours, or billing audits).
4.All improved processes will continue to be analyzed for a specified time to determine if
QM strategic action has resulted in sustained improvement.
Omega Health Services LLC
Incident Reporting
______________________
POLICY
Omega Health Services will identify and analyze all incidents or near miss events.
______________________
PURPOSE
To identify processes for responding to incident reports.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
______________________
PROCEDURE
1.Omega Health Services LLC defines incidents as an unintended event that disturbs
normal operations. OSHA defines an incident as "an unplanned, undesired event that
adversely affects completion of a task."Incidents range in severity from near misses to
fatal accidents
2.For purposes of this policy, the incident reporting definition only applies to OHS patients
and not to staff. However, OHS may consider significant events occurring with staff as
incidents, e.g., rape, murder, or death in an automobile accident while on duty.
3.Incident Reporting for patients include:
● Unexpected recipient death. • Life threatening injury. • Any sexual activity, as described in
section 393.135 F.S., between provider and a recipient regardless of consent of the recipient,
incidents of nonconsensual sexual activity between recipients, or sexual activity involving a
child. • The unexpected absence or unknown whereabouts, beyond one hour, of a recipient
who is a minor or an adult who has been adjudicated incompetent. • Negative news media
reports regarding a provider or client. • Recipient arrest for a violent criminal offense. •
Verified report of abuse, neglect, exploitation, abandonment, or human trafficking.
●Major permanent loss of function or limb not present at time of admission to Agency
that requires continued treatment or lifestyle change.
Omega Health Services LLC
●Second or third degree burns involving twenty percent or more the body surface area
of an adult patient.
●Any occurrence in which drugs intended for use by patient are diverted to use by
another person.
●A development, that is, unauthorized departure, of a patient from an around -the
-clock care setting resulting in death (suicide, accidental death or homicide) or major
permanent loss of function.
●Any occurrence involving misappropriation of a patient’s property. This includes,
misappropriation of a patient’s property means a pattern of or deliberately misplacing,
exploiting, wrongfully using, either temporarily or permanently, a patient’s
belongings or money without the patient’s consent.
●A patient fall that results in death or major loss of function as a direct result of
injuries sustained from the fall.
4.All staff will be educated during orientation and on an ongoing basis of OHS policy.
5.OHS will identify and respond appropriately to all incidents as defined. The staff member
identifying a incident must report the event immediately to the Administrator or
Supervisor. Appropriate emergency services will be initiated.
6.The OHS Clinical Director and/or Administrator will initiate an intensive
assessment/analysis of the incident by performing a thorough and credible root cause
analysis, which will focus on systems and processes.
7.OHS will create, document and implement risk-reduction activities and a action plan.
The effectiveness of system and/or process improvements will be measured and analyzed.
8. All incidents will be reported to external organizations as required by applicable federal
or state law.
9.On an ongoing basis, OHS leaders will monitor published data regarding incidents in the
home. Such data will be considered for improvement strategies and risk reductions within
the agency.
Omega Health Services LLC
Client/Family Perception of Care
______________________
POLICY
Omega Health Services will collect data on an ongoing basis from and families regarding their
satisfaction and perceptions of care.
______________________
PURPOSE
To gather information about OHS performance and to give insight about process design and
functioning.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
Florida Regulations Chapter 59A-18 – Nurse Registries Standards and Licensing
______________________
Indicators Performance Expectations
Satisfied with care provided 100%
Understand Written Notice of Patient Rights 100%
Was it easy to access OHS after hours/weekends for emergencies 100%
Satisfied with staff that provided care 100%
Satisfied with self participation in care 100%
Understood plan of care 100%
Agreed to changes in plan of care 100%
Response to problems/complaints was timely 100%
Client needs/expectations met 100%
DATA SOURCES AND COLLECTION METHOD: SAMPLING
Telephone and/or written survey will be conducted on an ongoing basis with current and
discharged clients randomly. Survey will be conducted by the Administrator or Clinical
Director. Survey interview will be conducted with the client and/or family member(s). The
collective results will be tabulated and the performance expectations actually achieved for each
indicator computed.
Omega Health Services LLC
ANALYSIS AND ACTIONS
The Quality Management team are responsible for comparing the data against the established
performance expectations, taking actions, analyzing the effectiveness of the actions, integrating
information, problem tracking and communicating findings. All comments of the surveys will be
noted and actions taken immediately, if necessary. Individual staff who receive comments on the
surveys may have copies of the surveys placed in their personnel records for assistance in
performance appraisal/evaluation.
COMMUNICATION
The results of the data collection and analysis will be collected and reported to the QM team and
then to the Management Team. The staff will also receive results during staff meetings.
Omega Health Services LLC
CLIENT SATISFACTION SURVEY
Please let us know how we are doing. Survey results will be kept confidential and will be shared with your aide
and/or nurses in a statistical format and not in an individualized manner.
To better serve our patients, we have a Medical Social Worker that provides resources and research assistance to
families. To take this survey online visit www.omegahealthservices.org
Scale: Agree Disagree
Rate on a scale from 1 to 5, with 5 being Strongly Agree N/A 5 4 3 2 1
Omega Health Services
I am pleased with my companion/homemaker/chore services.
I feel safe, comfortable, and independent when I am with my aide?
My aide listens and respect my needs as a client
The administrative team at OHS is helpful, and listens to my needs
Comments about your services:
(Optional)
I would appreciate a call to discuss the issues above in a confidential manner.
Name:____________________________________________________________________________________
Phone Number:_____________________________________________________________________________
THANK YOU
Omega Health Services LLC
CLIENT/FAMILY PERCEPTION OF CARE
QM Data Collection and Analysis Summary
Time Period: __________________________________Sample Size: _____
Percent Scale: Agree Disagree
Rate on a scale from 1 to 5, with 5 being
strongly agree
% 5 - 4 5 4 3 2 1
pleased w services.
pleased w nursing
pleased w PT
pleased w OT
pleased w ST
Summary of comments on needs/expectations and improvements for patient
safety:________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Step #2: Was performance expectation met? Yes ____No ___
Step #3: A problem or opportunity exists to improve care/service? Yes ____No ___
If yes, explain :
___________________________________________________________________________________________
____________________________________________________________________________________________
Step #4:Cause of problem related to:
_____ Knowledge
_____ Systems
_____ Behavior/Performance
_____ Other (specify) _________________________________________
Step #5:Recommendation for action:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Step #6 : Actions to be taken/date/by whom: ____________________________
Step #7: Reported to QM committee and date? Yes ____ No ____ Date: ___________________
______________________________________
Signature
_____________________
Date
Omega Health Services LLC
Conducting the Quality Management Program
______________________
POLICY
The Quality Management program will include all departments, disciplines, divisions and
services.
______________________
PURPOSE
To define additional QM requirements.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
Florida Regulations Chapter 59A-18 – Nurse Registries Standards and Licensing
______________________
RELATED DOCUMENTS
“Patient Record Audit” and “Quarterly Patient Record Audit,” and “Quarterly Audit
Performance Plan” forms
______________________
PROCEDURE
1.Client/Family Perception of Care Surveys
●Satisfaction surveys are e-mailed to randomly selected patients annually.
●When satisfaction surveys are submitted via email they are read and any immediate
issues are addressed by the Administrator.
●Submitted surveys are reviewed annually and tallied on the Customer Satisfaction Audit.
Based on the results, action items may be written on the Audit Performance Plan.
●Threshold for this area is 100%; any area that falls below 90% will be tracked.
2.Client Record Audit
●Each quarter 10% or fifteen (15) total clients charts will be reviewed using the client
Record Audit tool.
●An adequate sampling of open and closed records is selected to determine the
completeness of documentation
●The record audits will be tallied on the Quarterly Patient Record Audit tool. Based on the
tallied results, action items may be written on the Quarterly Audit Performance Plan.
●Threshold for each area of this audit is 90%. Any area that falls below will be tracked.
Omega Health Services LLC
3.Patient Complaints and/or Incidents/Occurrence and/or Infection Audit
●Quarterly the logs will be reviewed and, based on the results, action items may be written
on the Quarterly Audit Performance Plan.
4.Each quality improvement activity must include the following items:
●A description of indicator(s) activities to be conducted
●Frequency of activities
●Designation of who is responsible for conducting the activities
●Methods of data collection
●Acceptable limits for findings
●Who will receive the reports
●Plans to re-evaluate if findings fail to meet acceptable limits in addition to any other
activities required under state or federal laws or regulations
●Any other activities required under state or federal laws or regulations
5.A written plan of correction/activity plan is developed in response to any quality
improvement activity that does not meet an acceptable threshold. The plan of
correction/activity plan may identify changes in policy, procedure, or processes that will
improve performance.
6.A written summary describes changes made as a part of a corrective action plan. This
summary may be a separate document, or a part of the minutes of the governing body
meetings, or as a part of the QM reports.
Omega Health Services LLC
Client Record Audit
Client: __________________ Auditor Name: ___________________ Audit Date ______
Requirement Met Not
Met
N/A
Identification data.
Names of next of kin/legal guardian/emergency contact with phone numbers.
Name of primary caregiver(s) with phone numbers.
Source of referral.
Admission and discharge dates from hospital or other institution (if applicable).
Hospital and emergency room records for known episodes or documentation of
efforts to obtain the information.
Advance directives.
Names of power of attorney and/or healthcare power of attorney.
Name of physician responsible for care.
Diagnosis.
Physician orders, including medications and dietary, treatment and activity orders.
Signed release of information and other documents for protected health
information.
Admission and informed consent documents (including signed notice of Bill of
Rights and election of Hospice services (if applicable).
Assessment of the home.
Medical equipment provided by the Agency or related to the care, treatment
and services provided including assessment of patient and family
comprehension of appropriate use and maintenance.
Patient and family education and training on services or treatments and the use
of equipment at the time of delivery to the home.
Documentation of safety measures taken to protect the patient from harm
including fall risk assessments, and documentation why any identified or planned
safety measures were not implemented or continued.
Diagnostic and therapeutic procedures, treatments, tests and their results where
known to have occurred.
Initial assessments.
Ongoing assessments (if applicable).
Initial written plan of care.
Updated written plans of care (if applicable).
Transfer summaries/records (if any) received from transferring organizations.
Discharge planning and/or prognosis.
Omega Health Services LLC
Evidence of coordination of service/care provided by the organization with
others who may be providing service/care.
Referrals to and names of known home care agencies, individuals and
organizations involved in the patient’s care.
Patient Record Audit (continued)
Requirement Met Not
Met
N/A
Documentation of communications with the patient or authorized
representative regarding care, treatment and services (phone calls, emails, etc).
Signed and dated clinical notes.
Copies of summary reports sent to physicians.
Patient/family response to service/care provided.
Discharge summary (when applicable).
Omega Health Services LLC
Quarterly Patient Record Audit
Client: __________________ Auditor Name: ___________________ Audit Date ______
Requirement Met Not
Met
N/A
Identification data.
Names of next of kin/legal guardian/emergency contact with phone numbers.
Name of primary caregiver(s) with phone numbers.
Source of referral.
Admission and discharge dates from hospital or other institution (if applicable).
Hospital and emergency room records for known episodes or documentation of
efforts to obtain the information.
Advance directives.
Names of power of attorney and/or healthcare power of attorney.
Name of physician responsible for care.
Diagnosis.
Physician orders, including medications and dietary, treatment and activity orders.
Signed release of information and other documents for protected health
information.
Admission and informed consent documents (including signed notice of Bill of
Rights and election of Hospice services (if applicable).
Assessment of the home.
Medical equipment provided by the Agency or related to the care, treatment
and services provided including assessment of patient and family
comprehension of appropriate use and maintenance.
Patient and family education and training on services or treatments and the use
of equipment at the time of delivery to the home.
Documentation of safety measures taken to protect the patient from harm
including fall risk assessments, and documentation why any identified or planned
safety measures were not implemented or continued.
Diagnostic and therapeutic procedures, treatments, tests and their results were
known to have occurred.
Initial assessments.
Ongoing assessments (if applicable).
Initial written plan of care.
Updated written plans of care (if applicable).
Transfer summaries/records (if any) received from transferring organizations.
Discharge planning and/or prognosis.
Omega Health Services LLC
Evidence of coordination of service/care provided by the organization with
others who may be providing service/care.
Referrals to and names of known home care agencies, individuals and
organizations involved in the patient’s care.
Quarterly Patient Record Audit (continued)
Requirement Met Not
Met
N/A
Documentation of communications with the patient or authorized
representative regarding care, treatment and services (phone calls, emails, etc).
Signed and dated clinical notes.
Copies of summary reports sent to physicians.
Patient/family response to service/care provided.
Discharge summary (when applicable).
Scoring: # Met: _______ / # Applicable (Met + Not Met): _______ = Percentage: _______
Omega Health Services LLC
Quarterly Audit Corrective Action Plan
Qtr/Year Area of Concern Plan of Correction Steps Date
Completed
Outcome
Omega Health Services LLC
Omega Health Services LLC
Compliance Program
______________________
POLICY
Omega Health Services Compliance Program provides both general and specific guidance as to
various internal anti-fraud and abuse controls.
______________________
PURPOSE
The Compliance Program identifies and discusses numerous compliance risk areas particularly
susceptible fraud, waste and abuse.
●To advance the prevention of fraud, abuse and waste in health care while simultaneously
furthering the fundamental mission of the agency to provide quality care, treatment and
services to patients.
●To establish a culture that promotes the prevention, detection and resolution of potential
violations of laws, regulations and standards, and company policies and procedures.
●To identify and discuss potential compliance risk areas susceptible to fraud and abuse.
●To increase the likelihood of preventing, or at least identifying unlawful and unethical
behavior.
●This document is a description of the agency’s Compliance Program that reflects not only
policies and procedures, program activities, but also the commitment of senior management
and the support of all staff, vendors and agents to make the program effective.
●The agency recognizes that although an effective compliance program may not entirely
eliminate fraud, waste, and abuse, it significantly reduces the risk of unlawful, unethical, or
otherwise improper conduct. OHS supports the program with financial and staffing
resources, to the successful implementation of an effective Compliance Program that
addresses the following elements:
●Establishment of compliance standards and procedures.
o Development and distribution of written standards of conduct.
o Policies and procedures that promote compliance and address areas of potential fraud,
waste and abuse.
●Oversight of the compliance program by high-level personnel.
o Designation of a compliance officer who reports directly to the Administrator and
Governing Body of the organization
o Establishment of other appropriate systems/processes such as a compliance committee.
o Prompt responses to detected violations/offenses through corrective action plans.
●No discretionary authority given to individuals either known to engage in or suspected of
engaging in criminal action.
o Policies addressing the non-employment or retention of sanctioned individuals.
Omega Health Services LLC
●Effective communication of the compliance standards and procedures to all employees
and/or agents of the organization.
o Development of regular, effective education and training programs.
●Monitoring, auditing and reporting systems which encourage the reporting of criminal
conduct without retaliatory consequences.
o Implementation of a system/process such as a hotline to report and respond to allegations
of improper/illegal activities.
o Adoption of policies to protect the anonymity of reporters and protect them from
retaliation/retribution.
-Use of audits and other evaluative techniques to monitor compliance and reduce risk
in identified problem areas.
●Establishing and disseminating Agency disciplinary guidelines for failure to comply with the
organization’s standards and procedures, and applicable statutes and regulations.
-Use of appropriate and consistent discipline of employees and/or agents who have
violated internal compliance standards, applicable statutes, regulations, or federal
health care program requirements will not be tolerated.
●Appropriate response to a known violation of the compliance standards, applicable statutes,
regulations, or federal health care program requirements, and development of corrective
action plans to prevent and detect future violations.
______________________
REFERENCE
Health Facilities and Emergency Medical Services Division, 6 CCR 1011-1, Standards for
Hospitals and Health Facilities, Chapter XXVI – Home Care Agencies
Florida Regulations Chapter 59A-18 – Nurse Registries Standards and Licensing
http://www.cms.gov/FraudAbuseforProfs/
______________________
POLICY/ PROCEDURE
●The agency’s Compliance Program is dynamic evolving process that reflects the company’s
commitment to the highest standards of corporate conduct.
●The development, implementation and distribution of written policies and procedures and
standards of conduct that are in compliance with applicable laws, regulations and federal
health care program requirements is an integral part of the OHS Compliance Program.
Omega Health Services LLC
●Agency staff and management personnel receive compliance training during orientation and
at least annually, or more frequently if there are changes in applicable statutes, regulations, or
federal health care program requirements.
●The Compliance Program is reviewed at least annually and more often if necessary to ensure
that Agency risks are addressed appropriately and effectively.
●Copies of the Compliance Program are available to patients, referral sources and/or the
general public upon request.
Written Standards
●The Code of Ethics articulates the fundamental principles, values, standards and ethical
principles that guide the company’s daily operations and provide a framework for action.
●The Code of Ethics is very clear that management and staff are expected to behave in
compliance with applicable laws, regulations, standards and company policy.
●Upon hire, reference checks include verification of employment history and education.
●Criminal background investigations, and national sex registry investigations as appropriate,
are conducted that search for any felony or misdemeanor on both a county and federal level.
●If deemed appropriate to the position, checks are also conducted of professional certifications
and licenses and motor vehicle records.
Leadership and Structure
●There is a designated Administrator is charged with oversight of the Compliance Program,
who along with the OHS leadership regularly monitors the program to ensure appropriate
responsiveness to the company’s compliance risks.
●The Administrator has the authority to review all documents and other information that are
relevant to compliance activities, including, but not limited to, patient and billing records,
contracts and any other obligations that may contain referral and payment provisions that
could violate the anti-kickback statute.
●OHS Management team functions as the Compliance Committee, and advises the
Administrator and assists in the implementation of the program. The Office of the Inspector
General (OIG) recognizes that a home health agency/nurse registry may tailor the structure of
the Compliance Committee in consideration of the size and design of the home health
agency/nurse registry while endeavoring to address and accomplish the responsibilities of
the Compliance Officer and Compliance Committee. As OHS grows, the Compliance
Committee shall include individuals with varying responsibilities in the organization, such as
operations, finance, audit, human resources, and clinical management, as well as staff and
managers in key operating positions. These individuals should have significant professional
experience working with billing, clinical record, and documentation and auditing principles.
●The Administrator is responsible for ensuring that a culture of compliance is sustained
throughout the company, for providing strategic guidance for oversight of the processes,
Omega Health Services LLC
training, and implementation strategies to ensure compliance with applicable laws and
regulations, and company policies.
●The Compliance Officer/ Administrator primary responsibilities include:
o Overseeing and monitoring the implementation of the compliance program;
o Reporting at least quarterly or more often if necessary to the OHS Management team
about the implementation of the program, and assisting in establishing methods to
improve the agency’s efficiency and quality of care, treatment and services, and to reduce
the agency’s vulnerability to fraud, abuse, and waste;
o Periodically revising the program in light of changes in OHS needs, and in applicable
laws, regulations, and policies and procedures of government and private payer health
plans;
o Reviewing employee personnel files to ensure that they have received, read, and
understood the standards of conduct;
o Developing, coordinating, and participating in a multifaceted educational and training
program that focuses on the elements of the compliance program, and seeks to ensure that
all relevant employees and management are knowledgeable of, and comply with,
pertinent federal and state standards;
o Ensuring that independent contractors and agents who provide health care services to the
patients of the agency or provide billing services that, are aware of the agency’s
compliance program requirements, including but not limited to: coverage issues, billing
and marketing.
o Coordinating compliance review and monitoring activities of the OHS financial
management;
o Independently investigating and acting on matters related to compliance, and any
resulting corrective actions relative to all departments, subcontracted providers and
healthcare professionals, and any other agents if appropriate;
o Monitoring the OIG website to ensure compliance with all applicable laws, regulations
and OIG recommendations; and,
o Continuing to monitor and evaluate the momentum of the compliance program and
whether or not the goals and objectives of the program are being met.
●The agency conducts ongoing assessments/internal audits of the Compliance Program to
monitor identified potential risk areas and to identify new and emerging areas of risk and to
develop processes and/or systems to address those areas.
Education and Training
●OHS is committed to taking all necessary and appropriate steps to communicate agency
standards and procedures to all personnel and business associates.
●OHS staff are educated and trained about their legal and ethical obligations in order to be in
compliance with company policy and applicable laws, regulations, and standards.
Omega Health Services LLC
●Education and training is provided during orientation, at least annually, and more often if
necessary.
●The content of all training is evaluated on a regular basis to ensure that the content and the
training are effective. The training is updated as necessary to reflect current laws, regulations
and standards.
Internal Communications
●Within the agency is a commitment to a culture of open communication between staff and
management. To that end, the company has adopted open-door policies, as well as
confidentiality and non-retaliation policies. Procedures have been established to report
incidents/issues anonymously.
●Staff is encouraged to bring workplace issues of any type to the attention of management/the
Administrator without fear of retaliation or recrimination.
●Staff is encouraged to first discuss workplace issues with their immediate supervisors. If the
matter is not successfully resolved, an employee may pursue the matter with the next level of
management or the Compliance Officer.
Responding to Violations
●Although a compliance program decreases the likelihood of unlawful and unethical behavior,
DHHR-OIG recognizes that even an effective Compliance Program cannot prevent all
violations. In the event that the company becomes of aware of violations of law or company
policy, the issues will be promptly investigated, disciplinary action shall be taken if
appropriate, and plans of correction will be implemented, if necessary, to prevent future
violations.
●The Agency will not conduct business with persons or organizations that have been excluded,
debarred, suspended or otherwise ineligible to participate in Federal healthcare programs.
●If an Agency employee violates the law or regulations and/or company policy, the Agency
has implemented a disciplinary process that outlines the potential consequences up to and
including termination that addresses these violations.
●The Agency also assesses whether identified violations may be due in part, to the structure of
company policies, procedures, processes and/or systems, and if so, develops appropriate
corrective plans of action to decrease the possibility of violations occurring in the future.
●If credible evidence is discovered of misconduct from any source and after reasonable
inquiry the Agency has determined there is credible evidence the misconduct has possibly
violated any criminal, civil, or administrative law, the Agency shall report the existence of
such misconduct to the appropriate federal and state authorities and regulatory bodies within
a reasonable period of time, but no more than sixty (60) days after the determination.
Omega Health Services LLC
Auditing and Monitoring
●Audits conducted at regular intervals address, but are not limited to, the Agency’s
compliance with anti-kickback laws, claim processing, cost reporting, marketing, the
Medicare/Medicaid Conditions of Participation, as well any areas that have been identified
by OIG, any federal or state entity, or internally by the Agency itself.
●Internal audits of the Agency’s processes and systems and adherence to the Compliance
Program elements are conducted at regular intervals and at least during the company annual
evaluation. Reports of the audits are submitted to the Management team and analyzed to
determine the necessity for improvements to be made, and if so, plans of correction are
developed and implemented to improve the OHS operations. Internal audits are an integral
part of the organization’s Performance Improvement program.
COMPLIANCE PROGRAM EDUCATION
●Omega Health Services provides Corporate Compliance Program education to all staff
during orientation, annually, and more often if necessary as indicated by changes in
applicable laws, regulations, standards or guidelines or as required due to the sensitivity of
the work.
●The Compliance Officer is responsible for:
o Assuring that the information provided during any Compliance Program training, and
information disseminated to employees and any agents of the Agency, is accurate, current
and reflects applicable laws, regulations, and standards; and
o Ensuring appropriate documentation of any compliance training
●All employees shall receive formal training in at least the following:
o Organization Policies and Procedures;
o Ethics, including the Agency’s Code of Ethics; and,
o Procedures for notifying senior management of problems and concerns
●Targeted training is provided to managers, clinicians and other employees whose actions
impact the claims submission process to the government and other third party payors.
●The contents of the Compliance Program training shall include, but is not limited to:
o Federal, state and private payer reimbursement rules, regulations and guidelines
o Organization Policies and Procedures
o Anti-kickback Laws
o Fraud and Abuse Laws
o Prohibitions related to inducing referrals
o Appropriate admission and discharge of patients
o Claims development and submission process:
-Confirming and prioritizing diagnosis
-Accurate and appropriate coding principles
Omega Health Services LLC
-Physician signatures
-Visit verification
-Equipment/supplies verification
o Documentation requirements for services rendered and items provided
o Altering medical records
o Misrepresenting services and/or items provided
o Reporting misconduct/potential violations
o Cost Reports
o Waiver of Copayments/Accepting Assignment
o Marketing Practices
o Standards of Practice
o Scope of Practice
●A variety of teaching methods may be used to present the information in a manner that is
understandable to the employees.
Omega Health Services LLC
Department of State /Division of Corporations /Search Records /Detail By Document Number /
Document Number
FEI/EIN Number
Date Filed
Effective Date
State
Status
Detail by Entity Name
Florida Limited Liability Company
OMEGA HEALTH SERVICES LLC
Filing Information
L18000098556
NONE
04/19/2018
04/18/2018
FL
ACTIVE
Principal Address
5921 WASHINGTON ST
APT 120
HOLLYWOOD, FL 33023
Mailing Address
5921 WASHINGTON ST
APT 120
HOLLYWOOD, FL 33023
Registered Agent Name & Address
SAINT PREUX, AGNES
5921 WASHINGTON ST
APT 120
HOLLYWOOD, FL 33023
Authorized Person(s) Detail
Name & Address
Title MGR
SAINT PREUX, AGNES
5921 WASHINGTON ST APT 120
HOLLYWOOD, FL 33023
Title MGR
RICHARD, MIRLINE
1600 NE 135TH ST APT 807
NORTH MIAMI, FL 33181
Title MGR
DIVISION OF CORPORATIONSFlorida Department of State
Page 1 of 2Detail by Entity Name
11/7/2018http://search.sunbiz.org/Inquiry/corporationsearch/SearchResultDetail?inquirytype=Entity...
ZOA EXPRESS LLC
5921 WASHINGTON ST APT 120
HOLLYWOOD, FL 33023
Annual Reports
No Annual Reports Filed
Document Images
04/19/2018 -- Florida Limited Liability View image in PDF format
Florida Department of State, Division of Corporations
Page 2 of 2Detail by Entity Name
11/7/2018http://search.sunbiz.org/Inquiry/corporationsearch/SearchResultDetail?inquirytype=Entity...
Selection Committee
Final Ranking Sheet
RFP #: 18-7470
Title: Services for Seniors
Name of Firm Louise Blanca Wendy Dora Akiko Total
Selection
Committee
Final Rank
Marantha Home Care Inc. dba A Better Health
Care 1 1 2 2 1 7 1.0000
The ADT Corporation dba ADT LLC 1 2 2 2 1 8 2.0000
Summit Home Healthcare Products 3 2 1 1 1 8 3.0000
Southern Home Care Services Inc.dba ResCare
Inc.3 3 3 4 3 16 4.0000
Accu-Care Nursing Service Inc.2 4 5 6 2 19 5.0000
VIP America of Southwest Florida LLC 5 6 4 3 4 22 6.0000
Bidwell Home Care Service LLC dba Home
Instead Senior Care 4 5 5 6 7 27 7.0000
Omega Health Services LLC 7 6 5 5 5 28 8.0000
Almost Family PC of SW Florida LLC 6 7 4 7 6 30 9.0000
Procurement Professional Viviana Giarimoustas
Step 1: Upon direction by the Procurement professional, the individual selection committee member should provide their ranking of the proposals
(from highest being number one (1) to lowest.
Step 2: The procurement professional will review the mathematically calculated final rank and discuss the rank order and determine if consensus is
reached.
Page 1 of 1
16.D.6.e
Packet Pg. 1431 Attachment: 18-7470 Final Ranking (7591 : RFP-7470 Omega)
Addendum #1
Date: 10/22/18
From: Viviana Giarimoustas, Procurement Strategist
To: Interested Bidders
Subject: Addendum # 1
Solicitation #18-7470 Services for Seniors
The following change is made to the above mentioned Collier County solicitation:
A revised insurance statement has been attached.
If you require additional information please post a question on the Online Bidding site or contact
me at the information noted above.
Please sign below and return a copy of this Addendum with your submittal for the above referenced solicitation.
(Signature)
Date
(Name of Firm)
Email:
Viviana.Giarimoustas@colliergov.net
Telephone: (239) 252-8375
16.D.6.f
Packet Pg. 1432 Attachment: 18-7470 Addendum #1 (7591 : RFP-7470 Omega)