WHEREAS, the County wishes to engage Contractor to provide services under this Agreement containing mutually satisfactory terms and covenants; and

Transcription

1 Page 1 of 379 AGREEMENT BETWEEN BROWARD COUNTY AND ECHO CONSULTING SERVICES, INC. FOR ENTERPRISE BUSINESS APPLICATION FOR HUMAN SERVICES DEPARTMENT (RLI No. R R1} This is an Agreement ("Agreement") made and entered into by and between Broward County ("County"), a political subdivision of the state of Florida, and Echo Consulting Services, Inc. d/b/a The Echo Group ("Contractor"), an active New Hampshire corporation authorized and registered to do business in the state of Florida (County and Contractor are collectively referred to herein as the "Parties"). WHEREAS, this Agreement is the result of the procurement selection process begun by County's Request for Letters of Interest for Enterprise Business Application for Human Services Department, RLI No. R R1 ("RLI"); and il \ f i WHEREAS, Contractor submitted a response to the RLI and represented that it has the technology, equipment, and expertise to provide County with the requested system and the experience necessary to adequately and competently perform the services; and WHEREAS, the County wishes to engage Contractor to provide services under this Agreement containing mutually satisfactory terms and covenants; and WHEREAS, negotiations pertaining to the services to be performed and the compensation therefor were undertaken between the County and Contractor, and this Agreement incorporates the results of such negotiations; and WHEREAS, the Board hereby determines that the services and expenditure of public funds will serve a public purpose; NOW, THEREFORE, IN CONSIDERATION of the mutual terms, conditions, promises, covenants and payments hereinafter set forth, County and Contractor agree as follows: ARTICLE 1 DEFINITIONS AND IDENTIFICATIONS 1.1 Agreement means this document, Articles 1-16, inclusive, and any Work Authorizations, Statement of Work(s), and/or amendments thereto. Other terms and conditions are included in the Exhibits which are expressly incorporated by reference. This Agreement includes and incorporates the following Exhibits: Exhibit A Statement of Work ("SOW") Exhibit B Maintenance Support Services and Service Level Agreement Exhibit C Work Authorization form ExhibitD Exhibit E Exhibit F Broward County and The Echo Group System Services Agreement Certificate of Insurance Business Associate Agreement The Echo Group Response to RLI

2 Page 2 of Board means the Board of County Commissioners of Broward County, Florida, which is the governing body of the Broward County government created by the Broward County Charter. 1.3 Business Day means Monday through Friday. 1.4 County Business Enterprise or "CBE" is a small business located in Broward County, Florida, which meets the criteria and eligibility requirements of Broward County's CBE Program and must be certified by Broward County's Office of Economic and Small Business Development. 1.5 Contract Administrator means the County Administrator or the Director of Broward County's Human Services Department. The primary responsibilities of the Contract Administrator are to coordinate and communicate with Contractor and to manage and supervise execution and completion of the Statement of Work and the other terms and conditions of the Agreement. In the administration of the Agreement, as contrasted with matters of policy, all parties may rely on the instructions or determinations made by the Contract Administrator. 1.6 County Attorney means the chief legal counsel for County who directs and supervises the Office of the County Attorney pursuant to Section 2.10 of the Broward County Charter Defect(s) mean incorrect implementation or failure to conform to the Documentation or the Final Acceptance Criteria resulting in inadequacy, malfunction, or imperfection. In the event of a conflict between the Final Acceptance Criteria and the Documentation, the Final Acceptance Criteria shall prevail. 1.8 Deliverables mean all Software Goods, Software Licenses, and Documentation to be delivered by Contractor and all items of Services to be performed for, and provided to, County by Contractor under the Agreement. 1.9 Documentation means such documentation as delivered by Contractor to County and accepted by County at Final Acceptance of the System relating to the use, function and Support ofthe System, as may be amended from time to time. Such Documentation shall be provided in hardcopy and softcopy and shall include, but not be limited to, the Statement of Work, the Preliminary and Final Acceptance Criteria as set forth in the Agreement and the changes, modifications, alterations and configurations made by Contractor or its subcontractors to the Software hereunder to provide County the System. For purposes hereof, Documentation also includes the User and/or System Administrators' Guides and other written or electronic material as made generally available by Contractor to its customers relating to the use, function and Support of the Software, as may be amended from time to time by Contractor, including any Derivative Works thereto. County may modify, add to, or customize the Documentation for Broward County and The Echo Group System Services Agreement 2

3 Page 3 of 379 its internal use. County may copy the Documentation as needed for its internal use at no additional fee to Contractor Enterprise License means an unlimited number of copies of the Licensed Software running in County with an unlimited number of server copies and an unlimited number of concurrent end user licenses, excluding Third Party User Licenses, for on and off-site, wired, and wireless access ofthe Licensed Software Event means an incident whereby the System is either not working or its operation is. inconsistent with the Documentation. Events are divided into categories. The categories are Priority 1, 2, 3, or 4 as further defined below. PRIORITY 1 - CRITICAL BUSINESS IMPACT EVENT means the impact of the reported Defect is such that the County is unable to either use the System or reasonably continue work using the System. PRIORITY 2 - SIGNIFICANT BUSINESS IMPACT EVENT means important features of the System are not working properly. While other areas of the System may not be impacted, the reported Defect has created a significant, negative impact on County's productivity and/or service level. PRIORITY 3 - MINOR BUSINESS IMPACT EVENT means important features of the System are not working properly. County impact is minimal loss of operational functionality. PRIORITY 4 - MINIMAL BUSINESS IMPACT EVENT means the County submits an Event, information request, software enhancement or Documentation clarification which has no operational impact. The implementation or use of the System by the County is continuing and there is no negative impact on productivity Final Acceptance means the acceptance ofthe System by County as required by Section of the Broward County Administrative Code which has a requirement for inspection and testing of all computer application software purchased or developed for County by third parties costing over Twenty Thousand Dollars {$20,000.00) 1.13 Good(s) means all tangible property to be provided by Contractor, if any, pursuant to this Agreement including, but not limited to, the items as set forth, described and designated "to be provided by Contractor." 1.14 Hardware means the physical components or equipment which make up a computer system including the programs that control the operations of the computer and support the Software Licensed Software means Contractor's System Software and any other Software delivered to County by Contractor under this Agreement, including each computer program or Broward County and The Echo Group System Services Agreement 3

4 Page 4 of 379 module, application, and patent which makes up the Licensed Software and each copy, translation, update, or modification of all or any part of the Licensed Software in any medium, delivered to the County by, and capable of running on the Hardware configuration recommended by Contractor, together with any materials related thereto, such as, any human readable program listings, flow charts, logic diagrams, output forms, manuals, specifications, instructions, Documentation, and other materials, and any copies of the foregoing, in any medium, related to the Licensed Software and normally provided by Contractor to any other licensee of the Licensed Software and all released modifications, enhancements, upgrades, or new versions acquired by County Maintenance means any activity intended to eliminate faults, to improve or to keep the System in satisfactory working condition, including tests, measurements, adjustments, and changes, modifications, enhancements or repairs, and updates as set out in Exhibit B, Maintenance Support Services Phase means a subset of the work to be performed as defined in the SOW Preliminary Review means twenty (20) business days' time period, subsequent to County's receipt of a Phase for County to perform a review of the submitted Phase. Preliminary Review and/or Preliminary Acceptance shall have no bearing on County's Final Acceptance determination Release(s) means those versions of the Licensed Software which add functionality to the Software, including any Updates and Upgrades Services means the work, duties, and obligations to be carried out and performed by Contractor under the Agreement and pursuant to Exhibit A, Statement of Work, attached hereto and made a part of this Agreement. Without limiting the foregoing, the Services to be performed by Contractor may fall into the following general categories: (i) consulting, (ii) installation of Software, (iii) Software programming or modification/configuration of the Licensed Software, (iv) project management, (v) programming agreed upon interfaces, (vi) conversion of County's current data, (vii) training of County staff, and (viii) maintenance support Software means programs which (i) tell a computer what to do, and (ii) are required to perform the tasks specified in the Agreement, whether or not the programs are to be supplied by Contractor Sublicense means a County license to County for Third Party Software that Contractor provides to County as part of the System under its original license Support means the type of services, including, but not limited to, those identified in the "Maintenance Support Services" per Exhibit B. Broward County and The Echo Group System Services Agreement 4

5 Page 5 of System means Contractor's Electronic Health Record and Billing System, as well as the Software, enhancements, Third Party Software, Goods, Services, Documentation, Licensed Software, custom Software, and other items, tangible and intangible, which together will (i) allow County's Human Services Department to have and maintain an automated and integrated patient tracking system, and (ii) provide the Documentation and Services required by the Agreement(s). As applicable, System shall also mean Contractor's fully integrated, web based suite of Software with on and off-site, wired and wireless, intra net or Internet access capability, as updated and upgraded pursuant to the Agreements, that tracks patient records, as more fully described in Exhibit A Third Party Users means those individuals or entities authorized by County to perform services on behalf of County and/or to access the System, or those individuals or entities otherwise authorized to use the System by County Third Party Software means non-contractor software that is necessary for the System to perform its functions and is independently acquired by County or is sublicensed by Contractor to County under the Agreement Update(s) means periodic release(s) of the Licensed Software, Software, and Third Party Software that may contain fixes or incremental enhancements to the Licensed Software, Software, and Third Party Software and are included in Maintenance Support Services Upgrade(s) means periodic releases of the Licensed Software, Software, and Third Party Software that contain significant enhancements that may include changes of hardware platform, database platform, operating system, or major change in capability and functionality and are usually identified by a new whole number revision number that is, Revision 4.0 compared to Revision 3.8. ARTICLE 2 PERFORMANCE AND TESTING 2.1 System Performance. The Parties understand that the Agreement is the result of County's procurement process and negotiations. Contractor understands that County, after entering into this Agreement, has no need for Contractor's Deliverables nor for the products or Services of third parties, both goods and intangible products, unless the System performs as represented and County accepts the System in accordance with the acceptance criteria described and set forth in the Agreement. Contractor acknowledges that County's acquisitions made as a part of this Agreement are subject to the acceptance criteria described and set forth in the Agreement being met and such is an essential element and condition of this Agreement. 2.2 Inspection, Testing and Acceptance. Broward County Administrative Code, Section , relating to County's Computer Software Policy, established a requirement for inspection of all computer application software systems purchased or developed for Broward County by others costing over Twenty Thousand Dollars ($20,000.00) prior to its acceptance by Broward County and The Echo Group System Services Agreement 5

6 Page 6 of 379 County. Contractor recognizes that all computer application Software purchased or licensed by Broward County from Contractor, and without limiting the foregoing, in particular, the System acquired under the Agreement, shall be inspected and tested by the County's Enterprise Technology Services Division ("ETS") prior to acceptance of the System. Also, all contracts for the purchase of computer application software costing more than Twenty Thousand Dollars ($20,000.00) shall include clauses providing (i) for inspection and testing by the Enterprise Technology Services Division of such computer application Software prior to formal acceptance of that software by Broward County, and (ii) that final payment shall not be made prior to formal acceptance of the System by County. The County's Enterprise Technology Services Division will coordinate its acceptance responsibilities with those of other County entities utilizing the standards for acceptance set forth and described in the Agreement. The Enterprise Technology Services Division's failure to accept the System shall constitute non-acceptance by County. In the event of such non-acceptance, Contractor shall repay to County any and all monies paid by County to Contractor for the Phase(s) that were not accepted pursuant to the Agreement within thirty (30) business days after written notice of non-acceptance. The Parties also recognize and agree that County's obligations under the Agreement are specifically conditioned upon its accepting the System as set forth and described in the Agreement. ARTICLE 3 SCOPE OF SERVICES 3.1 Contractor shall perform all work identified in this Agreement and Exhibit A, Statement of Work, attached and made a part of this Agreement. The Parties agree that this Agreement and the Statement of Work describe Contractor's obligations and are deemed to include preliminary considerations and prerequisites, labor, materials, equipment, and tasks which are such an inseparable part of the work described that exclusion would render performance by. Contractor impractical, illogical, or unconscionable. 3.2 For a period of three (3) years from the Final Acceptance of the System by County, Contractor agrees to provide consulting and programming services as requested by County for customization and/or enhancements to the System. County shall pay Contractor for the services, object code related to any programming, and documentation related to the development work at the rate for the service categories as set forth and described in Exhibit A, Statement of Work, attached and made a part of this Agreement. Where the programming to be provided by Contractor is for Custom Software, Contractor will also provide the source Code for such programming. 4.1 License to County ARTICLE 4 LICENSE Contractor hereby grants to County a royalty free, perpetual, non-exclusive Enterprise License for the Licensed Software, with no geographical limitations, limited to use by Broward County staff and Broward County contracted providers, with an Broward County and The Echo Group System Services Agreement 6

7 Page 7 of 379 unlimited number of server copies, and an unlimited number of concurrent end user licenses, excluding Third Party User licenses, for on and off-site, wired and wireless, intranet or Internet access and use of the Licensed Software. Contractor also sublicenses to County to the full extent otherwise provided herein, the Contractor provided Third Party Software identified in Exhibit A to this Agreement as well as any embedded third party Software within the Licensed Software. Contractor grants to County a nonexclusive, nontransferable perpetual license to use the Licensed Software subject to the terms and conditions set forth in this Agreement County's license shall not be dependent upon or require County to purchase any other product or service, including Maintenance Services, from Contractor or any third party, and such License shall continue in perpetuity irrespective of the termination of this Agreement or any other agreement between the Parties Platform Compatibility and Portability. Contractor agrees to maintain, support, and improve its Licensed Software and the custom Software so as to ensure continuing compatibility with updates and upgrades to the hardware and operating systems with which the Licensed Software and custom Software operate, so as to ensure that the Licensed Software and custom Software operates on platforms defined by Echo in the RLI response and upgraded under active software maintenance agreement or as the parties may otherwise agree. At all times during the term of this Agreement, County shall not only receive the enhancements, Updates, and Upgrades set forth in this Agreement, but also shall be entitled to receive upon request and under the licensing terms of this Agreement, at no additional charge, any version, release, renamed product, or platform of the Licensed Software or commercial version of the custom Software, to the extent licensed to Contractor, which is then supported by Contractor, so long as County maintains active software support and maintenance per Exhibit B, in exchange for County's version of the Licensed Software. 4.2 Warranted Functions The Licensed Software is warranted by Contractor to provide the functions, features, and capabilities specified and described in the Agreements and the Documentation. Contractor further warrants and represents that: All items shall be installed as described in the Agreements, the Statement of Work attached thereto, and the Documentation, on Hardware identified in the Statement of Work to this Agreement as part of the configuration of the Contractor System, and along with the Licensed Software, shall operate together as a whole to perform the functions in the manner specified and delineated in the Agreements, Statement of Work and Documentation. Except as expressly set forth herein: Contractor makes no other warranties of fitness; Contractor makes no warranty or representation that the use of the software or product documentation will ensure the County's receipt of state or federal funds; and Contractor makes no Broward County and The Echo Group System Services Agreement 7

8 Page 8 of 379 warranty of any kind regarding third party software, hardware or equipment and is under no obligation to County with respect to the same Contractor expressly warrants that each module of the Licensed Software will be free from reproducible Defects that cause the Licensed Software to fail to conform to the operational and performance specifications as set forth in the Agreements, Statement of Work, and Documentation This express warranty for the Licensed Software for each Phase shall be for a period of one (1) year from the date of County's Preliminary Acceptance, and for the System for a period of one (1) year from the date of the County's Final Acceptance as set forth in the Agreements between County and Contractor of even date herewith. Contractor's warranty shall not apply where the Defect in the Licensed Software is the result of: (i) (ii) (iii) Use of the Licensed Software in other than the manner for which it was installed. Damage to the Licensed Software caused by County or its employees or agents. Modification of the installed Licensed Software by County not authorized by Contractor During the warranty period and upon notification in writing by County of any Defect and/or Priority Event, Contractor, at its option, will promptly commence making any needed repair to the Licensed Software and continue to proceed to a solution within a reasonable time (as defined in Exhibit B) or promptly replace the Licensed Software. In the event Contractor is unable to remedy any material Defect within twenty (20) business days after such notification by County that a material Defect exists, then County, at its sole option, may terminate this Agreement and Contractor shall immediately repay County any and all monies paid by it for the System pursuant to the Agreements. In the event of such termination by County and after full repayment by Contractor, subject to third party claims against Contractor, County shall return the Licensed Software, Documentation and other material received from Contractor and will promptly remove the Licensed Software from any and all hardware upon which the Licensed Software may reside Contractor also warrants that the input media upon which the Licensed Software are contained, and the Licensed Software itself, are free from Defects, viruses, and/or malicious software which would prevent the Licensed Software from being operated as described and set forth in the Documentation. Contractor warrants that the Licensed Software has been run through a virus detection system and is free from currently known viruses and/or malicious software. Broward County and The Echo Group System Services Agreement 8

9 Page 9 of Without limiting any other remedies available to County for breach of this warranty, Contractor will, at no charge to County, promptly correct any Priority Event, error and/or Defect in the Licensed Software reported to Contractor by providing to County either (a) a new version of the Licensed Software in which the error and/or Defect has been corrected, or (b) additional software code that, when installed in accordance with Contractor's instructions, will correct the error and/or Defect. In addition, Contractor will immediately provide to County any known methods of operating the Licensed Software in a manner that eliminates the practical adverse effects of the error and/or Defect. If Contractor is unable to correct the error and/or Defect as provided above within a reasonable period of time not to exceed twenty (20) Business Days, Contractor will refund to County all fees paid for the applicable Phase or System (in addition to any other rights and remedies County may have). 4.3 Use of Licensed Software: The Licensed Software is licensed to the County solely for County's governmental and business purposes which shall include on and off-site access and use of the Licensed Software by authorized Third Party Users, including, but not limited to, any persons or entities which County may contract to operate the System, and for the benefit of and by all governmental entities within Broward County, including the offices of the County's Constitutional Officers. County may use the Licensed Software on computer systems not described in Exhibit A at no additional fee, although for purposes of continued Maintenance, County shall request Contractor to approve a configuration other than as provided in Exhibit A, which approval shall not be unreasonably withheld. i 4.4 County has a disaster recovery plan and uses the recovery resources provided by a third party contractor to County at the contractor facility ("Center-Based"} and/or delivered by contractor to County designated locations (i.e., "Mobile"). County may, if required by reason of an emergency, disaster or operational need, and also for testing of the recovery resources, temporarily use the Licensed Software on any such recovery resources, at no additional fee, whether presently contracted for or that may be contracted for in the future and which recovery resources Contractor understands may not be owned by County. 4.5 County may install and operate the Licensed Software in separate servers used in any and all development, test, production, failover, and backup configurations, at no additional fee. County may also install the Licensed Software in its Emergency Operations Center in replication of its production environment for use in any emergency event which results in County operations from the Emergency Operations Center, at no additional fee. 4.6 County may, because of operational needs, and at no additional fee, request Contractor to approve a Hardware configuration not recommended by Contractor in Exhibit A, which approval shall not be unreasonably withheld Except as otherwise provided for in this Agreement: County shall not reproduce, publish, or license the Licensed Software to others. Broward County and The Echo Group System Services Agreement 9

10 Page 10 of County shall not copy, in whole or in part, the Licensed Software except for use by County for backup and archiving purposes and copying the Licensed Software into Random Access Memory for the purposes of support and/or maintenance by County or others hired by County to provide such support and/or maintenance Except as allowed by law, County shall not modify, adapt, translate, reverse engineer, decompile, disassemble or create derivative works based on the Licensed Software without the prior written consent of Contractor County shall not modify, adapt, translate, or create derivative works based on the Documentation without the prior written consent of Contractor All licenses to Third Party Software provided to County by Contractor shall be sublicensed to County by Contractor. 4.8 Contractor will notify County's Human Services Department of any intended Update(s), Upgrades and/or Releases prior to the deployment thereof. If an Update, Upgrade, and/or Release occurs during the Initial Term, or any subsequent Maintenance term, Maintenance Service will be provided at no additional cost to County, inclusive of any Updates, Upgrades and/or Releases. 4.9 Contractor also agrees to maintain a level of version currency with Third Party Software required to operate the System equal to currently supported releases of Third Party Software. ARTICLE 5 COMPENSATION OF AND METHOD OF PAYMENT 5.1 County agrees to pay Contractor, in the manner specified in Article 5 herein, for Exhibit A (Statement of Work), for Deliverable(s) and Services actually performed and completed for the System as follows: The County's Director of the Purchasing Division or any individual acting in such capacity is hereby granted authority to approve, award, and execute all Work Authorizations, agreements, documents, or other instruments required to acquire enhancements to the System under this Agreement. The parties agree that the maximum amount payable by the County to the Contractor during the term of this Agreement, including any renewal or term, shall not exceed Two Million Six Hundred Eighteen Thousand Three Hundred Eighty-Five and 00/100 Dollars ($2,618,385.00} plus any remaining, unpledged funds allocated for the goods or services under the System and Services Agreement between Broward County and the Echo Group, dated September 24, 2002, as amended, or the Software License Agreement between Broward County and the Echo Group, dated September 24, 2002, as amended ("BARC Funds"). A copy of the Work Authorization form is attached hereto as Exhibit C. Broward County and The Echo Group System Services Agreement 10

11 Page 11 of The maximum not-to-exceed amount of Two Million Sixty-Three Thousand Seven Hundred Fifty and 00/100 Dollars ($2,063,750.00) is the cost for the attached Statement of Work, Deliverable(s) and Services including Reimbursables actually performed and completed pursuant to this Agreement. In addition, the amount of Five Hundred Fifty Four Thousand Six Hundred Thirty-Five Dollars ($554,635.00), plus any applicable BARC Funds, is hereby set aside for Optional Services which may become necessary or which may not have been previously anticipated in the attached Statement of Work. Therefore, as stated above, the potential allowable spending funds for this Agreement shall not exceed the amount of Two Million Six Hundred Eighteen Thousand Three Hundred Eighty-Five and 00/100 Dollars ($2,618,385.00), plus any applicable BARC Funds. It is acknowledged and agreed to by Contractor that this amount is the maximum payable and constitutes a limitation upon County's obligation to compensate Contractor for Deliverables and Services related to this Agreement. This maximum amount, however, does not constitute a limitation, of any sort, upon Contractor's obligation to perform all items of work required by, or which can be reasonably inferred from this Agreement The amount set forth in this Agreement above includes any and all of Contractor's overhead, operating costs, outlays, profit, and other out-of-pocket costs, associated out-of-pocket costs including, but not limited to, photocopying, long distance telephone, special mailings and the like. Contractor shall also bear all of its own expenses arising from its performance of the obligations under this Agreement and the Statement of Work including (without limitation) expenses for facilities, work spaces, utilities, management, clerical and reproduction services, supplies, and the like. The prices and costs stated for Deliverables include all taxes. It is understood that County is a tax-exempt entity in the State of Florida and shall only be responsible for the payment of applicable taxes, if any, if and when it loses tax-exempt status To the extent Contractor is entitled to reimbursement for travel expenses as stated in the attached Statement of Work; all such travel shall be as approved in advance in writing by the Contract Administrator. Reimbursables directly attributable to the services provided will be charged at actual cost, and shall be limited to the following: a) Identifiable transportation expenses in connection with the services, subject to the limitations of Section , Florida Statutes, as amended. Transportation expenses to locations outside the Miami-Dade-Broward-Palm Beach County area or from locations outside the Miami-Dade-Broward-Palm Beach County area will not be reimbursed unless specifically pre-authorized in writing by the Contract Administrator. Transportation expenses to and from locations within the Miami-Dade/Broward/Palm Beach County area will not be reimbursed. Broward County and The Echo Group System Services Agreement 11

12 Page 12 of 379 b) Identifiable per diem, meals and lodging, taxi fares and miscellaneous travelconnected expenses for Contractor's personnel subject to the limitations of Section Florida Statutes, as amended. Meals for class C travel inside Broward County will not be reimbursed. Meals and lodging expenses will not be reimbursed for temporarily relocating Contractor's employees from one of Contractor's offices to another office if the employee is relocated for more than ten (10) consecutive County working days. Lodging will be reimbursed, subject to Section , Florida Statutes, as amended. c) A detailed statement of expenses shall accompany any request for reimbursement. Expenses other than automobile travel must be documented by copies of paid receipts, checks, or other evidence of payment. 5.2 METHOD OF BILLING AND PAYMENT Payment for the Licensed Software shall be Four Hundred Fifty Six Thousand and 00/100 Dollars ($456,000.00} payable in accordance with the Payment Schedule stated in the SOW for Licensed Software, and all Software Deliverables hereunder are included in such Licensed Software. Contractor will perform the configuration and installation of the Licensed Software, Contractor will also furnish County with sufficient instructions, Documentation or other written materials as may be necessary to install the configured Licensed Software in an efficient and expeditious manner. Contractor will instruct County personnel in the installation process in the event County is required to reinstall the Licensed Software at a subsequent date Maintenance and support services shall be provided at no cost from the effective date of the Agreement for a period of six (6) months (the "Initial Term"). Thereafter, the cost for Maintenance for each one {1) year term after the Initial Term ("Annual Maintenance Charge") will be One Hundred and One Thousand Two Hundred Fifty and 00/100 Dollars ($101,250.00), which shall be paid quarterly in advance, if renewed at the sole discretion of County's Human Services Department on an annual basis. Hosting fees shall be invoiced and paid in accordance with the Payment Schedule set forth in Exhibit A Following the Initial Term, County agrees to pay the Annual Maintenance Charge in advance quarterly payments for those years it elects to purchase Maintenance. Contractor shall provide an invoice to County for such Maintenance no later than fortyfive (45) calendar days prior to the quarterly payment due date In the event County decides to resume Maintenance Support Services for a terminated or non-renewed portion of the Licensed Software, Maintenance Support Services shall be reinstated upon County's paying the prorated amount of prior outstanding maintenance fees defined above and may incur a reinstatement fee not to exceed fifty percent (50%} of the then-current Annual Maintenance Charge. Broward County and The Echo Group System Services Agreement 12

13 Page 13 of County, through its Human Services Department, may terminate Maintenance Support Services any time for any portion or module of the Licensed Software. Maintenance Support Services terminated prior to the end of the quarter will not incur a refund of associated quarterly maintenance fees Contractor may submit invoices for compensation no more often than on a monthly basis, but only in accordance with the Payment Schedule as stated in the SOW. An original invoice is due within thirty (30} calendar days after Preliminary Acceptance of each Phase or completion of the relevant travel or training course(s) as outlined in the SOW at Exhibit A except the final invoice which must be received no later than sixty (60) calendar days after Final Acceptance. Invoices shall designate the nature of the Services performed and/or the expenses incurred. Invoices shall comply with the requirements of County's Prompt Payment Ordinance set forth below County shall pay Contractor within thirty (30) calendar days of receipt of Contractor's proper statement, as required by the "Broward County Prompt Payment Ordinance" (Broward County Ordinance No , as may be amended from time to time). To be deemed proper, all invoices must comply with the requirements set forth in this Agreement and must be submitted on the form and pursuant to instructions prescribed by Contract Administrator. Payment may be withheld for failure of Contractor to comply with a term, condition, or requirement of this Agreement Periodic payments shall be made for the Services set forth in the Statement of Work in Phases County shall pay Contractor Eighty Five Percent (85%) of the total shown to be due on each invoice for each Phase as detailed above and in the Statement of Work and/or the Deliverables and Payment Schedule and the remaining Fifteen Percent (15%) retainage shall be remitted as each Phase is accepted as provided for in Article 5 herein below and Article 12 below Contractor shall notify County in writing when Contractor contends that a Phase is completed and ready for Preliminary Review by County. Within twenty (20} Business Days following receipt of Contractor's written notice, County's Contract Administrator shall issue its written statement of Preliminary Acceptance or its written notice that the Work comprising the Phase Milestone(s) is not Preliminarily Accepted. Preliminary Review shall include, at a minimum, a scheduled meeting between County's Contract Administrator and Contractor to review all Deliverables to this point, discuss outstanding or known issues, and determine whether to proceed with the next Phase. County's Contract Administrator will not unreasonably withhold Preliminary Acceptance of a Phase if Contractor has provided the required Deliverables for that Phase to County within the established timeframes to be established in the project work Broward County and The Echo Group System Services Agreement 13

14 Page 14 of 379 plan and County's Contract Administrator has determined that each Deliverable satisfies its associated acceptance criterion. Contractor shall not submit any invoice for payment for a Phase until County has agreed to Preliminary Acceptance of the particular Phase. Preliminary Review and/or Preliminary Acceptance shall have no bearing on County's ETS's Final Acceptance determination as set out in Article 2 and Article Contractor agrees that all Software that is part of the System shall be inspected and tested by County together with the licensed Software and the System as a whole as set forth herein and final payment shall not be made until County has completed the "Final System Acceptance" as set forth in Exhibit A, Article 2, and Article 12 below The Parties acknowledge that Exhibit A may not delineate every detail and minor work task required to be performed by Contractor to complete its Services and provide the Deliverables and the System. If, during the course of the performance of the Services, Contractor determines that work should be performed to complete the System which, in Contractor's opinion, is outside the level of effort originally anticipated in Exhibit A, whether or not Exhibit A identifies the work items, Contractor shall notify the Contract Administrator in writing in a timely manner. If Contractor proceeds with said work without notifying the Contract Administrator, said work shall be deemed to be within the original level of effort of Exhibit A, whether or not specifically addressed in Exhibit "A." The provision of prior written notice to the Contract Administrator by Contractor does not constitute authorization or approval by County to perform the work. Performance of work by Contractor outside the originally anticipated level of effort without prior written County's Contract Administrator approval is at Contractor's sole risk and at no cost to County County or Contractor may also request changes that would increase, decrease, or otherwise modify Exhibit "A." Such changes must be made in accordance with the provisions ofthe Broward County Procurement Code and must be contained in a written amendment executed by the Parties hereto prior to any deviation from the terms of this Agreement including the initiation of any additional services. County shall compensate Contractor for such additional services as provided in Article 5 herein above. Subject to the not-to-exceed amounts set forth in Section 5.1.2, Optional Services as provided on the attached Statement of Work may be done through a Work Authorization in the form attached as Exhibit C In the event a dispute between the Contract Administrator and Contractor arises over whether requested services constitute additional work or services or is outside the level of effort originally anticipated in Exhibit A and such dispute cannot be resolved by the Contract Administrator and Contractor, such dispute shall be promptly presented to County's Chief Information Officer at ETS for resolution pursuant to the procedures set out in Article 13 of this Agreement. During the pendency of any dispute, if requested in Broward County and The Echo Group System Services Agreement 14

15 Page 15 of 379 writing by the Contract Administrator, Contractor shall promptly perform the disputed services County's Purchasing Director or any individual acting in such capacity shall have the authority to approve, award and execute all documents or other instruments required to effectuate changes, modifications or additional service contemplated by Article 5 herein above, so long as the then cumulative financial obligation of County for such additional items does not exceed the Purchasing Director's authority under the Procurement Code. Any change, modification or additional service that causes the cumulative financial obligation of County for such additional items to exceed the Purchasing Director's authority under the Procurement Code shall be presented to the Board for its approval. 5.3 Any payment to Contractor shall be payable to "The Echo Group" at: Echo Consulting Services, Inc. d/b/a The Echo Group Attn: Debbie Angelico, Chief Financial Officer 15 Washington Street Conway, NH County is already in receipt of Contractor's federal identification number; however, Contractor agrees to complete additional forms relating to same if requested by Contract Administrator. 5.4 Contractor acknowledges and agrees that the Contract Administrator has no authority to make changes that would increase, decrease, or otherwise modify the Scope of Services to be provided under this Agreement except as expressly authorized by the Broward County Procurement Code (Chapter 21 of the Broward County Administrative Code), as may be amended from time to time. Any material change in scope shall require a prior written amendment. 5.5 County agrees to pay Contractor, in the manner specified in the Payment Schedule in the SOW and this Article 5, the total amount of Two Million Sixty-Three Thousand Seven Hundred Fifty and 00/100 Dollars ($2,063,750.00) for work actually performed and completed pursuant to the SOW attached to this Agreement including Thirty Eight Thousand Four Hundred Dollars ($38,400.00) for all reimbursables agreed to in Section 5.1.4, which amounts shall be accepted by Contractor as full compensation for all such work and expenses under the SOW (excluding Optional Services). It is acknowledged and agreed by Contractor that this amount is the maximum payable and constitutes a limitation upon County's obligation to compensate Contractor for its services and expenses related to this Agreement. This maximum amount, however, does not constitute a limitation, of any sort, upon Contractor's obligation to perform all items of work required by or which can be reasonably inferred from the Scope of Services. Broward County and The Echo Group System Services Agreement 15

16 Page 16 of 379 REIMBURSABLE$ In accordance with and pursuant to the Broward County Procurement Code and subject to the limitations set forth below, expenses, reasonable in amount and nature, which are directly attributable to the Project may be charged at no more than actual cost. The maximum sum which may be charged for expenses shall not exceed Thirty-Eight Thousand Four Hundred Dollars ($38,400), and shall be limited to the following: a) Identifiable transportation expenses in connection with the Project, subject to the limitations of Section , Florida Statutes, as may be amended from time to time. Transportation expenses to locations outside the Miami-Dade/Broward/Palm Beach County area or from locations outside the Miami-Dade/Broward/Palm Beach County area will not be reimbursed unless specifically authorized in advance and in writing by the Contract Administrator. Transportation expenses to and from locations within the Miami-Dade/Broward/Palm Beach County area will not be reimbursed. b) Cost of printing drawings and specifications which are required by or of Contractor to deliver services set forth in this Agreement. A detailed statement of expenses must accompany any request for reimbursement. Expenses other than auto travel must be documented by copies of paid receipts, checks, or other evidence of payment. It is acknowledged and agreed to by Contractor that the dollar limitation set forth in Section 5.5 is a limitation upon, and describes the maximum extent of, County's obligation to reimburse Contractor for expenses, but does not constitute a limitation, of any sort, upon Contractor's obligation to incur such expenses or perform the services identified in Article 2. Notwithstanding any provision of this Agreement to the contrary, County may withhold, in whole or in part, payment to the extent necessary to protect itself from loss on account of inadequate or defective work which has not been remedied pursuant to Sections 4.2 or Article 12 herein or from loss due to fraud or reasonable evidence indicating fraud by Contractor or failure to comply with this Agreement. When the above reasons for withholding payment are removed or resolved in a manner satisfactory to the Contract Administrator, payment may be made. The amount withheld shall not be subject to payment of interest by County. Broward County and The Echo Group System Services Agreement 16

17 Page 17 of 379 ARTICLE 6 TERM OF AGREEMENT AND NOTICE TO PROCEED 6.1 Term of Agreement. The term of this Agreement shall begin on the date it is fully executed by both parties and shall end five (5) year(s) after County's ETS's written Final Acceptance. In the event this Agreement extends beyond a single fiscal year of County, the continuation of this Agreement beyond any such fiscal year shall be subject to the availability of County funds in accordance with Chapter 129, Florida Statutes, as amended. The County's represents that its fiscal year currently commences on October 1 of each year and ends on September 30 of each year. The term of the System services component of this Agreement shall not affect any perpetual Software license to County or any Maintenance term and such terms shall be independent ofthe System services term. 6.2 Notice to Proceed. "Notice to Proceed" means written notice issued by the Contract Administrator authorizing Contractor to proceed with providing the Goods and Services pursuant to this Agreement. Prior to beginning the performance of any Services, Contractor must first receive a written Notice to Proceed from the Contract Administrator. Prior to the execution of this Agreement, Contractor shall provide County with a properly completed Insurance Certificate, the completion of, and submittal of, which is considered a condition precedent to the County's execution of this Agreement. 6.3 Completion of System Timetable. Contractor shall complete the System, through Final Acceptance, within eighteen (18) months from the date of the issuance of the Notice to Proceed. If Contractor is unable to complete the System, including Final Acceptance, within twenty four (24) months from date of the issuance of the Notice to Proceed, County shall have the option to terminate the Agreement by written notice from its Contract Administrator, and Contractor shall then refund to County all funds paid by County for the incomplete or unaccepted Phase(s) of the System as outlined in the SOW at Exhibit A. In addition, all Professional Services Fee and Training fees for Phase #2 shall be discounted by fifty percent (50%) if (a) Contractor fails to submit Phase #2 to County for Preliminary Acceptance on or before the latter of 60 days after the Effective Date or December 1, 2013, or (b) if Phase #2 fails to receive Preliminary Acceptance on or before the latter of 90 days after the Effective Date or January 1, 2014, provided that County completes Preliminary Acceptance testing within twenty (20) business days of submission for testing. The Contract Administrator shall have the option to extend in writing the completion time period prior to the deadlines stated herein for good cause shown. Any delays caused by County shall extend the time of completion in accordance with the extent of the County's delay. 6.4 Contractor acknowledges that County, through its Contract Administrator, retains the sole discretion of whether to exercise the remedy of termination or retain age for the specific default conditions mentioned herein. The Parties further stipulate that the refund, discount, and retain age amounts provided for in this Agreement are not intended to be a penalty and are purely intended to reasonably compensate County for unknown and unascertainable damages. The Parties agree that if County allows Contractor to continue completion of the work to be Broward County and The Echo Group System Services Agreement 17

18 Page 18 of 379 provided pursuant to this Agreement, or any part of it, after the expiration of the time allowed in Article 6 herein above, including extensions of time granted to Contractor by County's Contract Administrator, that County's action shall in no way act as a waiver on the part of County of the discount or retainage due under this Agreement, unless otherwise agreed in writing by the parties. ARTICLE 7 INDEMNIFICATION, WARRANTIES AND LIMITATION OF LIABILITY 7.1 INDEMNIFICATION. Contractor shall at all times hereafter indemnify, hold harmless and, at the County Attorney's option, defend or pay for an attorney selected by the County Attorney to defend County, its officers, agents, servants, and employees from and against any and all causes of action, demands, claims, losses, liabilities and expenditures of any kind, including attorney fees, court costs, and expenses, caused or alleged to be caused by intentional or negligent act of, or omission of, Contractor, its employees, agents, servants, or officers, or accruing, resulting from, or related to the subject matter of this Agreement including, without limitation, any and all claims, losses, liabilities, expenditures, demands or causes of action of any nature whatsoever resulting from injuries or damages sustained by any person or property. In the event any lawsuit or other proceeding is brought against County by reason of any such claim, cause of action or demand, Contractor shall, upon written notice from County, resist and defend such lawsuit or proceeding by counsel satisfactory to County or, at County's option, pay for an attorney selected by County Attorney to defend County. The provisions and obligations of this section shall survive the expiration or earlier termination of this Agreement. To the extent considered necessary by the Contract Administrator and the County Attorney, any sums due Contractor under this Agreement may be retained by County until all of County's claims for indemnification pursuant to this Agreement have been settled or otherwise resolved; and any amount withheld shall not be subject to payment of interest by County. 7.2 GENERAL WARRANTY. Contractor warrants and represents that any Services and Licensed Software or custom Software provided and/or to be provided to County are original with or owned by Contractor and that no portion of such Services or Licensed Software or custom Software, or its use by County pursuant to the terms of this Agreement, violates or is protected by the right, title, interest or similar right of any third person or entity, however organized, except as may be set forth in this Agreement. County shall have the quiet and peaceful enjoyment of the use of the Licensed Software to be supplied by Contractor for the duration of its license or until its proper and lawful termination, free from interference by any and all Parties, including Contractor. Contractor is not aware of any products, processes, Software or practices of Contractor relating to the Deliverables and Services provided hereunder, which have or could reasonably be expected to form the basis of any claim, action, suit, proceeding, hearing, or investigation of, against or relating to Contractor which may constitute an infringement of a third party's copyright, patent, trade secret, or other intellectual property. Broward County and The Echo Group System Services Agreement 18

19 Page 19 of Notwithstanding the foregoing in Article 7.2, the County acknowledges that sovereign immunity shall not extend to a claim by Contractor for breach of contract subject to Florida's laws. 7.4 WARRANTY AS TO INTELLECTUAL PROPERTY INFRINGEMENT. Contractor represents and warrants that it owns the Licensed Software and has all rights necessary to license the Licensed Software to County, and at the time of entering into this Agreement no claims have been asserted or action or proceeding brought against Contractor which alleges that all or any part of the Licensed Software to be supplied by Contractor or the operation or use thereof by County, infringes or misappropriates any patent, copyright, mask copyright or any trade secret or other intellectual or proprietary right of a third party, nor is Contractor aware of any such potential claim. Contractor also represents and warrants that its Services to be provided pursuant to this Agreement to modify the Licensed Software will not infringe or misappropriate any patent, copyright, mask copyright or any trade secret or other intellectual or proprietary right of a third party. In the event of a breach of this representation and warranty, Contractor shall be responsible for and pay County for any and all actual harm, injury, damages, costs and expenses incurred by County by reason of the breach including as provided in the General Indemnification provisions in Section 7.1 above. County will use reasonable efforts to notify Contractor promptly of any third party claim, suit, or action (a "Claim") for which County believes it is entitled to indemnification under this Section and which County desires Contractor to defend. However, County's failure to provide such notice or delay in providing such notice will relieve Contractor of its obligations under this Section only if and to the extent that such delay or failure materially prejudices Contractor's ability to defend such Claim. If County tenders the defense of a Claim to Contractor, Contractor will have the right and the obligation to defend such Claim with counsel of its choice; however, County may participate in the defense of the Claim with its own counsel and at its own expense. Once Contractor assumes defense of a Claim, it will be conclusively presumed that Contractor is obligated to indemnify County for such Claim, and County will cooperate with Contractor, except if such cooperation requires disclosure of information exempted from disclosure by reason of any Federal or State law or would require County to violate any Federal or State law, at Contractor's reasonable request and at Contractor's expense, in the defense of the Claim. No settlement of a Claim will be binding on County without County's prior written consent. This intellectual property infringement indemnification obligation shall survive the expiration or earlier termination of this Agreement. Nothing in Section 7.3 herein as to intellectual property indemnification shall be deemed to place any limitations on the Contractor's obligation to indemnify County under the General Indemnification provisions in Section 7.1 above. 7.5 WARRANTY REGARDING VIRUSES. The term "Virus" means any computer code that could (a) disrupt, disable, harm, or otherwise impede in any manner the proper operation of a computer program or computer system, or (b) damage or destroy any data or files residing on a computer system without the user's consent, including (without limitation) any "back door," "time bomb," "Trojan Horse," "worm," "drop dead device", spyware, and "virus" (as these terms are commonly used in the computer software field). Contractor warrants that the Licensed Software does not and will not contain any Virus. Contractor warrants that it will use Broward County and The Echo Group System Services Agreement 19

20 Page 20 of 379 state-of-the-art anti-virus screening software to screen the media containing the Licensed Software for Viruses before delivery of such media to County. Contractor shall be liable to County for any and all losses, damages, liabilities, costs, and expenses caused by any such Virus. Contractor further warrants that it will not perform any action that will hinder County's freedom to use or physically and electronically transport the Licensed Software within County's facilities, and that it has not included in the Licensed Software any software, hardware, electronic, or other security mechanism (including password, CPU serial number validation or dependency, electronic initialization protection, and time dependent execution) or any other disablement, de-installation, deactivation, or deletion mechanism. 7.6 GOVERNMENTAL IMMUNITY. Nothing herein is intended to serve as a waiver of sovereign immunity by any party nor shall anything included herein be construed as consent to be sued by third parties in any matter arising out of this Agreement or any other contract. County is a state agency or political subdivision as defined in Chapter , Florida Statutes (as amended), and agrees to be fully responsible for the acts and omissions of its agents or employees to the extent permitted by law. 7.7 LIMITATION OF LIABILITY. Neither Contractor nor County shall be liable to the other party for any damages under this Agreement that exceed the largest of the following amounts: (a) $100,000; (b) twice the maximum compensation amount payable to Contractor under the Agreement for license fees and professional services; or (c) the amount of insurance Contractor is required to provide under Article 8 below. Neither party shall be liable for the other party's special, indirect, punitive, or consequential damages (including damages resulting from lost data or records other than costs incurred in the recovery thereof), even if the party has been advised that such damages are possible, or for the other party's lost profits, lost revenue, or lost institutional operating savings. These limitations of liability shall not apply to (i) any claim resulting from Contractor's actual or alleged disclosure of County Confidential Information, (ii) any claim resulting from an actual or alleged infringement of any interest in any Licensed Software or other intellectual property, or (iii) any indemnification obligation under this Agreement. 7.8 NO LIABILITY FOR CERTAIN DAMAGES. In no event will Contractor be liable for any consequential, special, incidental, indirect, exemplary or punitive damages, even if Contractor has been advised of the possibility of such damages. 7.9 FORCE MAJEURE. Neither Party shall be responsible to the other for non-performance, default or delay in performance of the terms and conditions herein due to, but not limited to, acts of God, act of government, wars, riots, strikes, fire, theft, accidents in transportation, material shortages or other causes beyond the control of Contractor (as determined and approved in writing by Contract Administrator) or County (as determined and approved in writing by Contractor's Chief Financial Officer). Either Party desiring to rely upon such a cause shall, when the cause arises, give prompt oral notice thereof to the other Party and, when the cause ceases to exist, shall give prompt written notice thereof to the other Party. Such notice for County shall be given by its Contract Administrator. Broward County and The Echo Group System Services Agreement 20

21 Page 21 of 379 ARTICLE 8 INSURANCE 8.1 Provider shall, at a minimum, provide, pay for, and maintain in force at all times during the term of this Agreement (unless a different time period is otherwise stated herein) all insurance coverage as stated in this Article Professional Liability Insurance with mm1mum limits of One Million Dollars ($1,000,000.00) per claim. Policy shall contain an extended reporting period of One year after the completion of services under this Agreement Commercial General Liability Insurance with minimum limits of One Million Dollars ($1,000,000} per occurrence combined single limit for bodily injury and property damage and Two Million Dollars ($2,000,000.00} per aggregate Business Automobile Liability Insurance, if driving is necessary in performance of duties under this Agreement, with minimum limits of One Million dollars ($1,000,000.00) per occurrence combined single limit for bodily injury and property damage Workers' Compensation Insurance for all employees in compliance with applicable state and federal laws. Policy shall include Employers' Liability coverage with minimum limits of One Million Dollars ($1,000,000.00} each accident. 8.2 Such policies shall be issued by companies authorized and licensed to transact business in Provider's home state and rated at least "A-" by A.M. Best Co., unless otherwise approved in writing by County. If any deductible amounts are permitted, Provider shall be responsible for the payment of all such deductible amounts. 8.3 Provider agrees to list County as an additional insured under Provider's commercial liability insurance policy and excess liability insurance policy. The listed certificate holder on these policies shall be "Broward County." 8.4 Coverage must be provided on forms no more restrictive than the latest edition of the applicable forms filed by the Insurance Services Office. 8.5 Provider shall notify County in writing within thirty (30} days after Provider learns of any claim exceeding $250,000 (inclusive of defense costs) against Provider's professional liability insurance policy. 8.6 Within fifteen (15) days of execution of this Agreement, Provider shall provide County with proof of insurance in the form of Certificate(s) of Insurance and applicable endorsements, Declarations pages, or insurance policies. Failure to timely provide acceptable proof of Broward County and The Echo Group System Services Agreement 21

22 Page 22 of 379 insurance, as determined by County in its reasonable discretion, shall entitle County to terminate this Agreement without any liability to Provider. 8.7 All insurance policies required under this Article must expressly provide County with at least thirty (30) days' prior written notice of expiration, cancellation, or restriction of coverage. Providershall provide certified copies of any policy to County upon County's request. 8.8 If Provider subcontracts any work under this Agreement, Provider shall ensure that each subcontractor names County as an additional insured under the subcontractor's general liability and excess coverage policies (if any). ARTICLE 9 GOODS TO BE SUPPLIED BY CONTRACTOR 9.1 Contractor will sell and County will purchase from Contractor the following Goods: None For purposes of this Agreement, and unless otherwise stated herein, the term "Goods" includes any associated firmware and operating software licensed as an integral part of the Goods. Contractor (or the applicable third party owner, as the case may be) retains all right, title and interest in all firmware and associated software, whether operating or application software, delivered under this Agreement subject only to the following license rights. Any firmware delivered as a component of Goods shall be deemed licensed to County on a nonexclusive basis strictly for use as an integral part of the Goods. Any associated software delivered with the Goods shall be deemed licensed to County according to the terms and conditions of the software license agreement included with the Documentation or, if not so included, then County shall be deemed granted a nonexclusive license in object code form to install, store, load, execute and display (collectively, "Use") the software as part of using the Goods for the purposes contemplated herein. All Goods will be new and unused except normal manufacturers' testing for product control and verification of quality. County shall have the right to sell the Goods and, in such event, it is understood and agreed that County may transfer the licenses to all Software, including any elements of the Licensed Software, that are an integral part of the Goods to the purchaser(s) of the Goods, but only if the purchaser agrees to accept and be bound by the terms and conditions of the licenses being assigned with the Goods. 9.2 Contractor represents and warrants that it will convey to County good and marketable title to the Goods free and clear of all liens and encumbrances or a proper license to use the Software. Risk of Loss shall pass to County when the items are duly tendered to a County Representative at a facility designated by County, so as to allow County to inspect the items and accept delivery of same. Title to the Goods shall pass to County when the items are duly tendered to a County Representative at a facility designated by County's Contract Administrator in advance in writing, so as to allow County to inspect the items and accept delivery of same. Contractor will install those elements of the Licensed Software to be Broward County and The Echo Group System Services Agreement 22

23 Page 23 of 379 furnished by Contractor described in the Statement of Work, so that such Software will function with the Goods as set forth and described in the Statement of Work. Contractor or the owner of the software associated with the Goods retains title to such software. Subject to applicable federal and Florida laws, as amended from time to time, all patent, copyright, trade secret, trademark, and other intellectual property rights remain solely with Contractor or the owner of the software. ARTICLE 10 TERMINATION 10.1 This Agreement may be terminated for cause by the aggrieved party if the party in breach has not corrected the breach within ten (10) days after written notice from the aggrieved party identifying the breach. This Agreement may also be terminated for convenience by the Board or the County Administrator. Termination for convenience by the Board or the County Administrator shall be effective on the termination date stated in written notice provided by County, which termination date shall be not less than thirty (30) days after the date of such written notice. This Agreement may also be terminated by the County Administrator upon such notice as the County Administrator deems appropriate under the circumstances in the event the County Administrator determines that termination is necessary to protect the public health or safety. The parties agree that if County erroneously, improperly or unjustifiably terminates for cause, such termination shall be deemed a termination for convenience, which shall be effective thirty (30) days after such notice oftermination for cause is provided This Agreement may be terminated for cause for reasons including, b.ut not limited to, Contractor's repeated (whether negligent or intentional) submission for payment of false or incorrect bills or invoices, failure to suitably perform the work; or failure to continuously perform the work in a manner calculated to meet or accomplish the objectives as set forth in this Agreement. The Agreement may also be terminated for cause if the Contractor is placed on the Scrutinized Companies with Activities in Sudan list or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector list created pursuant to Section , Florida Statutes, as amended or if the Contractor provides a false certification submitted pursuant to Section , Florida Statutes, as amended Notice oftermination shall be provided in accordance with the "NOTICES" section ofthis Agreement except that notice of termination by the County Administrator, which the County Administrator deems necessary to protect the public health, safety, or welfare may be verbal notice that shall be promptly confirmed in writing in accordance with the "NOTICES" section of this Agreement In the event this Agreement is terminated for convenience by County, Contractor shall be paid for any services properly performed under the Agreement through the termination date specified in the written notice of termination. Contractor acknowledges and agrees that it has received good, valuable and sufficient consideration from County, the receipt and adequacy Broward County and The Echo Group System Services Agreement 23

24 Page 24 of 379 of which are, hereby acknowledged by Contractor, for County's right to terminate this Agreement for convenience In the event this Agreement is terminated for any reason, any amounts due Contractor shall be withheld by County until all documents are provided to County pursuant to the Rights in Documents and Works provisions in Section of Article 16. ARTICLE 11 CONFIDENTIAL INFORMATION 11.1 Subject to applicable Florida and federal laws, as amended from time to time, both Parties recognize that, during the performance of Services under this Agreement, a Party may be involved in analyzing automated systems, computer software applications and programs. During the performance of such work and Services, a Party may be required to review and/or use software programs and applications licensed to, or by, the other Party or by third parties which may be subject to confidentiality agreements and disclosure restrictions. Also, a Party may have access to the other Party's or third parties' data, information, memoranda, documents, trade secrets and ideas which also may be subject to confidentiality agreements and disclosure restrictions, including requirements imposed by law, as amended from time to time Subject to applicable Florida and federal laws, as amended from time to time, both Parties hereby acknowledge that each Party may be exposed to confidential and proprietary information of the other Party and providers of software and confidential and proprietary information, business information, and information that may be exempted from disclosure or prevented from being disclosed by reason of law. "Confidential Information" must be expressly identified in writing by the Party claiming such confidentiality (prior to allowing access by the other Party if so required by applicable laws), and such Party must provide the other Party with a written statement of the nature of such claim. Confidential Information does not include the following: information already known or independently developed by Contractor or County; information in the public domain through no wrongful act of Contractor or County; information received by Contractor or County from a third Party who was free to disclose it, or information required to be disclosed by law or an order of court Subject to applicable Florida and federal laws, as amended from time to time, with respect to the Confidential Information, both Parties hereby agree that during the term of this Broward County and The Echo Group System Services Agreement 24

25 Page 25 of 379 Agreement and at all times thereafter, neither shall use, commercialize, or disclose such Confidential Information obtained from the other to any person or entity, except to such other Parties as the Party's representative (such as Contract Administrator for County) claiming confidentiality may approve in writing and under such conditions as such claiming Party may impose in advance in writing unless otherwise required by law or court order Both Parties agree that the provisions in the "Confidential Information" section herein are subject to court orders, administrative orders, applicable Florida and federal laws, as amended from time to time. In addition to any protections afforded to Contractor by the federal copyright and patent laws, Contractor also represents to County for its reliance thereupon that its software and confidential proprietary software material documentation are also trade secrets under Florida laws, including Section , Florida Statutes (as amended). Contractor shall be solely responsible for ensuring that all copies of its confidential proprietary and trade secret materials are properly marked with appropriate written and/or electronic notice(s) identifying same as confidential, proprietary and/or trade secret as appropriate prior to providing any of them to the County Contractor has represented that the Licensed Software and Documentation are owned by it and are protected by applicable copyright laws. Contractor further represents that the Licensed Software constitute trade secrets of Contractor as the term "trade secrets" is defined in Section of the Florida Statutes (as amended). Contractor claims exemption from disclosure of the Licensed Software as provided under Chapter 119, Public Records Law, Florida Statutes (as amended). County agrees prior to any disclosure of the Contractor's Confidential Information, the Licensed Software, the source code and/or documentation related to such source code for Licensed Software under the Public Records Law, that County will promptly notify Contractor of any request for disclosure so that Contractor may take such action or actions Contractor deems necessary to prevent such disclosure and/or to defend against or settle any suit or proceeding against County for the failure to make disclosure of the Licensed Software as provided under Chapter 119, Public Records Law, or other laws requiring disclosure by County In the event Contractor elects to prevent disclosure as above provided, Contractor agrees at its expense to protect, defend and indemnify County against any claim, demand, action, proceeding, loss, liability, cost and expense (including court costs and reasonable fees of attorneys and other professionals) incurred or suffered by County as a result of any claim against County for the failure to make disclosure of the Licensed Software as provided under Chapter 119, Public Records Law, or other laws requiring disclosure by the County Notwithstanding anything to the contrary contained above or elsewhere in this Agreement, County shall have the right to use the Licensed Software to provide access to the public to the data base, files or information derived from the use of the System and/or to generate reports from such data, files or information or to provide such data, files or information on electronic media to the public where required or allowed by the laws of the State of Florida or other laws allowing disclosure by County. Contractor acknowledges and Broward County and The Echo Group System Services Agreement 25

26 Page 26 of 379 agrees that County is the owner and custodian of its information and data, whether or not such is electronically retained and regardless of the retention media and that the use of the Licensed Software in relation to such information or data does not in any way restrict County in County's rights of disclosure of its data and information County Data Confidentiality and Use Restrictions: (i) Contractor agrees and understands that all files and other information and data created in connection with this Agreement constitute a public record, except to the extent it is exempt or confidential under Florida law, including, but not limited to, Chapter 119 of the Florida Statutes (as amended), from disclosure. Contractor agrees to maintain for public record access such files and to maintain for public access such files after termination of this Agreement in accordance with the laws of the State of Florida. (ii) All data and written and oral information exempt or confidential under Florida law, including, but not limited to, social security numbers which is obtained, or supplied to Contractor pursuant to this Agreement shall be kept confidential by Contractor and shall not be used or disclosed to any other Party, directly or indirectly, without the County's prior written consent unless required by an order issued by a court of lawful jurisdiction. To the extent that a County employee or agent causes the unauthorized disclosure of County's Confidential Information, Contractor shall not be liable or responsible for such disclosure, except to the extent that Contractor or its agents are also a cause of the unauthorized disclosure. All data provided by County or its agents or Third Party Users under this Agreement and all results derived therefrom through the use of the System shall be and remain the County's property and may be reproduced and reused solely at the discretion of the County PUBLIC RECORDS DISCLOSURES: Public records are subject to applicable Florida and federal laws, as amended. The Parties agree that this Agreement, including all its exhibits and any attachments, is a public records document subject to Florida Statutes, including Chapter 119, as amended. Any amendments to the Agreement or any authorizing purchasing document relating to this Agreement, including Exhibit A, shall also be deemed to be a public records document subject to applicable Florida's laws, as may be amended from time to time. In the event Contractor elects to prevent disclosure as provided above, Contractor agrees at its expense to protect, defend, and indemnify County against any claim, demand, action, proceeding, loss, liability, cost and expense (including court costs and reasonable fees of attorneys and other professionals) incurred or suffered by County as a result of any claim against County for the failure to make disclosure of the Licensed Software as provided under Chapter 119, Public Records Law, or other laws requiring disclosure by the County. Broward County and The Echo Group System Services Agreement 26

27 Page 27 of 379 (i) (ii) (iii) Nondisclosure by County shall not apply to information that is or becomes known to the public without fault or breach on the part of County; Contractor regularly discloses to third parties without restriction on disclosure; or County receives from a Party other than Contractor without restriction on disclosure THE ABOVE DUTIES AND OBLIGATIONS SHALL SURVIVE THE EXPIRATION OR EARLIER TERMINATION OF THIS AGREEMENT SUBJECT TO GENERAL INDEMNIFICATION OF COUNTY AS PROVIDED IN ARTICLE 7. ARTICLE 12 TESTING, ACCEPTANCE OR REJECTION OF THE SYSTEM PHASES 12.1 There shall be a testing period during which the Phases and System can be used by County. The purpose of the testing period is to permit County, including County's ETS, as to each Phase ("Preliminary Acceptance") and, upon completion of all Phases, as to the System in its entirety ("Final Acceptance"), to determine whether the System Phases have been properly installed so that they: Properly function in accordance with the Acceptance Criteria and provide the capabilities described therein. Properly function together with the operating software, if any, and other items as described in the Documentation so as to provide the functions described in the Documentation; Properly function in accordance with the Documentation and provide the capabilities described therein, and Properly function as a part of the Hardware configurations as agreed upon by and between Contractor and County's ETS The period for testing for each Phase and, upon completion of all Phases, for the System will be for twenty (20) business days which period shall commence on the first business days after Contractor informs County in writing that it has completed the Services required to be performed prior to testing and is ready for the testing to begin of the System Phase. If County, in ETS's discretion, determines that a Phase or the System is incomplete (rather than merely containing a Defect), testing will cease, and Contractor shall complete the Phase or System and resubmit the Phase or System for Preliminary Acceptance or Final Acceptance testing and the time periods herein shall be reset to that of a first submission for testing. Broward County and The Echo Group System Services Agreement 27

28 Page 28 of During the testing period, County may, at the option of the Contract Administrator, notify Contractor in writing of any error and/or Defect within twenty (20) business days after it is determined such exists so that Contractor, at its option, can commence making any needed changes, modifications, adjustments, or repairs to the Phase, System or parts thereof. County's Contract Administrator shall notify Contractor in writing of its acceptance or rejection of the Phase or System, or any part thereof, within ten (10) business days after the end of the testing period. If County rejects the Phase or System, or any part thereof, its Contract Administrator shall specify the reasons therefore which reasons shall specify the Acceptance Criteria(s) that the Phase or System failed to meet. Upon receiving the written notice of rejection, Contractor shall have ten (10) business days after receipt of notice within which to either (a) modify, repair, adjust or replace the Phase or System or any portion thereof or (b) set forth in writing the reasons the Phase or System or portion thereof meet the Acceptance Criteria specified in County's notice. Any dispute as to whether the Phase or System or portion thereof complies shall be impartially determined by County's Chief Information Officer pursuant to Article 13 of this Agreement, whose decision shall be final. If Contractor modifies, repairs, adjusts, or replaces the Phase or System or portion thereof, then County, including its ETS, shall have twenty (20) additional business days to retest the Phase or System to confirm its proper operation and shall notify Contractor in writing of any rejection in the same manner as specified above In the event that Contractor is unable to remedy the reason or reason(s) for County's rejection, or any part thereof, within a total of twenty (20) business days after receipt of County's initial notification, County, including its ETS, shall elect either to accept the Phase or System as it then exists or reject the Phase or System and terminate the Agreement in whole or in part (including as to any Phase) by written notice from the Contract Administrator. If County, including its ETS, elects to accept the Phase or System as it then exists (partial acceptance), Contractor shall continue to remedy the reason(s) for County's partial acceptance and shall provide County with the complete Phase or System meeting the Acceptance Criteria set out in this Agreement, prior to any final payment being made by County after County's ETS' written Final Acceptance. If Contractor fails to remedy the reason(s) for County's partial acceptance within twenty (20) business days after Contractor's receipt of County's partial acceptance written notification, including testing by County, then County shall be entitled to deduct from any final payment, or be paid by Contractor, the value of the rejected portion of the Phase or System as mutually determined and approved in writing by the Contract Administrator and Contractor's Chief Financial Officer (CFO). In the event the Parties' representatives cannot mutually agree to such a value within ten (10) business days after Contractor's receipt of County's partial acceptance notification, then all retaiilage for the partially accepted Phase or System held by County as set forth in ArticleS shall be retained by, or paid to, County as reimbursement for accepting a Phase or System that has failed to meet the Acceptance Criteria. If County elects to reject the Phase or System as a whole, Contractor shall refund to County any and all funds paid for the unaccepted Phase(s) and, if the System is rejected, County shall retain any unpaid retainage, as detailed in the SOW at Exhibit A by County to Contractor under the Agreement within thirty (30) business days after the written notice from Contract Administrator. Broward County and The Echo Group System Services Agreement 28

29 Page 29 of 379 ARTICLE 13 RESOLUTION OF DISPUTES 13.1 In order to provide a means of resolving disputes, reducing delays in performance and lessening the likelihood of litigation, it is agreed by the Parties hereto that all questions, claims, difficulties and disputes of whatever nature which may arise relative to the provisions of this Agreement will first be submitted in writing to County's Contract Administrator and Contractor's CFO who will meet and confer in good faith in an effort to resolve the matter. Such claims, questions, difficulties, and disputes shall be submitted to the referenced individuals in writing as soon as practicable (but within ten_(10} business days) after the issue arises. In the event the individuals are unable to satisfactorily resolve the issue, the matter shall be presented to County's Chief Information Officer (CIO} as soon as practicable. Such CIO's decision shall be in good faith and shall be final and binding on the Parties. Notwithstanding this section, the Parties shall retain all their legal rights and remedies provided in law or equity In the event the determination of a dispute under this Article is unacceptable to any of the Parties' stated representatives in Article 16 herein, the Party (through its stated representative in Article 16 herein) objecting to the determination must notify the other Party in writing within thirty (30} business days of receipt of the written determination. The notice must state the basis of the objection and must be accompanied by a statement that any contract price adjustment claimed is the entire adjustment to which the objecting Party has reason to believe it is entitled to as a result of the determination. Within sixty (60) business days after the date of such notice, the Parties may participate in mediation to address all objections to any mediator mutually agreed upon by Contractor's CFO and County's Contract Administrator. Should any objection not be resolved in mediation, the Parties retain all their legal rights and remedies provided under State of Florida law. The Party requesting mediation shall be responsible for all costs and fees associated with the mediation, but each Party shall be responsible for its own attorney's fees and costs relating to the mediation During the pendency of any genuine dispute arising pursuant to this Agreement, and after a determination thereof, Contractor and County shall act in good faith to mitigate any potential damages or delays in the project referenced in this Agreement. ARTICLE 14 DATE STANDARDS Contractor warrants that each item of Software that it delivers, develops, modifies, or recommends to County for use under this Agreement shall be able to accurately store and process date/time data in four (4) digit year fields (including, but not limited to, calculating, comparing, interfacing and sequencing) from, into, and between the nineteenth through the twenty-second centuries, and leap year calculations. The duration of this warranty and the remedies available to County for breach of this warranty shall be as defined in, and subject to, Broward County and The Echo Group System Services Agreement 29

30 Page 30 of 379 the terms and limitations of Contractor's warranties contained in this Agreement; provided that notwithstanding any provision to the contrary in any such warranty provision(s), or in the absence of any such warranty provision(s), the remedies available to County under this warranty shall include repair or replacement, at no cost to County, of any of the products whose noncompliance is discovered and made known to Contractor in writing, within three (3) year(s) after written Final Acceptance of the System by County. Nothing in this warranty shall be construed to limit any rights or remedies County may otherwise have under this Agreement with respect to Defects. ARTICLE 15 WORK MADE FOR HIRE 15.1 CUSTOM WORK PRODUCT. "Custom Work Products" means all finished or unfinished documents, data, configuration files, templates, studies, maps, models, photographs, reports, other work products, or any portions or derivatives thereof, (including all information, ideas, results, data, improvements, developments, functional and technical designs, routines, subroutines, data diagrams and other work products) created by Contractor after the date of complete execution of this Agreement which are the result of, or derived from, any of the services provided by Contractor in furtherance of the work performed under the Statement of Work, or other services rendered to County hereunder. "Custom Work Products" also means application software or computer programs, documentation and technical information or any portions thereof, finished or unfinished, (including any project specific information, ideas, results, data, improvements, developments, functional and technical designs, routines, subroutines, modules, flowcharts, data diagrams, and documentation), created by Contractor after the date of complete execution of this Agreement which are the result of the Services provided by Contractor in furtherance of the Statement of Work performed for or services rendered, to County hereunder. For the purposes ofthis Agreement, County shall own all right, title, and interest to all Custom Work Products which are clearly identified as Deliverables in the Agreement, including the Statement of Work and any subsequent Work Authorizations, amendments or procurement agreement documents relating to this Agreement. Contractor expressly acknowledges and agrees that the Custom Work Products shall be deemed to constitute "work made for hire" under the Federal copyright laws (17 U.S.C. Sec. 101) and, alternatively, Contractor hereby exclusively and irrevocably assigns all ownership or other rights Contractor might have in Custom Work Products to County. Without limiting the foregoing, Contractor shall: (a) assign and transmit all Custom Work Products only to County; (b) regard the Custom Work Products as County's exclusive property; and (c) maintain the Custom Work Products as confidential and shall not disclose the same to any other person or entity without County's Contract Administrator's prior written consent. Without limiting the foregoing, it is understood and agreed that County's Board or Purchasing Director may assign, transfer or otherwise convey the Custom Work Products to others without restriction. Except for Custom Work Products specifically identified as such in the Statement of Work, the term "Custom Work Products" shall not include any copyrighted Software of Contractor or a third party nor any previously developed trade secret, previously developed copyrighted material, or other previously developed proprietary material of Contractor but shall not include any custom made Broward County and The Echo Group System Services Agreement 30

31 Page 31 of 379 modifications or changes to Contractor's Licensed Software paid by County hereunder. Where applicable, Contractor will provide County with the source code and object code for Custom Work Products upon Final Acceptance of the System or within thirty (30) calendar days after receipt of a written request by the Contract Administrator, whichever date is earlier MODIFICATION TO LICENSED SOFTWARE. All software modifications performed by Contractor that are not labeled in the SOW as a Custom Work Product are deemed to be a modification to the licensed software. In the case of modification to licensed software, Contractor shall own all rights, title and interest to all software deliverables. Such software shall be licensed to County pursuant to the terms of Article 4 as described herein and Contractor will provide maintenance for such deliverables to the extent County has a license agreement including maintenance services or a maintenance agreement with Contractor EEO COMPLIANCE EEO Compliance ARTICLE 16 MISCELLANEOUS PROVISIONS (A) Contractor shall not unlawfully discriminate on the basis of race, color, national origin, sex, religion, age, marital status, political affiliation, familial status, disability, sexual orientation, pregnancy, or gender identity and expression in the performance of this Agreement, the solicitation for or purchase of goods or services relating to this Agreement, or in subcontracting work in the performance of this Agreement and shall not otherwise unlawfully discriminate in violation of the Broward County Code, Chapter 16Y,, as may be amended from time to time. Contractor shall include the foregoing or similar language in its contracts with any subcontractors or subconsultants, except that any project assisted by the U.S. Department of Transportation funds shall comply with the non-discrimination requirements in 49 C.F.R. Parts 23 and 26, as amended. Failure to comply with the foregoing requirements is a material breach of this Agreement, which may result in the termination of this Agreement or such other remedy as County deems appropriate. (B) Contractor shall not unlawfully discriminate against any person in its operations and activities or in its use or expenditure of funds in fulfilling its obligations under this Agreement. Contractor shall affirmatively comply with all applicable provisions of the Americans with Disabilities Act (ADA) in the course of providing any services funded by County, including Titles I and II of the ADA (regarding nondiscrimination on the basis of disability), and all applicable regulations, guidelines, and standards. In addition, Contractor shall take affirmative steps to ensure nondiscrimination in employment against disabled persons. (C) By execution of this Agreement, Contractor represents that it has not been placed on the discriminatory vendor list (as provided in Section , Florida Statutes, as amended). County hereby materially relies on such representation in entering into this Broward County and The Echo Group System Services Agreement 31

32 Page 32 of 379 Agreement. An untrue representation of the foregoing shall entitle County to terminate this Agreement and recover from Contractor all monies paid by County pursuant to this Agreement, and may result in debarment from County's competitive procurement activities CBE Compliance Although no CBE goal has been set for this Agreement, County encourages Contractor to give full consideration to the use of CBE firms to perform work under this Agreement PUBLIC ENTITY CRIMES ACT. Contractor represents that the execution of this Agreement will not violate the Public Entity Crimes Act (Section , Florida Statutes, as amended), which essentially provides that a person or affiliate who is a contractor, consultant, or other provider and who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a bid on a contract to provide any goods or services to County, may not submit a bid on a contract with County for the construction or repair of a public building or public work, may not submit bids on leases of real property to County, may not be awarded or perform work as a contractor, supplier, contractor, or consultant under a contract with County, and may not transact any business with County in excess of the threshold amount provided in Section , Florida Statutes (as amended), for category two (2) purchases for a period of thirty-six (36) months from the date of being placed on the convicted vendor list. Violation of this section shall result in termination of this Agreement by written notice from County's Purchasing Director or Contract Administrator and recovery of all monies paid hereto, and may result in debarment from County's competitive procurement activities. In addition to the foregoing, Contractor further represents that there has been no determination, based on an audit, that it committed an act defined by Section , Florida Statutes (as amended), as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money of funds involved or whether Contractor has been placed on the convicted vendor list INDEPENDENT CONTRACTOR. Contractor is an independent contractor under this Agreement. Services provided by Contractor pursuant to this Agreement shall be subject to the supervision of Contractor. In providing such Services, neither Contractor nor its agents shall act as officers, employees, or agents of the County. No partnership, joint venture, or other joint relationship is created hereby. County does not extend to Contractor or Contractor's agents any authority of any kind to bind County in any respect whatsoever THIRD PARTY BENEFICIARIES. Neither Contractor nor County intends to directly or substantially benefit a third party by this Agreement. The Parties expressly acknowledge that it is not their intent to create any rights or obligations in any third person or entity under this Agreement. Therefore, the Parties agree that there are no third party beneficiaries to this Agreement and that no third party shall be entitled to assert a claim against either of them based upon this Agreement. Broward County and The Echo Group System Services Agreement 32

33 Page 33 of NOTICES. Whenever either Party desires to give notice to the other, such notice must be in writing, sent by certified United States Mail, postage prepaid, return receipt requested, or by hand-delivery with a request for a written receipt of acknowledgment of delivery, or by overnight commercial carrier, delivery receipt requested, addressed to the Party for whom it is intended at the place last specified. The place for giving notice shall remain the same as set forth herein until changed in writing in the manner provided in this section. For the present, the Parties designate the following for notice: County: Broward County's Human Services Department Attn: Director 115 S. Andrews Ave., Suite 303 Ft. Lauderdale, Florida Contractor: Echo Consulting Services, Inc. Attn: Chief Financial Officer 15 Washington Street PO Box 2150 Conway, NH County through its Contract Administrator or County Administrator and Contractor, through its CFO, may change the information provided herein using the notices procedures stated in the "NOTICES" section herein ASSIGNMENT AND PERFORMANCE. Neither this Agreement nor any interest herein shall be assigned, transferred, or encumbered by Contractor except as expressly permitted herein or as authorized by the Board or the County's Purchasing Director in writing through Contract Administrator, and Contractor shall not subcontract any portion of the work required by this Agreement, except as authorized in advance in writing by the Contract Administrator unless already expressly stated herein. Contractor may subcontract any portion of the work required by this Agreement to a wholly owned subsidiary of Contractor. Contractor represents that all persons delivering the Services required by this Agreement have the knowledge and skills, either by training, experience, education, or a combination thereof, to adequately and competently perform the duties, obligations, and Services set forth in the Statement of Work, and to provide and perform such Services to County's satisfaction for the agreed compensation. Contractor shall render all Services under this Agreement in a professional manner. The standards to be applied in the performance of Services by Contractor shall be measured as that deemed reasonable for Contractor's employee category applicable to the service being performed and not that of a reasonable person. Contractor shall perform its duties, obligations, and work under this Agreement in a skillful and respectable manner. The quality of Broward County and The Echo Group System Services Agreement 33

34 Page 34 of 379 Contractor's performance and all interim and final product(s) provided to, or on behalf of, County shall be comparable to the best local and national standards CONFLICTS. Neither Contractor nor its employees shall have or hold any continuing or frequently recurring employment or contractual relationship that is substantially antagonistic or incompatible with Contractor's loyal and conscientious exercise of judgment related to its performance under this Agreement. Contractor further agrees that none of its officers or employees shall, during the term of this Agreement, serve as an expert witness against County in any legal or administrative proceeding in which he, she, or Contractor is not a Party, unless compelled by court process. Further, Contractor agrees that such persons shall not give sworn testimony or issue a report or writing, as an expression of his or her expert opinion, which is adverse or prejudicial to the interests of County in connection with any such pending or threatened legal or administrative proceeding unless compelled by court process. The limitations of this section shall not preclude Contractor or any persons in any way from representing themselves, including giving expert testimony in support thereof, in any action or in any administrative or legal proceeding. In the event Contractor is permitted pursuant to this Agreement to utilize contractor to perform any services required by this Agreement, Contractor agrees to require such contractor, by written contract, to comply with the provisions of this section to the same extent as Contractor WAIVER OF BREACH AND MATERIALITY. Failure by County to enforce any provision of this Agreement shall not be deemed a waiver of such provision or modification of this Agreement. A waiver of any breach of a provision of this Agreement shall not be deemed a waiver of any subsequent breach and shall not be construed to be a modification of the terms of this Agreement. County and Contractor agree that each requirement, duty, and obligation set forth herein is substantial and important to the formation of this Agreement and, therefore, is a material term hereof COMPLIANCE WITH LAWS. Contractor shall comply with all federal, state, and local laws, codes, ordinances, rules, and regulations, as amended, in performing its duties, responsibilities, and obligations related to this Agreement SEVERANCE. In the event this Agreement or a portion of this Agreement is found by a court of competent jurisdiction to be invalid, the remaining provisions shall continue to be effective unless County's Contract Administrator or Purchasing Director (in consultation with the County Attorney's Office) and Contractor's CFO elects to terminate this Agreement with written notice to the other Party. The election to terminate this Agreement based upon this provision shall be made within seven (7) calendar days after the finding by the court becomes final. Broward County and The Echo Group System Services Agreement 34

35 Page 35 of JOINT PREPARATION. The Parties acknowledge that they have sought and received whatever competent advice and counsel necessary for them to form a full and complete understanding of all rights and obligations herein and that the preparation of this Agreement has been their joint effort. The language agreed to expresses their mutual intent and the resulting document shall not, solely as a matter of judicial construction, be construed more severely against one of the Parties than the other Party ENTIRE AGREEMENT. This Agreement contains the entire agreement between Contractor and County regarding the Services and Deliverables herein. Any modifications to this Agreement shall not be binding unless in writing and signed by both Contractor and County (including through the County's Purchasing Director, if authorized). This Agreement shall not impact the terms and conditions of any prior agreement between County and Contractor PRIORITY OF PROVISIONS. If there is a conflict or inconsistency between any term, statement, requirement, or provision of any exhibit attached hereto, any document or events referred to herein, or any document incorporated into this Agreement by reference and a term, statement, requirement, or provision of Articles 1 through 16 of this Agreement, the term, statement, requirement, or provision contained in Articles 1 through 16 shall prevail and be given effect. The order of priority shall be as follows: 1. This Agreement, including Articles 1 through 16; 2. Exhibits to this Agreement APPLICABLE LAW, VENUE AND WAIVER OF JURY TRIAL. This Agreement shall be interpreted and construed in accordance with and governed by the laws of the state of Florida. All parties agree and accept that jurisdiction of any controversies or legal problems arising out of this Agreement, and any action involving the enforcement or interpretation of any rights hereunder, shall be exclusively in the state courts ofthe Seventeenth Judicial Circuit in Broward County, Florida, and venue for litigation arising out of this Agreement shall be exclusively in such state courts, forsaking any other jurisdiction which either Party may claim by virtue of its residency or other jurisdictional device. In event federal jurisdiction is determined to be the exclusive jurisdiction, the parties agree that jurisdiction shall be solely in the United States District Court of the Southern District of Florida with all filings to done in Broward County, Florida. BY ENTERING INTO THIS AGREEMENT, CONTRACTOR AND COUNTY HEREBY EXPRESSLY WAIVE ANY RIGHTS EITHER PARTY MAY HAVE TO A TRIAL BY JURY OF ANY CIVIL LITIGATION RELATED TO THIS AGREEMENT AMENDMENTS. No modification, amendment, or alteration in the terms or conditions contained herein shall be effective unless contained in a written document prepared with the same or similar formality as this Agreement and executed by the County's award authority (such as its Purchasing Director if authorized) and Contractor AUDIT RIGHT AND RETENTION OF RECORDS. County shall have the right to audit the books, records, and accounts of Contractor and its subcontractors that are related to this Broward County and The Echo Group System Services Agreement 35

36 Page 36 of 379 Agreement. Contractor and its subcontractors shall keep such books, records, and accounts as may be necessary in order to record complete and correct entries related to the Agreement. All books, records, and accounts of Contractor and its subcontractors shall be kept in written form, or in a form capable of conversion into written form within a reasonable time, and upon request to do so. Contractor or its subcontractor, as applicable, shall make same available at no cost to County in written form. Contractor and its subcontractors shall preserve and make available, at reasonable times for examination and audit by County, all financial records, supporting documents, statistical records, and any other documents pertinent to this Agreement for the required retention period of the Florida Public Records Act (Chapter 119, Florida Statutes, as amended), if applicable, or, if the Florida Public Records Act is not applicable, for a minimum period of three (3) years after termination of this Agreement. If any audit has been initiated and audit findings have not been resolved at the end of the retention period or three (3) years, whichever is longer, the books, records, and accounts shall be retained until resolution of the audit findings. If the Florida Public Records Act is determined by County to be applicable to Contractor's and its subcontractors' records, Contractor and its subcontractors shall comply with all requirements thereof; however, no confidentiality or non-disclosure requirement of either federal or state law shall be violated by Contractor or its subcontractors. Any incomplete or incorrect entry in such books, records, and accounts shall be a basis for County's disallowance and recovery of any payment upon such entry. Contractor shall, by written contract, require its subcontractors, if any, to agree to the requirements and obligations of this Section WARRANTY AS TO INTELLECTUAL PROPERTY INFRINGEMENT. Contractor represents and warrants that, at the time of entering into this Agreement, no claims have been asserted or action or proceeding brought against Contractor which alleges that all or any part of the Software to be supplied by Contractor or the operation or use thereof by County, infringes or misappropriates any patent, copyright, mask copyright or any trade secret or other intellectual or proprietary right of a third party, nor is Contractor aware of any such potential claim. Contractor also represents and warrants that its Services and Deliverables to be provided pursuant to this Agreement will not infringe or misappropriate any patent, copyright, mask copyright or any trade secret or other intellectual or proprietary right of a third party COUNTERPARTS. This Agreement may be fully executed in up to five (5) copies by all Parties, each of which, bearing original signatures, shall have the force and effect of an original document MOST FAVORED NATION PRICING AND EXCLUSIVE ARRANGEMENT. The Parties agree that the term "Most Favored Nation" shall mean that the Deliverables are offered to County by Contractor on terms and conditions, including price, that are at least as favorable as those offered to other entities that are comparable in size and scope to County. Contractor commits that the pricing provided to County shall be at least as low as for comparable volume levels and Broward County and The Echo Group System Services Agreement 36

37 Page 37 of 379 similar Deliverables and services as that provided to any other Contractor customer. Contractor agrees and covenants that it shall not enter into, or offer to enter into, an agreement with any other entity to provide Deliverables and services comparable to the Deliverables and services in this Agreement on pricing terms which are more favorable to such other entity than those set forth in this Agreement TIME IS OF THE ESSENCE. Time is of the essence throughout this Agreement, including the attached Statement of Work or any subsequent Work Authorization(s) OFFSHORE LIMITATION. Contractor shall not source any development and/or support for this Agreement or transfer any County data outside the territorial limits of the United States of America, without the prior written approval ofthe Contract Administrator REMOTE ACCESS. The Parties envision that Services and Support to County's development and/or test environment may be provided by remote electronic means (remote access). The manner, including any security restrictions, method, equipment, software and other considerations for remote access {high speed on County's end) shall be provided on a request by request basis subject to County's internal security requirements. County, at its own expense, shall provide the equipment and software at its location to permit remote access by Contractor. Contractor, at its own expense, shall provide the equipment and software at its location to permit remote access by Contractor to County. Physical access for Contractor personnel to the System as necessary during Services and Support to allow Contractor to perform Services and Support shall be provided by County. In addition, County shall provide, within County's premises, adequate space for Services and Support to be performed on-site. Contractor will assume its respective telephone access costs incurred to perform Services and Support on the System by remote access. Contractor represents and warrants that while performing Services and Support by remote access it will use all commercially available methods not to transmit any type of undocumented software routines or other elements which are designed to, or capable of, permitting, allowing, or causing: (a) unauthorized access to or intrusion upon; (b) disabling of; (c) erasure of; or (d) interference with any hardware, software, data or peripheral equipment whether directly or by transference. In the event of a breach of this representation and warranty, Contractor shall be responsible for, and pay the County for, any and all actual harm, injury, damages, costs and expenses incurred by County by reason of the breach within thirty {30) calendar days after Contract Administrator's written demand for same in accordance with Section KEY PERSONNEL. The Key Personnel are the Contractor personnel designated by Contractor, and approved in writing by County's Contract Administrator, who will be responsible for Contractor's day-to-day project operations as described in the Statement of Work. The initial Key Personnel and any changes or substitutions in the Key Personnel must be made known to County, and County must grant prior written approval before any such initial personnel or change or substitution can become effective. County agrees not to unreasonably withhold any such approval; however, such decision is subject to its Contract Administrator's Broward County and The Echo Group System Services Agreement 37

38 Page 38 of 379 sole discretion. Contractor will provide the Key Personnel as long as said staff are in Contractor's employment. In the event of injury, illness, or death of Contractor's Key Personnel, or if such Key Personnel leave Contractor's employ, Contractor shall replace such individual with an individual reasonably acceptable to County within ten (10) business days after such injury or illness, where such individual is not available to perform the Services or work contemplated by this Agreement, or from the date of departure from employment or of death. Contractor will obtain prior written approval of the Contract Administrator to replace Key Personnel. At the time of Contractor's request, it shall provide the Contract Administrator with such information as necessary to determine the suitability of proposed new Key Personnel. The Contract Administrator will act reasonably in evaluating Key Personnel qualifications. In the event County's Contract Administrator determines in good faith that the continued assignment of any such Key Personnel is not in the best interests of County, then County's Contract Administrator shall give Contractor written notice to that effect requesting that the employee be replaced. Promptly after its receipt of such a request, Contractor shall investigate the matters stated in the request and discuss its findings with County's Contract Administrator. If County's Contract Administrator still in good faith requests replacement of the Key Personnel, Contractor shall replace the employee with a person of suitable ability and qualification, which replacement shall be subject to the prior written approval of County's Contract Administrator (such approval not to be unreasonably withheld). Nothing in this provision shall be deemed to give County the right to require Contractor to terminate any Contractor employee's employment; it is intended to give County only the right for its Contract Administrator to request that Contractor discontinue using a specific employee on the County's work, services, or Project. Contractor will use its reasonable best efforts to avoid replacing or reassigning any Key Personnel under this Agreement, except in accordance with a County request pursuant to the above paragraph. If, notwithstanding this commitment, it becomes necessary for Contractor to replace any Key Personnel under this Agreement, Contractor will give County as much advance written notice of the replacement as is feasible and will provide County with reasonable written details concerning the proposed replacement. County's Contract Administrator shall have the right to approve the replacement, which approval shall not be unreasonably withheld. At a minimum, Contractor agrees to provide County with at least thirty (30) calendar days' advance written notice of changes to Contractor's project team participants. Contractor agrees to provide County with resumes of proposed new project team participants, and County, through its Contract Administrator and/or ETS, may choose to interview proposed new project team members REFERENCES TO COUNTY OR CONTRACTOR. Contractor agrees that during the term of this Agreement or thereafter, Contractor may not reference County in Contractor's website, and/or press releases, and, may not place County's name and logo on Contractor's Web site or in collateral marketing materials relating to Contractor's products and services without prior Broward County and The Echo Group System Services Agreement 38

39 Page 39 of 379 review and written approval by County's Contract Administrator. Further, Contractor agrees that it may not use County's name, logo or any trademarks in any press releases, customer "case studies," and the like) without County's Contract Administrator prior written consent. Termination or expiration of this Agreement shall not affect Contractor's obligation as stated in this Section. Additionally, upon termination or expiration of the Maintenance portion which may be under separate written agreement between the Parties, Contractor agrees it will discontinue any previously authorized use of County's name and/or logo on any Web site, press release, or promotional literature. Contractor's Licensed Software or Deliverables shall not contain any references to Contractor on any screenshots, user screens, or other output, except that Contractor may include applicable copyright notices or similar documentation required for protection of Contractor's intellectual property prior to delivering same to County or prior to allowing access by County TAXES. Contractor acknowledges that County is a tax-exempt entity in the State of Florida and County agrees to provide Contractor with written proof of such status, if requested PAYABLE INTEREST Payment of Interest. Except as required by the Broward County Prompt Payment Ordinance, County shall not be liable for interest for any reason, whether as prejudgment interest or for any other purpose, and in furtherance thereof Contractor waives, rejects, disclaims, and surrenders any and all entitlement it has or may have to receive interest in connection with a dispute or claim based on or related to this Agreement Rate of Interest. In any instance where the prohibition or limitations of Section are determined to be invalid or unenforceable, the annual rate of interest payable by County under this Agreement, whether as prejudgment interest or for any other purpose, shall be.025 percent simple interest (uncompounded) EFFECTIVE DATE. This Agreement is effective upon the date signed by County, subject to prior execution thereof by Contractor RIGHTS IN DOCUMENTS AND WORKS. Any and all reports, surveys, and other data and data compilations provided or created in connection with this Agreement are and shall remain the property of County, to the extent permitted by law. In the event of expiration or earlier termination of this Agreement, any reports, photographs, surveys, and other data and data compilations, and other documents prepared by Contractor in connection with this Agreement and in accordance with Article 15, whether finished or unfinished, shall become the property of County and shall be delivered by Contractor to the Contract Administrator within seven (7) calendar days of expiration or earlier termination of this Agreement by either Party. Any compensation due to Contractor shall be withheld until all documents and/or data are received Broward County and The Echo Group System Services Agreement 39

40 Page 40 of 379 as provided herein. Contractor shall not compile, collect, store or distribute any data obtained pursuant to this Agreement unless expressly authorized herein. County has the absolute and unrestricted right to convert its data from the format used by the System to any other format MAINTENANCE SUPPORT SERVICES. Contractor shall provide maintenance support services in accordance with the Maintenance Support Services and Service Level Agreement attached hereto as Exhibit B PUBLIC RECORDS: Public records are subject to applicable Florida and federal laws, as amended from time to time. The Parties agree that this Agreement, including all its exhibits and any attachments, is a public records document subject to Florida Statutes, including Chapter 119, as amended. Any amendments to the Agreement or any purchase order or any authorizing purchasing document relating to this Agreement, including Exhibit A, shall also be deemed to be a public records document subject to applicable Florida's laws, as amended HIPAA COMPLIANCE. It is expressly understood by the Parties that County personnel and/or their agents have access to protected health information (hereinafter known as "PHI") that is subject to the requirements of 45 CFR 160, 162 and 164 and related regulations. In the event Contractor is considered by County to be a covered entity or business associate and/or is required to comply with the Health Insurance Portability and Accountability Act of 1996 (hereinafter known as "HIPAA"), Contractor shall fully protect individually identifiable health information as required by HIPAA, as amended by Subtitle D of the Health Information Technology for Economic and Clinical Health Act Where required, Contractor shall handle and secure such PHI in compliance with HIPAA and its related regulations and, if required by HIPAA or other laws, include in its "Notice of Privacy Practices" notice of Contractor's and County's uses of client's PHI. The requirement to comply with this provision and HIPAA shall survive the expiration or earlier termination of this Agreement. The Parties agree that Exhibit E contains additional terms and conditions governing the Parties' responsibility and obligations FUNDING. If, in any budget year, funding, for any reason, is not provided for the Services and Deliverables including, but not limited to, Maintenance services, or other monetary or funding obligations herein, then such obligation may be terminated by County in writing through its Purchasing Director without penalty or further payment to Contractor CONTINGENCY FEE. Contractor warrants that it has not employed or retained any company or person, other than a bona fide employee working solely for Contractor, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for Contractor, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For a breach or violation of this provision, County shall have the right, at its discretion, to terminate this Agreement without liability, or to deduct from this Agreement price or otherwise recover the full amount of such fee, commission, percentage, gift, or consideration. Broward County and The Echo Group System Services Agreement 40

41 Page 41 of DRUG-FREE WORKPLACE. It is a requirement of County that it enter into contracts only with firms that certify the establishment of a drug-free work place in accordance with Chapter 21.31(a)(2) of the Broward County Procurement Code. Execution of this Agreement by Contractor shall serve as Contractor's required certification that it either has or that it will establish a drug-free work place in accordance with Section , Florida Statutes, as may be amended from time to time, and Chapter 21.31(a)(2) of the Broward County Procurement Code as may be amended from time to time DOMESTIC PARTNERSHIP REQUIREMENT- Contractor certifies and represents that it will comply with County's Domestic Partnership Act (Section 16Y,-157 of the Broward County Code of Ordinances, as amended) during the entire term of the Agreement. The failure of Contractor to comply shall be a material breach of the Agreement, entitling County to pursue any and all remedies provided under applicable law including, but not limited to (1) retaining all monies due or to become due Contractor until Contractor complies; (2) termination of the Agreement; (3) and suspension or debarment of Contractor from doing business with County BANKRUPTCY RIGHTS OF COUNTY. All rights and licenses granted under or pursuant to this Agreement or any attachments hereto by Contractor to County are, and shall otherwise be deemed to be, for purposes of Section 365(n) of the United States Bankruptcy Code (the "Code"), or replacement provision therefore, licenses to rights to "intellectual property" as defined in the Code. The Parties agree that County, as licensee of such rights under this Agreement, shall retain and may fully exercise all of its rights and elections under the Code. The Parties further agree that, in the event of the commencement of a bankruptcy proceeding by or against Contractor under the Code, County shall be entitled to retain all of its rights under this Agreement. (The remainder of this page is intentionally left blank.) Broward County and The Echo Group System Services Agreement 41

42 Page 42 of 379 IN WITNESS WHEREOF, the parties hereto have made and executed this System and Services Agreement: BROWARD County, Between Broward County, through its BOARD OF COMMISSIONERS, signing by and through its Mayor or Vice-Mayor, authorized to execute same by Board action on the day of 2013, and Contractor,, signing by and through its,duly authorized to execute same. County ATIEST: BROWARD County, by and through its Board of County Commissioners Broward County Administrator, as Ex-officio Clerk of the Broward County Board of County Commissioners Mayor County Administrator day of, 20 Approved as to Insurance Requirements by County's d''m~;~~ -R~in /. ~Mfi~g~~~~~e-~ /'' Jacqueline A. Binns Risk Insurance and Contracts Manager ASF:RDH Enterprise Bus App Agreement 08/14/2013 # Approved as to form by Office of the County Attorney Broward County, Florida JON I ARMSTRONG COFFEY, County Attorney Broward County Governmental Center Suite South Andrews Avenue Fort Lauderdale, FL Telephone: (954) Telecopier: (954) By~ v/z./,j AssiSOUil\IAtOffiey (Date) Broward County and The Echo Group System Services Agreement 42

43 Page 43 of 379 AGREEMENT BETWEEN BROWARD COUNTY AND ECHO CONSULTING SERVICES, INC. FOR ENTERPRISE BUSINESS APPLICATION FOR HUMAN SERVICES DEPARTMENT ECHO CONSULTING SERVICES. INC. WITNESSES: ~~ 1g ure / Print Name ECHO CONSULTING SERVICES, INC. By fltlju._i ~! Authorized Signature Name: ()e..001'e A~'1~~L co Title: cj1, ef. Fl'l'v<h U<~. { () ~ 1 ~1 c..e r 20 /J ATTEST: Print Nam' (SEAL OR NOTARY) Broward County and The Echo Group System Services Agreement 43

44 Page 44 of 379 EXHIBIT A STATEMENT OF WORK The Echo Group ("Echo" or "Contractor") shall provide the following work under this Statement of Work ("SOW"). 1. Project Request The purpose of this SOW is to engage the services of Echo to provide an enterprise business application that replaces several data systems, automates and improves existing processes, reduces paperwork, provides user friendly tracking, and integrates data among Human Services Department ("HSD" or "Department") agencies. The goal is improvement of service levels, management of customer/client base information across organizational boundaries, and integration of data in the areas of finance, accounting, grants deliverables, contract services, direct services, and quality management. The current systems and processes are delineated in the HSD Enterprise Business Process Flow attachment included in the Request for Letters of Interest (RLI) solicitation R R1, Enterprise Business Application for Human Services document, a copy of which is attached to the Agreement as Exhibit I. Echo agrees that the System and related services provided under the Agreement, including this SOW, will provide this functionality and solution. 2. Background HSD currently has approximately 16 different data applications in use, with the primary client data system, Client Services Management System (CSMS) purchased in Several internal and external reviews of the Department since 2008 have highlighted inefficiencies specifically with the client data systems. Additionally, a private consulting firm evaluated all operations (including the client data system) and also delineated data integrity concerns with most ofthe business applications in use. 3. Scope The scope of this project is to (1) acquire a customized web-enabled enterprise system that will serve as the primary data source for the HSD, and (2) leverage the functionality derived from Broward Addiction Recovery Center's (BARC) Echo Upgrade Project. The solution will include automation and standardization of existing processes for data management, fiscal reporting, and performance management. The application must be accessible to staff and select agencies outside HSD via a secure Intranet or Internet connection. The ability to share real-time data and reporting with select agencies and the ability to provide functionality for those selected agencies to upload or directly enter required information is also required. Clinician's Desktop and Revenue Manager will be configured and installed according to the prioritization schedule established in the Deliverable Products and Services section of this SOW. Some of the functionalities included in BARC's Echo Upgrade that HSD will leverage include, but are not limited to: the Visual Health Record, paperless component, Substance Abuse and Mental Health Information System (SAM HIS) export options consult, and forms. Broward County and The Echo Group Exhibit A (Statement of Work) 44

45 Page 45 of 379 The timeframe for full implementation ofthis enterprise system (from Contract Administrator's notice to proceed through Final Acceptance) is estimated at eighteen (18) to twenty-four (24) months, to occur in the following Phases: Phase Agency I Components 1- Development of Project Plan, Information HSD Administration Gathering and Leveraging of BARC's Echo Upgrade BARC Project 2- Dire.ct Services (Part 1): Elderly and Veterans EVSD Behavioral Health and Substance Services Division (EVSD)- Behavioral Health Abuse Section 3- Direct Services (Part II): Family Success Community Action Agency, Family Administration Division Success Centers 4- Direct Services (Part Ill): EVSD- Community Care Elderly and Veterans Services for the Elderly (CCE), Veterans Services Section, and Community Care for the Elderly Customer Relations Unit (CRU) Veterans Services Sections, CRU 5- Contract Services (Part 1): Community Community Partnerships Children's Partnerships Services and Health Care Services Sections 6- Contract Services (Part II): Elderly and Veterans Elderly and Veterans Services Services Division 7- Direct Services (Part IV): BARC Migration BARC Note: Phase 7 is optional, subject to election by County Any of the Phases may, with the prior written approval ofthe County's Contract Administrator, be implemented concurrently. The sequence ofthe Phases shall be as directed by the County's Contract Administrator, based upon the County's needs and in conjunction with discussion with the Contractor. For example, County may direct the Contractor to commence a highernumbered phase before a lower-numbered phase. 4. Technical Approach Echo shall provide a vendor-hosted, web-enabled Human Services Enterprise system for HSD. Other responsibilities will include, but are not limited to, providing necessary batching uploads to/from the County and conducting all required services for full implementation of this enterprise system. Additionally, the County will work in conjunction with Echo to identify the required interfaces needed to support the HSD's business requirements. A. Echo shall provide the following Licensed Software and Third-Party Software under this Agreement: Health Record r behavioral health including treatment planning, alert management, incident reporting, progress notes, etc. Broward County and The Echo Group Exhibit A (Statement of Work) 45

46 Page 46 of 379 software Accounts application turning client activity into a billable service; produce bills, track nonbillable services, enter, track and report payments for all types offunding sources, generate reports, create HIPAA compliant transactions, etc. create new or existing reports. The number of licenses would be dependent upon the users creating and/or modifying reports. County would purchase from ide i to work within the application. County will need to purchase licenses, if needed, to create new reports. (not required to run vendor created reports) Crysta ap One user license for one year from final acceptance at no cost is provided as part of the implementation. Annual license fees $500 I year Echo will offer one license as part ofthe implementation; additional licenses will have an additional cost. Planners nner content B. Echo shall provide and maintain the hardware and infrastructure as needed to meet all service level agreements, which includes all hardware and infrastructure required to host the agreed solution. The network and System topology shall be as provided in Echo's response to the RLI (Exhibit F to the Agreement) unless the parties otherwise agree. Broward County and The Echo Group Exhibit A (Statement of Work) 46

47 Page 47 of 379 C. Echo affirms the following as the minimum and recommended standards for equipment and software used by County to connect to the application: Workstation Configuration: Minimum: Processor: 2.0+ Ghz Processor RAM: 2GB Disk: SG free Supported Operating System: Microsoft Windows XP. Recommended: Supported Operating System: Processor: 3.0+ Ghz Processor Dual Core Microsoft Windows 7 RAM: 5GB Disk: lg free 5. Project Communications, Reporting, and System Updates A. Lines of Communication: During the term of this project all communications to the County by Echo will be directed to the County's Project Managers. Communications to Echo will be directed by County to Echo's Project Manager. B. Documentation: All communications between staff that involves varying from the project schedule or clarifying the scope shall be in writing and approved in advance by Echo's Contract Manager and the County Contract Administrator. The County staff will not use verbal communication to direct Echo staff for any activities that vary from the scope ofthe project as contained in the project documents. Echo staff will use written communication to advise the County's staff of project status as defined in Section 7 Written Reports. 6. Key Personnel This section addresses the implementation team for both Echo and the County. Echo will ensure that the persons responsible for performance of the Services under this SOW and, to the extent applicable, identified below (collectively "Key Personnel") are appropriately trained and experienced and have adequate time and resources to perform in accordance with the terms of this SOW. Specific individuals will be identified and confirmed by both Echo and the County prior to the start of each phase. To the extent Echo seeks or is required to make any change to the composition of the Key Personnel, they will provide County with advance notice as specified in Article of the Agreement. County shall not be responsible for any additional costs associated with a change in Key Personnel. Project Staffing Responsibility Outline Echo Project Manager/Business Analyst- (to be assigned by Echo) Echo Software Engineer- (to be assigned by Echo) Echo Quality Assurance Engineer- (to be assigned by Echo) Broward County and The Echo Group Exhibit A (Statement of Work) 47

48 Page 48 of 379 Echo Technical Support Engineer- (to be assigned by Echo) Echo Training Coordinator- (to be assigned by Echo) Echo Customer Support Account Manager- (to be assigned by Echo) Broward County Primary Stakeholders- HSD Director and Deputy Director Broward County Project Managers - Office of Evaluation and Planning Administrator and Business Applications Analyst Ill Broward County Lead Business Experts a/k/a/ Primary Phase Stakeholders: Phase!-Information Gathering/Development of Project Plan Phase 2- EVSD Part I (Behavioral Health and Substance Abuse Section): Phase 3- Family Success Administration Division: Phase 4- EVSD Part II (CCE and Veterans Services Sections; CRU): Phase 5- Community Partnerships Division Phase 6- EVSD Part Ill (Contracts) Phase 7- Broward Addiction Recovery Center Broward County Enterprise Technical Services Infrastructure: (to be provided by ETS) Broward County Enterprise Technical Services Applications: Senior Information Technology Specialist Broward County Security Experts- HIPAA Security Officer Broward County Privacy Experts- HIPAA Privacy Officer 7. Written Reports A. Weekly Status Report: During the term of the project, Echo will provide the County's Project Managers with a project status report on a weekly basis or as the County otherwise requests. The project status report will include an updated schedule and a narrative identifying project progress and the next steps. The narrative will also identify any issues and the impact of the issues on the schedule. B. Phase Completion Report: At the completion of each Phase, the Echo Project Manager will submit a Phase Completion Report to the County Project Managers as attached in Exhibit A-1. The Report will provide any required documentation associated with the Phase and identify any outstanding items that, while not affecting completion of the Phase, are required for full completion of the project. 8. Deliverable Products and Services All deliverables ofthis SOW are set forth below in Phases. Upon completion of each Phase, the deliverables will be presented to, and reviewed by, the primary phase stakeholders and Project Managers for written approval. In accordance with the terms of the Agreement, each Phase will be subject to preliminary review and acceptance testing, and upon conclusion of all Phases, the Services (including all Phases) shall be subject to Final Acceptance Testing. Broward County and The Echo Group Exhibit A {Statement of Work) 48

49 Page 49 of 379 Meeting I 1 project review and HSD's project team. Includes review ofthe project team structure; project scope; contracted items and budget; project success criteria; and project management protocol for communication, change control, and risk management for the expansion of the BARC implementation to an Devel I Expansion Plan Project during phase and will include a review of County requirements, workflow, and processes for inclusion in the Project Plan. Conduct Business Process I ers II approve the Project Plan which supports the Project Charter, results ofthe Information gathering meetings, and supporting documentation. Project Plan deliverables are confirmed to include but are not limited to: tasks to meet the deliverables, identification of pre-requisites, resources required, hours and resources assigned to complete the work. Echo's IT staff will work with County system administrators to identify and develop controls and ease of access limits appropriate for each phase and County staff job descriptions. rants a performance measures (Office of Budget and Management) Broward County and The Echo Group Exhibit A (Statement of Work) 49

50 Page 50 of 379 Training to process request payments for client assistance and send to Accounting (2) Percent of contracted funding utilized and (3)Amount of funding (in millions) leveraged by County (new grant dollars awa User Man and System Administrator Manual, Echo's entity relationship diagram (ERD) (which shall be updated for each Phase), and completion of training, including support and technical assistance. Training may include, at County's option: #501 System Orientation #SODA Revenue Manager Configuration Workshop #SOOB Clinician's Desktop Configuration Workshop #505 Windows Designer Workshop #520 Data Flow #515 Report Writer Workshop #599 Business Intelligence for Your Organization #560 Creating Structured Notes Trainee to rati.o is 10:1. Key stakeholders will receive the training documentation and high level one-on-one, hands-on classroom instruction from Echo on all related software applications to enhance the information gathering stage for each of the subsequent phases. meets criteria, and criteria as listed above, as evidenced by a signed phase acceptance team TBD. llnf<>rmo~ti''" Gathering Stage for Elderly & Veterans Behavioral Health Section ings co as needed or requested during this phase and will include a review of County requirements, workflow, and processes for with the Plan. Broward County and The Echo Group Exhibit A (Statement of Work) 50

51 Page 51 of 379 nrro\tioip a tra tool to capture information relating to internal staff supervision. Information to be captured will include, but is not limited to, date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track services provided against grants and enforce capitations and preauthorization requirements. System will support information gathering and reporting requirements for the following data elements: Division, Section, Name of Grant, Funder, Total Award, Multi-year Funding (Y/N), Award Period, Current Fiscal Year Award, County Cash Match Amount, County In-Kind Match Amount, Other (provider match/funding leveraged), Total Budget, and Type of Grant. I enter supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant and related pay source. Information from the pay source updates to its parent grant. User will enter data, generate report and compare against the test case. In a successful test the report must accurately reflect the data entered. ntact System will generate Broward County Office of Management and Budget (OMB) Performance Measures including: (1) percentage of case manager time engaged in direct service provision and (2) percentage of monthly invoices and error-free required supporting documentation submitted to Managing Entity and considered to be on time. presents for services, System will enable staff to perform the following: (1) entry of basic demographic information (including importation of data from referral test the user's ability to (1) enter contact information for a customer (2) search for the customer record and retrieve the saved information and Broward County and The Echo Group Exhibit A (Statement of Work) 51

52 Page 52 of 379 schedu e a conduct/document Prescreening assessment and (3) track admission to program or closure of file. (Based on prescreening results and program eligibility criteria, prospective client may be admitted to the program or closed.) program enrollment for a client including: (1) complete demographic and financial information; (2) document employment history; (3) schedule and conduct Bio Psychosocial Assessment (BPS); (4) schedule and complete Adult Medical Risk assessment, Mental Health Advanced Directives (MH), Adult Mental Health Targeted Case Management Certification; (5) with the client, complete all consents, release of information, release to obtain information to contact record prepopulates to the same data element in subsequent forms and reports. A successful test will include the user's ability to (1) complete appointment book for agency and staff (2) schedule test customer appointment and (3) System should accurately provide staff availability for the appointment. Subsequent to scheduling the appointment the user may retrieve and update the appointment to reflect the activity. A successful test will require the user to (1) enter required screening information (2) retrieve the screening information based on contact and screening date sorted by the most recent screening date. A successful test of a closed contact record would include no longer appearing on any list. test forms/assessments would include (1) entry of customer information into the specified form or assessment (2) saving of the assessment (3) querying the form or assessment by customer and completion date to retrieve information (4) information completed on form or assessment would prepopulate to other forms and reports utilizing the same data elements. A successful test of uploaded documents would include (1) entry of a customer chart (2) scan and d a document Broward County and The Echo Group Exhibit A (Statement of Work) 52

53 Page 53 of 379 receipt; (6) complete the following funder required forms: Florida Department of Children and Families Substance Abuse and Mental Health, SAMH Admission, SAMH American Society of Addiction Medicine Admission (ASAM) (Substance Abuse only), Performance Measure Outcome Admission (Case Management), Substance Abuse Outcomes, and Functional Assessment Rating Scales (FARS) Admission; (7) schedule and conduct program orientation; (8) diagnose client based on information provided in BPS (Substance Abuse only); (9) track client's medications (program does NOT prescribe nor administer medication) and (10) complete Initial Treatment Plan. Ability to scan documents and link them directly to a customer chart. Security applied to the chart should also apply to any linked documents. to customer meta-data (3) query the customer chart and successfully retrieve the uploaded document and its associated meta-data. Successful test of grant submissions will include the acceptance of the submission by the respective grantor. A successful test of the medication form will include (1) completion of a medication form (2) successful query (by customer) and retrieval of the medication information. A successful test of the diagnosis functionality will include (1) entry of an applicable and available Axis diagnosis (DSM-IV/V) (2) during entry, user will be able to select the diagnosis from a validation list that includes agency approved and available DSM-IV/V and ICD-9/10 diagnoses. (3) User will be able to query customer chart and retrieve diagnosis information (4) System will appropriately leverage diagnosis information in the billing process. [Note: DSM-V codes are expected to be available by October 1, 2013, however, all payers may not be able to utilize DSM-V codes on that date; ICD-10 codes are expected to be available by January 1, 2014, however, all payers may not be able to utilize ICD-10 codes on that date] A successful test of the initial treatment plan would include (1) entry of a plan (2) duri the abil to Broward County and The Echo Group Exhibit A (Statement of Work) 53

54 Page 54 of 379 services, System will enable users to: {1) schedule and update upon completion activities which are related to both billable and non-billable services to include notes; Description, Assessment and Plan {DAP) for Case Management [sample attached at Exhibit A-2]; and Subjective, Objective Assessment Plan {SOAP) for Substance Abuse [sample attached at Exhibit A- 2]; (2) create a Comprehensive Service Plan (Case Management) or Individualized Treatment Plan (Substance Abuse); (3) create Corporate Agreement (Case Management only), Community Support Plan {Case Management only), Conditional Release Plan (Case Management only); {4) conduct a Plan review (with date based on the execution date ofthe Plan and program requirements); {5) discharge planning and {6) conduct and document follow-up services on closed charts. library based on program (whether developed by County or available from a Third party vendor) {3) ability to query the plan based on customer. A successful test of the contact/customer transition would include {1) entry of a contact record (2) completion of a program enrollment (3) review record to ensure status change from active customer. en a user to schedule and record completion of the activities. The System will facilitate processing of activities into billable or non-billable services. System will alert user if an activity does not have a case note for a period of time defined by organization. System will not process activities for billing without a corresponding note. User can successfully enter the respective plans to meet HSD formatting requirements and subsequently access the plan based on a client query based upon and sorted by the most recent plan date. A successful test will include the entry of a test BPS and Treatment Plan. User will generate report and review to determine if problems identified in the assessment are included in the plan. System will provide report comparing problems identified in the BPS assessment with problems identified in the Individualized Treatment Broward County and The Echo Group Exhibit A (Statement of Work) 54

55 Page 55 of 379 At System enable the user to: (1) finalize the Discharge/Transfer Summary, SAMH Discharge, FARS Discharge, Performance Measures Outcomes Discharge (PB2), and Substance Abuse Outcomes Discharge; (2} create an Exit Referral and (3) close the enrollment/episode. I process ng including, but not limited to, Medicaid (to include eligibility), Broward Behavioral Health Coalition, University of Miami Behavioral Health Medicaid Health Maintenance Organization (UMBH Medicaid HMO), United Way grant mnevention services), and an. ati1 vel v. will develop a process that populates the goal in the Treatment Planner based on needs identified in the BPA assessment. System will alert user that a Plan review is due based on the Plan date and programmatic requirements. User can successfully document planning portions ofthe Discharge Summary; this summary may be retrievable and edited as the client progresses through treatment. User can enter follow-up activities (activity and note) for discharged customers utilizing an aftercare chart that does not reactivate the customer file. I test e discharge functionality will include (1) completion of discharge including referral, plan, date and reason (2) the System will close the record and customer will no longer show on active enrollment lists. A successful test ofthe SAMH discharge functionality will include (1) a submission of the discharge file to BBHC and acceptance of SAMH records. Acceptance on a successful test submission (accepted by funder) for the listed fund sources. Based upon a successful import test, the user will then review grant information to ensure that the submission also updated appropriate data elements in the Broward County and The Echo Group Exhibit A (Statement of Work) 55

56 Page 56 of 379 rms 1 preau tncmlz :anon functionality for services limited to the creation of an ASC 270 compliant file. Form sam attached at Exhibit A-3; Form creation by Echo is capped at 9 forms and report creation by Echo is capped at 60 reports for Phase 2. encu utilization. Acceptance for the preauthorization functionality will include (1) preauthorization code received from the funder (2) service is updated with the preauthorization code (3) the funder accepts the test record without errors. The System accurately obtains pre-authorization for Grant Funded Services. Forms - User wil sea a test customer and then select the form being tested. Upon access to the form, the user will test to ensure the form contains the appropriate data elements, controls and layout as requested. Training User Man and System Administrator Manual and completion of training including support and technical assistance. #510 as in Section 6- Key Personnel will conduct a preliminary review and preliminarily accept the System as meeting their needs in the identified areas for the Reports- User will select the report to be tested from the report menu. The user will test to ensure the report includes the appropriate selection criteria and execute the report. The end result will be reviewed to ensure the appropriate format and the data provided in the report will be validated to ensure accu 10:1 Training Ratio: Seven users will receive the Train-the Trainer manuals and one-onone hands on classroom instruction from Echo on all I I meets all nee ~"' "i ~ ~ as listed above and as evidenced by a Phase preliminary acceptance in writing by the County Contract Administrator. Broward County and The Echo Group Exhibit A (Statement of Work) 56

57 Page 57 of 379 Gathering Stage for Family Success Administration Division during phase and will include a review of County requirements, workflow, and processes for validation with the Plan. tool to capture information relating to internal staff supervision. Information to be captured will include but is not limited to date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track services provided against grants and enforce cost capitations and pre-authorization requirements. Information gathered will support reporting requirements to include: Division, Section, Name of Grant, Funder, Total Award, Multi-year funding (Y/N), Award period, current fiscal year award, County cash match amount, County In-kind match amount, other (provider match/funding leveraged), Total budget, and type of grant. System will generate Broward County Office of Management and Budget (OMB) Performance Measures including: Family Success Administration: (1) Percentage utilization of grant funding. (2) Number of customers receiving case management that achieved stabilization (3) Average percentage of caseworker time that is used to provide direct service (4) Percentage of all Family Success individuals with a case n successful..,,.,,,n meeting recap a delivery of draft Project Plan. User wi I enter supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant and related pay source. Information from the pay source updates to its parent grant. User will enter data, generate report and compare against the test case. In a successful test the report must accurately reflect the data entered. Broward County and The Echo Group Exhibit A {Statement of Work) 57

58 Page 58 of 379 r case plan goals at time of discharge. (5) Percentage of individuals who received emergency assistance payments who maintained permanent housing for er presents for services, staff will perform the following: (1) entry of basic contact information to include: initial contact date, type of contact, and basic demographic information, (2) entry of household information (DOB, school enrollment status, gender, employment status, veteran status, contact information, household size, relation to primary, unique household identifier), (3) documentation of requested service(s), referring agencies, time spent to perform contact management, (4) conduct/document screening assessment. Based on screening results and program eligibility criteria, contact may be admitted to the program or closed. (5) Complete Information & Referral form. (6) Document the time spent performing contact management and Notice of Disposition. System will enable unique validations list for a data element based on program or user group. the user's ability to (1) enter contact information for a customer (2) search for the customer record and retrieve the saved information and (3) information saved in the contact record prepopulates to the same data element in subsequent forms and reports. A successful test will include the user's ability to (1) complete appointment book for agency and staff (2) schedule test customer appointment and (3) System should accurately provide staff availability for the appointment. Subsequent to scheduling the appointment the user may retrieve and update the appointment to reflect the activity. A successful test will require the user to (1) enter required screening information (2) retrieve the screening information based on contact and screening date sorted by the most recent screening date. A successful test of a closed contact record would include no longer appearing on any active contact list. A successful test will include the user's ability to (1) create a customer household record (2) System assigns a u e identifier for the Broward County and The Echo Group Exhibit A (Statement of Work) 58

59 Page 59 of 379 Program E ent Program II a customer includes: (1} Conduct program orientation. (2} Complete demographic and financial information. (3} Document employment history. (4} Document medical history. (5} Schedule and complete standard assessment, (6} Complete Household information (SSN, Alien Registration Number, first name, last name, middle name, alias, gender, DOB, relationship to client, veteran status, country of birth, USCIS (immigration status}, Date of US entry, ethnic origin, race, pri language, interpreter education nniij<pnniic1 reco System should facilitate retrieval of the household information based on customer or another household member. A successful test of the System's ability to determine customer eligibility and application of business rules will include (1} inclusion of business rules in the eligibility matrix (2} entry of customer data (3} System should facilitate an eligibility determination by crossreferencing customer data against eligibility business rules. A successful test of System validation lists based upon credentials will include (1} user accessing System with one set of credentials (program/user group} and reviewing available and then (2} accessing the System with a different set of credentials to determine if validation lists is A test forms/assessments would include (1} entry of customer information into the specified form or assessment (2} saving of the assessment (3} querying the form or assessment by customer and completion date to retrieve information (4} information completed on form or assessment would prepopulate to other forms and reports utilizing the same data elements. A successful test of uploaded documents would include (1) entry of a customer chart (2} scan and upload a document to the customer chart with Broward County and The Echa Group Exhibit A (Statement of Work) 59

60 Page 60 of 379 rna status, ho1meless, of household, needs outside assistance to evacuate, registered for SN transportation, employed (y/n)). (5) With the client, complete all consents, release of information, release to obtain information (authorization to secure), (6) Schedule and conduct program orientation. Ability to scan documents and link them directly to a customer chart. Security applied to the chart should also apply to any linked documents. System can successfully track services provided to both customer and household. query customer chart and successfully retrieve the uploaded document and its associated meta-data. Successful test of grant submissions will include the acceptance ofthe submission by the respective grantor. A successful test of the medication form will include (1) completion of a medication form (2) successful query (by customer) and retrieval of the medication information. A successful test of the diagnosis functionality will include (1) entry of an applicable and available Axis diagnosis (2) during entry, user will be able to select the diagnosis from a validation list that includes agency approved and available DSM IV/V and ICD-9/10 diagnoses. (3) User will be able to query customer chart and retrieve diagnosis information (4) System will appropriately leverage diagnosis information in the billing process. [Note: DSM-V codes are expected to be available by October 1, 2013, however, all payers may not be able to utilize DSM-V codes on that date; ICD-10 codes are expected to be available by January 1, 2014, however, all payers may not be able to utilize ICD-10 codes on that date] A successful test of the initial treatment plan would include (1) entry of a plan (2) during entry, the ability to select from a predefined Broward County and The Echo Group Exhibit A (Statement of Work) 60

61 Page 61 of 379 ng users will: which are to both billable and non-billable services. (2) Create a Comprehensive Care Plan. (3) Create Case notes (notes will be linked to customer, activity and Plan (if active)); ability to create structured individual and group notes that are linked to an activity, (4) Conduct a Plan review (with date based on the execution date of the Plan and program requirements), (5) Ability to electronically refer the customer's chart to other staff for review via Task Needs. This referral for review should include a note. (6) Request for Disbursement process (45 days to complete the application process (FSAD-LIHEAP)); ability to link supporting payment documentation to a request (W-9, Proof of Ownership form, Sun biz verification, Clerk of Court, Default Letter Threat of a ity to query based on customer. A successful test of the contact/customer transition would include (1) entry of a contact record (2) completion of a program enrollment (3) review record to ensure status change from contact to active customer. A successful test of service tracking by both customer and household would include (1) entry of a customer into a household (2) entry of a service for the customer (3) review service by customer and by household to validate service I enters case note. Activities identified as billable would be processed into an appropriate billable service, activities identified as non-billable would process into an appropriate non-billable service. System will alert user if an activity does not have a case note for a period oftime defined by program. System will not process activities for billing without a corresponding note. User will be able to successfully enterthe respective plans to meet HSD formatting requirements and subsequently access the plan based on a client query (most recent first). System will provide report comparing problems identified in the BPS assessment with problems identified in the Individualized Treatment n. Broward County and The Echo Group Exhibit A (Statement of Work) 61

62 Page 62 of 379 or notice, Rent Acc:epttarlce Letter (1" month's rent), Consent for Payment of Rent to Landlord, Tenant Verification form, Lease/Rental agreement, Management Agreements, RFD checklist, CDBG checklist, ESG checklist); application should calculate vendor payment using the recorded total payment requirement and the "RFD Calculator" to determine payment to be disbursed. RFD Calculator should allow for multiple percentage calculations. Ability to enter comments into the RFD. RFD approval will contain name, date and signature of each level of authorization. There are multiple authorization levels (at least 3). (7) Information and Referral management. (8) Discharge Planning. 1 rge, finalize the Disch=> oc/lr,,.,,<+,,. Summary, (2) Create an Exit Referral, and (3) close the enrollment/episode. (4) Provide follow-up services to include activity and case note to discharged customer. System I user predetermined due dates based on identified County business rules (example: 30 days subsequent to intake, 10 days for submission of documents). System will alert user if an activity does not have a case note for a period oftime defined by program. System will not process activities for billing without a corresponding note. System will alert user that a Plan review is due based on the Plan date and programmatic requirements. Successful test of the RFD process to include the documentation tracking, signature and date(s) for all approval points, provision of funding to the recipient, check number, check date, and check cashed notification. User will be able to successfully document planning portions of the Discharge Summary; this summary may be retrievable and edited as the client progresses through treatm test e discharge functionality will include (1) completion of discharge including referral, plan, date and reason (2) the System will close the record and customer will no longer show on active enrollment lists. A successful test of the customer follow-up functionality will include (1) closed enrollment (2) System alert provided for customers based on enrollment close Broward County and The Echo Group Exhibit A (Statement of Work) 62

63 Page 63 of 379 Fina Bus Pass process 1 relating to grant funding sources including LIHEAP (Low Income Home Energy Assistance Program) and CSBG {Community Services Block Grant), City of Fort Lauderdale grant. For General Fund, Emergency Assistance Payments can only be provided once every two years and three times in a lifetime per household unless given special consideration (authorization). Bus Pass to entry of bus passes into a screen. When agencies utilize the client assistance screen to allocate a pass to a customer, it would update the bus pass record with information relating to that allocation including client, assignment I I trigger 15 days prior to follow-up due dates. A successful test of the System's ability to process the follow-up data would allow the user to update a closed record with the follow-up data without rethe chart. wi on a successful test submission (accepted by funder) for the listed fund sources. Based upon a successful import test, the user will then review grant information to ensure that the submission also updated appropriate data elements in the grant such as dollars encumbered and service utilization. Acceptance of the System's ability to apply emergency assistance payment business rules will include {1) entry of an emergency assistance service that exceeds the eligible frequency criteria and (2) processing of the service. In a successful test, the system should not process the service (error) unless it includes special consideration (authorization) across all locations for the same User enter test us passes into the bus pass entry screen. User would then select a test customer and allocate a bus pass to the customer via the client assistance screen. User would run a report to determine whether the bus pass allocation is tracking Broward County and The Echo Group Exhibit A (Statement of Work) 63

64 Page 64 of 379 Tra creation i at 15 forms and report creation by Echo is capped at 50 reports for Phase 3. Ma and System Administrator Manual and completion of training including support and technical assistance. Training may include, at County's option: ng Upon access to the form, the user will test to ensure the form contains the appropriate data elements, controls and layout as requested. Reports- User will select the report to be tested from the report menu. The user will test to ensure the report includes the appropriate selection criteria and execute the report. The end result will be reviewed to ensure the appropriate format and the data provided in the report will be validated to ensure 10:1 {15) users I receive the manuals and one-on-one Trainthe-Trainer hands on classroom instruction from Echo on all related software applications. Manuals will be updated based on any changes to the system. Broward County and The Echo Group Exhibit A (Statement of Work) 64

65 Page 65 of 379 Gathering Stage for Elderly and Veterans Services Division CCE and Veterans Sections and Customer during 1 phase and will include a review of County requirements, workflow, and processes for validation with the Project Plan. ng tool to capture information relating to internal staff supervision. Information to be captured will include but is not limited to date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track services provided against grants and enforce capitations and preauthorization requirements. Information gathered for the direct services areas within EVS should support reporting requirements to include: Division, Section, Name of Grant, Funder, Total Award, multi-year funding {Y/N), Award period, current fiscal year award, County cash match amount, County in-kind match amount, other (provider match/funding leveraged), total budget, and type of grant. enter e supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant and related pay source. Information from the pay source updates to its parent grant. User will enter data, generate report and compare against the test case. In a successful test the report must accurately reflect the data entered. System will generate Broward County Office of Management and Budget {OMB) Performance Measures including: Elderly and Veterans Administration: (1) Dollar value of co-payments received; (2) percent of performance based grant outcomes achieved; and {3) total amount of in-service Broward County and The Echo Group Exhibit A (Statement of Work) 65

66 Page 66 of 379 Management Medicaid Waiver: (1) Percentage of annual assessments that are completed before the expiration date of the prior assessment; {2) percentage of completed annual Customer Levels of Care that are submitted to Florida Department of Elder Affairs (DOEA) Comprehensive Assessment and Review for Long-Term Care Services (CARES) before expiration of prior level of care; {3) average monthly service plan cost; and (4) percentage of consumers deterred from nursing home (institutional) placement. Veterans Services: {1) Dollar value of approved claims filed with the assistance of the Veterans Services Section; {2) Percentage of claims or appeals filed within one office contact with Veterans or dependent {3) Percentage of consumers who augment their income through participation in employment and/or benefit acquisition programs; and (4) Total number of claims and appeals filed for Veterans, dependents and dependent survivors. Once a prospective presents for services, staff will perform the following: (1) entry of basic demographic information (might come from referral source); (2) entry of household information (DOB, school enrollment status, gender, employment status, Veteran status, Veteran dependent, Veteran survivor the user's ability to (1) enter contact information for a customer (2) search for the customer record and retrieve the saved information and {3) information saved in the contact record prepopulates to the same data element in subsequent forms and reports. A I test will incl Broward County and The Echo Group Exhibit A (Statement of Work) 66

67 Page 67 of 379 relation to primary, unique household identifier); {3) document contact information including type of contact, contact date, requested service(s), referring agencies, time spent to perform contact management; {4) schedule and conduct/document Prescreening assessment. Based on pre-screening results and program eligibility criteria, contact may be admitted to the program or closed and {5) Complete Information & Referral form. ~hilitvto complete appointment book for agency and staff {2) schedule test customer appointment and {3) System should accurately provide staff availability for the appointment. Subsequent to scheduling the appointment the user may retrieve and update the appointment to reflect the activity. A successful test will require the user to {1) enter required screening information (2) retrieve the screening information based on contact and screening date sorted by the most recent screening date. A successful test of a closed contact record would include no longer appearing on any active contact list. A successful test ofthe System's ability to determine customer eligibility and application of business rules will include {1) inclusion of business rules in the eligibility matrix (2) entry of customer data {3) System should facilitate an eligibility determination by crossreferencing customer data against eligibility business rules. A successful test of System validation lists based upon credentials will include {1) user accessing System with one set of credentials (program/user group) and reviewing available and then {2) accessing the System with a different set of credentials to determine if validation lists is unique. A successful test will include the user's I to Broward County and The Echo Group Exhibit A (Statement of Work) 67

68 Page 68 of 379 Program a client includes: (1) complete demographic and financial information; (2) document employment history; (3) document medical history; (4) schedule and complete Risk assessment; (5) complete Household information (SSN, Alien number, First Name, Last Name, Middle Name, Alias, Gender, DOB, Relationship to client, Veteran status, country of birth, USCIS [immigration status], Date of US entry, ethnic origin, race, primary language, interpreter needed, education level, marital status, homeless, head of household, needs outside assistance to evacuate, registered for SN transportation, employed [y/n]); (6) with the client, complete all consents, release of information, release to obtain information (authorization to secure) and(7) schedule and conduct program orientation. Veterans Services: Admission occurs when the Veterans Services Officer facilitates the completion of a Veteran claim. Eligibility criteria matrix that can be managed locally as criteria changes on an annual basis. A contact will become a customer of a customer I (2) System assigns a unique identifier for the household record and (3) System should facilitate retrieval of the household information based on customer or another household member. forms/assessments would include (1) entry of customer information into the specified form or assessment (2) saving of the assessment (3) querying the form or assessment by customer and completion date to retrieve information (4) information completed on form or assessment would prepopulate to other forms and reports utilizing the same data elements. A successful test of uploaded documents would include (1) entry of a customer chart (2) scan and upload a document to the customer chart with meta-data (3 fields: date, category and description) (3) query the customer chart and successfully retrieve the uploaded document and its associated meta-data. Successful test of grant submissions will include the acceptance of the submission by the respective grantor. A successful test of the medication form will include (1) completion of a medication form (2) successful query (by customer) and retrieval of the medication information. A successful test of the diagnosis functionality will include 1) entry of an a and avail Broward County and The Echo Group Exhibit A (Statement of Work} 68

69 Page 69 of 379 Ability to scan documents and link them directly to a customer chart. Security applied to the chart should also apply to any linked documents. System can successfully track services provided to both customer and household. I entry, user will be able to the diagnosis from a validation list that includes agency approved and available DSM-IV/V and ICD- 9/10 diagnoses. (3) User will be able to query customer chart and retrieve diagnosis information (4) System will appropriately leverage diagnosis information in the billing process. [Note: DSM-V codes are expected to be available by October 1, 2013, however, all payers may not be able to utilize DSM-V codes on that date; ICD-10 codes are expected to be available by January 1, 2014, however, all payers may not be able to utilize ICD-10 codes on that date] A successful test of the initial treatment plan would include (1) entry of a plan (2) during entry, the ability to select from a predefined library based on program (3) ability to query the plan based on customer. A successful test ofthe contact/customer transition would include (1) entry of a contact record (2) completion of a program enrollment (3) review record to ensure status change from contact to active customer. A successful test of service tracking by both customer and household would include (1) entry of a customer into a household (2) entry of a service for the customer (3) review service by customer and by household to validate service information rovided. Broward County and The Echo Group Exhibit A {Statement of Work) 69

70 Page 70 of 379 SrtiPrllliP an upon completion of activities which are related to both billable and non-billable services. (2) Create a Comprehensive Service Plan. (3) Create Case notes (notes will be linked to client, activity and Plan (if active); ability to create structured individual and group notes that are linked to an activity, (4) Conduct a Plan review (with date based on the execution date ofthe Plan and program requirements), (S) Information and Referral management. (6) MedWaiver Program (requires quarterly face-to-face reviews, annual assessment, and monthly contacts. (7) Assisted Living (AL) requires all MedWaiver requirements plus monthly facility visits. (8) CCE requires semi-annual review, annual reassessment. (9) Home Care for the Elderly (HCE) requires monthly telephone contacts, semi-annual review, annual reassessment. (10) Discharge Planning. Veterans: Ability to track if claim was completed within one visit. Ability to capture the type of claim that is submitted (Service Connected, Non-Service Connected I Aid and Attendance (A&A), Re Opened Claim -Service Connected, Re-Opened Claim - A&A, Dependent Indemnity Compensation (DIC), DIC w/ A&A, Re-Opened Claim - DIC w/ A&A, Widow's Pension, Widow's Pension w/ A&A, Re Opened Claim - Widow's Pension, Re-Opened Claim- identified as billable would be processed into an appropriate billable service, activities identified as non-billable would process into an appropriate non-billable service. User can successfully enter the respective plans to meet HSD formatting requirements and subsequently access the plan based on a client query (most recent first). System will provide report comparing problems identified in the BPS assessment with problems identified in the Individualized Treatment Plan. System will alert user if an activity does not have a case note for a period of time defined by program. System will not process activities for billing without a corresponding note. Based upon test data, System will alert user to deficiencies relating to program specific business rules assigned to MedWaiver, Assisted Living, CCE and HCE programs. System will alert user that a Plan review is due based on the Plan date and programmatic requirements. User can successfully document planning portions of the Discharge Summary; this summary may be retrievable and edited as the client progresses through treatment. User may document claim related information for the specific consumer. User enter notes relating Broward County and The Echo Group Exhibit A (Statement of Work) 70

71 Page 71 of 379 m, UME/EVR Audit, Non Monetary Claim). Case notes use the DAP format [sample attached at Exhibit A- 2]. finalize the Discharge/Transfer Summary, (2) Create an Exit Referral, and (3) close the enrollment/episode. Veterans: Need the ability to update a closed consumer's record with respect to retroactive benefit date, retroactive benefit amount, monthly benefit award, yearly total (as provided by VA). Program process II relating to grant funding sources including: Medicaid Waiver Referral Rate Agreement (MedWaiver), CCE, HCE, Aging and Disability Resource Center (ADRC} Local Match Grant, State of Florida Veterans Directed Home and Community Based Services Program, Elder Housing First (County General Fund). Client copayment schedules based on income level and A discharge functionality will include (1) completion of discharge including referral, plan, date and reason (2) the System will close the record and customer will no longer show on active enrollment lists. A successful test of the customer follow-up functionality will include (1) closed enrollment (2) System alert provided for customers based on enrollment close date (3) alert should trigger 15 days prior to follow-up due dates. A successful test of the System's ability to process the follow-up data would allow the user to update a closed record with the followup data without re-opening the chart. test grant submission for the listed fund sources. User enters test data to ensure system accurately tracks grant related services and draw down/utilization information. System accurately invoices CCE clients. A successful test will require user to enter test data and system properly processes monthly based co payments. Successful test to ensure Broward County ond The Echo Group Exhibit A (Statement of Work) 71

72 Page 72 of 379.~ II I CCE- Upon client acceptance in the CCE program, an accounts receivable account is created using demographics from enrollment. Client can be exempt from capay (based on matrix) or waived (based on business rules). Active customers not waived or exempt are invoiced monthly for capay. Upon termination from program, system should deactivate client in AR and stop monthly invoice from date of termination. Active customers in system invoiced monthly for capay cross checked with Matrix User cannot pre-date payments. System must provide the ability to track capay/exemption/waived customers (Report verifying active customers and their capay status). System will provide DOEA Client Information and Registration Tracking System (CIRTS) enrollment verification. CCE enrollment prevents customer from receiving "Inhome" services (does not prevent customer from receiving Case Management program are deactivated in AR to stop monthly invoice from close date. Successful test of rule to exclude pre-dated payments. Successful test relating to the tracking of capay status (capay/exempt/waived). Suc~essful upload of CIRTS data' and verification of enrollment. User enrolls test client into system and tests to ensure the client with an active CCE enrollment cannot receive "In-home" services. rms Program Form attached at Exhibit A-5; Form creation by Echo is capped at 3 forms and report creation by Echo is at 80 Forms - User wil sea a test customer and then select the form being tested. Upon access to the form, the user will test to ensure the form contains Broward County and The Echo Group Exhibit A (Statement of Work) 72

73 Page 73 of 379 Trai ng on User Man and System Administrator Manual and completion of training including support and technical assistance. Training may include, at County's option: appropriate controls and layout as requested. Reports- User will select the report to be tested from the report menu. The user will test to ensure the report includes the appropriate selection criteria and execute the report. The end result will be reviewed to ensure the appropriate format and the data provided in the report will be validated to ensure 10:1 Train ng (13) users will receive the manuals and one-on-one Trainthe-Trainer hands on classroom instruction from Echo on all related software applications. criteria and criteria as listed above as evidenced by a <il"""'rl i i Gathering Stage for Contracting Sections Community Partnerships Children's Services and Health Care Services Sections I COIIU'U~I..,U during phase and will include a review of County requirements, data workflow, and processes for validation with the Project Plan. 1 The requirements of Phases 5 and 6 will be met as described herein by creating the ability to enter the contractual requirements and allowing the upload of contractor services. System will provide the ability to report on services, reconcile services against contractual limits and report on outcomes based on contractual data elements. There is no requirement that the System receive individual charges and approve or disapprove those charges on a claim by claim basis. Broward County and The Echo Group Exhibit A {Statement of Work) 73

74 Page 74 of 379 tool to capture information relating to internal staff supervision. Information to be captured will include but is not limited to date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track contracted provider services against contracts/grants and enforce cost capitations and pre-authorization requirements. System will generate Broward County Office of Management and Budget (OMB) Performance Measures including: Community Partnerships: (1) Average number of calendar days to process contracted services invoices and send to accounting. (2) Average number of contracts administered and monitored per contract manager. (3) Funding leveraged by County funds($ millions). (4) Number of consumers served through County contracts. (S) Percentage of performance based outcomes achieved in contracted programs. enter supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant, contract and related pay source. Information from the pay source updates to its parent contract and grant. Data required to provide OMB performance measure reporting will be evidenced and data will be entered. Performance measure will be run to verify accurate reporting. Children Services Section: (1) Percentage improvement in social and emotional functioning. (2) Percentage of children who maintain or improve functioning in at least one developmental area. (3) Percentage of children who spend at least 27 days in the community per month. (4) Percentage reductio on of use Broward County and The Echo Group Exhibit A (Statement of Work) 74

75 Page 75 of 379 Contract Setup Invoice Setup Health Care Services: (1) Number of medical encounters provided to patients for primary care. (2) Percent of clients that effectively stabilize/improve their condition (not readmitted within 30 days). (3) Percent of clinic patients seen and discharged within 150 minutes. (4) Percent of eligible children receiving appropriate immunizations. (5) Percent of patients reporting satisfaction with care services. a provider contract profile. Development of contract templates to be used for entering contracts (templates may require different data). Single point of entry for data (templates and forms will populate any information that would already be in the system). System will integrate the AIRS taxonomy list with HSD pay rate and staff credentials (if applicable) related to each taxonomy. Must have the ability to set capitations on contracts based on either units or dollars for either the life of the contract or a specific time-frame within the life of the contract. Profile will also include tracking of: insurance certificates, annual customer satisfaction surveys, annual financial audits, quarterly reports (which include demographic reports and outcome measurements) and invoices. Invoice templates will be with User com pi contract provider profile. A successful test will include a query to retrieve information and determine whether the information is prefilled to other components ofthe module. User will enter test contract. During the entry the user should have the ability to select a taxonomy(ies) from the list. A successful test will include (1) the selection of the taxonomy and (2) the inclusion of related rates to the corresponding staff credentials. User processes invoice for test contracts. In a successful test the System will not process an invoice that exceeds the allowable capitation(s). User will generate sample invoice based upon contract terms, validate allowable capitations, match, and required information for completeness and accuracy. A successful test will include of Broward County and The Echo Group Exhibit A (Statement of Work) 75

76 Page 76 of 379 I' { I! Contract Invoice Management System must provide error checking prior to importing any submission based on identified business rules. records to be added, edited, amended, renewed or extended, including contract requirements, invoicing, contract utilization review, outcome attainment, and corrective or remedial action. System must retain a history of all contracts, modifications, and renewals. Contract management processes will be based on the most recent amendment/renewal. The System will provide electronic alerts for due dates of all contractually required records and notifications upon Provider submittal. Provider invoices are due and will be imported by the 15th of the following month, or next business day. Final invoices are due 45 days after the end oft he contract term. System functionality will include user ability to amend invoices imported by Providers to include: deduction/revision/payback of units; revision of due date; and line item ection. Users afcjreme>ntlion,ed invoice components by the user. A successful test of the import functionality will require the test import of a data submission and review to ensure error checking is functioning properly. Based upon a successful import test, the user will then review grant information to ensure that the submission also updated appropriate data elements in the grant such as dollars encumbered and service utilization. User enter a test contract amendment and review to determine if the contract history is retained and business rules enforced from most recent amendment. User will review invoice. A successful test will establish if (1) system processes approvals based upon requirements {2) system maintains contractual requirement submission history (3) System processes invoices with filterable information such as by contract, taxonomy, amount and program. User will test invoice rejection functionality for both the complete invoice and a specific line item by {1) creating an invoice and (2) rejecting based upon business rules for appropriate return to Provider for action. A successful test will not process the rejected line items (or invoice) and will create an error report for the Provider. A successful test of an automated invoice rejection a submission of Broward County and The Echo Group Exhibit A (Statement of Work) 76

77 Page 77 of 379 to manage track all elements of the invoices including: calculation of remaining funding left after monthly reconciliation, and utilization rates based on contract/taxonomy, dollars expended (YTD and monthly), utilization percentage (by program, contract, taxonomy, section, agency), historical data for comparison and trending, contract value, contract amendments (amounts, dates, etc.), number of days to process invoice, number (and corresponding dollar values), of units by program, contract, taxonomy, section, and agency. Users will have the ability to (1) approve imported invoices submitted through approval process (multiple levels) or (2) reject imported invoices and return to Provider agency with reason for action. Based upon system generated reports derived from business rules users will have the ability to (1) request action plans from Providers with utilization concerns (2) identify underutilized dollars for contract amendment or (3) project Providers requiring additional funds based upon utilization level. Considerations will be made for additional monies through amendment of the contract terms for the remainder of the fiscal year. System will include error checking with rejection of invoices where the calculations (units to dollars) do not match and other criteria identified in business an not conform to a business rule which is enforceable at the System level (such as services submitted for a customer for whom we do not have an admission on file). For a successful test, the system will not process the nonconforming line item(s) and will include those items in an error report for the Provider. A successful test of an amended invoice would include: (1) user will enter an amendment to an invoice (2) user will process the invoice (3) processed invoice will include (but is not limited to) new total amount due for reimbursement, initial reimbursement amount, and deducted amount. To successfully test Year to date (y-t-d) reporting, user will generate system report for year-to-date invoice data and cross reference with monthly submission information to validate periodic and y-t-d cumulative totals. To successfully test reporting functionality for over and underutilization notifications user will (1) generate the contract utilization report (2) cross reference to see if appropriate notifications are provided. To successfully test receipt of Provider outcome submission data user will (1) import a test outcome file and (2) cross reference information with Provider contract profile for review of summary data. To successfully test the accuracy of the Provider outcome the user will Broward County and The Echo Group Exhibit A (Statement of Work) 77

78 Page 78 of 379 Provider Reporting Monitoring Contract Performance Provider will have the ability to submit contract related data for reporting to include: admissions (demographic/eligibility requirements), service events, periodically reported outcomes, and discharge). Reporting must allow for aggregate reports of outcome attainment using specific parameters as defined by Human Services. Outcome template will automatically calculate percentages of customers meeting the goal in each indicator; also track and calculate demographic information. annually for contract compliance, outcome performance and proper billing. System functionality will include development of a Risk Assessment template to extract Provider contract performance data (i.e. annual financial audit, amount of contract, number of contracts, prior monitoring performance, number of Corrective Action Plans (CAP) or Remedial Action items, number of customers to be served, and number of customers served). The contract factors will be populated into the Risk Assessment template resulting in a ranking of providers/vendors based on user defined business rules such as frequency, intensity of mcmiltoring needed, or order generate outcomes reports and cross reference with imported outcome file. Assessment functionality would include (1) entry of a Risk Assessment template for a test contract (2) entry of test Provider data (3) crossreference of system generated Risk Assessment values against Risk Assessment template and data entered/uploaded. User will test the system's ability to upload the Excel Monitoring report including CAP and Remedial Action findings for inclusion of all monitoring related information. A successful test of the CAP business rule will include (1) test invoice for a Provider with a Monitoring Report but no CAP in the system (2) user will process invoice. System should not process the invoice. An error report should be generated that line Broward County and The Echo Group Exhibit A (Statement of Work) 78

79 Page 79 of 379 System will allow for upload of User's Excel Monitoring Report Tool with report findings. System functionality will track completion of monitoring reports due 45 days after exit interview. Management of this process will also include: Corrective and/or Remedial action plan (multiple items), due date, provider response to action items, individual(s) responsible, provider completion date, submission date, approval or rejection date, follow-up date and the outcome. System will maintain a history of both accepted and rejected plans. System will not process payment, and issue notice if plan is not received and or accepted. Notice will be automatically issued to Provider of suspension of payment and cause. User must have to override and/or e as Forms- a test customer and then select the form being tested. Upon access to the form, the user will test to ensure the form contains the appropriate data elements, controls and layout as requested. Reports- User will select the report to be tested from the report menu. The user will test to ensure the report includes the appropriate selection criteria and execute the report. The end result will be reviewed to ensure the a priate Broward County and The Echo Group Exhibit A {Statement of Work) 79

80 Page 80 of 379 Acceptance User M and System Administrator Manual and completion of training including support and technical assistance. Training may include, at County's option: End User Traini Ratio: Seven users will receive the manua and one-on-one Train-the Trainer hands on classroom instruction from Echo on all related software applications. meets Gene criteria and criteria as listed above as evidenced by a signed team TBD. Gathering Stage for Contracting Sections Elderly and Veterans Services Meetings during this phase and will include a review of County requirements, workflow, and processes for validation with th i ng tool to capture information relating to internal staff supervision. Information to be captured will include but is not limited to date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track contracted provider services against contracts/grants and enforce and pre- Written meeting recap a delivery of draft Project Plan. enter supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the. activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant, contract and related pay source. Information from the pay source updates to its contract and 2 The requirements of Phases 5 and 6 will be met as described herein by creating the ability to enter the contractual requirements and allowing the upload of contractor services. System will provide the ability to report on services, reconcile services against contractual limits and report on outcomes based on contractual data elements. There is no requirement that the System receive individual charges and approve or disapprove those charges on a claim by claim basis. Broward County and The Echo Group Exhibit A (Statement of Work) 80

81 Page 81 of 379 Contract Setup Invoice Setup Information received from contracted providers will support reporting requirements to include: Division, Section, Name of Grant, Funder, Total Award, Multi-year funding (Y/N), Award period, current fiscal year award, County cash match amount, County In-kind match amount, other (provider match/funding leveraged), Total budget, and of nt. Create an maintain a provider profile. Development of contract templates to be used for entering contracts (templates may require different data). Single point of entry for data (templates and forms will populate any information that would already be in the system). Must have the ability to set capitations on contracts based on either units or dollars for either the life of the contract or a specific time-frame within the life of the contract. Profile will also include tracking of: insurance certificates, annual customer satisfaction surveys, annual financial audits, quarterly reports (which include demographic reports and outcome measurements) and invoices. Invoice templates will be created with required data fields. System must provide error checking prior to importing any submission based on identified business rules. User com r profile. A successful test will include a query to retrieve information and determine whether the information is prefilled to other components of the module. User processes invoice for test contracts. In a successful test the System will not process an invoice that exceeds the allowable capitation(s). User will generate sample invoice based upon contract terms, validate allowable capitations, match, and required information for completeness and accuracy. A successful test will include acceptance of each of the aforementioned invoice components by the user. A successful test of the import functionality will require the test import of a data submission and review to ensure error checking is functioning properly. Based upon a successful import test, the user will then review grant information to ensure that the submission also updated appropriate data elements in the Broward County and The Echo Group Exhibit A {Statement of Work) 81

82 Page 82 of 379 Invoice Management System records to be added, edited, amended, renewed or extended, including contract requirements, invoicing, contract utilization review, and outcome attainment. System must retain a history of all contracts, modifications, and renewals. Contract management processes will be based on the most recent amendment/renewal. Provider invoices are due and will be imported as specified in the contracts. System functionality will include user ability to amend invoices imported by Providers to include: deduction/revision/payback of units; revision of due date; and line item rejection. Users will be able to manage and track all elements ofthe invoices including: calculation of remaining funding left after monthly reconciliation, and utilization rates based on contract/taxonomy, dollars expended (YTD and monthly), utilization percentage (by program, contract, taxonomy, section, agency), historical data for comparison and trending, contract value, contract amendments (amounts, dates, etc.), number of days to process invoice, number (and corresponding dollar values), of units by program, contract, taxonomy, section, and agency. Users will have the ability to approve imported invoices I enter a test contract amendment and review to determine ifthe contract history is retained and business rules enforced from most recent amendment. User will review invoice. A successful test will establish if (1) system processes approvals based upon requirements {2) system maintains contractual requirement submission history (3) System processes invoices with filterable information such as by contract, taxonomy, amount and program. User will test invoice rejection functionality for both the complete invoice and a specific line item by {1) creating an invoice and (2) rejecting based upon business rules for appropriate return to Provider for action. A successful test will not process the rejected line items (or invoice) and will create an error report for the Provider. A successful test of an automated invoice rejection would include a submission of an invoice that does not conform to a business rule which is enforceable at the System level (such as services submitted for a customer for whom we do not have an admission on file). For a successful test, the system will not process the nonconforming line item(s) and will include those items in an error report for the Provider. A successful test of an amended Broward County and The Echo Group Exhibit A (Statement of Work) 82

83 Page 83 of 379 Reporting process i to transmitting to Accounting for payment or (2) reject imported invoices and return to Provider agency with reason for action. Based upon system generated reports derived from business rules users will have the ability to (1) request action plans from Providers with utilization concerns (2) identify underutilized dollars for contract amendment or (3) project Providers requiring additional funds based upon utilization level. Considerations will be made for additional monies through amendment of the contract terms for the remainder of the fiscal year. System will include error checking with rejection of invoices where the calculations (units to dollars) do not match and other criteria identified in business rules. wil to submit contract related data for reporting to include: admissions (demographic/eligibility requirements), service events, periodically reported outcomes, and discharge). Reporting must allow for aggregate reports of outcome attainment using specific parameters as defined by Human Services. Outcome template will automatically calculate percentages of customers meeting the goal in each indicator; also track and calculate demographic information. user enter an amendment to an invoice (2) user will process the invoice (3) processed invoice will include (but is not limited to) new total amount due for reimbursement, initial reimbursement amount, and deducted amount. To successfully test Year to date (y-t-d) reporting, user will generate system report for year-to-date invoice data and cross reference with monthly submission information to validate periodic and y-t-d cumulative totals To successfully test reporting functionality for over and underutilization notifications user will (1) generate the contract utilization report (2) cross reference to see if appropriate notifications are provided. test Provider outcome su"~ 'l' ~ ~ data user will (1) import a test outcome file and (2) cross reference information with Provider contract profile for review of summary data. To successfully test the accuracy ofthe Provider outcome report the user will generate outcomes reports and cross reference with imported outcome file. for a Broward County and The Echo Group Exhibit A (Statement of Work) 83

84 Page 84 of 379 System functionality will include development of a Risk Assessment template to extract Provider contract performance data (i.e. annual financial audit, amount of contract, number of contracts, prior monitoring performance, number of Corrective Action Plans (CAP) or Remedial Action items, number of customers to be served, and number of customers served). The contract factors will be populated into the Risk Assessment template resulting in a ranking of providers/vendors based on user defined business rules such as frequency, intensity of monitoring needed, or order of monitoring schedule. test contract, enter test Provider data, and review system generated Risk Assessment values to determine validity. User will test the system's ability to upload the Excel Monitoring report including CAP and Remedial Action findings for inclusion of all monitoring related information. User will. import invoice for Provider with a Monitoring Report but no CAP to test if system processes invoice. User will enter a CAP and test whether it processes an invoice. System will allow for upload of User's Excel Monitoring Report Tool with report findings. System functionality will track completion of monitoring reports due 45 days after exit interview. Management of this process will also include: Corrective and/or Remedial action plan (multiple items), due date, provider response to action items, individual(s) responsible, provider completion date, submission date, approval date, follow-up date and the outcome. System will maintain a history of both accepted and rejected plans. will Broward County and The Echo Group Exhibit A (Statement of Work) 84

85 Page 85 of 379 s payment, plan is not received and accepted. User must have ability to override and/or rule. attached at Exhibit A-7 1 User ov ~ n""' and System Administrator Manual and completion of training including support and technical assistance. Training may include, at County's option: 1 a test customer and then select the form being tested. Upon access to the form, the user will test to ensure the form contains the appropriate data elements, controls and layout as requested. Reports - User will select the report to be tested from the report menu. The user will test to ensure the report includes the appropriate selection criteria and execute the report. The end result will be reviewed to ensure the appropriate format and the data provided in the report will be validated to ensure accura Ratio: (13) users will receive the manuals and one-on-one Trainthe-Trainer hands on classroom instruction from Echo on all related software applications. inary Phase Acceptance 9. Optional Services and Transition/Disentanglement Services: A. Optional Services County may request that Echo provide additional optional services including functionality to allow review of records for acceptance, processing services, creation and submission of invoices and reports, collection activities, posting of receivables, and account reconciliations. For any such services as County may request, the parties will Broward County and The Echo Group Exhibit A (Statement of Work) 85

86 Page 86 of 379 ', execute an appropriate Work Authorization pursuant to Section of the Agreement with a supporting Statement of Work for that Work Authorization. To the extent County elects any Optional Services in the first two years after the Effective Date ofthis Agreement or before Final Acceptance, such elected Optional Services shall be included in the Final Acceptance testing for the System pursuant to the terms of the Agreement. Additionally, to the extent any additional work is requested by County, Echo will provide additional consultation, customization, configuration, system integration or other professional services which shall be invoiced monthly as incurred at the following rates: Professional Services: $ per hour Phase#7 Phase #7 (BAR C) is optional and may be elected by County upon written notice to Echo. I Gathering Stage for BARC ngs i during this phase and will include a review of County requirements, workflow, and processes for validation with the Plan. System 1 a tra tool to capture information relating to internal staff supervision. Information to be captured will include but is not limited to date, beginning and ending time, supervisor and staff name, and discussion summary. The system will track services provided against grants and enforce capitations and preauthorization requirements. System will generate Broward County Office of Management and Budget (OMB) Performance Measures including: Administration: (1) Percentage increase in Medicaid billing. (2) Percentage increase in revenue collections. (3) Pe1rcent<1!Ze of consumers who User enter supervision activity with corresponding summary of discussion. A successful test will include the user's ability to search and retrieve the activity and summary and generate a report that accurately lists documented supervision sessions. User will be able to enter a grant and related pay source. Information from the pay source updates to its parent grant. Data required to provide OMB outcome reporting will be evidenced and data will be entered. Outcomes will be run to verify accurate reporting. Broward County and The Echo Group Exhibit A (Statement of Work) 86

87 Page 87 of 379 treatment at any within the agency. {4) Percent of state contract funding utilized. Outpatient Services: {1) Number of consumers who enroll in any level of Outpatient Treatment Services. (2) Percent of consumers who successfully complete Outpatient treatment. {3) Percent of clients who successfully complete the Intensive Outpatient Level of Care within Outpatient Treatment Services. {9) Percent of clients who successfully complete the Non-Residential Day {NRD) Treatment Level of Care within Outpatient Treatment Services. {10) Percent of consumers with no alcohol or drug use during the 30 days prior to discharge Residential Services: {1) Number of consumers who enroll in Residential Treatment Services. (2) Percent of Residential beds utilized. {3) Percent of consumers who successfully complete Residential Treatment. Detoxification: {1) Number of detoxification screenings at triage. {2) Percent of Detoxification beds utilized. {3) Percent of consumers who successfully complete Detoxification. {4) Percent of consumers who complete Detoxification and who are referred and enroll in Residential or any Outpatient Treatment Program within the agency. {5) Number of consumers who enroll in the Broward County and The Echo Group Exhibit A (Statement of Work) 87

88 Page 88 of 379 Matrix on Admissions: (1) Number of consumers who enroll in treatment services. (2) Percent of Criminal Justice consumers presenting at admissions who enroll in treatment. (3) Percent of all consumers presenting at admissions who enroll in treatment. (4) Number of assessments conducted at admissions. (5) Percent of consumers who are assessed at Admissions and are referred to and enroll in treatment are the current stan for clinical and medical diagnosis. User will input the DSM-IV/V diagnosis and the system will correlate the equivalent ICD- 9/10 diagnosis for billing purposes. M current implementation to the new vendor hosted enterprise and System Administrator Manual and completion of training including support and technical assistance. Training may include, at County's option: enter a test ent including demographic and financial information and (2) a billable DSM-IV /V diagnosis and activities. Billing processing will then be performed to generate an invoice and validate if the appropriate ICD-9/10 diagnosis lied. ing i (13) users will receive the manuals and one-on-one Trainthe-Trainer hands on classroom instruction from Echo on all related software applications. System meets all General criteria and criteria as listed above as evidenced by a signed ase team TBD. Transaction Management: ECHO's sole compensation for all billing services performed by ECHO for COUNTY shall be a fee equal to a percentage ofthe total sum of all amounts collected on COUNTY's Broward County and The Echo Group Exhibit A (Statement of Work) 88

89 Page 89 of 379 Accounts in each payer category, including, but not limited to, all amounts collected from Third Party Payers and is payable to Echo monthly in arrears. Not included are all amounts collected on Delinquent Accounts referred to a collection agency or an attorney. Note that the percentage applicable to the COUNTY is defined below: Fees for batch submissions for Grant payments/reconciliation will be calculated at a reduced rate, as agreed by the parties in writing in advance, to the extent applicable. DrFirst with EPCS Gold e-prescribinq: Available through Echo's proud partnership with DrFirst providing our users with best of breed, e-prescribing technology fully integrated with our solutions. The annual user fee for this software is $ per named DEA licensed prescriber. Non-prescribing staff can access DrFirst at no additional cost. Wilev Treatment Planners: Wiley provides predefined treatment planner content accessible through your Echo EHR. The content subscription is payable annually in advance depending on the number of datasets and clinical users required. A review of the required need at the time of implementation will determine annual cost for each program. The Enterprise price for all datasets is as follows: B. Transition & Disentanglement Services The parties acknowledge and agree that upon the expiration or earlier termination of this Agreement, the good faith efforts of Echo to facilitate the smooth, efficient, and secure transition of data and services to another provider (or to County, to the extent applicable) without any unnecessary interruption or adverse impact on County operations ("Disentanglement") is a critical objective ofthe parties and a material obligation of Echo under this Agreement. All obligations of Echo under this Agreement shall be construed consistent with this objective. At request of County, Echo shall provide prompt, good faith, and reasonable assistance to County in disentangling County data, business, and operations from the System and, to the extent applicable, transitioning to a new software, system, or provider. Broward County and The Echo Group Exhibit A (Statement of Work) 89

90 Page 90 of Final Acceptance Test Plan: Review preliminary acceptance of all Phases including Phase Seven if elected prior to Final Department, its divisions, and contracted Providers to produce aggregate reports such as unduplicated client count. to tren information across agencies (internal and contracted) such as lm Electronic Health Records (EHR) requirement. approach to Human Services customer care by identifying problems, tracking provision of services, and determining unmet needs for all dimensions. generate a report consisting of cumulative data entered at the division/ program level or by contracted services Providers. A successful test will include a comparison ofthe report results against information received from the Department and its agencies. test a combined report displaying information from the HSD agencies to allow comparative analysis of amount of grant funding or utilization of grant System wil individual electronic health information and provide a means to share the information with other entities when deemed appropriate. A successful test will include the ability to produce requested information in a shareable format such as HL-7, pdf I System 1 on information from customer records to include service plans and services rendered to provide information related to unmet customer needs identified during the provision of services. A successful test would include the entry of test service plans and services, generation of reports, and comparison of information to determine that all identified needs that were not met by HSD are included in the re Broward County and The Echo Group Exhibit A (Statement of Work) 90

91 Page 91 of 379 Implementation of enterprise processes allows Human Services to leverage quality improvement standards. Data Quality HSD users will identify the business rules in the System based upon a quality improvement standard such as no processing of services without an accompanying activity note. The System will be configured to enforce the aforementioned rule. A successful test will include (1) entry of a service without an accompanying note (2) process services (3) review results to determine whether the service was processed or rejected with an error message. The System will allow HSD users to improve data through the use of a report that compares data from all agencies that provides information such as completeness, accuracy, timeliness, and consistency. For example, a successful test of data completeness would include a cumulative score of the overall percentage ofthe number of records entered and elements missing. The report would also provide a detailed list of all error record to facilitate correction. Broward County and The Echo Group Exhibit A (Statement of Work) 91

92 Page 92 of Payment Schedule The rates specified below shall be in effect for the entire term ofthe Agreement, including any renewal term, unless the contrary is expressly stated below. Any goods or services required under this Agreement for which no specific fee or cost is expressly stated in this Payment Schedule shall be deemed to be included, at no extra cost, within the costs and fees expressly provided for in this Payment Schedule. Echo License Fee Enterprise License Fee for Clinician's Desktop/Revenue Manager Due 50% upon execution; 35% at 9 months following execution; 15% at 12 months following execution N/A $456, Rapid Insight Lite No Charge for first year after County's election to commence; Renewal upon Anniversary if Selected by 60 days prior to Annual Renewal Date $500.00/annually afteryear1 Crystal Dashboard Included at no charge N/A N/A Hosting Fee BARC Hosting Fee (if elected by County) Quarterly upon Execution ofthe Quarterly Quarterly $135, in advance annually Quarterly in $46, advance annually Broward County and The Echo Group Exhibit A (Statement of Work) 92

93 Page 93 of 379 Support and Maintenance Fee Initial Term Initial Term No cost N/A Support and Maintenance Fee Annually after Initial Term Quarterly Quarterly in advance $101, annually BARC Maintenance Fee (if elected by County) Quarterly Quarterly in advance $34, annually I Agreement. commence Professional Services Fee: Implementation, Project Management, IT, Customization, Hourly Upon preliminary acceptance for each Phase As per Phase payment schedule Training Fee for all training under the Agreement 3 Per Course Upon completion of each course Not to exceed $49, #501 System Orientation 2 days Upon completion of each course $2, ea. #SODA Revenue Manager Configuration Workshop 3 days Upon completion of each course $4, ea. #SOOB Clinician's' Desktop Configuration Workshop 3 days Upon completion of each course $4, ea. #520 Data Flow 3 days Upon completion of each course $4, ea. 3 Course fees are based upon a ratio of 10: I. Broward County and The Echo Group Exhibit A {Statement of Work) 93

94 Page 94 of 379 #515 Report Writer Workshop 2 days Upon completion of each course $2, ea. #599 Business Intelligence for Your Organization 3 days Upon completion of each course $4, ea. #560 Creating Structured Progress Notes 1 day Upon completion of each course $1, ea. #540 Developing Treatment Plans and Predefined Content 3 days Upon completion of each course $4, ea. #505 Windows Designer Workshop 2 days Upon completion of each course $2, ea. #510 End User. 3 days Upon completion of each course $4, ea. Per statutory reimbursement Travel Fee- Reimbursable Expenses Monthly Upon completion of travel rates. Not to exceed Phase 1 preliminary acceptance Phase 2 preliminary acceptance Phase 3 preliminary acceptance Phase 4 preliminary acceptance $37, $84, $84, $48, $5, $32, $12, $71, $12, $71, $7, Phase 5 preliminary acceptance Phase 6 preliminary acceptance $67, $67, $10, $57, $10, $57, Broward County and The Echo Group Exhibit A (Statement of Work) 94

95 Page 95 of 379 THROUGH FINAL ACCEPTANCE Price Schedule 100% Price Schedule Not to Exceed $389, Broward County and The Echo Group Exhibit A (Statement of Work) 95

96 Page 96 of 379 Hourly Monthly as incurred $175/hour Additional Training Hourly Monthly as incurred $175/hour Development Hourly Monthly as incurred $175/hour Configuration Hourly Monthly as incurred $175/hour DrFirst with EPCS Gold e- Prescribing License Rapid Insight Lite Per prescriber Annually 60 days prior to Annual Renewal Date Annually in advance, $GOO/prescriber 500/annually (first year included at no Wiley Treatment Planner License Subscription Per user 60 days prior to Annual Renewal Date $34.32-$ per user Transaction Management Phase 7 (BARC) Monthly Phase Monthly in arrears Professional Services Upon Preliminary Percentage as set forth in Section 9 of the sow $25, (subject to 15% retainage) Hosting for BARC Maintenance for BARC Quarterly Quarterly Quarterly in $46, advance annually Quarterly in $34, advance annually Broward County and The Echo Group Exhibit A (Statement of Work) 96

97 Page 97 of 379 Broward County and The Echo Group Exhibit A (Statement of Work) 97

98 Page 98 of 379 Exhibit A-1 Forms Acceptance Signoff for Accepted Phase 10/Ref: ID REFERENCE: EXHIBIT A: STATEMENT OF WORK (SOW) Date: Date ID:/D Ref: Ref Task Description: Description Feature/Requirements: Requirement Phase: 1 Test Plan: Test Plan from SOW Comments: Requirement fulfilled with attached document dated DATE. This Acceptance Sign off for Phase _is pursuant to Article 5 Method of Billing and Payment, Section of the Agreement. Accepted By: Signature Authorized Signatory Printed Name Date Broward County and The Echo Group Exhibit A (Statement of Work) 98

99 Page 99 of 379 Exhibit A-2 Forms Echo's SOAP and DAP Samples SOAP Note Example: SOAP Nate Jl!llil 1 Client Abbott, Amanda, ABBAOO Family Members attending Subjective.!. Objective ::...!. A&sessment ::...!. Plan.!. Broward County and The Echo Group Exhibit A (Statement of Work) 99

100 Page 100 of 379 DAP Note Example: OAP Note ~~~~~~~ f!i Type of Contact Jlii ~ Face to Face li!llnstructions "'0'"- Subjective and objective infonnation Bbout the cfi&nt "'A"- Assessment clinical impression "P"- Plan for future treatment CUrrentMeasurel 3 Currant statusiactive ~Report Broward County and The Echo Group Exhibit A (Statement of Work) 100

101 Page 101 of 379 Exhibit A-3 Forms Phase 2 Form Templates Broward County and The Echo Group Exhibit A (Statement of Work) 101

102 Page 102 of 379 Adult Medical Risk Assessment Consumer's Name: ' Date: Date of Birth: Sex: Height. Weight: Date of Last Physical Exam: Personal Physician (Include Name, Address, and Phone Number): Emergency Contact (Include Name, Address, and Phone Number): Allergies: Are you allergic to any medications? yes no If yes, which ones? Are you allergic to any food? yes no If yes, which ones? Are you allergic to Bee Stings? yes no Have you or a family member ever suffered from any of the following medical problems? Check each Item Self Family When? Check each item Self Family When? Severe and/or frequent headaches Frequent Dizzv Scells Severe Head Injury Difficulty with Vision Difficulty with HearinQ Gout Sinus Trouble Allergies to Pollen, Weeds, Dust Frequent Nose Bleeds Severe Tooth or Gum Problem Anemia or Blood Disease Heart Disease Pal citations or Poundina Heart Pain or Pressure in Chest Hiqh Blood Pressure Scarlet Fever Rheumatic Fever Varicose Veins Phlebitis in Leqs Blood Clots in Legs Asthma or Wheezing Arthritis or Rheumatism Swollen or Painful Joints Any Broken Bones Loss of Limb Bone Joint or Other Deformity Buzzing or Ringina in Ears Blackout Soells Seizures Stroke Frequent Crying Spells Trouble Sleeoina Paralysis, Polio Skin Trouble Stomach Ulcers Frequent lndioestion Gall Stones or Gall Bladder Problems Appendicitis Liver Disease Jaundice (Yellow Skin and Eves) Cancer Frequent Diarrhea 102

103 Page 103 of 379 Check each Item Self Family When? Check each Item Self Family When? Emphysema Diabetes Pneumonia Tuberculosis Bronchitis Shortness of Breath Sh:mificant Problems with Couqhinq Bladder or Kidney Infection Kidnev Stones Goiter or Thyroid Trouble Hernia Other: Frequent Constipation Recent Gain/Loss of Weight Loss of Aooetite Syphilis Gonorrhea Herpes Chlam dia HIV/AIDS: Hepatitis B Heoatitis C Are you on a special diet (i.e. low salt, low fat, diabetic, etc)? When was the last appointment with your Primary Care Physician? Do you wear glasses? YES NO Do you wear a hearing aid? YES NO Do you wear a brace/prosthesis? YES NO When was your last tetanus shot? Date: Have you ever attempted suicide or self harm? YES NO If so, when? Do you have suicidal thoughts currently? YES NO If consumer answers yes to the above question: Does the consumer have the: Means? YES NO Plan? YES NO Opportunity? YES NO HIV RISK ASSESSMENT SEXUAL HISTORY (To be completed only by designated clinicians) Sexual partners What type of When do you How long have What Is the What type, If Consistency of (Last 5 10 sex are you have sex with you been nature of your any, of safer sex safer sex years, starting having? (oral, this person? having sex with relationship practices are practices (i.e. with most anal, vaginal, (Fridays, lonely, this person and with this you using with how often?) recent. No other?) need money, last date of person? this person? names just sex incarcerated exposure? of partner) etc.?)

104 Page 104 of 379 STD and Tuberculosis Risk 1. Are you aware of being exposed to any STD's recently? If Yes Explain: 2. Have you been treated for or recently diagnosed with an STD's: 3. Do vou know what are the bodily fluids transmit HIV, Hep C? 4. Do you know which behaviors put someone at risk for acquiring or transmitting HIV, Hep C or other STD's? 5. Do you know how you can reduce the risk for transmitting or acquiring HIV, Hep C other STD's? 6. Did you receive a transfusion of blood or blood products or a transplant before 1992? 7. Have you ever injected illegal or legal drugs, including use once many years ago? B. Have you ever received any clotting factor concentrates produced before 1987? 9. Are you currently receiving chronic (long-term) hemodialysis? 10.Do you have persistently abnormal liver enzyme tests or an unexplained liver disease 12. Have you ever had a needle stick, sharps or mucosal exposure to HIV or Hep C? 13. Do you have or have you had in the recent past a non-productive or productive cough that has lasted more than one month. Yes No N/A Referral Needed? Yes No If yes, where? Testing Recommended? Yes No If yes, where and for what? Signature of Recorder: Date: Supervisor: Date: 104

105 Page 105 of 379 ADULT CERTIFICATION ADULT MENTAL HEALTH TARGETED CASE MANAGEMENT Recipienfs Name: CSMS ID: Is hereby certified as meeting all of the following adult mental health targeted case management criteria: 1. Is enrolled in Department of Children and Families adult mental health population; 2. Has a disability which requires advocacy for and coordination of services to maintain or improve level of functioning; 3. Requires services to assist in attaining self-sufficiency and satisfaction in the living, learning, work and social environments of choice; 4. Lacks a natural support system with the ability to access needed medical, social, educational and other services; 5. Requires ongoing assistance to access or maintain needed care consistently whhin the services delivery system; 6. Has a disability duration that, based upon professional judgment, will last for a minimum of one year; 7. Is not receiving duplicate case management services from another provider; 8. Check all that apply Meets at least one of following requirements: A.,Js awaiting admission to or has been discharged from a state mental hospital (Provide dates as applicable): B. Has been discharged from a mental health residential treatment facility (Provide dates as applicable): c. Has had more than one admission to crisis stabilization unit (CSU), short-term residential facility (SRn, inpatient psychiatric unit, or any combination of these faciihies (Provide dates as applicable): D. Is at risk of institutionalization for mental health reasons (provide explanation): E. Is experiencing long-temn or acute episodes of mental impalmnent that may put him or her at risk of requiring more intensive services (provide explanation); or 9. Has relocated from a Department of Children and Families district where he or she was receiving mental health targeted case management services. Case Manager Date Case Manager Supervisor Date Revision date7115/

106 Page 106 of 379 Board of County Commissioners, Broward County, FL Human Services Department Elderly and Veterans Services Division INFORMED CONSENT _ Behavioral Health Section Case Management Services _ HUD Housing Program Services Behavioral Health Section Substance Abuse Services Veterans Services _ Community Care for the Elderly Section Services CRU/CDC/EHF Services I, ~ hereby consent to and authorize Broward County Elderly and Veterans Services Division staff to provide services and/or treatment. I understand that by signing this agreement, I am consenting to voluntarily participate in the Broward County Elderly and Veterans Services Division services and/or treatment. Furthermore, I agree to have my information placed in the Client Services Management System (CSMS), and as applicable into GIRTS, ARTT, SAMHIS, KIT Solution database, and LAVATS which are funder-required databases; and if my service is provided by Medicaid, the Florida Medicaid program's EDS system for billing purposes. I also understand that my records are protected under Federal Confidentiality regulations (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that my medical record may contain information concerning my psychiatric, psychological, drug or alcohol abuse, HIV/AIDS and/or related conditions. I have been given the opportunity to receive answers to all my questions before participating and during the treatment process. I understand that I may refuse to participate at any time and that my decision will be honored and respected. Customer/Guardian/Legal Representative Date Witness Date This form is good for only twelve months from the date of the signature and must be completed annually. 106

107 Page 107 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPATRMENT Elderly and Veterans Services Division Behavioral Health Section 'ATEMENT OF RIGHTS AND!EXPRESS AND INFORMED CONSENT FOR SERVICES onsumer's Name: CSMS 10:_~ ward County Elderly and Veterans Services Division are committed to ensure that you receive professional and manistic services directed toward your needs iri a manner that protects your dignity and feelings of self-worth. To this d, the following Statement of Rights has been formulated: VllRIGHTS: You have the right to be treated with dignity and respect. You retain all rights, benefits, and privileges guaranteed by law. SCRIMINATION; Services will be provided to you and/or family member without discrimination, Ethic background, personal or social creed, racial membership, gender, religion, sexual orientation or age will not affect our services provided to you. You will not be refused any services based on a lack of, or limited personal financial resources: No physical barriers will preclude treatment. ONFIDENTIALITY: The right to confidentiality, whereby, information revealed by me during treatment or when I'm With my case manager will be kept strictly confidentiat' and will not be,revealed to anyone wl\hl)ut my written.permission. Jhe law provides for the following exceptions to this provision:.. a. When a clinician, nurse, case manager, case worker and /or mental health specialist/peer specialist has information concerning suspected child abuse, neglect or abandonment; disabled or elder or neglect. They a(e mandated by Florida Statutes, to report. b. When the consumer is a danger to, or has intent to harm self or others. c. Wheri a court order is received to the contrary.. d. When a consumer enters litigations against Broward County Elderly and Veterans Services Division. e. When a medical emergency.necessitates disclosure. f. When a consumer. commits a crime on Broward County Elderly and Veterans Services Division premises. g. When you give written permission to disclose information to another provider or Individual, you have the right to review the information being disclosed.. You have the right to be informed, verbally or in writing, If any of the above exceptions apply. TREATMENT: 1. You have the right to an individual plan for treatment and will be expected to participate In your plan for treatment. 1. You have the right to know the name and professional credentials of anyone working with you. l. You may request to participate in any staff meeting yourself. t You may review your clinical records upon written request. 5. You will be assigned a clinician and/or case manager, who will assist you in obtaining serl(ices throughout your case 11anagement and/ or treatment program. 5. You will be advised of the positive effects and possible complications of any medications. 7. You have the right to refuse to participate in, or be interviewed for, re.search pu(poses. B. You have the right to terminate treatment at any time. 9. You have the right and shall be informed of the potential benefits, risks, and side effects of proposed interventions, treatment, care, services or medications. 10. The right to participate in your assessment and to develop your care/service/treatment plan; to a complete explanation of your treatment plan, of which you will receive a copy. 11. The right to be provided a copy of the Universal Precautions/Infection Control policy and procedure, when requested. 107 CONSUMER INITIALS:-----

108 Page 108 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT Elderly and Veterans Services Division Mental Health Section. ~ ~... ; am currently receiving services through the Mental Health Seetioo of Broward County Elderly and Veterans Service~. I was Pf~vided i~nylati~n by ~Y- case man~ger.on Mental Health Advancie Directives ,......: ;-.~ -c.- v - r= r... n'.,.;..;.-.tj.-~.-~- : "...:...;:~-, =~ _,... "-'..::,;.~.,.. After recemng information a~ut ~~ Health Advanced DirectiVes, l.informed. my case manager that o I ~ave an Mental Health Advanced Directive in place o J do not have an Mental Health Advanced Directive in place and do not wish to have one at this time o I do not have a ""ental Health Advanced Directive in place and would like to have a copy of one.. o B was given a copy of the Mental Health Advar1ced Directive and provided information and/or assistance regarding completion. Consumer's Name:---~~ (Print) Signature of consumer !Date:----- Signature Qf Representative: ~~~~~---O,ate: ---- (If applicable) Signature of Case Manager: Date:

109 Page 109 of 379 Mental Health Advance Directive If you believe you may be hospitalized for mental health care in the future and that your doctor may think you aren't able to make good decisions about your treatment, completion of a mental health advance directive will help make your treatment preferences known. It is important that you decidel!llll what types oftreatment you do or do not want and to appoint a friend or family member to make the mental health care decisions that you want carried out. You can use the following advance directive form to direct your future care..read each section of the form carefully and talk about your choices with your case manager, doctor, or other trusted persons. The person you choose to be your health care surrogate and alternate must be a competent person who is at least 18 years old, whose civil rights have not been taken away. The person you choose should!jill be a mental health professional, an employee of a facility which mightprdvide services to you, an employee of the Department ofchildren &Family Services, or a member of the Local Advocacy Council. Make sure your surrogate understands your wishes and is willing to take the responsibility. You an_d your surrogate (and a back-up alternate surrogate if you wish) should sign the form in front of two witnesses. Have copies made and give them to your surrogate, your case manager, your doctor, the hospital or crisis unit at which you are. most likely be taken, your family, and anyone else who might be involved in your care. Discuss your choices with each of thorn. You elm change your advance directive at anytime you are competent to do so. If you travel, be sure to take a copy of the advance directive with you. Your advance directive will not take effect unless a physician decides that you are incompetent to make your own treatment decisions. If you are in a psychiatric facility, you will have an attorney sppointed to represent your interests, and will have a hearing in front of a judge or hearing master. A health care surrogate is not authorized to consent to treatment for a person on voluntary status. I, being of sound mind, willfully and voluntarily execute this mental health advance directive to assure that if I should be found incompetent to consent to my own mental health treatment, my choices regarding my treatment will be carried out despite my inability to make informed decisions for myself. If a guardian or other decision-maker is appointed by a court to make health care or mental health decisions for me, I intend this document to take precedence over all other means of determining my intent while competent. This document represents my wishes and it should be given the greatest possible legal weight and respect. If the surrogate(s) named in this directive are not available,' my wishes shall be binding on whoever is appointed to make such decisions. Ifl become incompetent to make decisions about my own mental health treatroent. I have authorized a mental health care surrogate to make certain treatment decisions for me. My surrogate is also authorized to apply for public benefits to defray the cost of my health care, to release information~: appropriate persons, and to authorize my transfer from a health care facility. My mental health care surrogate is: Name: Address_: Day Telephone: Evening Telephone: Baker Act Htmdbook and User R fimmce Golde I 200Z Stole qfploritkj Deportment ofchlldrrm & Families 109 CONTINUED

110 Page 110 of 379 '' I, mental health~ surrogate designated by 'hereby accept the designation. (Signature of Mental Health Care Surrog~) (Dale) If the person named above is unavailable or unable to serve as my mental health care surrogale, I hereby appoint and want immediate notification of my alternate mental health care surrogate as follows: NameofAJtemate: Address:~ =-~~~~ Day Telephone: Evening Telephone: I, ----, :'' ajternate mental health care surrogate designated by --~ 'hereby accept the designation. (Signature of Alternate Mental Health Care Surrogate) (Date) Complete the following or Inltlal In the blank marked yes. or no: ' A. Ifl become incompetent to give consent to mental health treatment, r give my mental health care surrogate filii p ower and authority to make mental health care decisions for me. This includes the right to consent, refuse consent, or withdraw consent to any mental health care, treatment, service, or procedure, consistent with any instructions and/or limitations I have stared in this.ailvance directive. If! have not expressed a choice in this advance directive, I authorize my surrogate to make the decision my surrogale determines is the decision I would make ifl were competent to do so. Yes No B. My choice of treatment facilities are as follows: I. In the event my psychiatric condition is serious enough to require 24-hour care, I would prefer to receive this oare in this/these facilities: Facility: Facility: I do not wish to be placed in the following facilities for psychiatric care for the reasons I have listed: Facility/Reason: Facility/Resson: C. My choice of a treating physician is: First choice of physician: :---- Second choice of physician: I do not wish to be trealed by the following physicians: Name of physician: Name of physician: Baker Act Handbook atul User Refersn~ Guide I 200Z Stale offlf»ido Deparlm,,t ofchl/d;u cl Pamiliu CONTINUED PAGE 2 110

111 Page 111 of 379 D. My wishes regarding confidentiality of my admission to a facility and my treatment while there are as follows:!. My representative may be notified of my involuntary admission. _Yes _No 2. Any person who seeks to contact me while I am in a facility may be told I am there. _Yes _No 3..- _I consent to release of information about my condition and treatment plan _Yes _No To the following persons: I do DQ! consent to the release of information about my admission or treatment to anyone unless I give specific consent at the time of the request or as otherwise allowed by law. _Yes _No E. Ifi am not competent to consent to my own treatment or to refuse mew cations relating to my mental health treatment, I have iilltialed one of the following, which represents my wishes: I. I consent to the medications that Dr. recommends. 2. I consent to the medications agreed to by my mental health care surrogate, after codsulting with my treating physician and any other individuals my surrogate may think appropriate, with the exceptions found in #3 below. 3. I specifically do not consent and I do not authorize my mental health care surrogate to consent to the administration of the following medications or their respective brand name, trade name, or generic equivalents: (list name of drug and reason for refusal 4. I am willing to take lhe medications excluded in #3 above if my only reason for excluding them is their side effects and the dosage can be adjusted to eliminate those side effects. S.. I have the following other preferences about psychiatric medications: F. My wishes regarding Electroconvulsive Therapy (ECT) are as follows:!. My surrogate may not consent to ECT wilhout express court approval. 2. I authorize my surrogate to consent to ECT. 3. Other instructions and wishes regarding ECT are as follows: G. If, during a stay in a psychiatric facility, my behavior requires an emergency intervention, my wishes regarding which form of emergency interventions should be made in the following order: (fill in numbers, giving I to your first choice, 2 to your second, and so on until each has a number). If an intervention you prefer is not listed, write it in after "other" and give it a number. Seclusion -Physical restraints -Both seclusion and physical restraints =Other: _Medication in pill funn Medication in liq!lid medication =Medication by injection 1Jaker Act Htmdbook a1jd User Reference Guide/ 2002 Sta~ off/oridtj Dapartn~er~t ofchildrfll'l & Rmriliu CONTINUED PAGE 3 111

112 .. Exhibit 2 Page 112 of 379 H. Florida law prohibifll a mental health care surrogate from consenting to experimental treatmenfll that have not been approved by a federally approved institutional review board without my prior written consent or tho express approval of the court. I consent to my participation in experimental drug stndies or drug trials I do not wish to participate in experimental drug studies or drug trials I. If I am incompetent to give consent, I want staff to immediately notizy the following persons that I have been admitted tn a psychiatric facility. Name: Relationship: Address: =--:--,:; Day Phone: Evening Phone: Name: Relationship: Address: Day Phone: ~=========-E;;;;b;gpho;;;,-:========== Evening Phone; J. Other instructions I wish to make about my mental health care are (use additional pages if needed): By signing here I indicate that I fully understand that this advance directive. will permit my mental health care surrogate to make decisions and to provide, withhold, or withdraw consent for my mental health treatment Printed Name (Declarant):------~-----= Signatnre: ~Date: This advance directive was signed by. in our presence. At his/her reques~ we hsve signed our names below as witness. We declare ths~ at the time Ibis advance directive was signed, the Dee!aran~ according to our best knowledao and belief was of sourid mind and under no constraint onmdue influence. We :furftierdeclarc that we are both adults" are not designateclm this advance directive as the mental health care surrogate, and at least one of us is ~either the person's spouse nor olood relative. Da~dM tlris =-~~dayof~~~----'-~-c-- (County & State) (Day) (Month) (Year) Witness Signatures: W1tness 1: S1gnatnre of witness I Printed name of witness 1 Hom~ 8ddie8s of witness 1 City, State, Zip Code of witness 1 Wltness2: Signature of witness 2 Printed name of witness 2 Home address of witness 2 City, State, Zip Code of witness 2 :Saker Act Htmdbook mul User Rej'Mente Guide I ZOOZ S/tlle of Florida Dspartmsnt qfcitildnn &: Patnl/ia 112 PAGE4

113 -..,. Human Services Department IE~der!y andl Veterans Services IDMsfion (Referred to in this document as "EVSD") Exhibit 2 Page 113 of 379 Broward County Notice of Privacy Practices Notice of Privacy Practices Acknowledgement of Receipt I received a copy of the EVSD Notice of Privacy Practices. I understand that if EVSD uses my personal health care information in a manner that is different than described by the Notice, EVSD must first get my permission. I am accepting this Notice on behalf of: D Myself or D Another person as a representative (parent, guardian, family member, etc.) I understand that my signature on this Acknowledgment does not authorize EVSD to disclose my personal health care information without a separate signed consent or authorization.. Individual's Name (Print) Date Signature of Individual or Personal Representative If you are signing for lhe individual, please print your name Description of Pemonal Representative's Authority Please return a signed copy to: Attention HIPAA Liaison Broward County Elderly and Veterans Services Division 2995 North Dixie Highway Fort Lauderdale, FL (954) For any questions regarding HIPAA, please contact: Privacy Officer HIPAA Privacy Office Broward County Governmental Center 115 S. Andrews, Suite A680 Ft. Lauderdale, FL (954)

114 Page 114 of 379 Board of County Commissioners, Broward County Florida Human Services.o.partment Elderly and Veterans Services Division Authorization for Release of Information ConsumerName: SS#: ::===:: DOB: _ <Name of Consumer) hereby give my permission to Broward County Elderly and Veterans Sanlicea Division (EVSD) to: release information contained in my medical record and/or financial statement. I understand that my medical record may contain information concerning my psychiatric, psyehologlcal. drug or alcohol abuse, HIV/Acquired Immune Deficiency Syndrome (AlPS} a Ad/or related conditions. If applicable io the above, I understand that my records ;~re protected under Federal ConfidentialfW regulations {42 CF~ Part 2) Pllb!ishedt\llgllst.:10, 1987; all!! cannel tje.diiciosed Witholit iny written consent unless otherwise provided 'for in lhe regulations. This lnfortnaoon whi be' released to the follciwing agency/organization:. (Please provide name/address/phone number of receiving.party) Information to be released: (please check appropriate area.) A. Summaiy of Care Dis.charge Summary --- Assessment. Progreis Notes --- Trealment PI~Care Plan Other (please specify data): ~-----'----- B. Letters Presence In Care/Treatment Other (please specify data): c. Telephone Calls (pleaee specify data):---' ~ ' R~nforRequeat: ~ Thls authorization will automatically expire one ( 1).year from the date of my signature. This authorization s.hall be In force arid effect until at which time this auihorization to use or disclose this pratected health Information expires. I may revoke. this aui~otiz;jtion at any tlrt!e upon Written I'!Oiice to Elderly and Veterans Services Division. I may send my written notice to the l"rivacy Ualsoh at 2995 N Dixie Highway, Ft Lauderdale, Fl I acknowledge that such revocation will not be effective if El!lerly and Veterans Services Division has alre;jdy acted In reliance upon this authorization. I hereby release Elderly. and Veterans Services Division from any liability which may arise as a rasult of the use of the information released in accordance with this authorization. 114

115 - - Hum.n Servl- De.-rtment l!ldeltylllld,.,... 8el via Dlvlllon Exhibit 2 Page 115 of 379 Authorization to Secure Information onsumer Name: SS#: ~ : (Nomoaf cane.mll) mtby give illy permission to Bnm d County EldtiiJ Mel Ve1illalis..._Division (EVSD) to: _obtain lnformallon OOIIIIIned In my lllldlcal recoid andlor ftnllncllllllllleinent. undetsland that my-..._...cold may contalillnfomlatlon concemlng my psyehlatl'lo, psychological, dn.lg or COIIOialiUie, HIV/Aoqulftld Immune Deftdenoy Syndrolfte (AIDS) andlcir_,..._. aondllonl.tf f!iipiic8ble to the IIOVe, lu~that~my PI~~f... ~... lftr~iii(g CFR-hft2) llblllhed Auguit 10, ; lllld ean110t be diiciolecl wllhoul my Wllilen consent unt... olheiwlse provided for In regulations. Thll l11formatlon wll_ be obtained frim the following egencyjolgllntzauon:.... 'leah provide nameladclmslphcme number of teeelvlnd party) tfonmdlon to be NlnHd: (pl1111 cheek appmpl'l*..._, _Diachalge Summary. Alea..,...nt ~ Progt ail Nole5 -Trealmenl Plan/Care Plan =Other (please spaglfy data):.- _ PresenQ!IIn CliWTI'6atlnent _other{llleise"*"j,dat!l):......;....;... c. Telephone Calle lpim specify dllta): -----~-----: ReMon for Request: This authorization wiu automalieatly expire one (1) year from the date of my algnature. This auihorilalion shall be In force and effect unill_ at which time this aulhol1zatlon to- use or disclose this piutectect huith infonnallon expires. I may revoke this authorizallon at any time upon Wltllen nouce to Eldetly lllld Vaterans Sei'Yices Division. 1 may send my wittten notice to-the PriYlicy Ualson at ext acknowiqdae that SUch revocation wid not be e«ect1ve If Elderly and Veterans services Division has already acted. In nallalice upon this authorization. I hereby release Elderly and Veterans Services Olvlslon from any liability which may arise as a resu_lt of the use of the Information released In 8CCORiance with Ibis aullorlzation. 115

116 Page 116 of 379 l!iderly...,. v...,., Dlvlalon unctej'iitand thai my reconss 818piotectecl under the 1-llldtlt lllsufarol POJtablllly and Accountability Act of 1888 P.L ), 42 u.s.c. Secllon 182Cid, et. Seq and cannot be dleciosed wllhout my._.n aulhol12atlon unless DtheiWise provided for In thue regulations. ' praalllloner will not Cllftdlllon my n11mem. pajiii8fll; enrullment In a he8llh plan or ellijblnty for bllnefiis (If 1ppUCIIble) on whether I pravlde ~ forlhe raquasted 1181 or dllal01111te except. I) If my trealmenlll.. tilled to niii4nrlh. or, l) health Clint I81'VIcea... provided to me aolely for 1he pu'p.jii of Cll"lllllniJ PioteWid hhiih lnfonnallon for llscioaul8 to alhhd party, or, t) the u. or ciiciiilure raqimiiiiad under IIIII aulhorlzaiion' will JeSUit In.dJIIct or lndii8cl.ienluriltallon to my. :lhyalc!an. lhlnl,.a,.... '!=urther, by ligi'iij18thl& 8UtiiOIIzatiOn I aaknowledal that I have been J)niVfded 8 copy of and have leed and lllldellllllnd The l!!fdllty and Vlllmlne 8aMCell Division Pflv&y Nollce oontalnlng a cojnplele cleaatpuon of my 1gtlt&, and the pennllled UHS and dlsclolu... under HIPM. 1 understand thet a revociiion If not effedhte to the extant'- my dln!ciii professlollfd has relied on the use or ~tsclosu.. of the PIQl8CteCI!leaJih lnfc,wmauon or if my aulhmzallon was obtained a a concihion of oblalnlng insuranoe C10V1118Q8 and the lnsu..r his a legal right to collleat a claim. 1 hel'llbr AJIIIa8e Browant County EldeJty and Veterilns """ Dlvlll!m. from 8IIJ Dabll~-~leh may.adse as a resull of the use of the Information released In accontance wltli thli authorization. '. VoM have tthellght to for and receive a copy of Ule foml you au. about to &Jgn. Bf you would Bike to receive a copy, please notify your cue mtllll!qer at the tll!lbe of ccmple!loill. Print Nlmlllifc-.-or"-011!1 Ro;awu Wloe..... ~..,. '.. ~ ', TO RECEMNG AGENCY: 1Ns Information has been disclosed to ~ from recont& whose con1ld8ntially Is Protected. Any further redlsclos11re Is prohibited. ' 116

117 Page 117 of 379 Exhibit A-4 Forms Phase 3 Form Templates Broward County and The Echo Group Exhibit A {Statement of Work) 117

118 Page 118 of 379 North Family Success Center Standardized Language revised Standard Assessment Standard Assessment completed previously posted on date. RFD Transition Case Note Please prepare RFD for (water, rent, 1 51 month rent) $ ; customer contribution is $ payable to. Period to cover is from to through (General Funds/EFSP). Payment is pending approval from Administration ' CM II ESFP/FEMA/General Funds The following documents were submitted: 1. Notarized letter from regarding financial support 2. Customers Consent 3. W-9 4. Current Month's Rent Acceptance Letter 5. Tenant Verification Form 6. Rent receipt for$-, ,----,---, The Assistance Inquiry was faxed and received approved eligible for assistance Special Consideration Waiver Special Consideration of to waive 20% customer contribution was approved by Regional Manager. Kathy W. Wesley, RM Received Check/ Discharge Emergency payment is evidenced by receipt of, (copy of check/verification in CSMS/verification by payment tracker). The amount of check is $ ; for housing/utility assistance; payable to, dated, on behalf of the customer. The care plan was updated and closed as: (Outcome- stable, at-risk etc.). (Performance Measure - Unsuccessful/Successful). Summary of case management activities/referrals is as follows:. The case is discharged and submitted for review ' CM II Follow up Housing Three month follow completed. Customer maintained housing. Customer does not anticipate moving within the next 3 months., CM II 118

119 Page 119 of 379 Follow up Utilities Three month follow completed. Customer maintained utilities. Customer does not anticipate future challenges., CM II Follow Up Not successful Efforts to conduct the 3 Months follow up were not successful. Several attempts to contact the customer, (Utility Company. Landlord. and other Contacts) were made to no avail ' CM II 119

120 Page 120 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Employer's Information: INCOME VERIFICATION 1. NameofCompany: Address: Phone Number: Other Phone FAX: 4. Name of Official completing information: Official's Position Title: Employee's Information: 1. Name of Employee: Social Security Number of Employee: This employee is paid: Daily Weekly Bi-Weekly Twice Monthly Monthly 4. Hourly rate of pay: 5. Weekly scheduled working hours: 6. List GROSS amounts and dates of checks or cash earned by this employee during the past _days: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: Date: Amount: 5. Does this employee receive tips in addition to the above earnings? Yes No Approximate amount of tips received: Date employment started: Date employment stopped: 7. Reason for termination: EA-05 Revised 02/22/2011 Page 1 of Reviewed 02/22/2011

121 Page 121 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION INCOME VERIFICATION WHAT I HAVE WRITTEN ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE. (Signature of Official) (Name of Official) Notary Certification: STATE OF FLORIDA CONTYOF The foregoing instrument was acknowledged before me this by, who is personally known to me or who has produced as identification. NOTARY SEAL (Notary Signature) (Name of Notary) Please have your employer complete this form and return it to Family Success Administration Division located at --=---:--;--;-.,...,.--..., ' in attention of-=,---:-;----,---:-;----,-- (Center's Address) (Case Manager's Name) Tel. # Fax# EA-05 Revised 02/22/2011 Page 2 of Reviewed 02/22/2011

122 Page 122 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Rent Acceptance Letter Request for payment#:---., ,-: (Housing Option Customers only) This is to confirm that and family, consisting of adults and children will be/is renting an apartment/house at and will be /is my tenant since. The amount of one month's rent is$ Please be aware that PAYMENTS ARE MADE BASED ON SUPERVISORY APPROVAL, AVAILABILITY OF FUNDS, VERIFICATION OF PROPERTY OWNERSIDP AND BUSINESS REGISTRATION IF LANDLORD IS INCORPORATED, AND TIMELY SUBMISSION OF THE REQUESTED DOCUMENTS. Landlord's Name: Business name (if different): Landlord's Address: Telephone #: Fax#: ' Landlord's Signature: Date: Case Manager's Name: Telephone #: Fax#: Case Manager's Signature: Date: NOTE TO LANDLORD: THIS FORM DOES NOT REPRESENT A COMMITMENT FROM BROW ARD COUNTY. THE SOCIAL WORKER ASSIGNED TO THE CASE WILL CONFIRM WITH YOU WHEN ASSISTANCE HAS BEEN APPROVED. EA-06 Revised 03/23/2011 Page 1 of 1 Reviewed 03/23/

123 Page 123 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION CONSENT FOR PAYMENT OF RENT TO LANDLORD I,,as the Tenant, give my consent for payment and authorize the Family Success Administration Division to pay to and ending on % of my monthly rent in the amount of$., the Landlord, for the period beginning on 1 understand that the rent assistance funds for which I am eligible, if any, can be paid only to the above-named Landlord, and cannot be transferred to any other landlord. Further, I understand that I am authorizing Broward County to pay the above-named landlord and, if I relocate or change my mind about staying at the above rental after signing this Consent for Payment of Rent to Landlord, I will not have any claim to the funds that are allocated to pay the above-named landlord. NOTE: PAYMENTS ARE MADE BASED ON SUPERVISORY APPROVAL, AVAILABILITY OF FUNDS, VERIFICATION OF PROPERTY OWNERSHIP AND BUSINESS REGISTRATION IF LANDLORD IS INCORPORATED, AND TIMELY SUBMISSION OF THE REQUESTED DOCUMENTS. Notwithstanding the amount authorized above for payment by the Family Success Administration Division, I agree to make payment of $ to the above named Landlord to bring my account current. Customer's Signature Date I, ' as Landlord, agree to accept the above referenced payment of$ from the Family Success Administration Division. I agree NOT to proceed with eviction for non-payment of rent of the Tenant named above, if payment by the Family Success Administration Division is granted and rendered to me within 30 to 45 days from the date of my signature below. Total amount owed by Tenant is $. FSAD assistance is $ Tenant's responsibility is$ Landlord: Check box if there is an acceptable payment plan for the Tenant's balance in place D Landlord's Name: Business name (if different): Landlord's Address: Telephone #:.,Fax#:, Landlord's Signature: Date: Case Manager's Name: ' Telephone #:.,Fax#:, Case Manager's Signature: Date: EA-07 Revised 08/07/2012 Page 1 of 1 Reviewed 08/07/

124 Page 124 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Request for Disbursement (RFD) Checklist o W-9 signed and dated within the same year (current)_ Name must match payee. o Not Applicable o Consent for payment of rent to landlord o Not Applicable D Emergency justification documents (Utility Final Notice, Eviction Notice/Default Notice) ' o Rent Acceptance Letter o Not Applicable o o Broward County Property Appraiser's Network ( printout o Not Applicable Florida Department of State Division of Corporations ( printout o Not Applicable o A copy of the documentation of Approval of Special Consideration request by FSAD Administration or Regional Manager's initials by Note in RFD indicating Special Consideration approval o Not Applicable o o A copy of the documentation of agreement between the Lending institution and customer to accept payment in lieu of foreclosure (Case Note) o Not Applicable A copy of the documentation of payee between the property owner and the payee; if paying other than the owner (Property Management Agreement) o Not Applicable o Copy of Eviction status from Clerk of Courts (htto:/lwww.clerk-17thflcourts.org/cierkwebsiteibccoc2/pasystemtransfer/courttypeselection.aspx?destina!lon=ca sesearch.aspx) o Not Applicable o Detailed description of the mathematical calculations reflecting the amount to be paid o A copy of the lease or a notarized Tenant Verffication FoiTll Prepared by: Date: Submitted by: Date: Approved by: Date: FSAD-RFD Checklist Revised Page 1 of 1 Reviewed

125 Page 125 of 379 Board of County Commissioners, Broward County, Florida Human Services Department FAMILY SUCCESS ADMINISTRATION DIVISION AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION I, SS# DOB: hereby authorize ----.,------,----.,----:---,---,-----,-,..,.--,---,--,,----,,----,---- ( name of agency/person who is authorized to release information) located at Phone: (address and phone number of agency/person who is authorized to r-e,-le-:-a-:-s.,-e"'"in""~-:-or=m-:-a::-;t"'io"'n")-~ to release information contained in my case management, housing, employment, education, financial, or other records (check all that apply), located at: -----=, Phone: (address and phone number where records are located) Sendto: ~ ~------e--,--.~--~-e---.--,-,-.---e-~~~.- (Name of agency and/or person authorized to receive the released information/records) Attn:, at the following address: Phone: "(a:-:d;:d;::re=s=-=s:-a:::n:-:d=ph"o:::n:-:e:-:::nu"'m=b-=-er:::o::-;f;-:a:-:g:::ec:nc:c:-:y/;:pc:e-=rs=-=o=-=n:-a:::u::-;t:;:h::-o::criz:::e:-:d;-t;:o-:r:::e-:-ce"'ic-::ve the rele--:a:-:s:::e 3 d'"in::-;fc:o-:-rm:::a-:-t"'io:-:n::-;/r=e=-=cc:o-:-rd:;:s:;-)- Your records become public upon applying for services with Family Success Administration Division. You have a right to review and approve any information exchange between Family Success Administration Division and another provider giving service to you. You must sign a release for any such information exchange. You have the right to review your case records at reasonable times upon prior written request with adequate notice. We request a minimum of 24 business hours or 3 days notice. Family Success Administration Division reserves the right to share information among agencies that use SSN to identify customer records needed to establish eligibility and provide services to customer. Information to be released: (Please check all acceptable items and cross out any disallowed items.) D Discharge Summary and Plan D Rental/Mortgage Payment History D Employment History D Return to Work/School D Financial Statement/History ~;]School Records D Goals and Goal Progress D Progress Notes DOther (Please specify): ReasonforRequest= This authorization shall automatically expire eighteen (18) months from the date of my signature. I may revoke this authorization at any time upon written notice to-,;,--..,..,.--,---;-;-., at the above address. I acknowledge that such revocation will not be effective if:-:-:-==:;::-====:-:: has already acted in reliance upon this authorization. TO RECEIVING AGENCY: If this information has been disclosed to you from records where confidentiality is protected, then any further re-disclosure is prohibited. Signature of Customer or Representative Date Signature of Staff (Agency Witness) Date Print Customer's Name and Relationship to Rep., if any Print Staff Name FSAD-2a Revised 02/22/2011 PagJ2f of 1 Reviewed 02/22/2011

126 Page 126 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION AUTHORIZATION FOR THE SHARING OF CONFIDENTIAL INFORMATION WITH BROWARD HUMAN SERVICE NETWORK (BHSNet) PARTICIPANT PROVIDERS Customer Name: Alias: DOB SSN Phone: Home _(_) --,----;W-;;-;-or-;-k-_-;-(~~~) understand that Florida and Federal laws and regulations require that information and documents involving me which may be contained in State and Federally funded program records, as well as criminal and medical records, be held in strict confidence and not be released without my written authorization except as allowed by State and Federal laws and regulations. I, do hereby authorize Family Success Administration Division (FSADl (Print Name of customer/legal representative) (Agency in possession of records) located at: (A~g-e_n_c--;y.-s~S~ite~N~a-m_e_a_n~d~S 7 tr-ee--;t--;a~d~d-re-s~s)~ ~(c~i 7 ty 7 )------~(S~t~at-;-e 7 ) ~(Z~ip~) to share customer information about me/my child/my ward and services provided to me/them contained in FSAD agency records, unless otherwise indicated below on this form under "limitations", with Broward Human Service Network (BHSNet) participant providers for the purpose of determining eligibility and appropriateness of services to be recommended or provided to or on behalf of me/my child/my ward in accordance with my/their case plan(s) at these agencies. This information will be available ONLY when I apply for services at a BHSNet participating agency and give them my Social Security Number. Other agencies that are not participating in the shared customer information system, BHSNet, will not have access to this information unless my social worker sends a separate, properly executed and signed Authorization for Release of Confidential Information to them. INFORMATION RELEASED IS SUBJECT TO i\)ne OF THE FOLLOWING TWO RESPONSES. MY INITIALS INDICATE THE RESPONSE I HAVE CHOSEN:,...-;----:-:- (initial) No limitations are placed on service dates, history of illness, or diagnostic and therapeutic information, including any treatment for alcohol and drug abuse, mental illness or HIV/AIDS.,...-;----:-:-(initial) Limitations are placed on service dates, history of illness, or diagnostic and therapeutic information, as follows: I FURTHER INDICATE MY UNDERSTANDING OF THIS AUTHORIZATION, AS FOLLOWS:...,.--..,.--- (initial) I understand that information used or disclosed pursuant to this Authorization may not be redisclosed without my written consent, unless otherwise provided by State or Federal laws and regulations. (initial) I have been furnished a current list of BHSNet providers from the online source. --.,..--,..--- (initial) I have been advised that the BHSNet and BIN Participant List may change during my service period or at any time in the future and that information about me and my services may be available to future BHSNet providers not currently on the list. -..,.,=---::-(initial) I have been advised that this Authorization will remain in effect until I am no longer a customer of Family Success Administration Division or I may revoke this Authorization at any time upon written notice to or to FSAD Administration at their office address. I acknowledge that such revocation will not be effective if FSAD has already acted in reliance upon this authorization, except to prohibit any further disclosure from my records to the BHSNet. Signature of Customer/Customer's Representative Date Signature of Agency Witness Date Print Name of Customer Relationship to Rep. Print Name of Agency Witness FOR CUSTOMER FILE: 1. ATTACH A COPY OF PHOTO ID OR LIST ID PRESENTED HERE: 2. ATTACH CURRENT BHSNet PARTICIPANT LIST (FROM ONLINE)-:~~~ FSAD-2b Revised 02/22/2011 Page 1 of Reviewed 02/22/2011

127 Page 127 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION CUSTOMER RIGHTS AND RESPONSIBILITIES Customer's Name SSN ---:-----:---:----,----,-- Family Success Administration Division is committed to ensuring that you receive professional services directed toward your needs in a manner that protects your dignity and feelings of self-worth. Please review this form, carefully, then initial that you understand each section and sign at the bottom of the second page. Initial Here A. CIVIL RIGHTS - You have the right to be treated with dignity and respect. - You retain all rights, benefits, and privileges guaranteed by law. B. DISCRIMINATION Services will be provided to you and/or your family members without discrimination. Ethnic background, nationality, marital status, physical or mental disability, personal or social creed, racial membership, gender, sexual orientation, religion, or age will not affect the quality of services provided to you. Travel and loss of work time will be discussed with you and kept to a minimum. Access to services will not be precluded due to lack of transportation or physical barriers. Intake and assessment may be conducted at our site or in your home or at a more convenient site based on individual need. Our facilities adhere to Americans with Disabilities Act (ADA) guidelines. Services will be provided with a minimum of waiting time. Agency service hours will be reasonably convenient to all customers requesting services. C. CONFIDENTIALITY - Your records become public upon applying for services with Family Success Administration. - You have a right to review and approve any information exchange between Family Success Administration and another provider giving service to you. You must sign a release for any such information exchange. - You have the right to review your case records at reasonable times upon prior written request with adequate notice. We request a minimum of 24 business hours or 3 days notice. - Family Success Administration reserves the right to share information among agencies that use SSN to identify customers/customer records needed to establish eligibility and provide services to customer. D. SERVICES You have a right to an individual plan of services. You have the right to know the name and professional credentials of anyon e serving you. You may request to participate in any staff meeting regarding you and/or your case plan. You may be assigned a case manager who will assist you in making a case plan, obtaining services and fulfilling your agreed-upon service plan. Whenever possible, you will be advised in advance of anything that affects you or your services. - You have the right to refuse to participate in, or to be interviewed for, research or survey purposes. - You have the right to terminate services at any time regardless of staff recommendations.,e. APPEAL/GRIEVANCE PROCEDURE - If you feel that your services have been denied incorrectly or have not been provided fairly, or reasonably, you may present your concerns, verbally and in writing, within three (3) business days following such action, to supervisory staff who will review the circumstances and render a decision within three (3) business days of receiving your complaint. If the matter is not resolved to your satisfaction, you may send a written Request for Appeal/Grievance Process to the agency~s Grievance Committee Chairperson, who will investigate and assign a hearing date for you to present your case before the Grievance Committee within three (3) business days from the date they receive your request. You will have a final decision within four (4) business days following your hearing. Forms and a copy of the complete Appeals/Grievance Policy is available from any FSAD Center-or from our Administrative Offices, 900 NW 31st Avenue, Suite 3100, Ft. Lauderdale, FL You have a right to seek legal recourse, through your own independent counsel, if you FSAD-3a Revised 02/22/2011 Page 1 of 2 Reviewed 02/22/

128 Page 128 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION believe that Civil Rights or confidentiality laws were violated in your case; however, you may request to resolve the issue through the agency~s Appeal/Grievance Process. F. EVALUATION - You have the right to refuse participation in the evaluation process( services offered every 24 months and 3 times in a lifetime) G. CUSTOMER RESPONSIBILITIES Establishing identification for all household members. - Providing proof that you are a Broward County resident. - Establishing that you have a need that can be met by the services we offer, which include assessment and referral, self-sufficiency case management, emergency financial assistance, and housing assistance. - Giving complete and correct information as requested. False information may result in denial of services. - Agreeing to apply for other services that will eliminate or reduce your need for public assistance. - Verifying income sources, income amount, expenses amount, assets and other information as requested. - Giving an informed consent to obtain information from others or to provide information to others. - Accepting case management, participating in the case management program, and making every effort to complete the service plan you create with your case manager. Following up on agreed-upon services and activities according to your service plan or requesting that the service plan be modified. Keeping all appointments or calling to cancel, at least one (1) full business day (a minimum of 24 hours) in advance, only when cancellation is absolutely necessary. NOTE: If you cannot give that much notice, please call anyway so that the person you are supposed to see will be free to see someone else. H. MUTUAL RESPONSIBILITIES OF AGENCY AND CUSTOMER Determining needs, goals and objectives through the application, intake and assessment process. Participating in all phases of planning for services, treatment, referral and discharge. Determining the frequency and duration of services. Involving family or significant others in service plans. Carrying out roles, responsibilities and activities according to the various plans created together. - Sharing information about all changes that impact services (income, residency, employment, household size; availability of services, changes in staff, and other changes). 1. AGENCY RESPONSIBILITIES: Obtaining information from you and assigning staff to work with you. - Verifying the accuracy of facts that are given by you and others regarding your case. - Making and following up on referrals to other service agencies. Communicating with Courts, protective agencies, medical personnel or responsible officials as mandated by Statute, Rule, or Court decision. Communicating with those whom you have authorized to obtain information from us. Communicating with those from whom you have authorized us to obtain information. Providing services and referrals according to your service plan. Providing follow-up and evaluation to determine whether your needs were met by services provided. I ACKNOWLEDGE THAT I HAVE READ, OR I HAVE BEEN FULLY INFORMED OF, VERBALLY, IN A LANGUAGE I UNDERSTAND. MY RIGHTS AND RESPONSIBILITIES CONTAINED IN THIS DOCUMENT AND I UNDERSTAND THEM AND AGREE TO BE BOUND BY THEM. Signature of Customer/Legal Guardian/Parent Date Signature and Title of Agency Witness FSAD-3a Revised 02/22/2011 Page 2 of2 128 Date Reviewed 02/22/2011

129 Page 129 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION STANDARD ASSESSMENT 0 Initial 0 Discharge 0 Follow-up Client's Name Case Manager Assigned ID # Date EDUCATION YES /STABLE= 3 NO/IN CRISIS = 1 1. Is your education sufficient to obtain and maintain employment and/or function in your daily life? 0 YES 0 NO 0 N/A 2. Comments N/A= EMPLOYMENT YES /STABLE= 3 NO/IN CRISIS = 1 3. Are you not in the workforce due to retirement or disability? 0 YES 0 NO 0 N/A 4. Comments N/A=O Is your employment sufficient to meet your needs at the present time? 0 YES 0 NO 0 N/A 6. Comments HOUSING YES /STABLE= 3 NO/IN CRISIS = 1 N/A= 0 7. Do you have permanent shelter (excluding homeless shelter arrangements/ programs)? 7. 0 YES 0 NO 0 N/A 8. Comments Do you believe that you will be able to maintain your current housing? YES 0 NO 0 N/A 1 0. Comments 10. INCOME YES /STABLE= 3 NO/IN CRISIS= 1 N/A=O 11. Is your income sufficient to cover all your basic needs at the present time? YES 0 NO 0 N/A 12. Comments 12. FSAD-7 Revised 09/17/2007 Page 1 of 3 129

130 Page 130 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Client's Name Assigned ID # MENTAL HEALTH YES /STABLE= 3 NO/IN CRISIS= Are you and all household members able to deal with crisis and/or emotional distress when it occurs? 0 YES 0 NO 0 N/A 14. Comments N/A= NUTRITION YES /STABLE= 3 NO/IN CRISIS= 1 N/A = Is there enough food in your home to feed all members? YES 0 NO 0 N/A 16. Comments 17. PARENTING/CAREGIVING YES /STABLE= 3 NO/IN CRISIS = 1 N/A= Do you have the skills and resources for effective parenting and/or caregiving? YES 0 NO 0 N/A 18. Comments Do you feel that all members of your household are safe from abuse or neglect? YES 0 NO 0 N/A 20. Comments 20. PHYSICAL HEALTH YES /STABLE= 3 NO/IN CRISIS = 1 N/A=O 21. Are you and all household members able to access medical care when needed? YES 0 NO 0 N/A 22. Comments If you or your household members need assistance to perform activities of daily living, are 23. you receiving it? 0 YES 0 NO 0 N/A 24. Comments If you are in need of reproductive health care and family planning services, are you receiving 25. them? 0 YES 0 NO 0 N/A 26. Comments 26. FSAD-7 Revised 09/17/2007 Page 2 of 3 130

131 Page 131 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Client's Name Assigned ID # SOCIAL FUNCTIONING YES /STABLE= 3 NO/IN CRISIS = 1 N/A= Do you have a reliable family and/or social support system? YES 0 NO 0 N/A 28. Comments 28. SUBSTANCE USE YES /STABLE= 3 NO/IN CRISIS = 1 N/A= Are you and other household members free from issues or problems due to substance use? YES 0 NO 0 N/A 30. Comments 30. TRANSPORTATION YES /STABLE= 3 NO/IN CRISIS = 1 N/A= Are you able to adequately meet all your transportation needs? YES 0 NO 0 N/A 32. Comments 32. Education #1 QUESTION SCORE LEVEL Employment #2 Employment #3 Housing#4 Housing #5 Income#6 Mental Health #7 Nutrition #8 Parenting/Caregiving #9 Parenting/Caregiving # 10 Physical Health # 11 Physical Health # 12 Physical Health # 13 Social Functioning # 14 Substance Use #15 Transportation #16 FSAD-7 Revised 09/17/2007 Page 3 of3 131

132 Page 132 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION CONSENT FOR CASE MANAGEMENT SERVICES Customer's Name SSN I, the undersigned customer, have read this document in its entirety and agree to the following: 1. I request and authorize case management services to be rendered to (PRINT NAME OF PERSON OR PERSONS TO RECEIVE SERVICES) by Family Success Administration Division (FSAD}, including any Agents or independent contractors with whom they contract. 2. I understand and agree that such case management services shall only be provided when requested by myself or by FSAD staff. I understand that I will be working closely with a case manager to assist me in obtaining services for problems I am currently experiencing to help improve my quality of life. 3. I understand and agree that the record generated as a result of my case management services at Family Success Administration Division is the sole custody of the agency, and that I or my legal guardian/representative has the right to request of the agency copies of records for verification of services rendered. Such verification for the purposes of disputing any services rendered by Family Success Administration shall be accomplished by participating in the FSAD grievance process which requires that I notify the agency within three (3) days of receiving services that I have a complaint or an appeal. 4. I understand and agree that the relationship with the provider for case management services rendered at Family Success Administration is limited in the time and scope to the actual case management services at Family Success Administration, and that this relationship automatically expires upon completion of services requested. Therefore, upon leaving or being discharged from services, and thereafter, it is my sole responsibility to seek all follow-up and additional services needed, whether or not included in my records, or discussed with me at discharge or anytime during participation in services. 5. I agree that a case manager can contact me for up to two years following termination, to collect follow up information about my progress. In the event that the case manager is unable to locate me, you have my permission to contact other agencies, friends or family that I have identified as alternate contacts in my case. Signature of Customer Indicating Agreement and Acceptance of the Above, Each Statement Having Been Individually Initialed by Signee. Date Signature of Agency Witness Date FSAD-9 Revised 02/22/2011 Page 1 of Reviewed 02/22/2011

133 Page 133 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION NOTICE OF DISPOSITION Name: Case#: Date: Address: Tel.#: REQUEST/SERVICE SPECIFIC SERVICE PERIOD COVERED AMOUNT REFERRED TO APPROVAL STATUS Shelter/Rent/Mortgage DYES DNO DPending Utility Assistance DYES DNO DPending Food Assistance DYES DNO DPending Bus Pass DYES DNO DPending Case Management DYES DNO DPending Child Care DYES DNO DPending CAA DYES DNO DPending H.O.P. DYES DNO DPending Other Services DYES DNO DPending Request for Assistance is being held for a maximum often WORKING DAYS pending further information/documentation requested below. If you do not provide this documentation by your case will be closed. If you are approved for this assistance, this agency will be making the payment to The Emergency Assistance from General Funds can be accessed one time every twenty-four (24) months, but no more than three (3) times in a lifetime. *Please be aware that PAYMENTS ARE MADE BASED ON SUPERVISORY APROV AL, AVAILABILITY OF FUNDS, VERIFICATION OF PROPERTY OWNERSHIP AND BUSINESS REGISTRATION IF LANDLORD IS INCORPORATED, AND TIMELY SUBMISSION OF THE FOLLOWING DOCUMENTATION: IDENTIFICATIONS DPending Copy of Picture ID for I DPending Copy of Social Security Cards for I I DPending If Social Security Card lost, copy of print screen from Social Security Administration verifying social security number. DPending If never applied for Social Security Card, copy of receipt from Social Security Administration verifying application received. DPending Hospital Foot Print Certificate (Newborns Only) DPending Birth Certificates for Minor Children EMERGENCY TYPE: DPending Eviction Notice DPending Late Notice or Letter of Default/Foreclosure from Mortgage Company threatening further action. DPending Utility Final or Shut -offnotice INCOME/BENEFITS DPending Copies of I I pay stubs from I 1 to 1 DPending Completed Verification oflncome Form DPending Proof of I I Benefit Income. Award letter that includes amount. DPending Proof of future employment: Letter written on company stationery or with attached business card, indicating start date, hourly rate, and hours you will be working. These earnings must be sufficient to meet monthly expenses. DPending Proof of Application for Food Stamp Benefits, with DCF's Receipt date stamp DPending Bank Statements for the month/s I DPending Notarized Statement from I I about I I (include address and phone number of person writing_ statement). FSAD-13 Revised 02/22/2011 Page 1 of Reviewed 02/22/2011

134 Page 134 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION Name: Case#: LOSS/INTERRRUPTION: opending Proof of Income Loss. If laid off or fired, letter with reason for termination and date of termination. opending Proof of Income Loss. If job is being held for you, letter on letterhead indicating last date worked; that time not worked will not be financially compensated; and that the job is being held for you pending your return to work. opending Proof of Income Loss. If unable to work due to illness, a doctor's statement is necessary indicating date of onset of illness, and approximate date you may return to work. opending Proof of Income Loss. In case of theft, copy of Police Report filed within 48 hours after incident. opending Proof of Income Loss. In case of benefits loss or reduction, letter indicating when this occurred and the amount of loss or reduction. opending Proof of Unexpected Expense. Copy of receipt to include total amount and date. oauto repair ohome repair odental omedical a Appliance repair otuition FROM LANDLORD opending Copy of Lease Agreement opending W-9 form completed by Landlord opending Consent of Payment of Rent to Landlord; signed by worker, landlord and tenant. opending Rent Acceptance Letter completed by new landlord. New residence must be within Broward County. Rent not to exceed $ -:-----=----===--=-:- DTenant Verification Form (FEMA ONLY) LIFE SKILL CLASSES DATE TIME OTHER: I Worker's Name: Worker's Signature Date: Customer's Name: Customer's Signature: Date: Office: Telephone #: Fax#: FSAD-13 Revised 02/22/2011 Page 2 of Reviewed 02/22/2011

135 Page 135 of 379 From: To: Customer Name: Address: Telephone: Services Requested: Reason for Referral: Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT FAMILY SUCCESS ADMINISTRATION DIVISION REFERRAL FORM Date: (Section or Agency Receiving Referral) -= o=.- ID# Last First Work Phone: Time: Customer Assigned Signature of Person Making Referral Supervisor's Signature Telephone Number Fax Number TO HELP US TRACK THE CUSTOMER'S PROGRESS, PLEASE REPLY BY FAXING BACK THE FOLLOWING FORM From: Date: Time: To: Customer Name: Address: Disposition: (Section or Agency Receiving Referral) Customer Assigned ID ~~ ~ # Last First Signature of Person Replying Telephone Number Fax Number FSAD-17 Revised 02/22/2011 Page 1 of Reviewed 02/22/2011

136 Page 136 of 379 Form W 9 Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Check appropriate box for federal tax classification (required): D Individual/sole proprietor D C Corporation D S Corporation D Partnership D Trust/estate D Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership).., i Exempt payee ' name Enter your I in the appropriate box. TIN provided must match the name given on "Name" fine to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. 1@111 Certification Under penalties of perjury, I certify that: I Employer identification number m-tlllllll 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are. currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Signature of Here u.s. person..,. Date..,. General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section ). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. N63fu231X Form W-9 (Rev )

137 Page 137 of 379 Form W-9 (Rev ) Page2 The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases: The U.S. owner of a disregarded entity and not the entity, The U.S. grantor or other owner of a grantor trust and not the trust, and The U.S. trust (other than a grantor trust) and not the beneficiaries of the trust. Foreign person. If you are a foreign person, do not use Form W-9. Instead, use the appropriate Form W-8 (see Publication 515, Withholding of Tax on Nonresident Aliens and Foreign Entities). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a "saving clause." Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items: 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 3D, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity not subject to backup withholding, give the requester the appropriate completed Form W-8. What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS a percentage of such payments. This is called "backup withholding." Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester, 2. You do not certify your TIN when required (see the Part II instructions on page 3 for details), 3. The IRS tells the requester that you furnished an incorrect TIN, 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or 5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only). Certain payees and payments are exempt from backup withholding. See the instructions below and the separate Instructions for the Requester of Form W-9. Also see Special rules for partnerships on page 1. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Name If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name, for instance, due to marriage without informing the Social Security Administration of the name change, enter your first name, the last name shown on your social security card, and your new last name. If the account is in joint names, list first, and then circle, the name of the person or entity whose number you entered in Part I of the form. Sole proprietor. Enter your individual name as shown on your income tax return on the "Name" line. You may enter your business, trade, or "doing business as (DBA)" name on the "Business name/disregarded entity name" line. Partnership, C Corporation, or S Corporation. Enter the entity's name on the "Name" line and any business, trade, or "doing business as (DBA) name" on the "Business name/disregarded entity name" line. Disregarded entity. Enter the owner's name on the "Name" line. The name of the entity entered on the "Name" line should never be a disregarded entity. The name on the "Name" line must be the name shown on the income tax return on which the income will be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a domestic owner, the domestic owner's name is required to be provided on the "Name" line. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on the "Business name/disregarded entity name" line. If the owner of the disregarded entity is a foreign person, you must complete an appropriate Form W-8. Note. Check the appropriate box for the federal tax classification of the person whose name is entered on the "Name" line (Individual/sole proprietor, Partnership, C Corporation, S Corporation, Trust/estate). Limited Liability Company (LLC). If the person identified on the "Name" line is an LLC, check the "Limited liability company" box only and enter the appropriate code for the tax classification in the space provided. If you are an LLC that is treated as a partnership for federal tax purposes, enter "P" for partnership. If you are an LLC that has filed a Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for C corporation or "S" for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation section (except for employment and excise tax), do not check the LLC box unless the owner of the LLC (required to be identified on the "Name" line) is another LLC that is not disregarded for federal tax purposes. If the LLC is disregarded as an entity separate from its owner, enter the appropriate tax classification of the owner 137 identified on the "Name" line.

138 Page 138 of 379 Fonn W-9 (Rev ) Other entities. Enter your business name as shown on required federal tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on the "Business name/ disregarded entity name" line. Exempt Payee If you are exempt from backup withholding, enter your name as described above and check the appropriate box for your status, then check the "Exempt payee" box in the line following the "Business name/ disregarded entity name," sign and date the form. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. The following payees are exempt from backup withholding: 1. An organization exempt from tax under section 501 (a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401 (f)(2), 2. The United States or any of its agencies or instrumentalities, 3. A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities, 4. A foreign government or any of its political subdivisions, agencies, or instrumentalities, or 5. An international organization or any of its agencies or instrumentalities. Other payees that may be exempt from backup withholding include: 6. A corporation, 7. A foreign central bank of issue, 8. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States, 9. A futures commission merchant registered with the Commodity Futures Trading Commission, 10. A real estate investment trust, 11. An entity registered at all times during the tax year under the Investment Company Act of 1940, 12. A common trust fund operated by a bank under section 584(a), 13. A financial institution, 14. A middleman known in the investment community as a nominee or custodian, or 15. A trust exempt from tax under section 664 or described in section The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 15. IF the payment is for... Interest and dividend payments Broker transactions Barter exchange transactions and patronage dividends Payments over $600 required to be reported and direct sales over $5.000' THEN the payment is exempt for... All exempt payees except for9 Exempt payees 1 through 5 and 7 through 13. Also, C corporations. Exempt payees 1 through 5 Generally, exempt payees 1 through 7 2 Part I. Taxpayer Identification Number (TIN) Page3 Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. If you are a sing-le-member LLC that is disregarded as an entity separate from its owner (see Limited Liability Company (LLC) on page 2), enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or partnership, enter the entity's EIN. Note. See the chart on page 4 for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local Social Security Administration office or get this form online at You may also get this form by calling Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EJN online by accessing the IRS website at and clicking on Employer Identification Number (EIN) under Starting a Business. You can get Forms W-7 and SS-4 from the IRS by visiting IRS.gov or by calling TAX-FORM ( ). If you are asked to complete Form W-9 but do not have a TIN, write "Applied For" in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note. Entering "Applied For" means that you have already applied for a TIN or that you intend to apply for one soon. Caution: A disregarded domestic entity that has a foreign owner must use the appropriate Form W-8. Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, below, and items 4 and 5 on page 4 indicate otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). ln the case of a disregarded entity, the person identified on the "Name" line must sign. Exempt payees, see Exempt Payee on page 3. Signature requirements. Complete the certification as indicated in items 1 through 3, below, and items 4 and 5 on page Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 1 See Fonn 1099-MISC, Miscellaneous Income, and its instructions. 2 However, the following payments made to a corporation and reportable on Fonn MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency. 138

139 Page 139 of 379 Form W-9 (Rev ) 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments to certain fishing boat crew members and fishermen, and gross Proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account: 1. Individual 2. Two or more individuals (joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law 5. Sole proprietorship or disregarded entity owned by an individual 6. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulation section (b)(2)(i)(A)) For this type of account: 7. Disregarded entity not owned by an individual 8. A valid trust, estate, or pension trust 9. Corporation or LLC electing corporate status on Form 8832 or Form Association, club, religious, charitable, educational, or other tax-exempt organization 11. Partnership or multi-member LLC 12. A broker or registered nominee 13. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments 14. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulation section (b)(2)(i)(B)} Give name and SSN of: The individual The actual owner of the account or, if combined funds, the first individual on the account ' The minor' The grantor-trustee ' The actual owner ' The owner" The grantor* The owner Legal entity ' Give name and EIN of: The corporation The organization The partnership The broker or nominee The public entity The trust Note. If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records from Identity Theft Page4 Identity theft occurs when someone uses your personal information such as your name, social security number (SSN), or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: Protect your SSN, Ensure your employer is protecting your SSN, and Be careful when choosing a tax preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at or submit Form For more information, see Publication 4535, Identity Theft Prevention and Victim Assistance. Victims of identity theft who are experiencing economic harm or a system problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling thetas toll-free case intake line at or TTY!TDD Protect yourself from suspicious s or phishing schemes. Phishing is the creation and use of and websites designed to mimic legitimate business s and websites. The most common act is sending an to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via s. Also, the IRS does not request personal detailed information through or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited claiming to be from the IRS, forward this message to [email protected]. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration at You can forward suspicious s to the Federal Trade Commission at: [email protected] or contact them at or IDTHEFT ( ). Visit IRS.gov to learn more about identity theft and how to reduce your risk. 1 list first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person's number must be furnished. 2 Circle the minor's name and furnish the minor's SSN. 3 You must show your individual name and you may also enter your business or "DBA" name on the "Business name/disregarded entity" name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships on page 1. *Note. Grantor also must provide a Form W-9to trustee of trust. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax retum. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. 139

140 Page 140 of Doportmont "'... Do not -lhlllorm far: A u.s. clllz$> or other U.S. parson, Including a resident allen lndlllldual A person claiming lncoma is alfacuvely connected with t11e conduct of a trade or business In ll1e Unill!d States A loralgn paj1ne1!511lp, a to111ign simple - or a lo111ign gnmtor trust (see Instruction$ for exceptions) A foreign govemmen~ lnll!mational organization, foralgn central bank of Issue, foreign lax-exempt ~lion. Fonn W BBEN (Rev. Ftlltul<y 2006) Certlflcate of Foreign Status of Beneficial Owner for United States Tax Withholding Sectlolltel-.""' tollle--ea """"""" lnalrucllans.... -lids fonn to ""' wllhhaldlng -'... Do not -to foreign private toi.wid8tion. or government of a U.S. p c san a ion that received effectively comscted Income or that ts claiming 111e applicability of section(s) 115(2), 501(o), 892, 895, or 1443(b) (see Instructions) Note: 7hese enlitios should use Fonn W-8BEN if they..., claiming trvaty benefits or""' prrwldlng ll1e fonn only to claim they""' a f'onjign petson exempt from baclwp wllhholdlng. A person acting as an intar(nediejy OMB No lnsllad, uu Form: W-9 W-8ECI W-8ECI or W-SIMY.W-8ECI or W SEXI' W-81MY ---for-e>«:epplons. of individual or Country of owner. lndmduaj Corporation PartnenlhiP Siri'IP'a tru:at 0 Grantor""" 0 Complex 1rUot 0 Estate 0 G""""'ment 0 lntomationalorganizalkjn 0 """""'ballk alissue 0 Tu...,. O!!!!!!!izalion 0 Private foundation 4 Pennanent reaidence addrese (eb'eet, apt. or sufte no., or rural route). Do not.., a P.O. bml: or ln-gara-of acldnll:l. City or town, state or pn>vince. Include po.slal cede where -opl18ta. Country (do not abbreviate) 5 Malfmg -ress (If-from above) City or ~wn, state or ptovince. Jndude postal code where appropriate. Country (do not abbreviate) e u.s. laxpeyer lden1ifioation number, ff required (see lnatructlons) 7 Fonllgn lax ldenlif)llng number, H any (options~ 0 SSNormN a Reference number($) (see lnslrucllons) I filii Claim of 'lllx 1l'eatY a-fits Of applicable) 9 1-'lfV_(_elllllat-"1: a 0 The benellclal..., ~a resident of... wllhmlho meaning ollho ""'""'taxjruty-. the Uriled llllles and lhol COlllllry. b 0 If requinki, lhe U.S. taxpayer Identification number Is stated on line 6 (see instructions). c 0 1he benetlclal owner is notan lndmdual, darivas the Item (or Hems) of lnccme for which 111e treaty benehis ere Claimed, and, ff applicable, meetsll1e requiremenls of ll1e treaty provision daaung. wilh limitation on beneftts (see inslruclions). d 0 The beneficial owner is not an lndivid\lal, is claiming treaty benehis lor dividends receiv8d from a foreign CO!pOI'ation or lntereat frqm a U.S. lfllda or businass of a toralgn corporation, end 1110ets qualified resident status (see inslluctlons). e 0 1he beneficial owner is rolated to 11M! parson obligated to pay ll1e Income within the meaning ol secllon 267(b) or 707{1>), and will file Form 8833 if the amount subject to withholding recej\oed during a calendar year xceeds, in the aggregate, $500, Special -and condillonsl!f applies~ lnstructiona): 1he beneficial owner is claiming 111e provisions of Article... oflho treaty identified on line 8a above to claim a % rate of withholding on (specify type of income):. Explain ll1e ressona ll1e beneficial owner meets the tanns ofth<> treaty article: ~ Sign Here L,.. ;,;;;;.;;:;.::ot """"....:.:.:.;.;~:;... -.::.:.:.:. 1.,... ind..;;:;;.::,.::.;.:.:;:.::;;.: "'""'...'""""' :.::, <.:.:;.::= ,.. om.;(mm:od-yyyy,--. --~-i"ti" ;h!qh acung For Paperworf< Roducllon Aot Notice, see _ ruotions. Cat. No. 2$047Z Fonn W 8BEN (Rev ) 140

141 Page 141 of 379 Board of County Commissioners, Broward County, Florida Human Services Department FAMILY SUCCESS ADMINISTRATION DIVISION Contact Information & Referral Form Date: Time: D Walk in D Phone D Agency Referral D Other Demographic Information: Last Name: First Name: Address: Apt#: City: Zip Code: Gender: M D F D Phone Number: Alternate Phone Number: Age: 0 Over 60? Ethnicity: SSN: ---=--==----- Have you been assisted by any Family Success Center in the past 24 months? YesD No D If yes, what kind of assistance did you receive? ::-,---, Primary Language: Services Requested: FOR OFFICIAL USE ONLY Orientation Attended: D YesD No Date: Referred To: Visit Staff Initials Date Time Missing Documents I Comments Appointment With: Date: Time: Comments: Entered in Database: D Date: Customer Ref. #: FSAD-Customer I&R Revised 11/16/2011 Page 1 of Staff Initials: D CSMS checked Reviewed 11/16/2011

142 Page 142 of 379 Exhibit A-5 Forms Phase 4 Form Templates Broward County and The Echo Group Exhibit A (Statement of Work) 142

143 Page 143 of 379 Florida Department of Elder Affairs 701 B Comprehensive Assessment Rule: 58-A , F.A.C. Provider ID: Assessor/Case Manager (CM) Name: Provider Assessor/CM ID: Signature: A. DEMOGRAPHIC SECTION 1. ASSESSOR/CM: What is the purpose of this assessment? D Initial. 0 Annual D Health D Living situation D.Caregiver 0 Environment 0 Income 2. Social Security number: ~------~----~ o--~~ Name: a. First: b. Middle initial: c. Last: ~--~----~ ~ ~ ~----~~--~ ~~ Medicaid number: 5. Phone number: 6. Date of birth (mm/dd/'fyyy): 7. Sex: DMale 8. Race (Mark off that apply).: D White 9. Ethnicity: 10. Primary language: D American Indian/Alaska Native D Hispanic/Latina D English D Female.0 Black/African American D Native Hawaiian/Pacific Islander D Other Dspanish Dother: D Asian 0 Other 11. Does client have limited ability reading, writing, speaking, or understanding English? D No D Yes 12. Marital status: 0 Married D Partnered D Single 0 Separated D Divorced D Widowed. 13. ASSESSOR/CM: Current Physical Location Address {If type is a facility, enter facility name.) a. Street: b. City: d.type: e. Name: ~ ~ ~------~--~c.zipcode: ~~--- 0 Private residence 0 Assisted livingfacility (ALF) D Nursing facility 0 Hospital 14. Home.Address (If different/rom current physical location) a. Street: b. City: 15. Is client's home address public housing? DNo DYes 16. Mailing Address {If different from current physical location) a. Street: c. State: Adult day care 0 Other b. City: c. ZIP code: ~-- d. ZIP code: ~----~ ~----~~ 1 DOEA701B,April

144 Page 144 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment A. DEMOGRAPHIC SECTION, CONTINUED 17. ASSESSOR/CM: Assessment date: (mm/dd/yyyy),...-,..-~-,..-,..-~--, ,------~ 18. ASSESSOR/CM: )l,s$essmentsite: D Home D A~F D N\)rSing facility D Hospital D Adult day care Dother 19. ASSESSOR/CM: Referral date: (mm/dd/yyyy) 20. ASSESSOR/CM: Referral SOIJrce: D Self/Family D Nursing facility D Case management agency D CARES D Aging out D Hospital D Department of Children and Families D Other D APS: Select level ofaps risk.: D High D Intermediate D Low 21. ASSESSOR/CM: Transitioning out of a nursing facility? D No DYes 22. ASSESSOR/CM: Imminent risk of nursing home placement? DNa DYes 23. Do you need outside assistance to evacuate? D No DYes 24. Are you enrolled on a special needs registry? DNa DYes 25. Is there a primary caregiver? D No DYes 26. Living situation: D With primary caregiver D With other caregiver D With other D Alone 27. Individual monthly income: $ D Refused ~------~~~~ 28. Couple monthly intonne: $ D Refused D N/A 29. Estimated total individual assets: $ D $0 to $2,000 D $2,001 to $5,000 D $5,001 or more D Refused 30. Estimated total couple assets: $ D $0 to $3,000 D $3,001 to $6,000 D $6,001 or more D Refused DN/A 31. Are you receiving S/NAP (food stamps)? D No DYes ~2. Do you need other assis.tanc::ejor food? D.No DYes 33. ASSESSOR/CM: Is someone besides the client providing answers to questions? D No (Skip to 34) D Yes. a. Name: b.relationship: 34. Besides your own children, how many children under age 19 do you live with and provide care for? (if zero, skip to 35) a. How many are grandchildren? # Name(sJ: _c#c,. b. How many are other related children? # Name(sJ: c. How many are other non'related children? # _,_N,CJ,_m,_,e~r~sl"': '--'-----' How many disabled adults age 19 to 59 do you live with and provide care for? (if zero, skip to 36) # -"-~a. How many are grandchildren? # Name(s): b. How many are other relatives? # Name(sJ: c. How many are other non-relatives? # Name(s): Notes & Summary: 2 DOEA701B,Apri

145 Page 145 of 379 B. MEMORY SECTION Florida Department of Elder Affairs: 701 B Comprehensive Assessment 36. Has a doctor or other health care professional told you that you suffer from memory loss, cognitive impairment, any type of dementia, or Alzheimer's disease? D No D Yes 37. ASSESSOR/CM: If the client is not answering questions, skip to Question 47 and check: D 38. "I am going fo say three words for you.to remember, Please repeat the words after I have said them. The words are: sock (something to wear), blue (a color), and bed (a piece of furniture). Now you tell me the three words." ASSESSOR/CM:. Select the number of words correctly repeated after the first attempt: D Sock D Blue D Bed Total number of correct words: D None D One D Two D Three "Thank you. I willask you to repeat these to me again later." 39. Please tell me what year it is: 0 Correct D Missed by one year D Missed by two to five years D Missed by five or more years D Noanswer 40. Please tell me what month it is: D Correct D Missed by one month D Missed by two to five months D Missed by five or more months D No answer 41. Please tell me what day (of the week) it is: D Correct D Incorrect D No answer 42.. "Let's go back.to an earlier question. What were those words r asked you to repeat back to me?" D Sock D Blue D Bed 43. ASSESSOR/CM: Number of words correctly recalled without prompting: DNone Done DTwo DThree 44. Have any friends or family members expressed concern about your memory? D No 45. Have you become concerned about your memory or had problems 0 D remembering important things? No (Skip to 47) 46. How often do you have problems remembering things? D Always D Often D Sometimes. D Rarely D Don't know DYes 47. ASSESSOR/CM: In your opinion, are cognitive problems present? D No DYes D Don't know Notes & Summary: Yes 3 DOEA 701B, April

146 Page 146 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment C. GENERAL HEALTH, SENSORY & COMMUNICATION SECTION 48. How would. you rate youroverall health at this time? D Excellent D Very Good DGood DFair DPoor 49. Compared to a year ago, how would you rate your health? D Much better D Better D About the same D Worse D Much worse 50. How often do you change or limit your activities out of fear of falling? D Never D Occasionally D Often D All of the time 51. How many times have you fallen in the last six months? # 52. How often are. there things you want to do but cannot because of physical problems? D Never y Occasionally D Often. D All of the time When you need medical care, how often do you get it? D Always D Most of the time D Rarely D Only in an emergency D Never 54.. When you need transportation to medical care, how oftendo you get it? D Always D Most ofthe time D Rarely D Only in an emergency D Never 55. Do you drive a car or other motor vehicle? D No DYes 56..How often do finances/insurance allow you to obtain health care and medications when you need them? D Always D Most of the time DRarely D Only in on emergency D Never 57. Have you visited the emergency room (ER) or been admitted to the hospital within the last year? D NoD Yes: How many times? ER# Hospital# 58. In the last year were you ino nursing or rehabilitation facility? D NO DYes. 59. Are you usually able to climb two or three stair steps? D No DYes D Don't know 60. ASSESSOR/CM: Are tht;!re any stairs within the dwelling or leading into/put of the dwelling? D No DYes 61. Are you usually able to carry a full glass of water across a room without spilling it? DNo DYes D Don't know 62. Has a doctor. told you thaf you currently have vision problems? DNo DYes D Blind.{If blind, Skip to 63) a. Have you had an eye exam in the past year? DNo DYes b. Do you bump into objects (people, doorways) because you don't see them? DNo DYes c. Is your vision getting worse than it was last year? D No D In one eye D Slightly worse D Much worse 63. Has a doctor told you that you currently have hearing problems? D No DYes D Deaf (If deaf, skip to 64) a. Have you had a hearing exam in the past year? D No DYes b. Can you understand words clearly over the telephone? DNo DYes c. Is your hearing worse than it was last year? DNo DIn one ear D Slightly worse D Much worse. 64. ASSESSOR/CM: DQes c:;lient rely on writing, gestures, or signs to c:;ommunic:;ate? D No DYes. 65. ASSESSOR/CM: Are the c:;lient's words formed properly, not slurred or c:;lipped? D No DYes 66. ASSESSOR/CM: Are any sensory aids or assistive devices currently used? D No DYes If yes, please list the type(s) used: 67. ASSESSOR/CM: Is there an unmet need for a sensory aid or assistive device? D No DYes If yes, please list the type(s) needed: 4 DOEA701B,April

147 Page 147 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment D. ACTIVITIES OF DAILY LIVING SECTION 68. How much assistance dqyau need with the following tasks? No Uses Needs Needs Needs total Task assistance assistive supervision assistance (but assistance needed device or prompt not total help) (cannot do at all) a. Bathing D D D D D b. Dressing D D D D D c. Eating D D D D D d. Using the bathroom D D D D D e. Transferring D D D D D f. Walking/Mobility D D D D D 69. ASSESSOR/CM: Is there an unmet need for an ADL assistive device? 0No DYes Type(s) needed: 70. How much assistance do you have with the following tasks? Task Has No assistance assistance Always has most of the Rarely has Never has needed assistance time assistance assistance a. Bathing D D D D D b. Dressing D D D D D c. Eating D D D D D d. Using the bathroom D D D D D e. Transferring D D D D D f. Walking/Mobility D D D D D Notes & Summary: 5 DOEA 701 B, April

148 Page 148 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment E. INSTRUMENTAL ACTIVITIES OF DAILY LIVING SECTION 71. How much assistance do you need with the following tasks.? No Uses Needs Needs Needs total Task assistance assistive supervision assistance (but assistance needed device or prompt not total help) (cannot do at all) a. Heavy chores D D D D D b. Light housekeeping D D D D D c. Using the telephone D D D D D d. Managing money D D D D D e, Preparing m$als D D D D D f. Shopping D D D D D g. Managing medication D D D D D h. Using transportation D D D D D 72. ASSESSOR/CM: Is there an unmet need for an /ADL assistive device? DNo DYes Type(s) needed: 73. How much assistance do you have with the following tasks? Has Task No assistance assistance Always has most of the Rarely has Never has needed assistance time assistance assistance a. Heavy chores D D D D D b. Light housekeeping D D D D D c. Using the telephone D D D D D d. Managing money D D D D D e. Preparing meals D D D D D f. Shopping D D D D D g. Managing medication D D D D D h. Using transportation D D D D D Notes & Summary: 6 DOEA 701 B, April

149 Page 149 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment F. HEALTH CONDITIONS & THERAPIES SECTION 74. Have you b<3ehfoldby a physic::iar1 thai you have any of.the following.h<3alth conditions? ASSESSOR/CM: Indicate whether.ci problem occurred in the past by.marklng the first box and when a problem is current by marking the.second box. Mark alpthat qpply. Past Current Health Conditions D D AcidreiiUx/GERD D D Allergies, list: D D Amputation, site: D D Anemia D Severe D Moderate DMild D D Arthritis, type: D D Bed sore(s) (Decubitus), location: D D Blood.pr<3ssure D High D Low D D Broken bones/fractures, location: D D Cancer, site: D D Chlamydia D D Cholesterol D 1-Hgh D Low. D D Dehydration D tj Diabetes D IDDM DNIDDM D D Dizziness D Constant D Frequent D Occasional D Rare D D Fibrotnyalgia D D Gallbladder D Removal D Problems D D Gonorrhea D D Heart problems D Pacemaker D CHF DMI D Other D D Head, brai.h, or spinal.cord trauma D D Herpes D D Humqn Immunodeficiency Virus (HIV) D D Human Papilloma Virus (HPV)/ Genital warts D D Incontinence, bladder D Constant D Frequent D Occasional D Rare D D Incontinence, bowel D Constant D Frequent D Occasional D Rare D D Kidney prqblems or renal disease tnd stqge? D No DYes D D Liver problems D Cirrhosis D Hepatitis D D L.l)ng problems D Emphysema D Asthma D Pneumonia D COPD D D Lupus D D Multiple Sclerosis D D Muscular Dystrophy D D Osteqporosis D D Parkinson's disease D D Paralysis D Full D Partial D Local, site: D D Seizure disorder, type & frequency: 7 DOEA 701 B, April

150 Page 150 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment F. HEALTH CONDITIONS & THERAPIES SECTION, CONTINUED Past Current Health Conditions D 0 Shingles D D Stroke /CVA D D Syphilis D D Thyroid problems/graves/myxedema D Hyper D Hypo D D Tumor(s)., site: D D Ulcer(s), site: D D Urinary Tract Infection (UTI) D D Other: 75. i'rovic:le information on the frequency of current therapies orspecialty care: Several Several N/A or times times Treatment t1'12e: None Monthl1' Weekl1' a week Dail1' a da'z' a. Bladder/bowel treatment D D D D D D b. Catheter, type: D D D D D D c. Dialysis D D D 0 D D d. Insulin assistance D D D D D D e. IV Fluids/IV Medications D D D D D D f. Occupational therapy D D D D D D g. Ostomy, site: D D D D D D h. Oxygen D D D D D D i. Physical therapy D D D D D D j. Radiation/Chemotherapy D D D D D D k. Respiratory therapy D D D D D [] I. Skilled nursing D D D D D D m. Speech therapy D D D D D 0 n. Suctioning D D D D D D 0. Tube feeding D D D D D D p. Wound care/lesion irrigation D D D D D D q. Other therapy, type: D D D D D D Notes & Summary: 8 DOEA 701 B, April

151 Page 151 of 379 G. MENTAL HEALTH SECTION Florida Department of Elder Affairs: 701 B Comprehensive Assessment ASSESSOR/CM: If the client is not answering questions, Skip to Question 80 and check: D 0 Satisfied Overy dissatisfied. 76. How satisfied are you. with your overall. quality of life? 0 Very satisfied D Neither satisfied nor dissatisfied 0 Dissatisfied 77. Thinking about how you were this time last year. how do you feel about the way things are now? 0 Much better 0 Better 0 About the same 0 Worse D Much worse 78. Over the past two weeks,how often have you.been bothered by any of the fouowing proolems? (Adapted from the PatienNHealth Questionnaire PHQ.9, Pfizer) a. Little interest or pleasure in doing things b. Feeling down. depressed. orhopeless c. Trouble falling or staying asleep, or sleeping too much d. Feeling tired or having little energy e. Poor appetite or overeating f. Feeling bad about Yourself- or that you are a failure or have le.t yourself or your family down Not at all More, than Nearly Several half the. every days days day D D 0 D D D 0 D D 0 D D 0 g. Trouble concentrating on things, such as reading the newspaper or watching television 0 D D 0 h. Moving or speaking so slowly that other peoplenoticed - Or, the opposite, beiog so fidgety. or restless that you have been moving oround o.lot more than usual i. Thoughts that you would be better off dead or of hurting yourself in some way D ~Thot~9hts of suicide: or seu-i~]~(y, hauucipt~ti6ns,: or aggr~ssi;e beho~fo~-;~r~:p d'te.nnqlly s~ri6us proble;-ns that should be r~pqrled immediately to a p~mary care physician_:_emergency core, law enforcfiment. and/or Adult Protective Services, as appropriate. ASSESSOR/CM: Only ask Question 79 if client answered "more than half the days" or "nearly every day" to at least one item in Question 78. Otherwise, skip to Question , H.ow difficult have these problems made it for you in your daily life activities and interactions with.others? 0 Not difficu!tatau D Somewhat difficult D Very difficult D Extremely clifficult 80. Have you been diagnosed with a mental condition or psychiatric disorder by a health professional? DNo DYes: List conditions: 81. Are you currently working with a professional to helpw c-ccit"'h-a,-.-m-e-n-cta--clc----d--n-o--0--,-.. -Y.-e_s_{_Sk-ip-to-B_)_ condition? 2 a. Have you or do you plan to discuss these issues with a professional? 0 No D Yes {Skip to 82) b. Do you talk about any of these issues with anyone else you know? D No D Yes 9 DOEA701B,Apri

152 Page 152 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment G. MENTAL HEALTH SECTION, CONTINUED 82. ASSESSOR/CM: Indicate whether you noticed problem behaviors or any recurring problems have been reported to you by the client, caregiver, in-home worker, family, or staff, and note the frequency of occurrence in!he last month. Provide details in the Notes & Summary section, below. More Nearly Several than half every Problem. behaviors Not at all Once days the days day a. Forgetful or easily confused D D D D D b. Gets lost or wanders off D D D D D c. Easily agitated or disruptive D D D D D d. Sexually inappropriate D D D D D e. Threatens or is verbally hostile* D D D D D f. Physically aggressive or violent* D D D D D g. Intentionally injures or harms him/herself* D D D D D h. Expresses suicidal feelings or plans* D D D D D i. Hallucinates, hears/sees things that are not D D D D D there* j. Other: D D D D D *Thoughts of suicide or self-injury, hallucinations, or aggressive behaviors are potentially serious problems that should be reported immediately to a primary care physician, emergency care, law enforcement, and/or Adult Protective Services, as appropriate. 83; ASSESSOR/CM: [)oes client need supervision? ONo DYes Notes & Summary: 10 DOEA701B,April

153 Page 153 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment H. RESIDENTIAL LIVING ENVIRONMENT SECTION 84. ASSESSOR/CM:.If information about the client's residenc:e is reported toyou,withoutyour observation, check here D.and an that apply below. If residence issues are directly observed by you, use the list below to observe and che.ck off the specific lssue(s) with the potential for safety or accessibility problems. Check all that apply: a. Exterior issues(s): b. Interior issues(s): c. Restroom issues(s): d. Utility issue(s): e. Furniture issue(s): f. Telephone issue(s): g. Temperature issue(s): h. Unsanitary condition(s): D Road D Doors D Driveway D Stairs D Door D Broken D Heat D Yard D Ramp D Windows D Roof D Floor D Walls D Ceiling D Lights D Handrails D Tub D Shower D Toilet D Plumbing D Water D Electric D Gas D Chair D Couch D Bed D Table D NOpllone D Disconnected/No service D Smoke detector D Odors D Insects D Accumulating items or garbage D Air conditioning D Rodents D Floors or pathways cluttered i. Other hazards:---,--,----,-,----"""=~-----,-,-,=-=--= =-=----,--,-- 8s. Is there a pet in your home oryord? D No.(Skip to86:/dyes a. Pleose specify the type and size: = b. ASSESSOR/CM: Pet comments/concerns: ----~~------~ ~~ 86. ASSESSOR/CM: Please rate the level of risk in the client's residential living environment: D No/low apparent risk from current living conditions. D Minor risk (One or more ospects are substandard and should be addressed in the following year to avoid potential injury.) D Moderate risk (Majoraspects are substandard andmust be addressed in the next few months to remain in home safely.) D High risk (Serious hazards ore present. The client must change dwellings or immediate corrective action must be token to correct the issues noted above.) Notes & Summary: 11 DOEA 701 B, April

154 Page 154 of 379 I. NUTRITION SECTION Florida Department of Elder Affairs: 701 B Comprehensive Assessment 87. Do you usually eat at least two me.als a day? DNo DYes 88. On a typical day, what types of food do you eat for: a. Breakfast: b. Lunch: c. Dinner: d. Snacks: 89. Do you eat alone most of the time? 0 No D Yes 90. How many cups of water, juice, or other liquid do you drink daily? (If more than eight, Skip to 91) # ""-~~a. Doyoueverlimitthe<lmountolfluidsyoudrink? D No (Skipto91) DYes b. Why and when do you limit the fluids you intake? 91. On average, how many servings of fruits and vegetables do you eat every day? (One "serving" is one small piece of fruit or vegetable, about one-half cup of cnopped fruit or vegetable, or one-half cup of fruit or veget.ab/e juice.) :'!# ~ 92. On average, how many servings of dairy products do you have every day? (One "serving" of dairy is about a slice of cheese, a cup of yogurt, or a cup of milk or dairy substitute.) -"# 93. Estimate your current heigh!.and weight: Height: ft. inches Weight: /bs. 94. Have you lost or gained weight in the last few months? D Unsure (Skip to 95) D No (Skip to 95) D Yes a: How much? D Less than five pounds D Five to ten pounds D Ten pounds or more b. Was the weight loss/gain on purpose (i.e., dieting or trying to lose/gain weight)? D No DYes 95. Are you on a special diet(s) for medical reasons? D No (Skip to 96) D Yes; check any/all: D Calorie supplement D Low fat/cholesterol D Low salt/sodium DLow sugar/carb Oother a. How long have you been on this diet? ~ ,--,-,..., b. Why are you on this diet? 96. Do you have any problems that make it hard for you to chew or swallow? D No D Yes; check any/all: D Mouth/tooth/dentures D Pain or difficulty swallowing D Taste D Nausea D Saliva production D Other, describe: ---~ ~ What working appliances do you have for storing/preparing food? D None D Refrigerator D Microwave D Toaster/Oven D Stove D Other: Notes & Summary: 12 DOEA 701 B, April

155 Page 155 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment J. MEDICATIONS & SUBSTANCE USE SECTION 98. Do you take three or more prescribed or over-the-counter medications a day? D No D Yes 99. May I see all the medications you take, both regularly and those taken only as needed? Also, please show me all types of over'the,counter medications and any supplements that you regularly take. ASSESSOR/CM: Check the original bottles in the medicine cabinet, nlghtsland, and refrigerator, as well as non-prescnpuon ' I' d rugs, over th e coun I er d rugs, s I eep a1 'd s, h er b a I reme d' 1es, VI 'I amms, ' an d supp1emen I I s..... Taken as Prescribed Prescribed prescribed? Administration. Medication name dose Frequency Yes/No* method Prescriber name I I... _, If you have a pnnted list of meds managed by a facility, attach sheet. If there are more medications to record, use the Notes & Summary section or a blank sheet of paper to write the information. l 00. *ASSESSOR/CM: Only ask when the client is not taking medications as indicated: "Why do you take [name of medication) differently than prescribed?" and explain each below: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: Medication and reason: 13 DOEA701B,April

156 ' Exhibit 2 Page 156 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment J. MEDICATIONS & SUBSTANCE USE SECTION, CONTINUED 101. Please list the doctors you usually go to for treatment and medications: '',,' ' Approx. ' ' date of Physician name,,, Phone number last visit Reason for last visit;,,''',, ' '' ' ' ',','.,', ', ''.., - '',. '... '......,..... '. '.. ' -'- If you have more than ten physicians to record, use the Notes & Summary section or a blank sheet of paper to write the information What pharmacies or drug stores do you use?.. < Are you able to tell the difference between your pills (i.e., colors, shapes, print)? D NoD Yes D N/A 104: ASSESSO~/CM: An~!he client's riledicatlons managed by afcicility/cdregiver? DNoDYeskJN/A, 105. ASSESSOR/CM: In your opinion, are the client's medications managed properly? D No D Yes D N/A 106. ASSESSOR/CM: Should client have a n.ew medication review by.a dodor or pharmacist? 107. How many days in a typical week do you drink alcohol? 108. D NoD Yes DN/A D Refused (Skip to 108) D None (Skip to 108) D One to two D Three to five D Six to seven a. On the days when you have some alcohol. aboufhowrnany drinks do you usually have?... D One to two (Skip to 108) D Three to five D Six or more b. About how many times in the last month have you had four or more drinks in a day? D None DOne to two D Three to five D Six or more Have you used any form oftobacco in the last six months? D No (Skip to 109) DY~s: a. What type{s)? D Chewing tobacco D Cigarettes D Cigars D Snuff D Other b. About how many times do you use tobacco. eadr.ddy? D One tolhree D Four to ten D Eleven or more 109. Do you regularly use drugs other than those required for medical reasons (i.e., controlled substances or "street drugs")? D Refused (Skip to 110) D No (Skip to 110) D Yes, what type(s): a. About how often do you use these? DRarely D Less than twice a month.... DLess thah once a week D Several times a week D Daily D Several times a. day b. How long have you been using that often? D Less than a year D One or more years Notes & Summary: DOEA 701B, Apri/

157 Page 157 of 379 K. SOCIAL RESOURCES SECTION Florida Department of Elder Affairs: 701 B Comprehensive Assessment 110: If needed, is there someone (besides \he primary caregiver)who.cowldhelp you? DNo (Skip to J72)0Yes 111. Do I have your permission to contact this person, if you need help? DNo {Skip to 112) DYes a. Name: b. Relationship to client: c. Phone: Two to Once Several Every A few About how often do you: Once a six times a times a lew times day a week week month months a year Never 112. Talk to friends, relatives, or others (by phone, computer, or other means)? 113. Spend time with someonewh.odoes riot live with yoi.j? D D D D D D D D D D n D D D 114. Participate in activities outside the home that interest you? D D D D D D D L. CAREGIVER SECTION ASSESSOR/CM: If client has no caregiv~r. stop the assessment here. If client has a caregiver; complete l15.1l ASSESSOR/CM: HCE Caregiver? If yes, check Caregiver full name: a.. First: b. Middle Initial: c. Last:~ ~ 117. Car.egiver date of birth: {mm/dd/yyyy) 118. ASSESSOR/CM: Caregiver identification number 119.Caregiver sex: DMale DPemdle 120. Caregiver race {Mark all that apply): Dwhite D Black/ African American D American Indian/ Alaska Native DNative Hawaiian/ Pacific Islander 0Asian Dother 121. Caregiverethf)icity: DHispanic or Latino Dother 122. Caregiver primary language: DEnglish Ospanish Dother 123. Caregiver relationship to.ciient: DWife DHusband DPartner DParent -~-..., ,--~ Dscm/ln-law Obal.lghter/ln-law Dother relative Dother Non'relative 124. Caregiver address: a. Street:. b. City: c. State: d. ZIP code: ~---~---..., ~ Caregiver phone number: 126. Do you work outside the home? D No DYes: D Full-time D Part-time 127. Do.you currently have anyone to assist you with providing care? D No {Skip to 129) D Yes 15 DOEA701B,April

158 Page 158 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment L. CAREGIVER SECTION, CONTINUED 128. Do I have your permission to contact this person if for some reason you are unable to provide care for the client? D No (Skip to 129) D Yes, please provide the name and relationship to client: a. First name:-'--~-"-----'---- b. Lastnarne: c. Phone: d. Relationship to client: DWife DHusband 0Partner DParent Dson/ln-law Doaughter/ln-law Dother relative Dother Non-relative 129. How long have you been providing care for this c.lient? D Less than six months D Six to twelve.months. D One to two years D Two or more years 130. How many hours per week do you currently spend providing care for the client? 13 LDoyou need training or assistance in performing caregiving fa*s? D No D Yes, please describe: # 132. How much of a mental or emotional strain is it on you to provide care for the client? D None D Some strain D A lot of strain Considering other aspects of your life, No Little Some Moderate A lot of please rate fhe.level of difficulty in your: difficulty difficulty difficulty difficulty difficl)lty a. Relationship with client D D D D D b. Relationship with family D D D D D c. Relationships with friends D D D D D d. Physical health D D D D D e. Finances D D D D D f. Functional abil.ities D D D D D g. Employment D D D D D h. Time for yourself.to do the things you enjoy D D D D D 134. How confident are you that you will have the ability to continue to provide care? D Very confident (Skip to 135) D Somewhat confident (Skip to 135) D Not very confident a. What is the main reason you may be unable to continue to provide care? Assessor/CM: Is the caregiver In crisis? DNo DYes; check all that apply: DFinancial DEmotional DPhysical 16 DOEA 701 B, April

159 Page 159 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment L. CAREGIVER SECTION, CONTINUED 136. Ask the caregiver to answer the following about the client. (An answer of "Yes, a change" indicates that there has been a change in the last year caused by thinking and memory problems.) a. Problems with judgment (problems making decisions, bad. financial decisions. problem.s with thinking) ' b. Less interest in hobbies/activities c. Repeats the same things over and over (questions, stories. or statements) d. Trouble learning how to use a tool, appliance, or gadget (TV, radio, microwave, remote control) e. Forgets the correct.month or year f. Trouble handling complicated financial affairs (balancing checkbook, income taxes, paying bills) g. Trouble remembering appointments h. Daily problems with thinking or memory Yes, a No change change D D D D D D D D D 0 Adapted from the "Eight-item Informant Interview to Differentiate Aging and Dementia," a copyrighted instrument of Washington University, St. Louis, Missouri. Copyright All rights reserved. D D D D D D Don't know or N/A 0 D 0 D D 0 0 D Notes & Summary: 17 DOEA701B.April

160 Page 160 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment [This page is intentionally left blank] 18 DOEA701B,Apri

161 Page 161 of 379 Florida Department of Elder Affairs: 701 B Comprehensive Assessment WHY ARE WE COLLECTING YOUR SOCIAL SECURITY NUMBER? We are required to explain that your Social Security number is being collected pursuant to Title 42 Code of Federal Regulations, Section , to be used for screening and referral to programs or services that may be appropriate for you. The provision of your Social Security number is voluntary, and your information will remain confidential and protected under penalty of law. We will not use or give out your Social Security number for any other reason unless you have signed a separate consent form that releases us to do so. 19 DOEA 701B, April

162 Page 162 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT Elderly and Veterans Services Division Overview: BROWARD COUNTY CONSUMER DIRECTED CARE PROJECT The Broward County Consumer Directed Care (BC/CDC) Project is designed to divert consumers from customary publicly funded services, such as the Community Care for the Elderly (CCE) wait-list, through the provision of "non-traditional," alternative supports. The Consumer Directed Care Project provides consumers and their families with a monthly care plan cost share reimbursement stipend up to $ for use toward approved formal and informal support services they coordinate on their own to help them maintain themselves in their own homes. Program consumers and their caregivers must meet program criteria, agree to and be able to follow program guidelines and instructions. Services provided to consumers are tracked on a monthly expenditure invoice form and monitored to ensure appropriate care is provided per the agreement entered into by Project staff and the consumer and/or caregiver. The consumer and/or caregiver invoice for reimbursement of up to 90% of total monthly care plan costs at a maximum monthly reimbursement amount of $ regardless of actual care plan expenditures. Project Criteria: 1. Consumers must be 60 years of age or older and a full-time Broward County resident living in a private residence, not an assisted living facility or other congregate setting 2. Consumers must have at least a moderate level of impairment that warrants intervention to prevent premature institutionalization (2 4 ADL Count) 3. Consumers must be willing and able to manage their service needs and care as well as follow Project requirements, including invoicing and home visits 4. Consumers must not be able to obtain funded services elsewhere due to having a higher income and/or asset level (Maximum individual asset level $30, Maximum couple asset level $50,000.00) 5. Consumers must not be enrolled in a DOEA Funded Program such as CCE, HCE, ADI and/or Medicaid Waiver nor meet criteria for the Medicaid Waiver Program; Consumers can be receiving OAA funded services, such as transportation and meals 6. Consumers and/or their caregivers must be willing and able to share in the cost of their care as consumers will be responsible for paying at least 10% of the total monthly cost of their required services; the reimbursement stipend is provided to ensure receipt of adequate services that might not otherwise have been obtain privately by the consumer 7. Consumers and/or their caregivers must be able to advocate and negotiate for themselves; Project staff, who provide some case management assistance, are primarily responsible to enroll, monitoring and support consumers and their caregivers to ensure adequate community care Consumer Name: Referral Name: CSMS ID#: Date: Please submit this completed referral form to Manny Fuentes, Unit Manager Date Received: Assigned to: Date Assigned: 162

163 Page 1 Exhibit 2 Page 163 of 379 Broward County Elderly and Veterans Services Division CUSTOMER RELATIONS UNIT INTAKE WORKSHEET Referral Date: I I Time: Receptionist: Select Receptionist Consumer Name: Telephone: - - Referral Source Information (If Applicable): Name: Relationship to Consumer: Telephone: - - 0Consumer is a VeteranNeteran Dependent/Spouse/Widow AND Under the Age of 60 Years. (Refer to CRU VSO Only) DConsumerNeteran over the Age of 60 Years (Refer to CRU Social Worker) D ConsumerNeteran over the Age of 60 Years (MH/SA BRITE Counselor Only) D Consumer is Spanish I Creole speaking (Refer to Appropriate CRU Social Worker) D Other Activity: "' Additional Information: Assigned Team Member: Select SW or Counselor Date of Pick-Up: I I Time of Contact: J Presenting Problem: Date of Birth: I I Address: City: State: Zip Code: NOTES and DISPOSITION:

164 Page2 Exhibit 2 Page 164 of 379 "'.. DESCRIPTION OF PROBLEM I NEED Veteran's Issues: D NO DYES D Veteran Services is Consumer's Primary Need D Elder Care Services is Consumer's Primary Need Problem with ADLs IIADLs: 0 NO IMPAIRMENT 0Personal Care 0 Housekeeping 0 Mobility 0Shopping/Errands 0 Nutrition/Meal Preparation OMedication Mgmt D Other: #of IMPAIRED ADLs: #of IMPAIRED IADLs: Physical Health Problems: 0NO CONDITION DYES (Describe): D Insurance Issues: Home Environment Issues: D NO PROBLEM OHurricane Damage 0General Home Repair 0Code Enforcement OOther: Mental Health Issues: 0 NO IMPAIRMENT/CONDITION 0Emotional Crisis/Distress D Depression 0Anxiety 0Severe and Persistent Diagnosis: 00ther: Substance Abuse Issues: D NO PROBLEM 0Aicohol Abuse 0Medication Misuse Olllicit Drug Use 0Gambling OOther: Income I Financial Problems: 0 NO PROBLEM OUtility Assistance 0Temporary Rent/ Mortgage Assistance D Other (Describe): Housing Needs: 0 NO PROBLEM 0Homeless DEviction 0Foreclosure OOther: Disaster Preparedness: D NO ISSUES 0Sheltering 0Evacuation Transportation OOther: Other Issues: PERSONAL RESOURCES ACTION TAKEN 0Private Assistance: 0 External Referral: 0BC-CDC 0ADRC OOther: 0Private Assistance OExternal Referral 0ADRC OOther: DPrivate Assistance: 0External Referral: D EVS Hurricane Relief 0ADRC 00ther: DB RITE OBH Case Management OBH Day Treatment 00ther: 0BRITE OSAProgram OOther: 0County Contingency Fund 0Foundation Request D Community Action 0ADRC OOther: D Homeless Case Management 0Veterans Services 0County Contingency Fund 0Foundation Request 0Eider Housing Subsidy OOther: OEVS Disaster Preparedness Team OOther:

165 Page 165 of 379 Broward County Commissioners, Broward County, Florida- HUMAN SERVICES DEPARTMENT Type of Claim Key 8. Widow's Pension 9. Widow's Pension w/ A&A 10. Re-Opened Claim -Widow's Pension 11. Re-Opened Claim- Widow's Pension w/ A&A 12. Burial Claim 13. Appeal 14. UME/EVR Audit

166 Page 166 of 379 Broward County Commissioners, Broward County, Florida - HUMAN SERVICES DEPARTMENT Eldlerlly and Veteran's Services Division (EVS -Veteran Services Section Type of Claim Key 8. Widow's Pension 9. Widow's Pension w/ A&A 10. Re-Opened Claim -Widow's Pension 11. Re-Opened Claim -Widow's Pension w/ A&A 12. Burial Claim 13. Appeal 14. UME/EVR Audit

167 Type of Claim Key 1. Service Connected 8. Widow's Pension 2. Non-Service Connected/Aid &Attendance (A&A) 9. Widow's Pension w/ A&A 3. Re-Opened Claim -Service Connected 10. Re-Opened Claim -Widow's Pension 4. Re-Opened Claim - A&A 11. Re-Opened Claim -Widow's Pension w/ A&A 5. Dependent Indemnity Compensation (DIC) 12. Burial Claim 6. DICw/ A&A 13. Appeal 7. Re-Opened Claim - DIC 14. UME/EVR Audit Exhibit 2 Page 167 of 379 Broward County Commissioners, Broward County, Florida - HUMAN SERVICES DEPARTMENT tl(]leriiv and Veteran's Services Division (EVSD)- Veteran Services Section 15 of 28

168 Type of Claim Key 1. Service Connected 15. Nm'-M''""""' 8. Widow's Pension 2. Non-Service Connected/Aid &Attendance (A&A) 9. Widow's Pension w/ A&A 3. Re-Opened Claim -Service Connected 10. Re-Opened Claim -Widow's Pension 4. Re-Clpened Claim - A&A 11. Re-Opened Claim -Widow's Pension w/ A&A 5. Dependent Indemnity Compensation (DIC) 12. Burial Claim 6. DICw/ A&A 13. Appeal 7. Re-Opened Claim- DIC 14. UME/EVR Audit Exhibit 2 Page 168 of 379 Broward County Commissioners, Broward County, Florida- HUMAN SERVICES DEPARTMENT EldleriiV and Veteran's Services Division (EVSD) -Veteran Services Section 18 of 28

169 Broward County Commissioners, Broward County, Florida- HUMAN SERVICES DEPARTMENT Exhibit 2 Page 169 of 379

170 Page 170 of 379 Broward County Commissioners, Broward County, Florida- HUMAN SERVICES DEPARTMENT Elderly and Veteran's Services Division (EVSD) -Veteran Services Section Widow's Pension 9. Widow~ Pension w/ A&A ~ :; :;;:_ ~ "" VETERAN SERVICE OFF 10. Re-Opened Oalm- Widow's Pension ~ 11. Re-Opened Oaim Widow's Pension w/ A&A 12. Burial Claim 13. Appeal 14. UME/EVRAudit.CQ.MMENTS 20 of28

171 - ~- - Exhibit 2 Page 171 of 379 Broward County Commissioners, Broward County, Florida- HUMAN SERVICES DEPARTMENT -- ~- Elderly and Veteran's Services Division (EVSD}- Veteran Services Section - ---~ ~ ~---~--=---=----=-...::: ~ - lo. R...Opened Claim -Widow's Pension ll. Re-Opened Claim -Widow's Pension w/ A&A l2. Burial Claim 24 of28

172 Page 172 of 379 Elderly and Veteran's Services Division (EVSD) Total Number of Total Number Total Number of1na!lk-ln"l

173 Page 173 of 379

174 Page 174 of 379 Home Visit Aid and Attendance Claim -A&A Claim 174

175 175 Exhibit 2 Page 175 of 379

176 Page 176 of 379 Exhibit A-6 Forms Phase 5 Form Templates Broward County and The Echo Group Exhibit A (Statement of Work) 176

177 Page 177 of 379 FLORIDA Community Partnerships Division Monitoring Visit Administrative Review Results for

178 Page 178 of 379 COUNTY FLORIDA Community Partnerships Division 0 Administrative Review Report Sections and Assigned Reviewer Tabs: Assigned to: Section 1: Non-Financial Administrative Section II: Financial Administrative 2

179 Page 179 of Summary of Results Section 1: Non-Financial Administrative A. Insurance/Risk Management and General B. HR Posting Compliance C. HR Policies, Reporting, Attendance Section II: Financial Administrative A. General B. Banking C. Journals and Ledgers D. Budget E. Program Revenues F. Payroll Taxes Items Results remaining to monitor #DIV/0! 6 #DIV/0! 11 #DIV/0! 13 #DIV/0! 15 #DIV/0! 14 #DIV/0! 2 #DIV/0! 3 #DIV/0! 3 #DIV/0! 4 Section Ill: Personnel File Contents SEE Separate Programmatic Report(s) Section IV: Invoice and Billing SEE Separate Programmatic Report(s) Section IV B: Units of Service Review Summary SEE Separate Programmatic Report(s) Section V: Client Service Reports SEE Separate Programmatic Report(s) Section VI: Client File Contents SEE Separate Programmatic Report(s) Section VII: Client File Contents SEE Separate Programmatic Report(s) Section VIII: Procedures by Service Category (if Ryan White) SEE Separate Service Category Report(s) 3

180 Page 180 of 379 Section 1: Non-Financial Administrative Provider Agency being monitored: 0 I = Interview O=Observation ~ CX> 0 workplace policy and 4

181 Page 181 of 379 Section 1: Non-Financial Administrative Provider Agency being monitored: 0 Area of Review Current organizational chart that reflects agency positions and lines of authority Does the Agency require training on child abuse and/or elder abuse reporting for staff and volunteers who serve children, the elderlv, and other vulnerable populations? Does the Agency post hotline numbers for employees to report cases of child abuse and/or elder abuse? Are new policies or changes in existing policies communicated in a systematic manner to all employees? Does the Agency-have a written policy that establishes a formal process to deal with employee complaints concerning illegal activities in the organization, and that prevents retaliation? Does the Agency have a process for reviewing and responding to ideas, suggestions, comments, and perceptions from all staff members? Did the Provider ensure that staffing patterns and staff qualifications are sufficient to provide culturally competent services described within the contract? Compliance I - Interview O=Observation D=Documentation Yes No NA (List Who or What) Comments 5

182 ----- ~ ~-~~ ~ ' ~ ~ Exhibit 2 Page 182 of 379 Section II: Financial Administrative Provider Agency being monitored: 0 6

183 Page 183 of 379 Section II: Financial Administrative Provider Agency being monitored: 0 Yes No I = Interview O=Observation D=Documentation co "' 7

184 Page 184 of 379 Section II: Financial Administrative Provider Agency being monitored: 0 agency prepare a Budget Variance Report or otheiwise expenditures versus budgeted amounts on a regular I I I Yes No NA I= I O=Observation D=Documentation 8

185 Page 185 of 379 COUNTY FLORIDA Community Partnerships Division "' Monitoring Visit Programmatic Review Results for Monitoring Dates of Evalutaion

186 Page 186 of 379 FLORIDA Community Partnerships Division 0 0 Programmatic Report Sections and Assigned Reviewer Tabs: Assigned to: Section 1: Non-Financial (in Separate Administrative Report) Section II: Financial (in Separate Administrative Report) Section Ill: PersonneiNolunteer File Contents Section IV: Invoice and Billing Section IV B: Units of Service Review Summary Section V: Client Service Reports Section VI: Client File Contents Section VII: Outcome Attainment 2

187 Page 187 of Programmatic Summary of Results for 0 Section 1: Non-Financial Administrative SEE Separate Administrative Report Results Items remaining to monitor Section II: Financial Administrative SEE Separate Administrative Report "' "" Section Ill: PersonneiNolunteer File Contents SEE Worksheet for Tab Ill A. PersonneiNolunteer File Review NA Total Employees Assigned to Program NA Total Volunteers Assigned to Program NA Number of Personnel Files Reviewed: NA Number of files missing one or more items NA B. PersonneiNolunteer File Items Reviewed G 1.00 Section IV: Invoice and Billing A. General #DIV/0! SEE Units of Service Review Summary NA Section V: Client Service Reports A. Client Service Reports Items Reviewed #DIV/0! NA NA NA NA NA NA -il.. Section VI: Client File Contents SEE Worksheet for Tabs VI and VII A Client File Review NA Total Clients Served During Review Period: 6 NA Number of Client Files Reviewed: 0 NA Client File Sample Size: #DIV/0! NA B. Client File Items Reviewed #DIV/0! Section VII: outcome Attainment SEE Outcome Attainment Detail NA NA NA NA NA 0 NA 3

188 Page 188 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 Number of files missing one or more i File i i qui;lifical:iorls, duties, reporting relationships and essential new orientation and understands personnel policies, infectious disease risk, provider's universal infection control procedures, standards of ethical conduct (including sexual harassment), abuse reporting procedures, and policies client rights and for each employee (either in job descriptions or other I 4

189 Page 189 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 Total volunteers (vol) assigned to County-funded ~~~;:;::~:3 Number of personnel/volunteer files ~~ Number of files missing one or more I I File I 5

190 Page 190 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 use i personnel files include proof of car insurance? 6

191 Page 191 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 Total volunteers (vol) assigned to County-funded Number of personnel/volunteer files Number of files missing one or more File Area of Review i other documentation as contractual terms & conditions? (if so, please 7

192 Page 192 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Counl:y-fun<Jed program: Total volunteers (val) assigned to County-funded program: Number of personnel/volunteer files reviewed: Number of files missing one or more items: File <0 " duties, reporting relationships and essential i orientation and understands personnel policies, infectious disease risk, provider's universal infection control procedures, standards of ethical conduct (including sexual harassment), abuse reporting procedures, and policies client and for each employee (either in job descriptions or other I I 8

193 Page 193 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: assigned to program: Total volunteers (val) assigned to County-funded program: Number of personnel/volunteer files reviewed: Number of files missing one or more items: File "' not guilty of nolo contendere or guilty to any offense 9

194 Page 194 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: County-fun<Jed program: Total volunteers (vol) assigned to County-funded program: Number of personnel/volunteer files reviewed: Number of files missing one or more File use personnel files include proof of car insurance? 10

195 Page 195 of 379 Section Ill: Personnel File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 1 program: Total volunteers (vol) assigned to County-funded program: Number of personnel/volunteer files reviewed: Number of files missing one or more items: "' 11

196 Page 196 of 379 Section Ill: Personnel File Contents WORKING NOTES Provider Agency being monitored: -;0; Program being monitored: 0 ~ "' C> 12

197 Page 197 of 379 Section Ill: PersonneiNolunteer File Contents Provider Agency being monitored: Program being monitored: 0 0 Total volunteers assigned to County-funded ~~~;:::c:l=] Number of personnel/volunteer files n Number of files missing one or more Contract #: 0 I = Interview O=Observation i i i duties, reporting relationships and essential new and understands personnel policies, infectious ~~~:~~~:~,;~ provider's universal infection control procedures, I of ethical conduct (including sexual harassment), reporting procedures, and policies regarding client rights - Personnel Files access 0 13

198 Page 198 of 379 Section Ill: PersonneiNolunteer File Contents Provider Agency being monitored: Program being monitored: 0 0 Contract #: 0 #of Yes 0 No 0 I = Interview O=Observation I:-'""'--"'--""""" is a Level 1 criminal background employee hired to provide direct services to children, vulnerable I 1 check i a response to the Level 1 checks within days) or communicate with the checking information? has/have not been found guilty nolo contendere or guilty to any offense the employee(s) of i centers, lintenmediate care facilities for developmentally disabled, or I health treatment facilities, has/have not committed an act violence defined in ? 14

199 Page 199 of 379 Section Ill: PersonneiNolunteer File Contents Provider Agency being monitored: Program being monitored: 0 0 Total volunteers assigned to County-funded ~:~~:::c:t:! Number of personnel/volunteer files ~E Contract #: 0 Number of files missing one or more 1 #of Yes 0 No 0 I = lnteniew O=Observation Personnel Files - Personnel Files - Personnel Files Personnel Files 15

200 Page 200 of 379 Section IV: Invoice and Billing Provider Agency being monitored: Program being monitored: 0 0 Yes No NA I = Interview O=Observation D=Documentation "' g 16

201 Page 201 of 379 Section IV B: Units of Service Review Summary Provider Agency being monitored: -:0; Program being monitored:..:0:... _ ~ Invoice Review Period (in date format) Units/Dollars Units/Dollars Units/Dollars Billed in Reviewed Invoiced Review in but Period Sample Unsupported Comments 17

202 Page 202 of 379 Section V: Client Service Reports Provider Agency being monitored: Program being monitored: 0 0 Yes No NA I = Interview O=Observation D=Documentation 18

203 Page 203 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 agreement? I ladldre!ssina their presenting and underlying needs (including: and 19

204 Page 204 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: 0 0 lln,dicate number of client files reviewed in column C: Client File 20

205 Page 205 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored:

206 Page 206 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: llndic;ate number of client files reviewed in column C: of clients' receipt Rights of clients' receipt of Provider Grievance all 22

207 Page 207 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: I indicate number of client files reviewed in column C: Client File Identifier: Area of Review do service plans contain measurable goals/ service plans' goals/objectives have timeframes N

208 Page 208 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: i i i Indicate number of client files reviewed in column C: Client Review 24

209 Page 209 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: i i Indicate number of client files reviewed in column C: Client File Identifier: i I 25

210 Page 210 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Indicate number of client files reviewed in column C: Client File i 26

211 Page 211 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: i i nrlir'"'" number of client files reviewed in column C: Client File Area of Review 27

212 Page 212 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: llnrlir.,~te number of client files reviewed in column C: Client documentation include income clients' receipt of Provider Grievance consent for treatment (clinical 28

213 Page 213 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored:!indicate number of client files reviewed in column C: Client Area of Review service plans contain measurable goals/ service plans' goals/objectives have timeframes for and discharge plan/follow-up or discharge 29

214 Page 214 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: llnrli..,~t" number of client files reviewed in column C: Client File Area of Review 30

215 Page 215 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: I Indicate number of client files reviewed in column C: File i 31

216 Page 216 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: lln,dic,ate number of client files reviewed in column C: File I Area of Review service plans' goals/objectives have timeframes 32

217 Page 217 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: llnclicate number of client files reviewed in column C: Client File Area of Review 33

218 Page 218 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: of clients' receipt of Client Rights of clients' receipt of Provider Grievance signed consent for treatment (clinical all 34

219 Page 219 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: lfn,dic le number of client files reviewed in column C: Client File Area of Review service plans' goals/objectives have 35

220 Page 220 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Area of Review 36

221 Page 221 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Indicate number of client files reviewed in column C: Client File documentation include income eligibility of clients' receipt of Client Rights of clients' receipt of Provider Grievance clients l;u,lrir<,ssina their presenting and underlying needs (including: and and 37

222 Page 222 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: I Indicate number of client files reviewed in column C: Client File Identifier: have timeframes or 38

223 Page 223 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Indicate number of client files reviewed in column C: I File Area of Review 39

224 Page 224 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: l1ncjic<3tenumber of client files reviewed in column C: Client File Identifier: 40

225 Page 225 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Area of Review service plans contain measurable goals/ service plans' have timeframes "' "' 41

226 Page 226 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: llnclicate number of client files reviewed in column C: Client File Identifier: Area of Review 42

227 Page 227 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: lln,rlir.,~t" number of client files reviewed in column C: Client File income of clients' receipt of Client Rights of clients' Provider consent ladldre,ssina their presenting and underlying needs (including: and and 43

228 Page 228 of 379 Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: lln,rli.-,~1" number of client files reviewed in column C: Client File "' "" 44

229 Page 229 of ~~ Section IV: Client File Contents WORKSHEET Provider Agency being monitored: Program being monitored: Indicate number of client files reviewed in column C: Client File I Area of Review " "' 45

230 Page 230 of 379 Sections VI and VII: Client File Contents/Outcome Attainment WORKING NOTES Provider Agency being monitored:.;0< Program being monitored: ~0'

231 Page 231 of 379 Section VI: Client File Contents Provider Agency being monitored: Program being monitored: 0 0 I= Interview O=Observation 47

232 Page 232 of 379 Section VI: Client File Contents Provider Agency being monitored: Program being monitored: 0 0 "' 48

233 Provider Agency being monitored: -;0; Program being monitored: 0 YTD Attainment Achieved? Yes No NA Exhibit 2 Page 233 of 379 Section VII: Outcome Attainment Period Reviewed (dates): Reported Required Level AHain Monitoring Visit 49

234 Page 234 of

235 Page 235 of 379 Exhibit A-7 Forms Phase 6 Form Templates Broward County and The Echo Group Exhibit A (Statement of Work) 235

236 This form is used to inform DATA when there are units posted in CSMS after any cut off period and need to be hand entered into GIRTS or EDS. We cannot batch fiscal year to date into GIRTS and only will be batching the current cut off period. Any units not entered in CSMS by the cut off period may be lost (left un-paid). To Data: The following units need to be hand entered into GIRTS or EDS for proper payment. Please ensure that the care plan and enrollments are correct in GIRTS Date Submitted Inputted By Date Stamp Exhibit 2 Page 236 of 379 Board of County Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT Elderly and Veterans SeiVices Division Community Care for the Elderly Section Hand Entry for Service Units Requesting Worker/Agency: Provider Location ID Code: Reason for hand entry 1. Missed cut- off date (other than #6) Total No. of Consumer Name Soc. Sec.# Case Manager 2. Adjustment to units already posted Service Funding Date 3. Consumer lost Medicaid Waiver 4. Consumer now Medicaid Waiver Provided Source Provided Units Provided (transaction 5. Billed to wrong funding source 6. Missed cutoff, delay in completing case notes total) " "' G:IDIV5\LAWIPDF MERGE\Hand-Data-Entry-Form.doc Latest revision: 08/24/09

237 Page 237 of 379 Consumer's Name: Board of County C.ommissioners, Broward County,. Florld.a HUMAN SERVICES DEPARTMENT Elderly and Veterans Services Division AUTHORIZED CARE PLAN SS#: Level o!gare: Medicaid #: Signature Date: New to New EffeCtiVe Date: provider Service Annul!ll Update Fund sources Include: CCE, HCE, MW, $nd BC EVSQ IN-HOME SERVICE INITIATION MUST BEGIN NO LATER THAN 14 DAYS AFTER AUTHORIZATION DATE FUND SOURCE Homemaker: Instruction of service: hrper visit Provider: Auth(lrized Date: units: hrslwk Personal Care Instructi!:>n of s.ervice: hr per visit Provider: AUthorized Date: Units: hrs/wk Respite care Instruction (lf service: hr per visit Provider: Authorize!;~ Date: Units: hrsiwk EARS: Authorized Date: days/ Units: 7 wk Cot~t,umablesiSupplies:.Authorized Date: time Units: Provider: /mo. Home Delivered Meals: lnsttut:tiori of service:. oreakfast provider: Autnorized Date: lunch Units: ml$/wk AdUlt Day care/day Health: Instruction of service: hr per visit Provider: Authorized Date: Units: hrs/wk Other SeMces: (specify Provider: Instruction of service:!:fays per week Authorized Date: ijnits: hrs/wk other Services: (specify Provider: Instruction of service: visit permo Authorized Date:.Units: tiil'lel mo. Work.. plans/order Forms Attached Yes No Duration of Service(s) From: To: Assessment bate tono or tne wn Montn Case Manager:. Print Date Authorization Completed: Date F.axed to Provider signature For Provider Use only: (Provider's are to return this form to the case manager with service(s} start date) Assignel;l Service(s): start Date: I I Worker: (14 days Max. from Faxed receipt of the AUthorization) Comments: Signature: Scheduling Coordinator Date: Provider Confirmation: Date faxed to CM: 237 gvel\forms\010104\auth careplan5 (latest revision

238 Page 238 of 379 Broward County Board of Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT EldeHy and VeWans Setvioss Division. TERMINATION/CHANGE/PROBLEM (TCP) TERMINATION ( ) CHANGE. ( ) PROBLEM ( ) (For Co-Pay changts include CSMS ID) Assigned Case Manager: CSMS 10: ~--- Consumer's Name: SS#: City:~ ' Service(s): Terminati.on Date: ---''---''- REASON: Change(s): o Hold Service Zip Code: AGENCY: '-- o Tr!!ns(er to a new provider (requires a comment) o Exceeds 30 day hold limit D. Deceased o NH/ALF Placement o Other Intervention D Other: o Resume Service o Additional Needs o Change of Address o Co-Pay Changes: Problem(s): o Service(s) o Worker o Consumer Action Taken/Comments: Signed By: Provider Confirmation: (Rev. 09/28/11) 238 TITLE TITLE Fax Date Date faxed to CM G:IELiForms\010104\TCP

239 Page 239 of 379 Vendor Name: Program Name: Vendor Agreement Number: Site Visit Information: Date of Monitoring Visit: Monitor: AGENCY Staff Involved: Type of Review: Previous Site Visit: Records Reviewed: Vendor Information: Lead Agency: Broward County Elderly and Veterans Services Division Agreement Administrator: Executive Director: AGENCY Address: Term of Agreement: Amendments: Services Provided: 239

240 Page 240 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT Section 1: Program Management A. Entrance Interview Objective: To assure AGENCY understands the purpose of the monitoring visit, what documents will be reviewed, and has an opportunity to offer what positive and noteworthy actions were initiated in the past year. lin attendance: Positive and Noteworthy Management Activities performed by AGENCY in the past year: I COMMENTS: N/A B. AGENCY Concerns/Lead Agency Concerns Agency's Management... Contract Monitor... C. Request for Technical Assistance D. Validate Corrective Action from Previous Year N/A 2 240

241 Page 241 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT E. Policies and Insurance Objective: To assure Agency is compliant in maintaining policies and submitting insurance required by County Agreement. 1. AGENCY has Record Retention Policy which meets Broward County YES Agreement requirements. (CCE-related records maintained for five (5) NO years.) 2. AGENCY has Americans with Disability Policy which meets Broward County Agreement requirements. YES NO 3. AGENCY has Equal Opportunity/Affirmative Action Policy which meets YES Broward County Agreement requirements. NO 4. AGENCY has developed a set of written internal policies and YES procedures which outline the safeguards they have established to NO prevent the inappropriate use and/or disclosure of Protected Health Information (PHI) received from County, or created or received on behalf of County. 5. AGENCY has an appointed staff (Privacy Officer) designated to ensure its internal policies and practices are in compliance with the HIPAA Privacy Rule. YES NO 6. AGENCY has documentation that all staff has received training regarding compliance with HIPAA Privacy Rule. 7. AGENCY has current Certificate of Insurance which meets Broward County Agreement requirements. Policy Expiration Date: YES NO YES NO AGENCY IS CURRENTLY LICENSED BY : TYPE OF LICENSE: CURRENT LICENSE EXPIRES: 3 241

242 Page 242 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT F. Fiscal Management service according Accountability. Objective: To assure AGENCY supplies authorized units of to Agreement and to determine AGENCY's Fiscal AGENCY'S Invoices are submitted in a timely manner. AGENCY attaches CSMS Service Activity Reports to Monthly Invoices. YES NO YES NO AGENCY'S Invoices are accurate and match units posted on attached CSMS Service Activity Reports. AGENCY'S Attendance Sheets are accurate and match units posted on attached CSMS Service Activity Reports. (See Exhibit No.1 ) AGENCY'S Invoices/Service Activity Reports to date are in agreement with Authorized Units of services. (See Exhibit No. 1 ) YES NO YES NO YES NO I COMMENTS: N/A 4 242

243 Page 243 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT G. Human Resources personnel. Objective: To insure AGENCY has sufficient and qualified AGENCY presented Monitor with updated Functional Organization Chart that includes Adult Day Care Services staff. AGENCY reports. all positions are filled. If no, explain AGENCY employs a sufficient number of qualified staff to meet the client to direct service staff ratio in accordance with Adult Day Care guidelines. Number of clients served on a daily basis Number of staff assigned to work directly with clients YES NO YES NO YES NO AGENCY conducts annual employee satisfaction surveys. AGENCY'S human resources practices conform to the County's nondiscrimination policies as specified in the Agreement. Vendor is currently enrolled in the E-Verify Program Vendor ensures compliance with background screening legislation. YES YES NO YES NO YES NO NO COMMENTS: 5 243

244 Page 244 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT H. Use of Volunteers Objective: to recruit, train and utilize volunteers in accordance with Chapter 18 of Community Care for the Elderly guidelines AGENCY has successfully recruited and trained volunteers to work in the Program. AGENCY maintains current files on volunteers working in Program AGENCY maintains logs reflecting volunteer hours given to Program. AGENCY uses Senior Aides to assist in Program Operations. AGENCY volunteers and Senior Aides received information regarding client confidentiality and HIPAA regulations regarding client information. YES NO YES NO N/A YES NO N/A YES NO N/A YES NO N/A I COMMENTS 6 244

245 Page 245 of 379 II Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT I. Quality Improvement AGENCY has implemented an Internal Quality Improvement Program. AGENCY has minutes of last meeting of Quality Improvement Committee and/or results of last Quality Improvement Assessment. AGENCY has a file of Unusual Incident Reports and procedures to investigate, report, record and respond to Unusual Incidents. AGENCY has procedure to conduct Annual Client/Caregiver Satisfaction Survey. Monitor reviewed individual responses resulting from AGENCY'S Annual Client Satisfaction Survey. Results of AGENCY'S Annual Satisfaction Survey met a 90% level of service satisfaction. AGENCY has a plan to improve areas of service delivery identified by Annual Client Satisfaction Survey which merit correction. AGENCY has a Cultural Competency Plan. AGENCY reports no client terminations due to behavior or other client challenges in past year. If terminations did occur explain YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO Participant Interview revealed client who is satisfied with services and Looks forward to attending the program. Caregiver Interview revealed caregiver is satisfied with services and Respite provided by program has been helpful to caregiver well Being. YES NO YES NO 7 245

246 Page 246 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT I COMMENTS Section II: Program Operations A. Operational Policies and Procedures Objective: To assure that AGENCY has set forth, in writing, policies which govern procedures pertaining to day to day program operations including personnel, emergency and precautionary measures. Data Source: Operational Policies and Procedures Manual 1. AGENCY has written procedures that govern the following program areas: a. Confidentiality of CCE client files and information. YES NO b. CCE clients' receipt of Client Rights policy regarding AGENCY YES service delivery, including a process for client to express NO grievances. 2. AGENCY has Transportation that is up to date and is effective in meeting client and caregiver transportation and respite needs. YES NO COMMENTS: 8 246

247 il li I! Exhibit 2 Page 247 of 379!I Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT B Trainina and Suoervision Documentation of staff training indicates compliance with Florida Statutes. Chapter 400, Part V and Florida Administrative Code Chapter 58A-6. AGENCY has documentation that Adult Day Care staff received orientation regarding mission and procedures related to the Community Care for the Elderly Program (CCE). AGENCY develops an annual training schedule for direct service staff. YES NO YES NO YES NO I COMMENTS: N/A Section Ill: Service Delivery PROGRAM OBSERVATION 1. AGENCY'S program operations appear to be meeting the following program goals: 2. Protected but Non-Institutional Environment for frail elders Respite for Caregivers Stimulating Activities for frail elders Socialization for frail elders AGENCY clearly displays Monthly Calendar of Events YES NO YES NO YES NO YES NO YES NO 247

248 Page 248 of 379 "' Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly... riu~icllllo""'" ~"u ~v.,mov~ ~ov. 0 Varied ANNUAL ON-SITE MONITORING REPORT 0 Age-appropriate 0 Stimulating/Entertaining 0 Educational 0 Include Health-Related 0 Include Leisure 0 Individualized by functional ability Off campus activities are regularly scheduled by staff Vendor has written description of range of activities offered YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO I COMMENTS

249 Page 249 of 379 jl!i :I II [j _I.! Section IV: DOEA Checklist Do the Project's providers participate in the Adult Food Program? Does the Project's Adult Day Care Centers assure the provision of wellbalanced meals that furnish a minimum of one-third of the RDA? Are the Project's Adult Day Care Centers open at least six hours daily with activities available to clients throughout all hours of operation? Is a registered or licensed practical nurse, licensed by the state of Florida, on duty at the site during primary hours of operation and available at other times? Does the Center adhere to maximum level of clients for which it is licensed? Is there coordination of Adult Day Care client transportation and a daily attendance log maintained indicating clients' names, times of arrival and departure, and total hours spent in the Center? Is there documentation of Adult Day Care policies and procedures that indicate: a) requirements for client eligibility; b) priorities for client admission considering greatest need; c) an intake process conducted to evaluate a potential client's functional level; d) methods for documenting and reporting incidents of illness and any major incident involving clients, family members, staff, or the Center itself; e) Requirements for discharge of clients from the Center? Yes No N/A Corrective Action Needed 249

250 Page 250 of 379 Yes No N/A Corrective Action Needed Is a written case file developed for each client and maintained on an ongoing basis, including but not limited to the following: a) medical and social history or copy of an examination by a physician and a copy of a social history by a social worker; b) any existing diagnosis; c) results of Tuberculosis testing; d) any disabilities and associated mental/physical limitations and rehabilitation potential; e) orders for medication; f) special needs for health or safety; g) frequency of attendance; h) Client progress notes completed on a regular basis indicating any problems, achievements, and a current blood pressure reading. Is the Adult Day Care Center's range of services described in written form and presented to all participants and families? A calendar or schedule of specific daily activities is maintained on a current basis and displayed in a conspicuous place? Do Adult Day Care services provide a protective environment; restorative, rehabilitative, and adaptive assistance with activities of daily living; and individualized tailoring of activities based on client needs that will enhance wellbeing and maximize individual functioning? Do Adult Day Care services provide optimum mental and physical stimulation by encouraging leisure activities, interaction and communication among participants through a variety of active and passive activities, such as reality orientation, re-motivation, reminiscence, group discussions, exercise, and therapy to the extent possible? Does the Adult Day Care Center maintain current State of Florida licensure with the Agency for Health Care Administration? 250

251 Page 251 of 379 EXIT INTERVIEW FINDINGS OF NON-COMPLIANCE For this Annual Monitoring Review was found to be compliance with all the standards set forth in the Agreement and Community Care for the Elderly guidelines. Contract Administrator Date 251

252 Page 252 of 379 Exhibit No. 1 Fiscal Management Invoices Match Authorized Units AGENCY: # CCE Clients Served Source: Attendance Sheets %Sampled CLIENT SERVICE ACTIVITY ATTENDANCE AUTHORIZED REPORT SHEET UNITS W/E W/E EXCEEDS AUTHORIZED UNITS BY 252

253 Page 253 of 379 EXHIBIT NO.2 Vendor: SERVICE DELIVERY I PARTICIPANT INTERVIEW DATE OF INTERVIEW: CLIENT INITIALS /AGE: LENGTH OF TIME ATTENDING PROGRAM: HEALTH ISSUES: REASON FOR ATTENDING PROGRAM: REPORTED BENEFITS FROM PROGRAM ATTENDANCE: REPORTED FAVORITE PARTS OF PROGRAM: ABOUT THE CLIENT: ADULT DAY CARE CAREGIVER INTERVIEW 253

254 Page 254 of 379 VENDOR: DATE OF INTERVIEW: 1. How long has your loved one been receiving services from the Center? 2. How did you first find out about the program? 3. When you enrolled your loved one in the program, how were you informed of the policies and procedures? 4. What are your loved one's health issues? 5. Describe how the Center is meeting yours and your loved one's needs? 6. How are you treated by the staff? 7. Would you recommend this Center to others? 8. Do you have any comments about the program or the services you receive? 9. What additional services would help improve the quality of life for you and your loved one? 254

255 Page 255 of 379 Vendor Name: Program Name: CCE In-Home Services Agreement Number: Site Visit Information Date of Monitoring Visit: Agreement Monitor: Vendor Staff Involved: Type of Review: Previous Site Visit: Records Reviewed: Personnel Files, Client Files, Policies and Procedures Manuals, Invoices, Service Item Reports, Service Tickets, Authorized Service Plans Agreement Information: Lead Agency: Broward County Elderly and Veterans Services Division Agreement Administrator: Vendor Director: Vendor Address: Term of Agreement: Amendments: Services Provided: Homemaker, Personal Care and Respite Care 255

256 Page 256 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT Section 1: Program Management A. Entrance Interview Objective: To assure Vendor understands the purpose of the monitoring visit, which documents will be reviewed, and has an opportunity to offer any positive and noteworthy actions implemented. lin attendance: Positive and Noteworthy Management Activities: I COMMENTS' NIA B. Vendor Concerns/Lead Agency Concerns I Vendor: Lead Agency: C. Request for Technical Assistance 2 256

257 Page 257 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT D. Validate Corrective Action from Previous Year E. Agreement Compliance: Reports and Policies Objective: To assure Vendor is compliant in maintaining policies and submitting reports required by County Agreement. Data Source: Administrative Policies and Procedures Manual 1. Vendor has Record Retention Policy which meets Broward County YES Agreement requirements for Community Care and Home Care for the NO Elderly Programs. (CCE records maintained for five (5) years.) 2. Vendor has Americans with Disability Policy which meets Broward YES County Agreement requirements. NO 3. Vendor has Equal Opportunity/Affirmative Action Policy which YES meets Broward County Agreement requirements. NO 3. Vendor has Non-Discrimination policy regarding provision YES of services. NO 5. Vendor has signed a Business Associate Addendum to current YES Agreement with Lead Agency. NO 3 257

258 Page 258 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT Vendor has developed a set of written internal policies and procedures which outline the safeguards they have established to prevent the inappropriate use and/or disclosure of Protected Health Information (PHI) received from County, or created or received on behalf of County. Vendor has developed a Log (or other written record format) to document disclosures of PHI and information related to such disclosures. ~ YES NO ~ YES NO I 8. Vendor has an appointed staff (Privacy Officer) designated to ensure its internal policies and practices are in compliance with the HIPAA Privacy Rule. ~YES NO 9. Vendor has documentation that office and field staff has received training regarding compliance with HIPAA Privacy Rule. ~YES NO 10. Vendor has developed and implemented policies that state that Clients newly admitted to services under the Community Care for the Elderly Program receive a copy of, or are otherwise notified about, Vendor's "Privacy" policies that incorporate HIPPA guidelines. ~ YES NO 11. Vendor has current Certificate of Insurance which meets Broward County Agreement requirements. Expiration Dates: ~YES NO General Liability:,; Worker's Compensation: Professional Liabilitv: 4 258

259 Page 259 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT AGENCY IS CURRENTLY LICENSED BY: TYPE OF LICENSE: CURRENT LICENSE EXPIRES: Vendor has submitted a copy of the State of Florida Monitoring Report for review. Date of Monitoring Report : Monitoring Agency: F. Fiscal Manaaement 1. Vendor's Invoices are submitted in a timely manner. 2. Vendor attaches CSMS Service Item Reports to Monthly Invoices. YES NO N/A YES NO YES NO Vendor's Invoices are accurate and match units posted on attached CMS Service Item Reports. Vendor's Invoices to date are in agreement with Authorized Units of services. Service Ticket Review indicates supporting documentation to invoice is accurate for week(s) reviewed. See Exhibit #3 YES NO YES NO YES NO I COMMENTS: 5 259

260 Page 260 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT G. Human Resources Objective: To insure Vendor has sufficient and qualified personnel. Data Source: Personnel Policies and Procedures Manual Personnel Files Vendor's functional organization chart clearly reflects lines of authority and staff positions form Board of Director through Direct Service personnel. Chart indicates number of persons in each position and percent of time each commits to CCE Project. All positions are filled. Vendor employs a sufficient number of qualified staff to address the needs of persons served under this Agreement. Number of CCE clients served Number of staff assigned to work with CCE clients Vendor's human resources practices conform to the County's nondiscrimination policies as specified in the Agreement. YES NO YES NO YES NO YES NO 5. Vendor estimates rate of staff turnover to be around 6 260

261 Page 261 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT 6. Vendor's current salary structure for direct service worker is : Home Health Aide Starting salary ----"'$ an hour Compensation for Mileage/ Travel Policy: Monitor's review of sample of workers' schedules indicated that Vendor develops schedules developed so worker has sufficient Time for travel between each scheduled client start times. Vendor ensures compliance with background screening legislation. Vendor is currently enrolled in the E-Verify Program YES NO YES NO YES NO I COMMENTS: N/A H. Quality Improvement 1. Vendor has implemented an Internal Quality Improvement Program. 2. Vendor has minutes of last meeting of Quality Improvement committee and/or results of last Quality Improvement assessment. 3. Vendor has a file of Unusual Incident Reports and has procedures to investigate, report, record and respond to Unusual Incidents. 4. Vendor has procedure to conduct Annual Client Satisfaction Survey required by Community Care for the Elderly Application. YES NO YES NO YES NO YES NO COMMENTS: N/A 7 261

262 Page 262 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT Monitor reviewed individual responses resulting from Vendor's Annual Client Satisfaction Survey. Results of Vendor's Annual Satisfaction Survey met a 90% level of service satisfaction. Vendor has plan to improve areas of service delivery identified by Annual Client Satisfaction Survey which merit correction. Vendor has a Cultural Competency Plan that includes reference to Agency self-assessment and training. YES NO N/A YES N/A YES NO YES NO I COMMENTS: N/A Section II: Program Operations A. Operational Policies and Procedures Objective: To assure that Vendor has set forth, in writing, policies which govern procedures pertaining to day to day program operations including personnel, emergency and precautionary measures. Data Source: Operational Policies and Procedures Manual\ 8 262

263 Page 263 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT 1.Vendor has written procedures that govern the following CCE program areas: Receiving and processing the authorization of CCE referrals Communication with CCE staff regarding client status or problems, including use of TCP forms Confidentiality of CCE client files and information. CCE clients' receipt of Client Rights policy regarding Vendor service delivery, including process for client to express grievances. Collecting and processing Service Tickets from CCE client service visits Vendor has written procedures that govern the following areas of direct service staff performance: Identification Badges. Restrictions regarding interactions with clients, such as prohibition against accepting gifts and money, transporting clients in vehicles, etc. Reporting of suspected abuse, neglect or exploitation. Appropriate responses to medical emergencies. YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO COMMENTS: N/A 9 263

264 Page 264 of 379 I II! ' Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT B. Training and Supervision 1. Direct service staff completed in-service training in the last year. YES NO YES 2. Field supervision of direct service staff serving CCE clients. NO 3. Direct service-staff for CCE clients receive an annual performance YES evaluation. NO 4. New direct service staff receives orientation regarding CCE mission YES and procedures. NO Comments: See Exhibit #1 c. Client Files client records. Objective: To assure Vendor maintains comprehensive current Vendor's CCE client files contain all required documents. (See Exhibit #2) Files are well organized. YES NO YES NO Section Ill: Service Delivery A. Positive and Noteworthy Service Deliverv Activities Agency's CCE coordinators maintain ongoing communications with clients and EVSD case managers, which contributes to better quality of services and client satisfaction

265 Page 265 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT B. Service Initiation 1. Vendor has met eighty-five (85%) CCE standard in providing timely initiation of service delivery for referrals to the following service areas: Homemaker Personal Care Respite Care COMMENTS: See Exhibit #2 YES NO NO NO YES YES C. Observation Home Visit (Client and Staff Interviews) Monitor conducted home visits to randomly selected clients receiving elderly services, who were contacted the same day of the visit to request permission to conduct the home visit. Neither workers nor agency had prior knowledge which clients were to be visited or when. Visits revealed that clients were with workers and services provided. See Exhibit #

266 Page 266 of 379 Human Services Department, Elderly and Veterans Services Division Community Care for the Elderly ANNUAL ON-SITE MONITORING REPORT EXIT INTERVIEW FINDINGS OF NON-COMPLIANCE For this current Annual Monitoring Review, was found to be in compliance with the County Agreement and CCE Application and Guidelines. Contract Monitor Date

267 Page 267 of 379 WORKER NAME AGENCY ORIENTATION CCE ORIENTATION IN-SERVICE (4 HOURS YEAR) SUPERVISION 90 DAY HM/PC/RC 267

268 Page 268 of ' SERVICE HM PC RC HM PC RC HM PC RC HM PC RC HM PC RC AUTHOR DATE MAX STARTUP SERV INITIATION W/110 DAYS YES NO YES NO YES NO YES NO YES NO COPY OF INITIAL TIME TICKET YES NO YES NO YES NO YES NO YES NO CCE WORKPLAN ON FILE ON FILE ON FILE ON FILE 268

269 Page 269 of 379 SIGNATURE VERIFICARTION CLIENT CAREGIVER CLIENT CAREGIVER CLIENT CAREGIVER CLIENT CAREGIVER CLIENT CAREGIVER VERIFIED VERIFIED VERIFIED VERIFIED VERIFIED PRIVACY POLICIES RECEIVED RECEIVED RECEIVED RECEIVED RECEIVED 269

270 Page 270 of 379 AREA OF COMPLIANCE NUMBER COMPLIANT OR N/A NUMBER NON COMPLIANT % COMPLIANT AUTHORIZATION TIMELY SERVICE INITIATION COPY OF INITIAL TIME TICKET CCE WORKPLAN SIGNATURE VERIFICATION RECEIPT OF PRIVACY POLICIES 270

271 Page 271 of 379 AREA OF COMPLIANCE NUMBER IN COMPLIANCE NUMBER IN NON COMPLIANCE SERVICE TICKET DATE MATCHES SERVICE ITEM REPORT (BILLING DATE) AND PRODUCTIVITY REPORT SERVICE TICKET CORRECTIONS INITIALED BY OFFICE STAFF CORRECT SERVICE INDICATED ON TICKET SERVICE TICKET TASKS INDICATED SERVICE TICKET SIGNED BY CLIENT SERVICE TICKET SIGNED BY WORKER SERVICE TICKET PRESENT FOR UNITS BILLED TOTAL NUMBER OF TICKETS TOTAL TICKETS IN NON-COMPLIANCE ACCURACY RATE 271

272 Page 272 of 379 MONITORING FORM IN-HOME CARE - CCE HOME VISIT WITH WORKER PRESENT EXHIBIT#4 AGENCY SERVICE CLIENT IDENTIFICATION: CITY OF HOME VISIT: DATE OF HOME VISIT: SPECIFIC HEALTH CONCERNS: ADL/IADL DEFICITS: RATE OF SERVICE AUTHORIZED: RATE OF SERVICE CLIENT REPORTS SERVICE WORKER TRAINING/QUALIFICATIONS /NEEDS SERVICE PROVIDER-REPORTED SUPERVISION FREQUENCY/QUALITY SERVICE PROVIDER KNOWLEDGE OF CCE PRQGRAM GOALS, EMERGENCY/ABUSE REPORTING AND CLIENT COMPLAINT PROCEDURES SERVICE PROVIDER CONCERN CLIENT-REPORTED TASKS DONE SERVICE PROVIDER-REPORTED TASKS DONE TIME TICKETS IN ORDER UNIFORM/SHOES CLEAN ID TAG WORN AND VISIBLE COPY OF CLIENT CCE WORKPLAN QUALITY OF JOB PERFORMANCE CLIENT'S HOME CLEAN CLIENT SATISFIED WITH SERVICES CLIENT SATISFIED WITH WORKER COMMENTS: 272

273 Page 273 of 379 EXHIDIT#S DOEA CHECKLIST HOMEMAKER Corrective Yes No N/A Action Needed Are satisfactory written procedures established for: a. Evaluating the individual's need for service. b. A specific determination of eligibility for in-home services. c. The preparation of a service plan including a service frequency that establishes duration of need, and/or referral for alternative or additional services. d. Provision for follow-up and reassessment of need at least annually, if the individual receives Project Homemaker services? Are satisfactory procedures established to restrict or limit Homemaker activities beyond the duties specified in the plan of care? Homemakers may not: a. Accept gifts from the client being served. b. Lend or borrow money or articles. c. Perform services requiring a nurse, home health aide or personal care worker. d. Handle money unless authorized by the supervisor and bonded or insured by the provider. e. Transport the client in a privately owned vehicle unless authorized by the supervisor. f. Give the Homemaker's address or home telephone number. Is service provision scheduled geographically, in order to achieve maximum service delivery and to minimize travel? Are service verification forms, including date of service, time service begin and ends, and duties performed signed and dated by clients? These forms are filed in the subcontracted providers offices and serve as documentation for service achievement reports. Does the Project coordinate Homemaker services with other agencies providing the same service in order to avoid duplication? 273

274 Page 274 of 379 PERSONAL CARE Corrective Yes No N/A Action Needed Is Personal Care being provided by home health aides or certified nursing assistants? Do home health aides or certified nursing assistants meet training, certification and background screening requirements? Is it clear in the service delivery plan that Personal Care does not include the performance of simple procedures as an extension of therapy or nursing services and does not include assistance with self-administered medications? Are services requested under Personal Care specified in a written service agreement that is essential to the needs of the individual rather than the individual's family? RESPITE IN-HOME Corrective Yes No N/A Action Needed Is a physician, registered nurse, or case manager verifying that respite care is needed to help maintain or improve living situation? Is the client unable to tend to his or her daily needs without the assistance of the caregiver with whom he lives and/or requires regular supervision due to mental or physical impairment? Is the level and intensity of care required by a respite care recipient determined by the case manager? Has the Project developed written emergency procedures in the event of a crisis during the course of care while the caregiver is out of the home? 274

275 Page 275 of 379 ANNUAL MONITORING : SFY Lead Agency: Broward County Elderly & Veterans Services Division Vendor Name: Agreement Number: Program Name: Service Provided: Emergency Response Systems Date of Monitoring: Previous Monitoring: Term of Agreement: Agreement Monitor: Number of Clients Served: % Files Reviewed: Service Period: Does the Client Does the case Is all equipment used Is the communicator designed to Is the communicator attached Is the communicator able to CLIENT have a private Manager verify that approved by the FCC and receive the wireless signal from in such a way as to not impair conduct a self-test at least NAME phone line for the client is both the button and the the button signaling a need for normal use of the telephone? once every 24 hours? And if a {Initials) service to be physically and communicator have proper assistance and have the capability Does the unit have the ability self-test is not received by connected to? mentally able to use identification numbers; and to digitally dial and transmit this to seize the line, even if the the Central Receiving Station, the equipment the button is able to send signal to the Central Receiving phone is off the hook, and the client is contacted and appropriately? the wireless signal no less Station? Does the communicator contact the Central Receiving asked to test the unit. If no than 200feet to the design include an audible and Station and transfer test signal is received, the receiver located in the visual indication of system information about the client service provider shall communicator? operation for visual and hearing in case of an emergency? If investigate and resolve. impaired persons? Does the unit the client has multiple phones also have a rechargeable battery on one line, an alarm jack, e.g. backup with ten hours backup in RJ31X will be installed by the case of a power outage? provider.

276 YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO Exhibit 2 Page 276 of 379

277 Page 277 of 379 "' :::j COMMENTS: YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES YES YES NO NO NO NO NO NO RESULTS: EVSD Contract Administrator Date

278 Page 278 of 379 ANNUAL MONITORING : SFY Lead Agency: Broward County Elderly & Veterans Services Division (EVSD) Vendor Name: South Florida Medical Supply, Inc. Agreement Number: 11-EVSD-3411-MS-03 Program Name: Community Care for the Elderly (CCE) Service Provided: Medical Supplies Date of Monitoring: May 2, 2012 Previous Monitoring: N/A Term of Agreement: 7/1/2011-6/30/2012 Agreement Monitor: Francisco Munoz Number of Clients Served: 32 % Files Reviewed: 25% Service Period: 1/15/12-2/11/12 Client Name (Initials) Are Specialized Medical Equipment, Services and Supplies provided only in cases where they cannot be purchased through Medicare, Medicaid or other third parties? Paying a Medicare co-payment is allowable. Do all items have direct or remedial benefit to the client? Are the goods and services provided related to the client's medical condition? Are Specialized Medical Equipment, Services and Supplies limited to the following: a.) Adaptive devices, controls, appliances or services that enable clients to increase their ability to perform activities of daily living. This service includes repair of such items or replacement parts; b) Dentures, walkers, "reachers", bedside commodes, telephone amplifiers; touch lamps; adaptive eating equipment; glasses, hearing aid~ and other devices; c) Supplies including adult briefs, bed pads, oxygen or nutritional supplements; and d) Medical or dental visit payment; and Prescription costs.

279 Page 279 of 379.._, N "' GA SD JH EL SM HR MT ChW YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO YES YES YES NO NO NO

280 Page 280 of 379 YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO YES YES NO NO "' o COMMENTS RESULTS: EVSD Contract Administrator Date

281 Page 281 of 379 Board ofcounty Commissioners, Broward County, Florida HUMAN SERVICES DEPARTMENT Elderly and Veterans Servl es Division Community Care for the Elde~y Sectlon ADULT D)I.Y CARE: I DAY HEALTH CARE SERVICES WORKPLAN Client's Name= ~----- Note: Do not use the Social Security No. on this form. I Case Manager's Name:. _ Emetgeney Contact: 1) Phone# Relationship 2)._ ----~---'----- Phone#..:..;_ Relationship. Do.ctor Phone#;, FUNCTIONAL STATUS SUMMARy 1. Living Arrangements: 2. Living conditions: Good_~-- Adequate---- SUb Standard Physical Condition: (Circle all that apply) a. Marital Status: Alert Confused Forgetful Depressed Other b. Ambulatlon: Independent Devices NoncAmbulatory c. Continence: Continent Incontinent Bowel Bladder MEDICAb INFORMATION _Allergies --.Ampu1atlon _Angina Arthritis, Rheumatism Asthma _Anemia _Bia!fder/Kidney. _Dialy!lill,. _Bflndness _. Plirtiai._Full _cancer _Dementia _Parkinson's Disease --Divetticulitls/Oiverticulosis _Respiratory _Diabetes _Insulin _Seizure Disorder _._Emphysema _skeletal Trauma _Glaucoma _Skin Disease/Ulcer _Low/High Blood Pressure _. Stroke _Paralysis R L Heart Disease 1-itV (with permission to disclose) _Aphasia.. -"-- No Effect _Thyroid _.Muscular Disease Ulcer (Internal)/ Hiatus Hernia Other MEDICATIONS Page 1 of.2 281

282 Page 282 of 379 Adult Day Care/Day Health Care ServlcesWorl\plan continued ASSIGN.MENT: (mark all those needed) 1. Nutrition.: Needs assistance y N Type: 2. Tolleting: Needs assistance y N Type: 3.. Mobility: Needs assistance y N T pe: 4. MediCation: Needs assistance y N Type:.5. Sensory Impairments: Impairs Functioning y N Comments:..... '..... ' ".. 6. Rest Patterns: Impairs Functioning y N C.olllments: 7. Elllotionalllntellectual. Needs: Cognitlvely Impaired y N Comments: Comments: Emotional Needs: y N COMMENTS/PRECAUTIONS: (Caregllll!r/ Client Slgnature) For,ns/010104/Daycare careplan (ujxlated ) Page 2 of '' Date (Temporary) lnternalfonn '

283 Page 283 of 379 Board of County Commis.sioners, Broward County, Florida HUMAN SERVICES DEPARTMENT ELDERLY AND VETERANS SERVICES DIVISION Community Care for the Elderly IN-HOME SERVICES WORKPLAN Client's Name -~~~-~~~~-'-~~--- Note: Do not use. the Soclal Security No. on tltls form. I Case Manager's Name: Ernerg~ncy Contatf: 1) Phone# Relationship 2) -' Phone# Relationship---- Doctor ~ Phone# FUNCTIONAL STATUS SUMMARY 1.Living Arrangements: Living Conditions: Good Adequate Sub-Standard, 3.Physical Condition: (Circle,all tnat apply) a~ Mental Status: Alert Confused Forgetful Depressed Other b. Ambulation: Independent Devices Non-Arril!ulatory c. Continenc.e:.SPECIAL NEEQS C.on.tinent Incontinent: Bowel Bladder 1.Ciient/Spo!Jse/Other smokes in house: No Yes. Has smoke alarm? No Yes 2.. Ciient has pet in house: No_ _ Yes (specify) ~ 3.Ciient'$ primary language: English Spanish Creole_. _ Other C.Iient h.as other special needs, not listed below, which worker should b.eaware: MEDICAL INFORMATION _Allergies _Amputation _Angina _Arthriti$, Rheumatism _Asthma _Anemia _Bladder/Kidney _Dialysis _Blindness _. _ Partial _Full _Cancer _._Dementia. _Parkinson'sDisea$e _Diverticulitis I Divertiquiosis _Respiratory _Diabetes _Insulin _Seizure. DisQrder _Emphysema _Skeletal Trauma _GI.aucorna _._Skin Disease/Ulcer _Low/High Blood.Pressure _Stroke _Paralysis R L _Heart Disease _Aphasia _ No Effect _HIV (with permission to disclose) _Tnyroid _Muscular Disease~ Ulcer (Internal)/ Hiatus Hernia Other G:\EL\Forms\010104\in-hm svcs wkpln.doc Latest review: 03/01/04 283

284 Page 284 of 379 MEDICATIONS Hous.e Size: HOMEMAKING ACTIVITIES #of Bedrooms_; # of Baths_; # of Other Rooms Please checkau tasks that worker needs to perform. General Cleaning Duties: _Dusting; -.. Mopping; _Sweeping; ~Vacuuming; _Laundry; _ Empty Trash Check specifi~d ro()ms to be cleaned (and cleaning needs of each): Kitchen Area Bathroomlsl (#to clean _) _ Bedroom (# to clean_) _Wash dishes _.Clean countert pslappliances _sweep /Vacuum floor _Mop floor _Clean Inside Refrigerator _C.Iean commode, sink, tub, and shower _Sweep floor - Mop floor _Change Linen _Make Bed Additional Rooms to clean ISQecifv): (may include living area, den, family room,.etc ~ Shop Ding _._ Grocerie.s (Payment Method,) _Medications (Payment Method-~---~ _ Other errands: Specify ) Meal Preparation: Does the Cons.umer have: Food Allergies? _Yes (specify :.,) or _No Does the Consumer follow a Special Diet? _Yes (specify: ) or _No Other HOm!!maldngActlvltles: CIRCLE ALL SUPPLIES IN.HOME: VaCl,lum/Sweepl!r Dust Cloths Cleaning Cloths Broom Mop Pail/Bucket Soap PE!RSONAL CARE/RESPITE CARE ACTIVITIES Pleas.e check au ta.sks that worker needs to perform. _Shower _Bath _Sponge Bath _Shampoo _Toiletlng _Transfer/Ambulation _Dressing Assistance _Supervision of self adm.inistered med _Meal Preparation _Emergency Shopping _Linen Change _.Light Laundry _Light Bathroom Cleaning _Emotional Support _O.ther < ;- --~-----> _Special Equipment used in Personal Care CLIENT/CAREGIVER'S SIGNATURE DATE WORKERS MAY NOT DRIVE IN CLIENT'S CARS, NOR TRANSPORT CLIENTS IN WORKERS' CARS. WORKERS MAY NOT WORK FOR CLIENT'S OTHER THAN AT CCE PROGR.AM TIMES. G:IEL\Forms\010104\in-hm svcswkpln.doc Latest review: 03/01/04 284

285 Page 285 of 379 Exhibit B- Maintenance Support Services Contractor shall provide County with Support and Maintenance Services so as to ensure and maintain optimal performance of the Software and System consistent with the Statement of Work, the Documentation, and the Service Level Agreement included herein as Exhibit Bl, which services shall include the following: a) Timely response and resolution of any errors, defects, malfunctions or other issues affecting the use or performance of the Licensed Software or the System (collectively, "Events") in keeping with the Required Response Times stated below; b) Providing and facilitating the installation of updates, upgrades and releases as they are made available to Contractor's other clients; c) On-call availability via telephone and during normal business hours to receive and respond to inquiries or questions from County regarding use, operation, or functionality ofthe Licensed Software or System; d) Use of ongoing best efforts to mai.ntain the optimal functioning of the Licensed Software and System, to correct programming and coding errors, and to provide solutions to known errors affecting the operation of the Software or System; e) Routine notification to County of new or updated information as it becomes available pertaining to the Licensed Software, System, and Documentation; f) Maintain a level of version currency with any Third Party Software required to operate the System; and. g) Any other support and maintenance services routinely provided to hosting clients of Contractor. Support and Maintenance Services shall be provided via telephone, electronic communication, on-site, or as otherwise appropriate to address the issue. Any update, upgrades, releases, or other modifications to the Software for local installation at County shall be provided via electronic communication and for download via the Internet, if practicable. To the extent necessary to resolve an Event or other support request, Contractor shall provide support onsite at any office or location of a Broward County agency. Contractor agrees that its personnel shall be suitably trained in the operation, support and maintenance of the Software and System. If in the reasonable opinion of County, the personnel provided are not acceptable, Contractor agrees to provide suitable replacements in accordance with Section of the Agreement. Required Response Times. Upon notice by County of an Event, Contractor shall address and resolve the Event consistent with the following priority, response and resolution levels: Broward County and The Echo Group Exhibit B (Maintenance Support Services) 285

286 Page 286 of 379 Priority 1 Critical Eventthatrendersthe Software, System and/or interfaces inoperable. 2 hours during normal business hours; or within 2 hours of beginning of next business day if outside of normal business hours Work until corrected Priority 2 Significant Event that results in a significant impairment of performance of the licensed Software or System or impairs essential 2 hours during normal business hours; or within 2 hours of beginning of next business day if outside of normal business hours Work until corrected during normal business hours Priority 3 Minor Priority 4 Minimal Event that has minor impact to County's business and that does not impact normal operation ofthe Software or Event that has minimal impact or no impact on County's business. 4 hours during normal business hours; or next business day if outside of normal business hours 4 hours during normal business hours; or next business day if outside of normal business hours Future patch or release Future release Notwithstanding the above-stated schedule, Contractor shall use its continuing best efforts to correct the Event as expeditiously as it can. The Priority Description for each error or issue shall be reasonably determined by the Contract Administrator. Hours of Service. Normal business hours are from 8:30 a.m. to 6:00 p.m. (Eastern), Monday Friday. After hours are from Friday at 6:00p.m. to Monday at 8:30a.m. (Eastern) and all day on Echo holidays which are: New Year's Day, Martin luther King Day, President's Day, Memorial Day, Independence Day, labor Day, Columbus Day, Veterans Day, Thanksgiving and the Friday following, Christmas Day. Records and Reports. Contractor will maintain records of its Support and Maintenance Services, which shall include at least the following: a) Date, time, and name of contact for each Event; b) Date and time of response by Contractor; c) Description of Event and analysis of error, defect, or other issue causing Event; d) All steps and actions taken to resolve the Event; e) Date and time of resolution and County representative notified of resolution; and f) All equipment and/or labor costs associated with resolution. At the request of County, Contractor shall provide monthly reports of the foregoing records and statistics of Contractor's average monthly compliance with the Required Response Times. Broward County and The Echo Group Exhibit B (Maintenance Support Services) 286

287 Page 287 of 379 Exhibit 81- ~ervice Level Agreement In connection with all Services provided under the Agreement, Contractor shall, at no additional cost to County, meet or exceed the requirements below including as to Application Service Provider (ASP) hosting. The standards set forth herein are intended to reflect the current industry best practices for the Services. If and to the extent industry best practices evolve to impose higher standards than set forth herein, this Service Level Agreement ("SLA") shall be deemed to impose the new, higher standards upon Contractor. Contractor shall notify County in writing of any material change to its standards. Any item addressed in this SLA that requires approval by County must be approved in writing. The Contract Administrator and Director of the County's Division of Enterprise Technology Services ("ETS") are authorized to approve those items on behalf of County. 1. Security 1.1 Contractor will ensure that County has the ability to set up a table with username, password, and IP address, and Contractor shall ensure that County users of the System are routed through a static IP address " 1.2 Contractor will support encryption using at least 256-bit encryption keys for the connection from County to Contractor's production network. 1.3 If and to the extent Contractor accepts, transmits or stores any credit cardholder data, then within thirty {30} days after the end of each calendar quarter, Contractor shall provide County a copy of the quarterly third-party Payment Card Industry compliance vulnerability scanning reports, and Contractor shall comply with the most recent version of the Security Standards Council's PCI Payment Application Data Security Standard. 1.4 All servers that Contractor uses to provide services under the Agreement shall be protected behind a redundant set of firewalls, the initial configuration of which must be approved by County prior to Final Acceptance. Any subsequent changes are subject to approval by County, which shall not be unreasonably withheld. All database servers will be protected behind an internal firewall located within a DMZ zone. 1.5 Contractor's procedures for the following must be documented and approved by County prior to Final Acceptance: Evaluating security alerts and installing security patches and service packs; Intrusion detection, incident response, and incident escalation/investigation; and Providing and resetting access controls. Broward County and The Echo Group Exhibit B (Maintenance Support Services) 287

288 Page 288 of Contractor shall apply for the SSAE16 certification upon the completion of the build out of its new data center. Upon the completion of the certification process, a copy of the certificate will be provided within 30 days. The certification process is anticipated to be completed in Once certification is achieved, Contractor must maintain its SSAE16 certification throughout the life oft he Agreement. 1.7 Contractor shall maintain a disaster recovery plan with mirrored sites with a Recovery Time Objective (RTO) of a maximum of eight (8) hours and a Recovery Point Objective (RPO) of a maximum of four (4) hours from the incident. Contractor shall replicate database back-up to its west coast operations in Oakland, CA on a daily basis. 1.8 Contractor shall conduct a disaster recovery test in coordination with County at least once per year. The timing and duration of the test will be subject to the approval of County, and shall be coordinated and timed so as to cause minimal or no disruption to the Services or the regular business of County. 1.9 Contractor agrees to provide Advanced Encryption Standard with 256 bit keys (AES-256) data encryption for SSN, TIN, EIN, bank account numbers, and any other data such as HIPAA and PHI or as otherwise directed by County, at no additional charge to County. Contractor shall also ensure that the encryption key(s) are not stored with the encrypted data. Contractor shall immediately notify County of any compromise of the encryption keys Contractor shall maintain industry best practices for data privacy, security, and recovery measures including disaster recovery programs, physical facilities security, server firewalls, virus scanning software, current security patches, user authentication, and intrusion detection and prevention. Upon request (or as otherwise provide in this SLA), Contractor shall provide documentation of such procedures and practices to County. In addition, Contractor agrees not to allow Peer to Peer Software (P2P) or any other PC file-sharing software to be installed onto any network where County data/files reside unless County specifically permits it in writing on a case-by-case basis Contractor shall report to County if any unauthorized parties are successful in accessing any of the servers (including fail over servers) where County's data/files are housed, within 24 hours of becoming aware of the incident. Contractor shall provide County with a detailed incident report within five (5) days of the breach including remedial measures instituted and any law enforcement involvement Contractor shall protect any Internet interfaces provided under this Agreement using a Security Certificate from a top tier or otherwise mutually approved Certification Authority (CA) Contractor shall comply with HIPAA and HITECH laws and regulations (42 CFR and 45 CFR) and, if requested by County, agrees to execute the Business Associate Agreement (BAA) in the form provided by County. Broward County and The Echo Group Exhibit B (Maintenance Support Services) 288

289 Page 289 of Contractor shall connect its hosting site through at least two independent Internet Service Providers (ISPs) with different Internet Points-of-Presence Contractor shall ensure adequate background checks have been performed on any personnel having access to County data/files. Contractor shall deny convicted felons, and other persons deemed by Contractor to be a security risk, access to any County data/files Contractor shall ensure that its service providers, subconsultants, and any thirdparty performing any Services relating to this Agreement shall comply with all terms and conditions specified in this Agreement unless County, in writing, excuses any specific compliance with any such term or condition. 2. Service Availability 2.1 System Availability Network Uptime Guarantee. Contractor guarantees 99.9% network uptime for our public Internet network, excluding scheduled maintenance. Notwithstanding the foregoing, the Internet is comprised of thousands upon thousands of autonomous systems that are beyond the control of Contractor. This SLA and the 99.9% Network Uptime Service Commitment cover the provision of access by Contractor to the global internet "cloud". Routing anomalies, asymmetries, inconsistencies and failures of the Internet outside of the control of Contractor can and will occur, and such instances shall not be considered any failure of the 99.9% Network Uptime Service Commitment. Contractor proactively monitors network uptime and the results of these monitoring systems shall provide the sole and exclusive determination of network uptime. Contractor will refund to County one percent (1%) of the monthly hosting fees (or monthly pro rata equivalent, if recurring fees under the Agreement are charged other than monthly) under the Agreement for each 30 minutes of System Availability/Network downtime (excluding scheduled maintenance) in excess of that permitted under the Network Uptime Guarantee (up to 100% of County's monthly fee), measured on a calendar month basis. Such refunds will be paid within 10 days of the applicable Monthly Report or, at County's option, may be credited against amounts due under any unpaid invoice. The following table contains examples of the percentages of Network Uptime translated into minutes of uptime and downtime for the 99.9% Network Uptime target: *Allowable Percentage by Days/Month 99.9% for 31 days 99.9% for 30 days 99.9% for 29 days 99.9% for 28 days Total Minutes/Month 44,640 43,200 41,760 40,320 Minutes Up 44,595 43,156 41,718 40,279 Minutes Down Broward County and The Echo Group Exhibit B (Maintenance Support Services) 289

290 Page 290 of 379 *excludes scheduled maintenance Scheduled Maintenance. Normal availability of the System shall be twenty-four (24) hours per day, seven (7) days per week. Planned downtime (i.e., taking the System offline such that it is not accessible to County) ("Scheduled Maintenance") shall occur during non Prime Time and with at least five (5) business days' advance notice to County. Contractor may conduct Scheduled Maintenance at other times and upon less notice upon written consent from County, which consent will not be unreasonably withheld. During non-prime Time, Contractor may perform routine maintenance operations that do not require the System to be taken offline but may have immaterial effect on System performance and response time without any notice to County. Such degradation in performance and response time shall not be deemed Network downtime. All changes that are expected to take more than four (4) hours to implement or are likely to impact user workflow require County's prior written approval, which will not be unreasonably withheld Monthly Report. By the tenth day of each month, Contractor shall provide to County a report detailing Contractor's performance under this SLA for the prior calendar month. To the extent the performance fails to meet the Network Uptime Guarantee, the report shall calculate the total number of minutes of uptime for each of Prime Time and non-prime Time, the total number of minutes for each of Prime Time and non-prime Time minus any applicable Scheduled Maintenance, respectively, and the percentage of uptime versus total time minus Scheduled Maintenance for each (e.g., Monthly minutes of non-prime Time network uptime I (Total minutes of non-prime Time - Minutes of Scheduled Maintenance) = _%) Hardware Guarantee. Contractor guarantees the functioning of all hardware components necessary for Contractor to provide the Services and Service Availability herein, and will replace any failed or defective component at no cost to County. Downtime for the purpose of building redundancy or other recovery systems that is approved by County in advance shall not be charged as downtime in computing the Network Uptime Guarantee. Network downtime due to hardware failure is subject to the Network Uptime Guarantee. 2.2 Infrastructure Management Network Bandwidth/Response Times. Contractor shall ensure packet loss of less than 1% and less than 60 milliseconds domestic latency within Contractor's network. Contractor shall maintain sufficient bandwidth to the hosting sites and ensure the server processing time to provide optimal response times from the server. Contractor's Data hosting environment shall be built for maximum uptime and performance. Contractor shall provide failover components throughout its environment to include, but not limited to, firewalls, switches and servers. All network interfaces shall have a minimum oftwo ports defined to each Broward County and The Echo Group Exhibit B {Maintenance Support Services) 290

291 Page 291 of 379 network component. The Internet connectivity to the data center shall be provided by a minimum of two providers with connections coming from 3 disparate locations. County and Contractor recognize that end user response times are dependent on intermittent Internet service provider network connectivity, and in the case of County's users, dependent on County's internal network health Transactions Processed. Contractor's Services shall ensure that an unlimited number of transactions may be processed to County production database, but Contractor may recommend that non-routine reports and queries be limited to certain timeframes, quantities or other specifications if Contractor determines that such reports and queries cause degradation to response times affecting performance levels established in the SLA Database Retention. Contractor will retain all database records regardless of number or size Software Maintenance. Contractor shall routinely apply upgrades, new releases, and enhancements to the System as they become available and ensure that these changes will not adversely affect the System Report Execution. To the extent Contractor's System includes an ad-hoc reporting tool and/or standard reports, Contractor agrees to provide unlimited access to such functionality to County. Contractor agrees to support an unlimited number of queries and reports against County's data. County agrees that Contractor may put reasonable size limits on queries and reports to maintain System performance, provided such limits do not materially impact County's regular business operations System Backups. Contractor shall conduct full System backups (including System and user data) weekly and shall conduct incremental backups daily. Backups will be written to a backup device with sufficient capacity to handle the data. Contractor shall maintain a complete current set of backups for County's System, including data, at a remote, off-site "hardened" facility from which data can be recovered. The Contractor shall store locally two (2) days of database and transaction logs from which data can be recovered. The recovery process will begin within one (1) hour of notification. If the database is to be recovered from a database within this two day window it can be recovered within two (2) hours. If data has to be recovered from media not stored locally, the time required is dependent upon the backup size of the data. System restoration performed as a recovery procedure after a natural disaster is included in Contractor's Services under this Agreement. Upon County's request, Contractor shall also provide restoration of individual file(s). Contractor agrees that County may extract all County Data from Contractor's database at will Test. A development and test system, which shall mirror the production system, shall be made available for use by County for testing purposes upon two business days' request, including without limitation upon request for County's testing of application upgrades and fixes prior to installation in the production environment. Broward County and The Echo Group Exhibit B (Maintenance Support Services) 291

292 Page 292 of Demo/Training. A Demo/Training System will be available for use by County upon two business days' request. County may control data that is populated on the Demo/Training System by requesting that Contractor (a) periodically refresh data from production; (b) perform an ad-hoc refresh of data from production; (c) not refresh data from production until further notice from County; or (d) refresh data on an ad hoc basis with training data supplied by County. 2.3 Performance Monitoring & Hosting Capacity Increases If requested by County, Contractor shall provide a portal for reporting metrics to County on an ad hoc basis which shall include: server load including CPU load, memory, disk and 1/0 channel and network utilization, service and back-up status. Contractor will continuously monitor the environment and will perform upgrades and deploy additional servers to meet increased capacity and improve system performance In the event County anticipates an increase in transaction volume or seeks to expand capacity beyond the then existing capacity, Contractor shall supply increased capacity within fifteen {15) calendar days of written notice by County provided that the request does not require the Contractor to purchase hardware. If the requested increased capacity requires the Contractor to acquire hardware, Contractor shall supply the requested increased capacity within forty-five (45) calendar days. 3. Data 3.1 County shall also have the right to use the Services to provide access to the public to the database, files, or information derived from the use of the System, to generate reports from such data, files, or information, and to provide such data, files, or information on electronic media to the public where required or allowed by applicable law. 3.2 All data and information provided by County or its agents under this Agreement and all results derived therefrom through the use of the System, whether or not electronically retained and regardless of the retention media (collectively "County Data"), are the property solely of County and may be reproduced and reused solely with the prior written consent of County. Contractor and its subcontractors will not publish, transmit, release, sell, or disclose any County Data to any other person without County's prior written consent. The provisions of this Section 3.2 shall survive the termination or expiration of the Agreement. 3.3 In the event of any impermissible disclosure, loss or destruction of County Data, Contractor must immediately notify County and take all reasonable and necessary steps to mitigate any potential harm or further disclosure, loss or destruction. 3.4 County shall have the option of receiving County Data at any time in any format, including, without limitation, XML, Sequel, or in another format as may be mutually agreed to Broward County and The Echo Group Exhibit B (Maintenance Support Services) 292

293 Page 293 of 379 by County and Contractor. 3.5 Upon the termination of this Agreement or the end of serviceable life of any media used in connection with this Agreement, Contractor shall, at County's option, (a) securely destroy all media (including media used for backups) containing any County Data and County information and provide to County a signed certificate of destruction, and/or (b) return to County all County Data and provide a signed certification documenting that no County Data or information is retained by Contractor in any format or media. 4. Transition/Disentanglement Contractor will complete the transition of any terminated Services to County and any replacement providers that County designates (collectively, the "Transferee"), without causing any unnecessary interruption of, or adverse impact on, the Services ("Disentanglement"). Contractor will work in good faith (including, upon request, with the Transferee) to develop an orderly disentanglement plan that documents the tasks required to accomplish an orderly transition with minimal business interruption or expense for County, and shall cooperate, take any necessary additional action, and perform such additional tasks that County may reasonably request to ensure timely and orderly Disentanglement. Specifically, and without limiting the foregoing, Contractor shall: a. Promptly provide the Transferee with all nonproprietary information needed to perform the Disentanglement, including, without limitation, data conversions, interface specifications, data about related professional services, and complete documentation of all relevant software and hardware configurations; b. Promptly and orderly conclude all work in progress or provide documentation of work in progress to Transferee, as County may direct; c. Not, without County's prior written consent, transfer, reassign or otherwise redeploy any of Contractor's personnel during the Disentanglement period from performing Contractor's obligations under this Agreement; d. If applicable, with reasonable prior written notice to County, remove its assets and equipment from County facilities; e. If County requests and to the extent permitted under the applicable agreements, assign to the Transferee (or use its best efforts to obtain consent to such assignment where required) all contracts including third-party licenses and maintenance and support agreements, used by Contractor exclusively in connection with the Services. Contractor shall perform all its obligations under such contracts at all times prior to the date of assignment, and Contractor shall reimburse County for any losses resulting from any failure to perform any such obligations; Broward County and The Echo Group Exhibit B (Maintenance Support Services) 293

294 Page 294 of 379 f. Deliver to Transferee all current, nonproprietary documentation and data related to County-owned assets and infrastructure. Upon written consent from County, Contractor may retain one copy of documentation to the extent required for Contractor's archival purposes or warranty support; and g. To the extent requested by County, provide to County a list with current valuation based on net book value of any Contractor-owned tangible assets used primarily by Contractor in connection with the Services. County shall have the right to acquire any or all such assets for net book value. If County elects to acquire such assets for the net book value, any and all related warranties will transfer along with those assets. (The remainder is left blank.) Broward County and The Echo Group Exhibit B (Maintenance Support Services) 294

295 I Exhibit 2 Page 295 of 379.I II ~ EXHIBITC WORK AUTHORIZATION FORM Contract: AGREEMENT BETWEEN BROWARD COUNTY AND ECHO CONSULTING SERVICES, INC. FOR ENTERPRISE BUSINESS APPLICATION FOR HUMAN SERVICES DEPARTMENT Work Authorization No. Contract Administrator Award Authority for Optional Services This Work Authorization is between Broward County and Echo Consulting Services, Inc. d/b/a The Echo Group as required pursuant to the Agreement, executed on. In the event of any inconsistency between this Work Authorization and the Agreement, the provisions of the Agreement shall govern and control. Services to be provided: [DESCRIBE IN DETAIL] Contract at issue is _lump Sum/ _Not-to-Exceed for amount: $. The time period for this Work Authorization will consist of (_) calendar days unless otherwise set forth in an attached quotation. Fee Determination: Payment for services under this Work Authorization is as follows: Professional Services $ General Services $ Equipment/Hardware $ Total Maximum Cost of this Work Authorization $ County Project Manager Date Contract Administrator Date Risk Management Date Board and/or Designee Date VENDOR Signed: Attest: Typed Name: Title: Broward County and The Echo Group Exhibit C (Work Authorization Form) 295

296 Page 296 of 379 A COR.Q. EXHIBIT D CERTIFICATE OF INSURANCE CERTIFICATE OF LIABILITY INSURANCE "" ~~~~ AS. A MATTER OF '_~D. _HOLDER. THIS CERTIFICATE DOES NO'r AFFIRMATIVELY OR NEGATIVELY AMEND, 'EXTEND ORAL TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUiNG INSURER(S), AUTHORIZED REPRESENTATIVE OR I.. 1_ ' ".~:I '?ollcles may require an A statement on this certificate does not confer rights to the '::'' '~..., uu" 15 ' Ito ~ l lnl ~ >usan Santos Mason & Masoh Techno 1 ogy Insurance Services, Inc..: I r~.no South Ave. Whitman, MA Susan Santos I... I"'URED INSURER A Travelers Ins Echo Consulting -Services Inc. DBA Echo Mngmnt INSUREROo PO Box 2150 Conway, NH ~ I'~MI I I :~!,BEl wfsucfil I I UREREo INSURERF o : lj-14 L lblllty I HAVE BEEN I },\'.>:;~~~:~Of-,THE I 1. ~""~""',,;'~~.' '"'" LIMITS ~ :.ucv~~~ x ~00,:: 1 I 1 - p CLAIMS-MADE [!] OCCUR r;;,ecl I' la - Is f- I rx1 POUCV r u& n ~:: ~ ANYAUTO All OWNED AUTOS,A r- SCHEDULED Al.JTOS ~ H(REDAUTOS NON-OWt DAUTOS I... I I I I (E"ooldooQ I OODLVI 'AGG I I 1,Q~~ I 1,000,000 Is... n.occur " 4, ' f- OXCESSLIAS A ' ~ 10,00( X ve~,f-1!\ A NIA I' I' 4,000, LJ 1, I $ 1,000,000 ''" I I mol...: ""'I ~ ~... """'""...,. ''""~ ~~..,... ~.,,,....,, ~.. ~"""" ~or the ongo1ng operations o~ the Insured on behalf of the Additional -~b~~ 1. '~'.uo, 113. Broward County Attention: HUmah Services_ Department 115 South Andrews Ave. Ft I le, FL 33301!Phil. Mason I A<;ut<U ACORD 25 ( ) The ACORD name and logo aro regis.ered marks_ of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE:UED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WIU. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. All rights rese.ved. Broward County and The Echo Group Exhibit D (Certificate of Insurance) 296

297 Page 297 of 379 EXHIBITE BUSINESS ASSOCIATE AGREEMENT BETWEEN BROWARD COUNTY, FLORIDA AND S;Jvo {! oas' tf fj r1vj SvrJICei!t Xnc y This BUSINESS ASSOCIATE_AGREEM~NT ("BAA") is entered into by and between Broward I 'd (" ") d F-C-fcV ( ijf\sti/oiijf d. j ~.. County, F on a County, an ymca kr 4 a fjewl-tv"'-/1511're' corporation authonzed to do. business in the State of Florida with its prlncipal office l~cated at tvnvj,,!f Nee-! f/4.1"-'f.ish,f'l ("Business Associate") in connection with the i(j,r;{("(._r;m.'<'ni- fkn,;e?l\. (bw-w~-4 G.J"b (i:he " A ") /Jcf..>" b/ /" I 0 greement. -~l a--vw c.oy\,jvfn:':j,y-t/\/jcaps,, j>tl., RECITALS 1. Business Associate provides services related to the operation of certain activities/programs that involve the use or disclosure of Protected Health Information ("PHI"); 2. The operation of such activities/programs is subject to the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and the Health Information Technology for Economic and Clinical Health Act ("HITECH"); 3. HIPAA and HITECH mandate that certain responsibilities of contractors with access to PHI be documented through a written agreement; and 4. The County and Business Associate desire to comply with the requirements of HIPAA and HITECH and acknowledge their respective responsibilities. NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: Section 1: Definitions 1.1 All terms used in this BAA not otherwise defined herein shall have the meanings stated in the Privacy and Security Rules, 45 CFR Parts 160, 162, 164, and 42 U.S.C "HIPAA Laws" mean collectively HIPAA, HITECH, 42 CFR Part 2 (if applicable), and the related regulations and amendments. 1.3 When the term "PHI" is used in this BAA, it includes the term "Electronic Protected Health Information" or "EPHI." 1.4 Penalties as used in Section 3.18 below are defined as civil penalties that may be applied to the Business Associate and its workforce members by the Secretary of Health and Human Services (HHS). The amount of the penalties range depending on the type of violation. In determining penalties, the Secretary may take into account: Broward County and The Echo Group Exhibit E (Business Associate Agreement) 297

298 Page 298 of 379 a. the nature and extent ofthe violation; b. the nature and extent of harm resulting from such violation; c. the degree of culpability of the covered entity or business associate; d. the history of prior compliance with the administrative simplification provision including violations by the covered entity or business associate; e. the financial condition of the covered entity or business associate, and f. such other matters as justice may require. Section 2: Confidentiality 2.1 County and Business Associate shall comply with all federal and state laws governing the privacy and security of PHI. 2.2 rgj If this box is checked, the County and Business Associate are required to comply with 42 CFR Part 2 with respect to patient identifying information concerning alcohol and substance abuse treatment. Section 3: Obligations and Activities of the Business Associate Use and Disclosure of PHI 3.1 The Business Associate shall not use or disclose PHI other than as permitted or required by this BAA or as required by law. Business Associate may: a. Use and disclose PHI only as necessary to perform its obligations under the Agreement, provided that such use or disclosure would not violate HIPAA Laws if done by the County; b. Use the PHI received in its capacity as a Business Associate of the County for its proper management and administration and to fulfill any legal responsibilities of Business Associate; c. Disclose PHI in its possession to a third party for the proper management and administration of Business Associate, or to fulfill any legal responsibilities of Business Associate, provided that the disclosure would not violate HIPAA Laws if made by the County, or is required by law, and Business Associate has received from the third party written assurances that (i) the information will be kept confidential and used or further disclosed only for the purposes for which it was Broward County and The Echo Group Exhibit E (Business Associate Agreement) 298

299 Page 299 of 379 disclosed to the third party or as required by law; (ii) the third party will notify Business Associate of any instances of which it becomes aware in which the confidentiality of the information may have been breached; and (iii) the third party has agreed to implement reasonable and appropriate steps to safeguard the information; d. Use PHI to provide data aggregation activities relating to the operations of the County; and e. De-identify any and all PHI created or received by Business Associate under the Agreement, provided that the de-identification conforms to the requirements of the HIPAA Laws. 3.2 Business Associate shall limit its use and disclosure of, and request for PHI when practical or as required by law, to the information making up a Limited Data Set, as defined by HIPAA, and in all other cases subject to the requirements of 45 CFR (b), to the minimum amount of PHI necessary to accomplish the intended purpose ofthe use, disclosure, or request. 3.3 Business Associate is prohibited from selling PHI, using PHI for marketing purposes, or attempting to re-identify any PHI information in violation of HIPAA Laws. Administrative. Physical. and Technical Safeguards 3.4 Business Associate shall implement administrative, physical, and technical safeguards that protect the confidentiality, integrity and availability of PHI that it creates, receives, maintains, or transmits on behalf of the County. The safeguards shall include written policies, procedures, a security risk assessment, training of Business Associate employees, and sanctions that are in compliance with HIPAA Laws. 3.5 Business Associate shall require all of its subcontractors, agents, and other third parties that receive, use, transmit, maintain, store, or have access to PHI to agree, in writing, to the same restrictions and conditions that apply to Business Associate pursuant to this BAA, including implementation of administrative, physical, and technical safeguards. Access of Information: Amendment of Information: Accounting of Disclosures 3.6 Business Associate shall make available to the County all PHI in Designated Record Sets within ten (10) days of the County's request for the County to meet the requirements under 45 CFR Business Associate shall make any amendments to PHI in a Designated Record Set as directed or agreed to by the County pursuant to 45 CFR in the time and manner reasonably designated by the County. Broward County and The Echo Group Exhibit E (Business Associate Agreement) 299

300 Page 300 of Business Associate shall timely document such disclosures of PHI and information related to such disclosures as would be required for the County to respond to an individual for an accounting of disclosures of PHI in accordance with 45 CFR Further, Business Associate shall provide to the County an accounting of all disclosure of PHI during the term of this BAA within ten (10) days of termination of this BAA, or sooner if reasonably requested by the County for purposes of any monitoring/auditing of the County for compliance with HIPAA Laws. 3.9 Business Associate shall provide the County, or an individual under procedures approved by the County, information and documentation collected in accordance with the preceding paragraph to respond to an individual requesting an accounting for disclosures as provided under 45 CFR and HIPAA Laws. Mitigation 3.10 Business Associate shall mitigate, to the extent possible and at its own expense, any harmful effect that is known to Business Associate of a use or disclosure of PHI by the Business Associate in violation ofthe requirements ofthis BAA or applicable law Business Associate shall take appropriate disciplinary action against any members of its workforce who use or disclose PHI in any manner not authorized by this BAA or applicable law. Reporting of Breaches and Mitigation of Breach 3.12 Business Associate shall notify the County's HIPAA Privacy Official at (954) of any impermissible access, acquisition, use or disclosure of any unsecured PHI within twenty-four (24) hours of Business Associate becoming aware of such access, acquisition, use or disclosure. Unsecured PHI shall refer to such PHI that is not secured through use of a technology or methodology specified by the Secretary of HHS that renders such PHI unusable, unreadable, or indecipherable to unauthorized individuals. A breach of unsecured PHI shall be treated as discovered by Business Associate as of the first day on which such breach is known to the Business Associate or, by exercising reasonable diligence, would have been known to Business Associate, including any employee, officer, contractor, subcontractor, or other agent of Business Associate Business Associate shall submit a written report of a breach to the County within ten (10) business days after initial notification, and shall document the following: a. The identification of each individual whose PHI has been, or is reasonably believed by Business Associate, to have been accessed, acquired, used, or disclosed during the breach; Broward County and The Echo Group Exhibit E (Business Associate Agreement) 300

301 Page 301 of 379 b. A brief description of what occurred, including the date of the breach and the date of the discovery of the breach, if known; c. A description of the types of PHI that are involved in the breach (such as full name, social security number, date of birth, home address, account number, diagnosis, etc.) d. A description of what is being done to investigate the breach, to mitigate harm to individuals, and the reasonable and appropriate safeguards being taken to protect against future breaches; e. Any steps the County or the individual impacted by the breach should take to protect himself or herself from potential harm resulting from the breach; f. Contact procedures for the Business Associate to enable individuals to ask questions or learn additional information, which may include, in the discretion ofthe County, a toll-free telephone number, address, website, or postal address, depending upon the available contact information that the Business Associate has for the affected individuals; and g. Any other reasonable information requested by the County In the event of a breach, Business Associate shall, in consultation with and at the direction of the County, assist the County in conducting a risk assessment of the breach and mitigate, to the extent practicable, any harmful effect of such breach known to Business Associate The County, in its sole discretion, will determine whether the County or Business Associate shall be responsible to provide notification to individuals whose unsecured PHI has been disclosed, as well as to the Secretary of HHS and the media. a. Notification will be by first-class mail, or by electronic mail, if the individual has specified notice in the manner as a preference. b. Information may be posted on the County and Business Associate's website where the Business Associate experienced, or is reasonably believed to have experienced, an impermissible use or disclosure of unsecured PHI that compromised the security or privacy of more than ten {10} individuals when no other current information is available to inform such individuals. c. Notice shall be provided to prominent media outlets with information on an incident where the Business Associate experienced an impermissible use and disclosure of unsecured PHI that compromised the security or privacy of more than five hundred {500) individuals within the same state or jurisdiction during the incident. Broward County and The Echo Group Exhibit E (Business Associate Agreement) 301

302 Page 302 of 379 -n,, li i! d. The County may report, at least annually, any impermissible use and disclosure of I!,, unsecured PHI by the Business Associate to the Secretary of HHS as required by i: HIPAA Laws. I 3.16 Business Associate agrees to pay the costs for notification to the County, individuals, and their representatives of any security or privacy breach that should be reported by Business Associate to the County. Business Associate also agrees to pay the costs for mitigating damages, including, but not limited to, the expenses for credit monitoring, if the County determines that the breach warrants such measures. 3,17 Business Associate agrees to have established procedures to investigate a breach, mitigate losses, and protect against any future breaches, and to provide such procedures and any specific findings of the investigation to the County in the time and manner reasonably requested by the County Business Associate is liable to the County for any civil penalties imposed on the County under the HIPAA laws in the event of a violation of the HIPAA Laws as a result of any practice, behavior, or conduct of Business Associate. Available Books and Records 3,19 Business Associate shall make its internal practices and books, related to the Agreement and the BAA, including all policies and procedures required by HIPAA Laws, available to the County Contract Grants Administrator within five (5) business days of the Agreement Business Associate shall make its internal practices, books, and records, including all policies and procedures required by HIPAA Laws and PHI, relating to the use and disclosure of PHI received from the County or created or received on behalf of the County available to the County or to the Secretary of HHS or its designee within five (5) business days of request for the purposes of determining the Business Associate's compliance with HIPAA Laws, Section 4: Obligations of the County 4.1 The County shall notify Business Associate of any limitations in its notice of privacy practices in accordance with 45 CFR , to the extent that such limitation may affect the Business Associate's use of PHL 4.2 The County shall notify Business Associate of any changes in, or revocation of, permission by an individual to use or disclose PHI, to the extent that such changes may affect Business Associate's use of PHL Broward County and The Echo Group Exhibit E (Business Associate Agreement) 302

303 Page 303 of The County shall notify Business Associate of any restriction to the use or disclosure of PHI to which the County has agreed in accordance with 45 CFR , to the extent that such changes may affect Business Associate's use of PHI. 4.4 The County shall not request Business Associate to use or disclose PHI in any manner that would not be permissible under the HIPAA Laws if done by the County. Section 5: Term and Termination 5.1 The term of this BAA shall be effective upon execution by all Parties, and shall terminate upon the latter of termination or expiration of the Agreement, or the return or destruction of all PHI within the possession or control of the Business Associate as a result of the Agreement. Termination 5.2 Upon the County's knowledge of a material breach of this BAA by Business Associate, the County shall either: a. Provide an opportunity for Business Associate to cure the breach or terminate this BAA and the Agreement if the Business Associate does not cure the breach within the time specified by the County; b. Immediately terminate this BAA and the Agreement if Business Associate has breached a material term of this BAA and a cure is not possible; or c. If neither termination nor cure is feasible, the County's HIPAA Privacy Official shall report the violation to the Secretary of HHS. Effect of Termination 5.3 Upon completion or termination of the Agreement, Business Associate agrees, at County's option, to return to the County or destroy all PHI gathered, created, received or processed pursuant to the Agreement. No PHI related to the Agreement will be retained by Business Associate, or a contractor, subcontractor, or other agent of Business Associate, unless retention is required by law and specifically permitted in writing by the County. 5.4 In the event that returning or destroying PHI is infeasible, Business Associate shall provide to the County a written statement that it is infeasible to return or destroy the PHI and describe the conditions that make return or destruction of the PHI infeasible. Under that circumstance, Business Associate shall extend the protections of this BAA to Broward County and The Echo Group Exhibit E (Business Associate Agreement) 303

304 Page 304 of 379 the PHI retained and limit further uses and disclosures of such PHI to those purposes that make return or destruction infeasible, for so long as Business Associate maintains the PHI, in which case Business Associate's obligations under this Section shall survive termination of this BAA. Section 6: Miscellaneous 6.1 Amendment. The County and Business Associate shall take such action as is necessary to amend this BAA for the County to comply with the requirements of HIPAA laws or other applicable law. 6.2 Interpretation. Any ambiguity in this BAA shall be resolved to permit the County to comply with HIPAA laws. Broward County and The Echo Group Exhibit E (Business Associate Agreement) 304

305 Page 305 of 379 BUSINESS ASSOCIATE AGREEMENT TO EXISTING AGREEMENT BETWEEN BROWARD COUNTY, FLORIDA AND BUSINESS ASSOCIATE, ENUMERATING THE RESPONSIBILITIES OF EACH REGARDING COMPLIANCE WITH HIPAA LAWS. WHEREAS, the parties have made and executed this Business Associate Agreement between BROWARD COUNTY and BUSINESS ASSOCIATE, on the respective dates under each signature: BROWARD COUNTY through its County Administrator, authorized to execute same, and BUSINESS ASSOCIATE signing by and through its duly authorized to execute same. COUNTY BROWARD COUNTY, through its County Administrator BY day of ' 20_. Approved as to form by Office of the County Attorney Broward County, Florida Joni Armstrong Coffey, County Attorney Governmental Center, Suite # South Andrews Avenue Fort Lauderdale, Florida Telephone: (954) Telecopier: (954) By Assistant County Attorney Broward County and The Echo Group Exhibit E (Business Associate Agreement) 305

306 Page 306 of 379 BUSINESS ASSOCIATE BUSINESS ASSOCIATE By: ~ aap't-rjj Print b bb1~~ f'ln~~{,,<~ 0 Title: CJte.~ hi\4j\.c,rcl {)~uv STATE OF D \=\ COUNTY OF Co QJ7n\ \ } ss } 1>1':>~ _ The foregoing instrument was acknowledged before me this }...5_ day of ~~ 2o_l5,by ~E~~ ~~~:Co.as C fo,ofthe G who has produced l'ho 0 k, ~=> c :t0a, who is personally known to me or as identifica on. Commission Expires: Print e: Notary Public, State of Commission No. EL B B KER Notary Public - New Hampshire My Commission Expires June 22, 2016 Broward County and The Echo Group Exhibit E (Business Associate Agreement) 306

307 Page 307 of 379 Exhibit F The Echo Group Response to RLI No. R Rl Broward County and The Echo Group Exhibit F (The Echo Group Response to RLI) 307

308 Page 308 of 379 echo Group Echo Customers are Creating Better Organizations Software & Services for Behavioral Healthcare 308

309 Page 309 of 379 Table of Contents Cover Letter 4 Addendum No. 3 Separate Doc Required Forms 6 Evaluation Criteria- Project Specific Criteria 7 Evaluation Criteria- Company Profile 11 Evaluation Criteria - Legal Requirements 14 Evaluation Criteria- Tiebreaker Criteria 19 Required Forms: 22 Attachment B - Letter of Intent Not incl. in your original Attachment C- Schedule of Participation Not incl. in your original Attachment D- CBE Unavailability Report Not incl. in your original Attachment E -Vendor's List 23 Attachment G- Domestic Partnership Certification 24 Attachment H- Lobbyist Registration -Certification 25 The Echo Group 2 7/6/2012 RLI Number: R R1 309

310 Page 310 of 379 Attachment J- Litigation History 26 Attachment K- Insurance Requirements 27 Attachment L- Cone of Silence Certification 29 Attachment N - Drug Free Workplae Policy Certification 30 Attachment 0- Non-Collusion Statement Form 31 Attachment P- Scrutinized Companies List Certification 32 Attachment Q - Local Vendor Certification 33 Attachment R- Volume of Work Over Five Years 34 Exhibit 1 - Detailed Scope of Work 36 Summary of Evaluation Criteria 40 Attachment A- Requirements Matrix Separate Doc attached to End. The Echo Group 3 7/6/2012 RLI Number: R Rl 310

311 Page 311 of 379 ~echo,\!ii Group July 9, 2012 Broward County Purchasing Division 115 South Andrews Avenue, Room 212 Fort Lauderdale, FL RE: RLI Number: R R1 Dear Sir/Madame, The Echo Group is pleased to have the opportunity to submit this response to Broward County as you explore available Enterprise Business Applications. Echo has been providing Clinical and Billing software to agencies across the country for over 30 years. We have both large and small size agencies for customers, with both single and multiple locations. We have had customers in the State of Florida since Echo can provide you with a comprehensive Electronic Health Record to help you manage and support the delivery of efficient, cost-effective, and high quality behavioral health services. Scott Taylor, Senior Account Manager, is a key resource for you in your evaluation of Echo products and services. He can offer clarification of our response, consultation on tuning your evaluation process, coordination of demonstration or calls, and access to many other Echo resources. Our goal is to ensure that you are making the best, most informed selection possible. Mr. Taylor can be reached via at [email protected] or by calling Echo's offices at Thank you in advance for this opportunity. Please note, as indicated in our table of contents as well as several pieces of communication to Broward County that Attachment B, Attachment C and Attachment D were not included in your original Bid, therefore, we did not include them in our response. Sincerely, <ha----;1~ J~e V~er Vice President of Business Development The Echo Group 4 7/6/2012 RLI Number: R R1 311

312 Page 312 of 379 Addendum No. 3 Hard copies submitted. The Echo Group 5 7/6/2012 RL/ Number: R Rl 312

313 Page 313 of 379 '{(~echo ~ Group.. Required Forms This Request for Letter of Interest requires the following CHECKED forms to be returned: (Please initial each Attachment being returned) Documents submitted to satisfy responsiveness requirement(s) indicated with an (R) must be attached to the RLI submittal and returned at the time of the opening deadline. Verification of return (Please I nitiall Attachment A Attachment B Attachment C Attachment D Attachment B Attachment C Attachment D Attachment E Attachment F Attachment G Attachment H Attachment I Attachment J Attachment K Attachment L Attachment M Attachment N Attachment 0 Attachment P Attachment Q Attachment R Bidders Opportunity List Letter of Intent (CBE) (R) ~ Schedule of (CBE) Participation (R) ~ CBE Unavailability Report (R) ~ Letter of Intent (DBE) Schedule of Federal Disadvantage Business Enterprise (DBE) Participation Federal Disadvantaged Business Enterprise (DBE) Unavailability Report Vendor's List (Non-Certified Subcontractors and Suppliers Information) ~ Contractors Assurance Statement Domestic Partnership Certification (R) ~ Lobbyist Registration- Certification ~ Employment Eligibility Verification Program Contractor Certification Litigation History ~ Insurance Requirements ~ Cone of Silence Certification ~ Living Wage Ordinance Drug Free Workplace Policy Certification ~ Non-Collusion Statement Form ~ Scrutinized Companies List Certification ~ Local Vendor Certification ~ Volume of Work Over Five Years ~ D D D D D D D Removed - Not Included Not incl. in orig request Not incl. in orig request Not incl. in orig request Removed - Not Included Removed - Not Included Removed - Not Included Removed - Not Included Removed - Not Included Removed - Not Included The Echo Group RLI Number: R R /6/2012

314 Page 314 of 379 t(techo 1. Group... o ont Evaluation Criteria With regard to the Evaluation criteria, each firm has a continuing obligation to provide the County with any material changes to the information requested. The County reserves the right to obtain additional information from interested firms. Evaluation Criteria - Provide answers below. If you are submitting a response as a joint venture, you must respond to each question for each entity forming the joint venture. When an entire response cannot be entered, a summary, followed with a page number reference where a complete response can be found is acceptable. 1) For the proposed software provider(s): Access Alliance of Michigan a. Provide three (3) references, preferably Leslie Thomas, Manager Business Services from the public sector (organization, 5455 Hampton Place year(s) installed, contact name, title, role SaginawMI on project, , telephone) that meet (989) the following criteria: [email protected] i. Successful implementation of a software solution to meet human or social services business needs. Mecklenburg County ii. Project references for sites where Christine Payseur, IT Business Analyst the proposed solution has been 429 Billingsley Road fully implemented and is currently Charlotte NC being utilized. (704) iii. Evidence of project completion on christine.qa:tseur@mecklenburgcount:tnc.gov time and within budget. iv. Evidence of solution scalability. Walworth County v. Evidence of user accessibility at Liz Aldred, Deputy Director multiple locations (facilities and W4051 County Road NN remote). Elkhorn WI vi. IF VENDOR HOSTED, SAS-70 (262) references must meet the following [email protected] criteria: (1) Use of the hosting entity's service no less than one (1) year. Project-Specific Criteria (1) Must include documentation of downtime performance, technical ( 1 ) Our contracts have a support complaint history, and maintenance clause that hosting traffic throughput speed. allows up to 2 hours per b. List all projects similar to this project month for scheduled including: scope, project duration, and maintenance. You can also date of completion. put that the system is c. List all projects, including project number, monitored 24x7. The with Broward County during the past five customers have full access to (5) years. the monitorinq system with the The Echo Group 7 7/6/2012 Rll Number: R R1 314

315 Page 315 of 379 ~0 ability to run up-time reports b) Echo currently has over 250 customers in more than 30 states utilizing Echo products. Our largest customers include large County Mental Health organizations and private non-profits. The customer organizations are varied in the type of treatments provided and populations served. Our customer user counts range from 8 to 300 concurrent users to unlimited user licenses. c) Please see Attachment R. 2) Narrative with adequate detail of respondent's knowledge and skills to successfully complete the project. Proposal must include the following: a. Work Plan - Include all project requirements, proposed tasks, services, activities, and resource requirements necessary to accomplish the scope of the project defined in this RLI. b. Project Schedule -Include a project schedule indicating when the elements of the work will be completed and when deliverables, if any, will be provided. c. Deliverables- Fully describe deliverables the consultant deems would be submitted under the proposed contract. 3) Project Approach/Methodology Description of the proposed approach and methodology for the project. 4) Project Team Structure- Proposed project structure for this project, including any subcontractors. If necessary, provide an organizational chart indicating governance for this project. 5) Staff Qualifications/Experience - If the consultant will be utilizing other staff in fulfillment of the terms and conditions of this RLI, including subcontractors, who will be assigned to the potential contract, indicate the responsibilities and qualifications of such personnel, and include the amount of tirne each will be assigned to the project. Please see this information beginning gon page 41 below. Please see this information beginning gon page 41 below. Please see page 59 below. Please see page 61 below. We have provided to you all the Professional Services bios and we acknowledge the fact that a subset of the staff whose bios we've provided will be performing the project work. Provide resumes' for the narned staff, which include information on the individual's The Echo Group 8 RLI Number: R R /6/2012

316 Page 316 of 379 particular skills related to this project, education, experience, significant accomplishments and any other pertinent information. The respondent must commit that staff identified in its proposal will actually perform the assigned work. aecho 1. Group ~ The Echo Group 9 7/6/2012 RLI Number: R R1 316

317 Page 317 of 379 ~echo,\,'~~group 6) Training - Provide a variety of training options to minimize the cost of training County employees. Echo offers high-quality training services to help your agency maximize the return on your investment. Our goal is to train your team in groups with no more than twelve participants. Staff who take courses will become "power users," capable of training other staff in that area. By building expertise in your organization, you will be able to reduce longterm training expense. As your staff grows or changes, you will have the resources to provide in-house training on your Echo software. If additional training is required for new staff Echo will work with the agency to determine the best location for the training. In the case of small topics, web cast trainings may be offered to help save the agency the cost of travel for the Echo trainer to come on-site. Other refresher trainings are performed on site. Echo understands the need for delivering products and services that assist our customers in providing the best care for their consumers. Agencies that purchase Clinician's Desktop and Revenue ManagerT" should plan to attend the following classes in support of a successful project outcome. Course 500 a-b -Configuring Clinician's DesktopT" and Revenue ManagerT", Course 505- Creating Custom Forms, Course 510- End User Training, Course 515 -Incorporating Custom Reports into Echo Systems, Course Using Revenue Manager, Course Developing Treatment Plans and Using Predefined Content, Course Business Intelligence for Your Organization Please see page 63 for full descriptions of each course. 7) Provide a formula for calculation of the County's Return on Investment (ROI). 8) Provide a list of the Key Performance Indicators (KPI) that will be used to determine the effectiveness of the proposed system after implementation. Please see page 70. Every organization has its own definition of what a "successful project" will look like. It is important to understand the business drivers which are motivating the project, and what business problems the project is intended to solve. These criteria will be referred to when The Echo Group 10 RLI Number: R R /6/2012

318 I Exhibit 2 Page 318 of 379 il)echo ~ Group - making critical decisions during the project implementation, and will be the basis upon which "success" will be measured at the project's closure. Objectives should be SMART: Specific, Measurable, Attainable, Realistic and Time-bound. The Echo Project Manager will track these objectives in order to determine if the project is on the path to success, and to measure success upon project closure. 9) Provide a process for analyzing the KPI Please see our answer to number 8 above. data. Evaluation Criteria - Provide answers below. If you are submitting a response as a joint Company Profile venture, you must respond to each question for each entity forming the joint venture. When an entire response cannot be entered, a summary, followed with a page number reference where a complete response can be found is acceptable. 1. Supply legal firm name, headquarters address, Echo Consulting Services, Inc. dba The Echo local office addresses, state of incorporation, Group. and key firm contact names with their phone 15 Washington Street numbers and addresses. Conway, NH The Echo group was Incorporated in the state of New Hampshire. Key Contacts: Debbie Angelico, CFO- 603/ [email protected] Scott Taylor, Sr. Account Manager- 603/ [email protected] 2. Supply the interested firm's federal ID number Federal Tax ID #: and Dun and Bradstreet number. Dun & Bradstreet #: Is the interested firm legally authorized, r:gj YES 0NO pursuant to the requirements of the Florida Statutes, to do business in the State of Florida? 4. All firms are required to provide Broward Please see separate document per the County the firm's financial statements at the instructions in this question. time of submittal in order to demonstrate the firm's financial capabilities. Failure to provide this information at the time of submittal may result in a recommendation by the Director of Purchasing that the response is non- The Echo Group 11 7/6/2012 RLI Number: R Rl 318

319 Page 319 of 379 'fiaecho '-\WGroup responsive. Each firm shall submit its most recent two (2) years of financial statements for review. The financial statements are not required to be audited financial statements. With respect to the number of years of financial statements required by this RLI, the firm must fully disclose the information for all years available; provided, however, that if the firm has been in business for less than the required number of years, then the firm must disclose for all years of the required period that the firm has been in business, including any partial year-to-date financial statements. The County may consider the unavailability of the most recent year's financial statements and whether the firm acted in good faith in disclosing the financial documents in its evaluation. Any claim of confidentiality on financial statements should be asserted at the time of submittal. (see below) only "IF" claiming Confidentiality The financial statements should be submitted in a separate bound document labeled "Name of Firm, Attachment to Proposal Package, RLI# - Confidential Matter". The firm must identify the specific statute that authorizes the exemption from the Public Records Law. CD or DVD discs included in the submittal must also comply with this requirement and separate any materials claimed to be confidential. Failure to provide this information at the time of submittal and in the manner required above may result in a recommendation by the Director of Purchasing that the response is non-responsive. Furthermore. proposer's failure to provide the information as instructed may lead to the information becoming public. Please note that the financial statement exemption provided for in Section (1) c, Florida Statutes only applies to submittals in response to a solicitation for a "public works" project. 5. Litigation History Requirement: The County will consider a vendor's litigation history information in its review and determination of responsibility. All vendors are required to disclose to the County all "material" The Echo Group is not seeking to perform any other work for the County. The Echo Group is not involved in any sort of litigation nor has it ever been in its history. The Echo Group has never filed for The Echo Group 12 RLI Number: R R /6/2012

320 cases filed, pending, or resolved during the last three (3) years prior to the solicitation response due date, whether such cases were brought by or against the vendor, any parent or subsidiary of the vendor, or any predecessor organization. If the vendor is a joint venture, the information provided should encompass the joint venture (if it is not newlyformed for purposes of responding to the solicitation) and each of the entities forming the joint venture. For purpose of this disclosure requirement, a "case" includes lawsuits, administrative hearings and arbitrations. A case is considered to be "material" if it relates, in whole or in part, to any of the following: 1. A similar type of work that the vendor is seeking to perform for the County under the current solicitation; 2. An allegation of negligence, error or omissions, or malpractice against the vendor or any of its principals or agents who would be performing work under the current solicitation; 3. A vendor's default, termination, suspension, failure to perform, or improper performance in connection with any contract; 4. The financial condition of the vendor, including any bankruptcy petition (voluntary and involuntary) or receivership; or Bankruptcy. Exhibit 2 Page 320 of 379 gecho ~ Group A criminal proceeding or hearing concerning business-related offenses in which the vendor or its principals (including officers) were/are defendants. Notwithstanding the descriptions listed in paragraphs 1-5 above, a case is not considered to be "material" if the claims raised in the case involve only garnishment, auto negligence, personal injury, workers' compensation, foreclosure or a proof of claim filed by the vendor. For each material case, the vendor is required to provide all information identified, on the "Litigation History" form. (Attachment J) Failure to disclose any material case, or to provide all requested information in connection with each such case, may result in the vendor bein!l deemed non- The Echo Group 13 7/6/2012 RLI Number: R R1 320

321 Page 321 of 379 responsive. Prior to making such determination, the vendor will have the ability to clarify the submittal and to explain why an undisclosed case is not material. 6. Has the interested firm, its principals, officers, ~YES DNO or predecessor organization(s) been debarred or suspended from bidding by any government during the last three (3) years? If yes, provide details. 7. Has your company ever failed to complete any DYES ~NO work awarded to you? If so, where and why? 8. Has your company ever been terminated from DYES ~NO a contract? If so, where and why? a~. ho ' 9. Insurance Requirements: Refer to the Please see Attachment K which is a copy sample Certificate of Insurance of our Insurance Certificate. Attachment K. It reflects the insurance requirements deemed necessary for this project. It is not necessary to have this level of insurance in effect at the time of submittal but it is necessary to submit certificates indicating that the firm currently carries the insurance or to submit a letter from the carrier indicating upgrade availability. Evaluation Criteria - Legal Requirements 1. Standard Agreement Language: Identify any standard terms and conditions with which the interested firm cannot agree. The standard terms and conditions for the resulting contract can be located at: htl!;!:// s/softwarelicagml.!;!df and htl!;!:l/ s/systemsvcsagml.!;!df. If you do not have computer access to the internet, call the Project Manager for this RLI to arrange for mailing, pick up, or facsimile transmission. Provide answers below. If you are submitting a response as a joint venture, you must respond to each question for each entity forming the joint venture. When an entire response cannot be entered, a summary, followed with a page number reference where a complete response can be found is acceptable. DYES (Agree) ~NO If no, you need to specifically identify the terms and conditions with which you are taking exception While not necessarily taking exception, Echo would need to negotiate/discuss several Broward County contract clauses that may conflict with Echo's standard commercial contract language, as we have done in the past, to include: The Echo Group 14 7/6/2012 RLI Number: R Rl 321

322 Page 322 of 379 ~0 Warranty Indemnity Liability Maintenance in Arrears Termination Maintenance during install and one year after acceptance Referenced (but not included) FL statutes and laws Works Made for Hire ownership and maintenance Correction, Conformity and Acceptance 2. Cone of Silence: This County's ordinance prohibits certain communications among vendors, county staff, and selection committee members. Identify any violations of this ordinance by any members of the responding firm or its joint venturers. The firm(s) submitting is expected to sign and notarize the Cone of Silence Certification (Attachment L). 3. Public Entity Crimes Statement: A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit an offer to perform work as a consultant or contract with a public entity, and may not transact business with Broward County for a period of 36 months from the date of being placed on the convicted vendor list. Submit a statement fully describing any violations of this statute by members of the interested firm or its joint venturers. 4. No Contingency Fees: By responding to this solicitation, each firm warrants that it has not and will not pay a contingency fee to any company or person, other than a bona fide employee working solely for the firm, to secure an agreement pursuant to this solicitation. For Breach or violation of this provision, County shall have the right to reject the firm's response or terminate any agreement awarded without liability at its discretion, or to deduct from the aqreement price or otherwise Please see Attachment L. The Echo Group has never been placed on the Convicted Vendor List. The Echo Group has not and will not pay a contingency fee to any company or person, other than the bona fide employee working solely for the firm, to secure an agreement pursuant to this solicitation. The Echo Group 15 RLI Number: R R /6/2012

323 Page 323 of 379 recover the full amount of such fee, commission, percentage, gift, or consideration. Submit an attesting statement warranting that the Responder has not and will not pay a contingency fee to any company or person, other than a bona fide employee working solely for the firm, to secure an agreement pursuant to this solicitation. 5. D If this box is checked, then the provisions of the Broward County Living Wage Ordinance , as amended, ("Living Wage Ordinance") will apply to this agreement. in accordance with the living wage ordinance, certain employers who do business with the county shall pay a living wage to its employees who work on service contracts nrr>vinlinn covered services identified under the ordinance. According to the page 7 "Required Forms" We are not required to submit Attachment M therefore it's not included. Therefore this is N/A. 6. DRUG FREE WORKPLACE: 1. Do you have a drug free workplace policy? 1 _ ~ YES 2. If so, please provide a copy of your drug free workplace policy in your proposal. 3. Does your drug free workplace policy 3. ~ YES comply with Section of the Florida Statutes? 4. If your drug free workplace policy complies 4 _ ~ YES with Section of the Florida Statutes, please complete the Drug Free Workplace Policy Certification Form. Attachment N DNO DNO DNO 5. If your drug free workplace policy does not comply with Section of the Florida Statutes, does it comply with the drug free workplace requirements pursuant to Section a.2 of the Broward County Procurement Code? 6. If so, please complete the attached Drug Free Workplace Policy Certification Form. 7. If your drug free workplace policy does not comply with Section a.2 of the Broward County Procurement Code, are you willing to comply with the requirements Section a.2 of the Broward County Procurement Code? 8. If so, please complete the attached Drug Free Workplace Policy Certification Form. (Attachment N) 5. DYES DNO 7. DYES DNO Please see page 71 for a copy of our policy Per our Drug Free Work Place Policy, item, we will comply with Section of the Florida Statutes within 30 days of executive of the contact. The Echo Group 16 RLI Number: R R /6/2012

324 Page 324 of 379 Failure to provide a notarized Certification Form in your proposal indicating your compliance or willingness to comply with Broward County's Drug Free Workplace requirements as stated in Section a.2 of the Broward County Procurement Code may result in your firm being ineligible to be awarded a contract pursuant to Broward County's Drug Free Workplace Ordinance and Procurement Code gecho 1.: Group ~ 7. Non-Collusion Statement: By responding to Please see Attachment 0 this solicitation, the vendor certifies that this offer is made independently and free from collusion. Vendor shall disclose on the "Non- Collusion Statement Form" (Attachment 0) to their best knowledge, any Broward County officer or employee, or any relative of any such officer or employee as defined in Section (1) (c), Florida Statutes (1989), who is an officer or director of, or had a material interest in, the vendor's business, who is in a position to influence this procurement. Any Broward County officer or employee who has any input into the writing of specifications or r!lquirements, solicitation of offers, decision to award, evaluation of offers, or any other activity pertinent to this procurement is presumed, for purposes hereof, a person has a material interest if they directly or indirectly own more than 5 percent of the total assets or capital stock of any business entity, or if they otherwise stand to personally gain if the contract is awarded to this vendor. Failure of a vendor to disclose any relationship described herein shall be reason for debarment in accordance with the provisions of the Broward County Procurement Code. 8. Scrutinized Companies List Certification: Please see Attachment P Any company, principals, or owners on the Scrutinized Companies with Activities in Sudan List or on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List is prohibited from submitting a bid, proposal or response to a Broward County solicitation for goods or services in an amount The Echo Group 17 7/6/2012 RLI Number: R Rl 324

325 Page 325 of 379 equal to or greater than $1 million. Therefore, if applicable, each company submitting a bid, proposal or response to a solicitation must certify to the County that it is not on either list at the time of submitting a bid, proposal or response. The certification form is referenced as "Scrutinized Companies List Certification" (Attachment P) and should be completed and submitted with your proposal but must be completed and submitted prior to award. rtl~ ho. The Echo Group 18 7/6/2012 RLI Number: R R1 325

326 Page 326 of 379 '{~echo ~ Group I Evaluation Criteria - Tiebreaker Criteria Provide answers below. If you are submitting a response as a joint venture, you must respond to each question for each entity forming the joint venture. Furthermore, to receive credit for a tiebreaker criterion, each entity forming the joint venture must meet the tiebreaker criteria. When an entire response cannot be entered, a summary, followed with a page number reference where a complete response can be found is acceptable. LOCATION in BROWARD COUNTY 1. Is your firm located in Broward County? 2. Does your firm have a valid current Broward County Local Business Tax Receipt? 3. Has your firm (a) been in existence for at least six (6) months prior to the proposal opening (b) providing services on a day to day basis (c) at a business address physically located within the limits of Broward County (d) in an area zoned for such business and (e) the services provided from this location are substantial component of the services offered in the firm's proposal? If so, please provide the interested firm's business address in Broward County, telephone number(s), address, evidence of the Broward County Local Business Tax Receipt and complete the Local Vendor Certification Form (Attachment Q) Failure to provide a valid Broward County Local Business Tax Receipt and the attached notarized Certification Form in your proposal shall prevent your firm from receiving credit under Broward County's tiebreaker criteria of Section d ofthe Broward County Procurement Code and, if applicable, shall prevent your firm from receiving any preference(s) allowed under Broward County's Local Preference Ordinance. 1. DYES 2. DYES 3. DYES Not Applicable DNO DNO DNO The Echo Group 19 RLI Number: R R /6/2012

327 Page 327 of 379 {(~echo ~ Group n Domestic Partnership Act - The requirements of the Broward County Domestic Partnership Act (Section 16-1/2-157 of the Broward County Code of Ordinances, as amended) do not apply to solicitations resulting in a contract for goods or services valued at $100,000 or less. However, firms providing domestic partnership benefits may receive credit in a tie breaker circumstance pursuant to Section d of the Broward County Procurement Code. Therefore, please note the following: The attached Domestic Partnership Certification Form (Attachment G) must be completed and returned with the RLI Submittal Response at the time of the opening deadline. 1. ~ YES 0NO 1. Do you have a domestic partnership benefit program? 2. If so, please provide a copy of your domestic 3. ~ YES partnership benefit program in your proposal and complete Attachment G "Domestic Partnership Benefit Certification Form." 3. Does your domestic partnership benefit program provide benefits which are the same or substantially equivalent to those benefits offered to other employees in compliance with the Broward County Domestic Partnership Act of 2011, Broward County Ordinance# , as amended? VOLUME OF WORK OVER FIVE YEARS Vendor that has the lowest dollar volume of work $ previously awarded by the County over a five (5) year period from the date of the submittal will receive the tie break preference. The work shall include any amount awarded to any parent or subsidiary of the vendor, any predecessor organization and any company acquired by the vendor. over the past five (5) years. If the vendor is a joint venture, the information provided should encompass the joint venture and each of the entities forming the joint venture. 0NO If applicable complete Attachment R. (Report only amounts awarded as Prime Vendor) To be considered for the Tie Break preference, The Echo Group 20 RLI Number: R R /6/2012

328 Page 328 of 379 this completed Attachment R must be included -~ with the RLI Submittal Response at the time of the opening deadline. [(l~ pho The Echo Group 21 7/6/2012 RLI Number: R R1 328

329 Page 329 of 379 II 1 Required Forms to be Returned The Echo Group 22 7/6/2012 RLI Number: R Rl 329

330 Page 330 of 379 BP{QWARD ~i:county FLORIDA Attachment "E" Vendor's List (Non-Certified Subcontractors and Suppliers Information) THIS FORM SHOULD BE SUBMITTED WITH THE RLI/RFP; HOWEVER, IT MUST BE SUBMITTED WITHIN 5 CALENDAR DAYS OF COUNTY'S REQUEST. Provide this information for any sub vendor{s) who will provide a service to the County for this solicitation. This includes major suppliers as well. 1. Firm's Name:. 2. Firm's Address:. 3. Firm's Telephone Number: Firm's Address: 4. Contact Name and Position: 5. Alternate Contact Name and Position:. 6. Alternate Contact Telephone Number: Address: 7. Bid/Proposal Number: Contracted Amount: 8. Type of Work/Supplies Bid: Award Date: 1. Firm's Name: 2. Firm's Address: 3. Firm's Telephone Number: Firm's Address: 4. Contact Name and Position: 5. Alternate Contact Name and Position: 6. Alternate Contact Telephone Number: Address:. 7. Bid/Proposal Number: Contracted Amount:. 8. Type of Work/Supplies Bid:,Award Date:. I certify that the information submitted in this report is in fact true and correct to the best of my knowledge Not Appllooblo I.~S~ig~n~a~tu~ffi~~~ ~T~it~le ~D~a~te I Note: the information provided herein is subject to verification by the Purchasing Division. Use additional sheets for more subcontractors or suppliers as necessary. The Echo Group 23 7/6/2012 RLI Number: R R1 330

331 Page 331 of 379 ~ ;I II "!i FLORIDA Attachment "G" - Domestic Partnership Certification (RESPONSIVE CRITERIA FORM) THIS FORM MUST BE COMPLETED AND SUBMITTED AT TIME OF SUBMITTAL FOR VENDOR TO BE DEEMED RESPONSIVE The Vendor, by virtue of the signature below, certifies that it is aware of the requirements of Broward County's Domestic Partnership Act, (Section 16-1/2-157 of the Broward County Code of Ordinances, as amended); and certifies the following: (Please check only one below). IZI1. The Vendor currently complies with the requirements of the County's Domestic Partnership Act and provides benefits to Domestic Partners of its employees on the same basis as it provides benefits to employees' spouses D 2. The Vendor will comply with the requirements of the County's Domestic Partnership Act at time of contract award and provide benefits to Domestic Partners of its employees on the same basis as it provides benefits to employees' spouses D 3. The Vendor will not comply with the requirements of the County's Domestic Partnership Act at time of award D 4. The Vendor does not need to comply with the requirements of the County's Domestic Partnership Act at time of award because the following exemption(s) applies: (Please check only one below). D The Vendor's price bid for the initial contract term is $100,000 or less. D The Vendor employs less than five (5) employees. D The Vendor is a governmental entity, not-for-profit corporation, or charitable organization. D The Vendor is a religious organization, association, society, or non-profit charitable or educational institution. D The Vendor does not provide benefits to employees' spouses. D The Vendor provides an employee the cash equivalent of benefits. (Attach an affidavit in compliance with the Act stating the efforts taken to provide such benefits and the amount of the cash equivalent.) D The Vendor cannot comply with the provisions of the Domestic Partnership Act because it would violate the laws, rules or regulations of federal or state law or would violate or be inconsistent with the terms or conditions of a grant or contract with the United States or State of Florida. Indicate the law, statute or regulation. (State the law, statute or regulation and attach explanation of its applicability.) I, ~D~e~bb~ie~A~ng~e~li~co~,, ~C~F~O~--~~~---- Of T~hwe~E~c~h~o~G~r~ou~pL- ~~~ (Name) (Title) (Vendor) hereby attests that I have the authority to sign this notarized certification and certify that the above-referenced information is true, complete and correct. Signature Debbie Angelico Print Name SWORN TO AND SUBSCRIBED BEFORE ME this 6 day of,j"'ul" ' 20_1L_ STATE OF NH COUNTY OF,c,a!!!rr.IIJolu_l Notary Public (Print, type or stamp commissioned name of Notary Public) My commission expires: (SEAL) Personally Known or Produced Identification The Echo Group 24 7/6/2012 RLI Number: R Rl 331 Type of Identification Produced:

332 Page 332 of 379 FLORIDA Attachment "H" Lobbyist Registration - Certification This certification form should be completed and submitted with your proposal but must be completed and submitted prior to award. The Vendor, by virtue of the signature below, certifies that: a. It understands if it has retained a lobbyist(s) to lobby in connection with a competitive solicitation, it shall be deemed non-responsive unless the firm, in responding to the competitive solicitation, certifies that each lobbyist retained has timely filed the registration or amended registration required under Section 1-262, Broward County Code of Ordinances; and b. It understands that if, after awarding a contract in connection with the solicitation, the County learns that the certification was erroneous, and upon investigation determines that the error was willful or intentional on the part of the vendor, the County may, on that basis, exercise any contractual right to terminate the contract for convenience. Based upon these understandings, the vendor further certifies that: (Check One) 1. X It has not retained a lobbyist(s) to lobby in connection with this competitive solicitation. 2. It has retained a lobbyist(s) to lobby in connection with this competitive solicitation and certified that each lobbyist retained has timely filed the registration or amended registration required under Section 1-262, Broward County Code of Ordinances. (Vendor Signature) Debbie Angelico (Print Vendor Name) STATEOF N~H~ COUNTY OF,C,.a,_,rr""'o,_ll The foregoing instrument was acknowledged before me this 6 day of,j,_,u,...ly" ' 20.1L_, by --~~-~---~~~-~~~~-~~~--as ~~ of (Name of person who's signature is being notarized) (Title) -::-:----'TL!.h':'e'::E"'c"'h"'o'-'G"":'ro,u":'p'::---~----- known to me to be the person described herein, or who produced (Name of Corporation/Company) =--::-:-:-::-::--::----c, as identification, and who did/did not take an oath. (Type of Identification) NOTARY PUBLIC: (Signature) My commission expires: (Print Name) The Echo Group 25 7/6/2012 RLI Number: R R1 332

333 Page 333 of 379 FLORIDA Attachment "J" - Litigation History D Vendor: Not Aeelicable RLI#: D Vendor's Parent Company: MATERIAL CASE D Vendor's Subsidiary Company: SYNOPSIS D Vendor's Predecessor Organization: Party Plaintiff D Defendant D Case Name Case Number Date Filed Name of Court or other tribunal Type of Case Claim or Cause of Action and Brief description of each Count Brief description of the Subject Matter and Project Involved CiviiD Criminal D Administrative/Regulatory D Bankruptcy D Disposition of Case Pending D Settled D Dismissed D (Attach copy of any applicable Judgment, Settlement Agreement and Satisfaction of Judgment.) Judgment Vendor's Favor D Judgment Against Vendor D If Judgment Against, is Judgment Satisfied? Yes D No D Name: Opposing Counsel Phone number: NAME OF COMPANY: NOT APPLICABLE. The Echo Group 26 7/6/2012 Rll Number: R R1 333

334 Page 334 of 379 FLORIDA Attachment "K" - Insurance Requirements GENERAL UABIUTY Broad form (X] COmmen:lal General UolliUiy (X] Promlaao-Operallons ( l Elqlloolon & COIIapoa Hazatd I I Underground Hazatd [x] ProductaiCompleted oparauono -.o,q (X] COIIflaolllallnsuranae (X]Independenl ContracloJa (x] P810onelln]ury other: Hired Noii-O'M1ed (X] ArrJ Auto II applicable MB>Cimum Oeducllble: $10 k DED for WIND or WIND & FLOOD not to exceed 8% of completed value CONTRACTOR: 18 RE8PON8t8LE POR DEDUCTIBI.I! Value Completed Value The Echo Group RLI Number: R R /6/2012

335 Page 335 of 379 ACORQ, CERTIFICATE OF LIABILITY INSURANCE --- l:cho Consulting.Sel"vices Inc:. DIA Echo Mngmnt PO Box 215"0 Conwoy, COPY ONLY. Echo Manag..-nt Group 1'0 lax 2150 ACORD 25 ~9109) tho ACORD name and k);o 1n11 rtghtend marks of ACORD The Echo Group RLI Number: R Rl /6/2012

336 Page 336 of 379 II 1) II II I' ~" FLORIDA Attachment "L" Cone of Silence Certification The undersigned vendor hereby certifies that: 1. X the vendor has read Broward County's Cone of Silence Ordinance, Section 1-266, Article xiii, Chapter 1 as revised of the Broward County Code; and 2. X the vendor understands that the Cone of Silence for this competitive solicitation shall be in effect beginning upon the appointment of the Evaluation Committee (for Requests for Proposals - RFPs) or Selection Committee (for Request for Letters of Interest - RLis) for communication regarding this RFP/RLI with the County Administrator, Deputy and Assistants to the County Administrator and their respective support staff or any person, including Evaluation or Selection Committee members, appointed to evaluate or recommend selection in this RFP/RLI process. For Communication with County Commissioners and Commission staff, the Cone of Silence allows communication until the initial Evaluation or Selection Committee Meeting. 3. X the vendor agrees to comply with the requirements of the Cone of Silence Ordinance. (Vendor Signature) Debbie Angelico (Print Vendor Name) STATE OF _---"!JNHo _ COUNTYOF~C~amrro~ll~---- The foregoing instrument was acknowledged before me this _6_day of J,..u..,l ' ' 20 1L_, by Debbie Angelico (Name of person who's signature is being notarized) as --=-"C"'F,_O of (Title) T!Jh! e.j;e;gchj!io'!-g,,r02!.u!ll.p~---.c,------, known to me to be the person described herein, or who produced (Name of Corporation/Company) --~~~~~~~ as identification, and who did/did not take an oath. (Type of Identification) NOTARY PUBLIC: (Signature) (Print Name) My commission expires: The Echo Group 29 7/6/2012 RLI Number: R R1 336

337 Page 337 of 379 FLORIDA Attachment "N" - Drug Free Workplace Policy Certification THE UNDERSIGNED VENDOR HEREBY CERTIFIES THAT: 1. _X THE VENDOR HAS A DRUG FREE WORKPLACE POLICY AS IDENTIFIED IN THE COMPANY POLICY ATIACHED TO THIS CERTIFICATION. AND/OR 2. THE VENDOR HAS A DRUG FREE WORKPLACE POLICY THAT IS IN COMPLIANCE WITH SECTION OF THE florida STATUTES. AND/OR 3. THE VENDOR HAS A DRUG FREE WORKPLACE POLICY THAT IS IN COMPLIANCE WITH THE BROWARD COUNTY DRUG FREE WORKPLACE ORDINANCE# , AS AMENDED, AND OUTLINED AS FOLLOWS: (a) (b) (c) (d) (e) (f) (g) Publishing a statement notifying its employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the offeror's workplace, and specifying the actions that will be taken against employees for violations of such prohibition; Establishing a continuing drug-free awareness program to inform its employees about: (i) The dangers of drug abuse in the workplace; (ii) The offeror's policy of maintaining a drug-free workplace; (iii) Any available drug counseling, rehabilitation, and employee assistance programs; and (iv) The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace; Giving all employees engaged in performance of the contract a copy of the statement required by subparagraph (a); Notifying all employees, in writing, of the statement required by subparagraph (a), that as a condition of employment on a covered contract, the employee shall: (i) Abide by the terms of the statement; and (ii) Notify the employer in writing of the employee's conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893, Florida Statutes, or of any controlled substance law of the United States or of any state, for a violation occurring in the workplace NO later than five (5) days after such conviction. Notifying Broward County government in writing within 10 calendar days after receiving notice under subdivision (d) (ii) above, from an employee or otherwise receiving actual notice of such conviction. The notice shall include the position title of the employee; Within 30 calendar days after receiving notice under subparagraph (d) of a conviction, taking one of the following actions with respect to an employee who is convicted of a drug abuse violation occurring in the workplace: (i) Taking appropriate personnel action against such employee, up to and including termination; or (ii) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state, or local health, law enforcement, or other appropriate agency; Making a good faith effort to maintain a drug-free workplace program through implementation of subparagraphs (a) through (f). OR 4. THE VENDOR DOES NOT CURRENTLY HAVE A DRUG FREE WORKPLACE POLICY BUT IS WILLING TO COMPLY WITH THE REQUIREMENTS AS SPECIFIED IN NO. 3 (VENDOR SIGNATURE) STATEOF ~N~HL _ DEBBIE ANGELICO (PRINT VENDOR NAME) COUNTYOF ~C~AR~R~O~L~L The foregoing instrument was acknowledged before me this _6 day of,j,u'"l c., 20R, by ---~~D~e~b~b~ie~A'"naae~l~ic~o~~~-~~~-~~~ as (Name of person who's signature is being notarized) CFO (Title) of ---~-T'-'h,e~E";c,h.oo,_G~ro!'u"'p""" --: known to me to be the person described herein, or who produced (Name of Corporation/Company) ---=----=.,..,---c,---c---c as identification, and who did/did not take an oath. (Type of Identification) NOTARY PUBLIC: (Signature) (Print Name) My commission expires: The Echo Group 30 RLI Number: R R /6/2012

338 Page 338 of 379 B 011 'A9XRD 1 }l!tgunty Attachment "0" - Non-Collusion Statement Form FLORIDA By signing this offer, the vendor certifies that this offer is made independently and free from collusion. Vendor shall disclose below, to their best knowledge, any Broward County officer or employee, or any relative of any such officer or employee as defined in Section (1) (c), Fla. Stat. (1989), who is an officer or director of, or has a material interest in, the vendor's business, who is in a position to influence this procurement. Any Broward County officer or employee who has any input into the writing of specifications or requirements, solicitation of offers, decision to award, evaluation of offers, or any other activity pertinent to this procurement is presumed, for purposes hereof, to be in a position to influence this procurement. For purposes hereof, a person has a material interest if they directly or indirectly own more than 5 percent of the total assets or capital stock of any business entity, or if they otherwise stand to personally gain if the contract is awarded to this vendor. Failure of a vendor to disclose any relationship described herein shall be reason for debarment in accordance with the provisions of the Broward County Procurement Code. NAME RELATIONSHIP Not Applicable (Vendor Signature) (Print Vendor Name) In the event the vendor does not indicate any names, the County shall interpret this to mean that the vendor has indicated that no such relationships exist. (Form is to be signed even if no names are listed) The Echo Group 31 7/6/2012 RLI Number: R Rl 338

339 Page 339 of 379 FLORIDA Attachment "P" - Scrutinized Companies List Certification This certification form should be completed and submitted with your proposal but must be completed and submitted prior to award. The Vendor, by virtue of the signature below, certifies that: a. The Vendor, owners, or principals are aware of the requirements of Section , Florida Statutes, regarding Companies on the Scrutinized Companies with Activities in Sudan List or on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and b. The Vendor, owners, or principals, are eligible to participate in this solicitation and not listed on either the Scrutinized Companies with Activities in Sudan List or on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List; and c. If awarded the Contract, the Vendor, owners, or principals will immediately notify the COUNTY in writing if any of its principals are placed on the Scrutinized Companies with Activities in Sudan List or on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List. (Authorized Signature) Debbie Angelico, CFO (Print Name and Title) The Echo Group (Name of Firm) STATE OF NH COUNTY OF Carroll The foregoing instrument was acknowledged before me this _6 day of July, _, by Debbie Angelico (name of person whose signature is being notarized) as CFO (title) of The Echo Group (name of corporation/entity), known to me to be the person described herein, or who produced ---,., (type of identification) as identification, and who did/did not take an oath. NOTARY PUBLIC: (Signature) State of at Large (SEAL) (Print name) My commission expires: The Echo Group 32 7/6/2012 Rll Number: R Rl 339

340 Page 340 of 379 BP{~ARD ~COUNTY FLORIDA Attachment "Q" - Local Vendor Certification Tiebreaker Criteria (or Local Preference if Applicable) THE UNDERSIGNED VENDOR HEREBY CERTIFIES THAT: NOT APPLICABLE 1. THE VENDOR IS A LOCAL VENDOR IN BROWARD COUNTY AND HAS A VALID BROWARD COUNTY LOCAL BUSINESS TAX RECEIPT WHICH IS ATTACHED TO THIS CERTIFICATION AND 2. THE VENDOR IS A LOCAL VENDOR IN BROWARD COUNTY AND: (a} Has been in existence for at least six (6) months prior to the proposal opening; (b) Provides services on a day to day basis at a business address physically located within the limits of Broward County and in an area zoned for such business; and (c) The services provided from this location are a substantial component of the services offered in the vendor's proposal. AND/OR 3. THE VENDOR IS A LOCAL VENDOR IN BROWARD OR MIAMI DADE COUNTY AND HAS A VALID CORRESPONDING COUNTY LOCAL BUSINESS TAX RECEIPT WHICH IS ATTACHED TO THIS CERTIFICATION AND: (a) Has been in existence for at least ONE YEAR prior to the proposal opening; (b) Provides services on a day to day basis at a business address physically located within the limits of Broward County and in an area zoned for such business; and (c) The services provided from this location are a substantial component of the services offered in the vendor's proposal. (VENDOR SIGNATURE} :TATE OF (PRINT VENDOR NAME) :QUNTYOF The foregoing instrument was acknowledged before me this day of, 20_, by --~~-~-~~~~~~~~-~~~ -----~~~ of (Name of person who's signature is being notarized) (Title) ---,==========:;- known to me to be the person described herein, or who produced (Name of Corporation/Company) IOTARY PUBLIC: ----:=---;-;-.,-=== as identification, and who did/did not take an oath. (Type of Identification) (Signature) (Print Name) My commission expires: The Echo Group 33 Rll N~mber: R R /6/2012

341 ' ' il!i 'I I, _, I' I' 'ARD B~, <[!- Wl,f!l;J (,1.':< - ' - -e;,~~~county FLORIDA Attachment "R" - Volume of Work Over Five Years Tie Breaker Criteria Broward County Projects Exhibit 2 Page 341 of 379 I ' The work shall include any amount awarded to any parent or subsidiary of the vendor, any predecessor organizatior and any company acquired by the vendor over the past five (5) years. If the vendor is a joint venture, the information provided should encompass the joint venture and each of the entities forming the joint venture. (Report only amounts awarded as a Prime Vendor) Item No. Project Title Solicitation Contract Number Bid- Quote- RLI- RFP Broward County Department or Division Date Awarded Awarded Dollar Amount 1 Please see Below Grand Total $303,424 The Echo Group 34 7/6/2012 RLI Number: R Rl 341

342 Page 342 of 379 BROWARD COUNTY VOLUME OF WORK OVER 5 YEARS PROJECT TITLE REFERENCE# DIVISION DATE AWARDED DOLLAR AMT 1. FLSAMH FY RO 8roward County HSD 5/11/07 $1, Software Main! Agreement 8roward County HSD 6/1/07 $38, CDT/RM Training RO 8roward County HSD 7/31/07 $7, Interface to Medical roward County HSD 11/29/07 $9, Exam Off 5. Modify 271 EIO Path roward County HSD 5/8/08 $ Change to FL SAMH roward County HSD 5/8/08 $ Submission 7. Change Toxicology roward County HSD 5/22/08 $9, Software Main! Agreement 8roward County HSD 6/1/08 $40, Change to FL SAMH roward County HSD 6/4/08 $ Submission 10. Create Toxicology Rep ARC 8roward County HSD 1/30/09 $1, Software Main! Agreement 8roward County HSD 6/1/09 $40, SAMH Modification 8ROWARD roward County HSD 6/25/09 $1, Create Custom Reports ARC 8roward County HSD 6/25/09 $9, Software Main! Agreement 8roward County HSD 6/1/10 $40, Self Pay Customization ST8ROWARD roward County HSD 9/10/10 $2, Software Main! Agreement 8roward County HSD 6/1/11 $42, FL SAMH Modification ST8ROWARD roward CountyHSD 6/30/11 $4, Onsite RM Training ST8ROWARD roward County HSD 5/22112 $9, Software Main! Agreement 8roward County HSD 6/1/12 $42, The Echo Group 35 7/6/2012 RLI Number: R Rl 342

343 Page 343 of 379 Exhibit "1" - Detailed Scope of Work The Echo Group 36 7/6/2012 RLI Number: R R1 343

344 Page 344 of 379 ~echo ~\WGroup The Echo Group is offering our award winning Clinician's Desktop and Revenue Manager as a solution to your Electronic Health Record project. Echo not only provides Behavioral Health software and implementation services, it also has a wide array of service offerings that cover Process Consulting, IT Services and Transaction Management Services. The Echo Group began implementing Clinician's Desktop/Revenue manager in The product continued to evolve, integrating new functionality with each release. This functionality was derived by both industry trends and requirements and feedback from our customer base. In recent years these enhancements include: We are 100% certified for the ambulatory care requirements under Meaningful Use Complete redesign to the user interface with the Echo Visual Health Record (VHR) Integration of electronic signature for both clinician and client A Client Merge tool a-prescribing integration with DrFirst Rcopia, the only Gold Certified SureScripts provider in all SureScripts certification categories Integration with Wiley PracticePianners content for our Treatment Planning module A comprehensive auditing solution Integration with Rapid Insight Statistical Modeling and Analysis software Integration with Crystal Xcelsius Dashboard tools The Echo traveiehr offline synchronized Electronic Health Record for Community Based staff Emergency Client Access/Break the Glass tool to enable emergency access to a client's record in the event their regular provider is not available. It's all fully logged within the Echo Audit Tool to support HIPAA privacy rules. A Client Portal allowing clients access to portions of their EHR in a secure environment. Health Information Exchange (HIE) capabilities to enhance quality of care and addressing mandated interoperability requirements including support to import HL7 Laboratory Results and exchange Continuity of Care Documents (CCD). Fully configurable Clinical Decision Support tools that automatically provide staff with recommendations based on a client's Medications, Diagnosis and more. Educational Resources can now be provided to a client based on their conditions, helping save your staff time and enhancing consumer care. This includes links to websites, documents or text-based instructions. The ability to capture Vital Signs and other Health Information and, for clients ages 2-20, provide automated growth charts. Enhanced Computerized Physician Order Entry (CPOE) functionality, giving you the ability to enter in Lab Orders and Radiology Orders. After carefully reviewing the requirements set forth in your Request for Proposal, we believe that Echo products and services provide an excellent match for Broward County. We have provided this screenshot of the Echo Visual Health Record (VHR). The VHR is unique among Behavioral Health EHRs in that it provides a completely visual representation of the Client's record, including built in visual alerting and the ability to see the temporal relationship between different items within the record. The Echo Group 37 7/6/2012 RLI Number: R R1 344

345 Page 345 of 379 'ililecho ~-Group Lethality Assessment Diagnosis 'Tl'eatm'erit Pl;m Activities Medications The Echo Group is a privately held company dedicated to providing behavioral health and social service agencies software solutions that make it easier for them to fulfill their missions. This includes software solutions for clinical records, billing and reporting. We have been in business for over 30 years and were founded by the deputy director of a Community Mental Health Agency. The Echo Group employs 75 people in offices in Conway, New Hampshire; Oakland, California; Columbus, Ohio and Lewiston, Maine. Our staff is unusually skilled and experienced with an average tenure of 8 years and expertise in human services, billing and technology. Echo employs staff with extensive experience in technology, project management, software and behavioral health. These full lime Echo employees deliver the services that make our customers successful including process consulting, implementation management, transaction management, information technology/infrastructure consulting, customization and system design services. Echo has a team of senior staff who provide a single point of contact for our customers and are responsible for the ongoing customer relationship. Echo has been profitable for 30 the last 31 years. We have never declared bankruptcy. Echo strives to be a full service partner with our customers. This includes implementation, training, technical support, software customization, workflow consultation, information technology consultation and billing services. We pride ourselves that all services are provided by Echo staff to ensure the highest quality experience for our customers. The Echo Group 38 7/6/2012 RLI Number: R R1 345

346 Page 346 of 379 Our customers cover all areas of Behavioral Health, including Mental Health, Substance Abuse, Developmental Disabilities, Foster Care and other related services. Installations range in complexity from small, local area network installations to customers with multiple locations in multiple states all connected remotely. Because of the flexibility of our software, we have been able to provide custom solutions to meet the unique needs of each of our customers. We have customer installations in over 30 states, including several large California Counties. Echo is committed to our customers in Florida. All of the implementation and training services we provided to our Florida customers was done ensile at the agencies and we have worked with these organizations to ensure compliance with specific state mandates. Echo achieved Complete Ambulatory Certification on February 9 1 h, Our Certification Number is We are 100% certified for the ambulatory care requirements under Meaningful Use as is required for Eligible Providers to attain Meaningful Use funds. Echo's Customer, Grand Lake Mental Health Center in Oklahoma was the first Behavioral Health organization that received meaningful use funds. Echo customers are at the forefront of delivering integrated care solutions. 5 different Echo customers have received SAMHSA PBHIT Grants to help them support the goal of true integrated care. With Echo's product being a fully Certified EHR, we already support key integration for exchanging data, including the ability to send and receive a Continuity of Care Document (CCD) as well as receive in Lab Results. Almost all of Echo's customers utilize some type of EDI for either billing, a direct interface or to meet state reporting requirements. Echo works with you and the vendor of the external system to provide as low a maintenance interface as possible. When interfaces require updating, Echo works with you and the other Vendor to determine the extent of the changes. We then provide you with an estimate of cost for the interface changes. The Ul utilizes a standard Windows interface for entering data. How we distinguish ourselves is the Echo VHR, which provides you with a complete graphical representation of the client's chart in timeline based format. It is all configurable by your organization. The goal is to "tell the client's story" through the use of the timeline and user defined icons. To access any of the data, it is simply one mouse click away. Feedback we have received from clinical users on the VHR has been extremely positive and they all remark that information is so easy to find. We also include a standard HL7 interface for interfacing with Laboratories for Lab Results. If you required other custom HL7 interfaces, we can work with you on further defining those. In our latest release we have also integrated support for Continuity of Care Documents and Continuity of Care Records (CCDs and CCRs) so that you can support Health Information Exchange standards to enable you to exchange important clinical information with other Mental Health or Ambulatory providers. The Echo Group's solution contains a dynamic management dashboard and reporting toolset. The Echo Group 39 7/6/2012 RLI Number: R R1 346

347 Page 347 of 379 Evaluation Criteria Project-Specific Criteria 2) Narrative with adequate detail of respondent's knowledge and skills to successfully complete the project. Proposal must include the following: a. Work Plan - Include all project requirements, proposed tasks, services, activities, and resource requirements necessary to accomplish the scope of the project defined in this RLI. b. Project Schedule - Include a project schedule indicating when the elements of the work will be completed and when deliverables, if any, will be provided. c. Deliverables - Fully describe deliverables the consultant deems would be submitted under the proposed contract. Please see below under #3. 3) Project Approach/Methodology- Description of the proposed approach and methodology for the project. The Echo Group 40 7/6/2012 RLI Number: R R1 347

348 Page 348 of 379 echo Group Echo Customers are Creating Better Organizations Software & Services for Behavioral Healthcare 348

349 Page 349 of 379 ~echo... Group Executive summary This charter defines to the project to <insert agency name and descriptive of the project, i.e., "install Clinician's Desktop rm and Revenue ManagerrM at Community Counseling Center. >. This document outlines the project scope, budget, objectives and success criteria, summary milestone schedule, risks, assumptions, constraints, and project stakeholders. The Echo Project Manager, <insert Project Manager's name>, is responsible for developing and maintaining the project plan schedule, and managing budget and scope during the project implementation. This includes change control and risk management, and taking corrective actions as required to ensure timely and successful completion of the project. The Project Manager is also responsible for project communication to the project stakeholders throughout the project. Project scope Insert high-level description of the project. For example: The scope of this project is to install Clinician's Desktop rm and Revenue ManagerrM at Community Counseling Center to transition from a paper-based system to fully utilizing Echo's VHR, and to ensure the system is being utilized in order to attain ARRA funding for CCC's eligible providers. This is a preliminary scope statement highlighting what the project will include, including high-level resource and/or requirement descriptions, and what will constitute completion of the project. This will be expanded upon in greater detail as the project progresses during the Business Process Workshop and subsequent detailed project planning. Changes to scope will be managed through a change control process and corresponding change log, and will be reviewed at the regular project status meetings. As the project is executed, any changes to scope will be included as Appendices to this Project Charter. Project budget The following are the planned cost components of the project, as per the project's contractual agreement. The project budget will be reviewed on a regular basis with the project team during the implementation. Any changes to scope impacting budget will go through a change control process, and will be subject to contract modification and approval before they will be integrated into the project plan. The Echo Group 42 7/6/2012 RLI Number: R Rl 349

350 Page 350 of 379 The contracted components of this project include the following: nse rtht""ldd"th VI( a /SinCU e m e con rae. tf or example: Service Hours Hourly Rate Total Cost Data Conversion 100 $175 $17,500 Svstem Administrator Trainino 48 $175 $8,400 Etc Project OBJECTIVES & success criteria Every organization has its own definition of what a "successful project" will look like. It is important to understand the business drivers which are motivating the project, and what business problems the project is intended to solve. These criteria will be referred to when making critical decisions during the project implementation, and will be the basis upon which "success" will be measured at the project's closure. Objectives should be SMART: Specific, Measurable, Attainable, Realistic, and Time-bound. The Echo Project Manager will track these objectives in order to determine if the project is on the path to success. Enter a bulleted list of measureable success criteria as defined by the customer and discussed in the kick-off. Ensure they are represented in the context of how goals will be met using the Echo solution. For example: All clinicians to be fully utilizing the Echo VHRTM by June 1, 2012 All billing to be processed through Revenue Manager by July 1, 2011 Project Methodology and i Agency project teams. Includes review of the project team structure; project scope; contracted items and budget; project success criteria; and project management protocol for communication, change control, and risk Meetings implementation, and will include a review of the project plan, action items, scope change items and risk identification and mitigation. First scheduled project status meeting following the project kick-off will include review and approval of the Weekly call agenda includes review of project plan, action item log, scope change log, and risk log status Business Process Workshop (BPW) Or Project Planning Workshop (PPW) Initial project consultation to provide deeper understanding of Agency processes and requirements, and to provide the foundation for project I The Echo Group RLI Number: R R1 43 7/6/

351 Page 351 of 379 project plan which supports the the BPW or PPW and supports the Project Charter; project plan deliverables are confirmed, activities to meet those deliverables are scheduled, and the resources are assigned to the work. execute the project plan Final project charter sign-off Echo Software Installation i non-echo software, purchase and acquisition, and installation. Echo software installation in Agency test/training and production environments. requirements guidelines Echo's IT requirements guidelines and software; overall infrastructure i Installed Echo software in test and production Clinician's Desktop TM Database Configuration Substitute with ShareCare as appropriate Revenue ManagerTM Database Configuration Substitute RM with ShareCare or XAKTclaim as appropriate Define and implement user groups/permissions, schedule and activity logs, service components, data entry check rules, group templates, alerts, quick links, Echo Mail, electronic signature, Staff setup, custom Widows Designer screens, client profiles, episodes, enrollments, consumer diagnosis, assessments, tasks/needs, incidents, treatment plans, medications, images, family/head of household, information and referrals, reports menu, etc. Emphasis is placed on configuration required to implement the Echo Visual Health Record (VHR) as a " Define i user groups/permissions, organization setup, diagnosis master, pay source configuration, client pay source configuration, client fee table, billing schedule, GL mapping, rate schedules, services, processing procedures, report services services Clinician's Desktop TM database configuration Substitute with ShareCare as appropriate Manager database configuration Substitute RM with ShareCare or XAKTclaim as appropriate Customizations Submissions/Billing I required for 837P, 835, CMS 1500, UB 04, Self Pay. Note this may require change control and contract modification/approval if outside the contracted scope of the project. i and Proposal. Approval through change control process, if The Echo Group RLI Number: R R1 on Statement of Work and customization 7/6/

352 Page 352 of 379 Configuring Clinician's Desktop r Training Provide Agency technical implementation project team resources training on how to set up and configure trained as per course Training on identifying the Agency specific workflow that will be implemented in the Echo software. Conduct preliminary walkthrough of that workflow with staff. Provide Agency how to use the features and functionality in the Echo software to conduct their daily workflow. and Training End User agenda Workflow diagrams. Staff or "train the trainer trainees" trained as per course objectives trainer trainees" trained as per course Data Flow Training Provide staff training on how data will move through the software to process charges and transactions, manage revenue, monitor receivables Data flow training agenda Staff or "train the trainer trainees" trained as per course objectives Training training agenda Developing Treatment Plans and Using Predefined Data Conversion Provide Agency staff training on how use the Echo Treatment Plan and Assessment functionality according to ' scope, requirements, collect sample data, create conversion mapping, agency review of conversion mapping, deliver and test first test conversion, make any necessary adjustments, deliver and test second conversion, receive agency acceptance, Treatment Plan training agenda Data conversion mapping Staff are trained as per course objectives Completed data conversion Implementation software, provide overview of functionality, review decision-points and train on the data structure of the auditing tables so scheduled reports can be created deployment and administration; technical installation assistance; configuration training on structured progress notes, treatment, Windows Desktopr installation and System Administrator I i Desktopr installation and System Administrator installed and System Administrators are trained software is installed and System Administrators are trained on The Echo Group RLI Number: R R1 45 7/6/

353 Page 353 of 379 and reported as required for traveiehr. NOTE: Agency completes the technical installation itself, or contracts with Echo for technical installation (custom quoted training traveiehr - related configuration and administration i for Your Training (Rapid Insight, Xcelsius) on i analyses to better understand trends and the impact of clinical and management decisions; quick access to how demographic and clinical variables and treatment decisions are related to outcomes, providing valuable "Meaningful Use" data. The Rapid Insight What-If option permits users to consider alternative treatment patterns, medications, etc., with the projected aforementioned training i i making based on data trends, statistical analysis and "what if' modeling Project Closure and Transfer to Support is being fully utilized by Agency staff as defined in project success criteria. Echo staff is on-site for first week of "Go Live" to provide Agency with hands-on assistance as ired. Following 30 day or as otherwise defined duration after "Go-Live," and upon confirmed completion of project deliverables, Agency formally moves from Implementation to Support. An introduction call is conducted with the Support manager, with a review of group's pan911el system usage Completed "Go Live" monitoring period of 30 days or otherwise defined duration. days or otherwise defined duration. Agency receives ongoing maintenance assistance from the Echo Technical Support organization Project summary milestone schedule Below is an estimated summary of high-level project milestones identified at the time of project kick-off. It is understood that this is only an estimate, and as the project progresses and tasks and requirements are more clearly defined this schedule may be modified. Any changes will be communicated through project status meetings by the Echo Project Manager and reflected in the project plan. Outline known milestones as understood in the kick-off call: Milestone Date Kick-off call January 1, 2011 Business Process Review January, 15, 2011 Hardware Procurement Complete March 2, 2011 Pilot Start June 1, 2011 Go-Live June 30, 3011 The Echo Group 46 7/6/2012 RLI Number: R R1 353

354 Page 354 of 379 Project Risk management The following risks for the project have been identified at the lime of the project kick-off. The Echo Project Manager will work with the agency and Echo project teams to employ the appropriate risk mitigation steps to minimize the likelihood of these risks and/or their impact on the project. On-going risk management activities will be captured in a project risk log and reviewed at the regular project status meetings. Insert a bullated list of known risks at the time of the project kick-off. For example: Risk Mitigation Contingency Plan Agency's hardware procurement Agency IT is escalating budget Redefine project "go-live" with new plan requires internal budget approval with agency project hardware readiness timeline approval, potentially impacting the sponsor project schedule Project Assumptions Other project plan considerations impacting the project plan, including assumptions and items out of scope for this project, are as follows. Note any other project considerations here. For example: Windows Designer screens X, Y, and Z were created as proof-of-concept during the pre-sales process and should be noted for use during the project. Agency's Crystal report writers will own the writing of any Crystal reports. Agency has staff fully trained on Windows Designer and will not require further training as part of this project. Project Constraints Project constraints other than those defined in the project scope and budget are captured in this section. The Echo Project Manager will work with the agency and Echo project teams to balance these constraints with available resources for a success project implementation. Insert any project constraints known at the time of project kick-off. For example: Agency will be conducting another parallel IT project during the timeframe of the Echo project implementation. Related milestones for this parallel project will be incorporated into the overall Echo project plan due to agency resources constraint considerations and impacted project dependencies. The Echo Group 47 7/6/2012 Rlf Number: R Rl 354

355 Page 355 of 379 Project stakeholders aecho 1. Group ~ m L' tth. t t b dth. F AGENCY Name ProJect Role Contact Information John Doe Execwt1ve projectsponsor E:ma11.and tel Jane Doe Clinical Director and project manager and tel Sally Doe Etc fr'director and technical project lead. and tel Account Manager Executive project sponsor and tel Project Manager Etc Project manager and tel Signatures of Lead Project Stakeholders John Doe, CEO Services Joanna Bull, VP, Professional Jane Doe, CFO, Echo Account Manager Sally Doe, IT Director, Echo Project Manager The Echo Group RLI Number: R R1 48 7/6/

356 Page 356 of 379 _u,, Appendix A I I, i CHANGE REQUEST FORM Case Number: I Case and CR Numbers to be assigned by Echo Customer: Requested by: Date: CR Number: I Authorized by (Customer): Date: Accepted by (Echo): Date: Subject: Category: (only one category shall be marked with an X) Proposed change: Addition of a feature Functional modification of a feature Adjustment to Contract Customization Reason for change: Funding Considerations Action Y/N Consequences if not approved: Project Plan step affected: Other specs affected: Other comments: Not applicable Re-Allocation of Project Planning Hours Additional Proposal Required Other Details (# hours) Attachment(s): Authorized By: Customer Printed Name and Title Customer Signature The Echo Group 49 RLI Number: R R1 7/6/

357 Page 357 of 379 _l l';jjlecho Group!! Echo project deployment methodology- Customer Outline While each project will have unique characteristics, the following outlines a standard Sales-to-Support methodology that the Echo Project Manager will customize based on project's scope and success criteria. Project INITIATION Conduct project kick-off Establish project team and project stakeholders within Echo and the agency Formalize protocol for communication, budget review, change control, and risk management Define project objectives and success criteria Establish a project charter, which is a comprehensive statement of the project scope, budget, objectives and success criteria, deployment methodology, summary milestone schedule, risk management, assumptions, constraints, and project stakeholders and their roles Project Planning Conduct Business Process Workshop (BPW) or Project Planning Workshop (PPW) Develop a detailed project plan schedule which supports the results of the BPW or PPW Identify project deliverables, and the activities to meet those deliverables Assign project resources to complete the work Project Execution & Monitoring Periorm the activities defined in the project management plan, including o Hardware and network readiness o Product installation o System configuration o Data conversion o Training Manage project success on an on-going basis by o Sharing information in regularly scheduled project calls and documentation o Measuring status of project activities o Identifying risks and taking corrective actions as appropriate o Managing change control Project Go Live & Closure Conduct parallel system use in test and production environments Measure attainment of project objectives and success criteria Formally transition project from the implementation phase to on-going maintenance with the Echo Technical Support organization The Echo Group 50 7/6/2012 RLI Number: R R1 357

358 Page 358 of 379 ~echo ~,\ill Group lif rft ~ DiiiiliOO... fmlstl I"CO- ~ I~ 1MiiijO I 0% 2 lli!r 5 ' ~ ~ "",,.._, "' ""~"" ""'W12 "'"4/IWI2.. """' - """""" "'"'""",.., "'"""'" WodSN12,,... "" Moo1W5112i ""'"'.. "" ruo6/2li/12 "" PiiPii&1 """'""! "'"411W12 ' "' ""'"...,...""' '""' T mo F.;= '".,_ """"" """"'- '""' Wo ,..,-w...,.... ~ '""' '""' ""...,.. ]1iiili!ll '""' "" ~ frt otoif "" Fo!4127/12.,. I.... ' Frt "'... "' ~! 19 '"' I --;;r...,...,., ""...,.,, """"'"" "' 21..,. IOO>I"M12 I "" -,:..,. 21 "' ' "' 24 """''"'"~ ~..,..,, m.511h12 I Mooli/2WI2 0%,...,1/12... lii2w12 ".. 2"T Thu>l dmd 11.., Fn&mu ' --,.- "" I Moo41>l '""' "" Moo " ""., 31 I... ProjQc:t: Clay Project Plan v1 Date: Tue T""... ~ Split ''"'""'"'""'' '""''"'' ' ' Progress PrOjeCt S!Jmrnary 4 """"'" '"""'" "' "" "' Frt ' """' """""T""' - Eldemal Milestone- {). The Echo Group 51 7/6/2012 RLI Number: R R1 358

359 Page 359 of 379 ID ~ - II Task Name '"'' ~"'....,._ """ "~"'' Mon Fll'lish,,.echo,gGroup IS I am -~ %"""""' 'rrnr Mon5128f12 "... "' "... ~ ~ ~'m"""~ Moofi/28112 Mon!i/ ~,. 5ervlces ConfigtraUon '"'" I 1 <loy MonS/28112 Tue Z 1 Mon5128/12 Tll9!i "",. "' Billable,,..,.. '"' ue Tue51211f12 Non-Bmable '"" "' 1\Je TU!l5129/12,. "" "'' "" Tue Wed "' '"' "' """""'" '""...::~~5131J/12 ed l..j!viiil!j RateS, Ser.ices & PaySouJteS 111 ""... "' PaySIIUI'CI9..,...,. Fti Thu5J " OtQanilJition "" ~ ".. setup Jdilys Frl Wed5rJOII2 0% "'"""w Illig~ ""'""" !. ~I Z1... comp~at8 Wlllllshsel 1 day Mon Tue "' 47 u 1 day TUe Wed '"' TllU:Y~lll.o! -T Dlagnosit Mlli!llet (defrnilions and U'OMWIIIk)..., Fri ThD6f7112 "' 00 RevleW\\furP.Shllet,..., J29112 ~ """''i... complete Wcrtsheel. Tue j Thu513JI ""' IJp(late 1\W!H:ation... lllu ljlu 6/1/ ,..., Frl!ir.i!51121 TliU % -"- -"- " RevieWWID.sMet -- '""' """" ThU """"' '"" ~ COinplete WCJilstJeet Updats Applll:allon ~ RevJew Client Chart tabs.. Dei'iijij iequlr&m11111s (Moclil'y atyvalldalion lists, tleld I!MIUiremenls)... "' Project 1: "" - Fri ' Mon '""' '"'"""" ~...,... '"'-1 MY' w...., " T"'... Thuli/21/12 Plqecl:: Clay Projed PfaiLV1 "... "" M """""'' Tue!il29/~2 Thll ".. ThU5/J1/f2 Thu6J Ju617/1;l. liiiiu/7112 " Thutll21f12.. "" TllU ,.. lllu5131n2 lllu611f12 " lllu 6J7112 l1lu set Up l;llerts/tisiis 5.38days ThU&lJ 112 llili6/t/12 ~ Team aeme ~tremerns ~ """"'~ """ ~Tue61f "". "'""'"" ' ' """"'"""""' Prqect &m1nary {). T""...- """"'T"" S!1it """""'..., ' The Echo Group 52 7/6/2012 RLI Number: R R1 359

360 Page 360 of T89kName 0 """""' """ """""""'' %COmplete 'rrw thu " '"' 66 Review and modiiy Incidents '"' ""~'"' "' 5.25""' Thu51J1/12 Thu6f7f12 ""... Project Team delln9 lnlm!!jlls (~ validation 1112 lbu6{f/12. " "' 66 "" I coo""'m llluw/12 lllu617/12 '"' "' T"l Thu617/12 lbu " ".. m Review ond Modify Tasks/Needs,...,.. ThU5131/12 lhu&mf2 71 ProJect Team define re lmrnents {ModliYvalldatlon lls1?) Th\ lllu.f!/7/12 53 "" "" 12 ~rtllw//12 lhu 6f """""'" '"' Thu617/12 lbu 6!1112 "" '"' " set up capacny Maintenance..,..,. lhu:n.jl/12 ~ ""., " "" ~ 1 earn oetn1 requnttmems... ThUOI'-'1/JL IIlii Oft/1 ~ = 1llU lliu "- """""'" '"'... n "" ~ "'"' "'"""" '"~'I " "" RevieW lllld modify llmages 8G.t6days Wed Thu6f1/12 " 79 ProjeCt Team. define requirements (Molitt validation list?),.. ThU lllu lllks OOI!!miiOO!I oy managemem. 0.25"' lllllb/'(112 "" ""''"'" --:;- AOO Add ca~orytp " VHRto c:orrectsecurily gllq!s Thu617/12 -l'tm617t "" "' ProJect Team define requlremerlls,.. lllu5131f12 TesllllKS 0.251Js Wed WedZillf1 " "" I' 83 set up Quick Ullks 5.06days Thu5J31/12 Thu6f1112 0% Thu AiJ(J the iiilisoo!armined by ma~agemllfll. "' I 025"' Thu617f12 1nu Tesllilks s Thu617/12 Thu "' 85 "" "" B7 set up I Portal 7.1Jd,ays lhu5131/t2 Mon % B8 Projecl Team define requ!ibments,.. ThU5131f12 lbl.im/12 "' m "" "'.. " "'"' set up Electrooll: Signatures ' 15.13doys ThuS/31112 Thu61211t2 "" " 92 Delermlne ~~wanted (Echo Mail cr Advanced Sl!lnalures),.. ll1u ll!u 6( ThU617/12] Thu ,. """""'" - ~ HIIIIJH Uwdf12 93 ~ set up Gro'-'l Templllt88 lllu 5131/12 TU& % 3""' -"" Prqact Team dbftne ~IIUIJiell1s -" ProjeCt Clay Pm)ect Plart_V1 T~k Sltit _... Date:Tuat!/ !111! !111 "'"' Extern!!! """""" "" "" Thu51311!2 Fri611f12 "' "" Tasks External Mleslooe """"""' PrOiect summa,y ' ' """"" {],.,.., The Echo Group 53 7/6/2012 RLI Number: R R1 360

361 Page 361 of 379 1'71ii1. echo ~-Group '" 0 ~ -- ~ 00- """ ~'" ~ '"" '"""' '' """'"~" 98..., ~~ '""..., ~ _.._ oom,. 100~""' ouo OU< I. "" "" mo ~~" """"'... ""~""'..., '" '""" ~ """ '"'~o " ~,_ "'"~"'"' '"'"~" ~ mo ~ 0., I TlJIJ~121 OU< """'"'" """ "" 0~ ow """""'re "" ""''""02 "'"'~02, '"' -.. "'" "" '"' '"' "" '""'"" '"'""'" '"'.. Fnm u Fn '"' '""" '" Fn 8/J/ "" '"' '"" '"wom2,.. "",, '"' AI 8131/12 "", "" "" '""' '""""' """"' U2 TMO "" '" "" 113 I '"""'",., "",, '" ~ '" "'"" '" """" ''"' """"" '"'oo >< ~ ""'~" "" - "00""' '" 00~0< "' "ou'""... 0~ ~ '"~~" ~~" "" -""- -~'"" ~"m" '""""'" uo o '""''"" '""~"" ~~~ '" '"~"" , '"'""" "'.. oa -"'- - m om '"' '"'""'' '"'""".. "" 0~ 0~ '"'""" 0~ om '"" '" "" ~ """'""" '"'''"" ~ "" 1000, RIJ/ "' '"'' om... External.. ~-~~m""'"'"" """' "''""" "' Tasks '""',., "..,. - -~ External MileS!me PrOject summaiy ' ' """""".().... The Echo Group 54 7/6/2012 RLI Number: R Rl 361

362 Page 362 of 379 ;I _U!I il!i li ii I' j, II ID,_,.,. lo c"""' ~m "' 130 m m 133 P- -m "" "'""'"'"'' "' 136 "' '"""''" ~ II "" """'"' I "" 141 ~ wm~"" Con110"'",...,,.. "' ~ 149 "" "~"""'"' M~mogruiUse "' """""' Fom" 152 I I "' 154 cowl~ 1" """'"" ~ 157 """"I I ~ "' ""'''" """.,_,1... "" '"'""'' I T.,, Prqed: ClayProjectPian_v1 Date: rue 6/19112 Splil... ' ; I i I ''"""" I Moomng"" u.. II! ,.. """" -u Slart """"""' '""'~" "' "" 129 '""" 1M< '"""""' '""'"" T"' '"' "" 1 - Frt~"""... "" '"~~" "'"'"" "' "" 1M< F041M3,"'... "" "" '""'"'" "" 1Wk 135,...,... nm~j11z no.,...,....,. Tna 1trtZ "' ~ "' "" '""~~" ~"'"" "" '"" "'"~"" """""' "" 1Wk 141 "" 200 days "'' '""""'" '"' "' Too ""' 11,40 '"""' "" omoo.. ~ """'"...,., '* "' Wod m >" "" '"~"'" "' Frt4112/13 140,99 '"" ~~ "" Frt tn4f.!ti/13 "'" '"".,. "",... '"""'"" '""""" "" '"""' '""""" ' "" 1""" 153 ""......,. '" "'"""..,.,, ~ "' Frt '"""""' '"""'" '""'"'' tn m~u 1hl Frt WII Fn5125/12 tntl/111 MileStone External TaskS SUmmmy External Milestone + PrqJectSUmmaJY... ' DeadHne v "' "" "' "' ~ "" ~ The Echo Group Rll Number: R R1 55 7/6/

363 Page 363 of 379 le I'= ~ ""''""'... ''""" -0 lu,.,, '~ '" """"'' '"""" '"'"'m"'' 1WI< Fll Fll6!10112,,, '",~ '",~,.,., ~ """'""~ - >OW1~1< ~ 164 Te" 1WI< Fn71ti112 Fn7113/ %,...,. "' - '""'"'" ~ '~ 100,., '"~=1< '""" """"'' ~ 167 I Tool Frt Ffiti/ %,~ '"'" '""'~" ~ 169 ; 161! '"'" '"'"'"" ""., "' ""'" "'""'"",.. "" '""~" ~ Cll"'1 muw<>n< Fri8/J/12 0% lm I mowluu -:- ~ '""""., """"'"... '"... ~ '""'"' '"'...,.. ',... ~,. 1 mrorma1on cummt " =,. UNOIL<H< "" "" ~ '"... '""~" ~ 8:= AO"',,..., '"0'3112 AOOI I "... '""'"" I '"..,,. ~ Fn W3f12 "" ; " ""''" '""~" "" i '"""'" "" '"""''... _ rn r-m-- ~ ; '".."" ~ CreoleOOIDM"' 7127/ %,, lllill creaw map""''""',.."""" ~ 187.,_.,., 111! ,., "'"""'"'map"""' ~ """"' '" illill """'" map'""'' en nmu """"' ~ !11 C!eale """map ano ruos "'',, ;llill creawomomapami I 22- no.,. "" ~ 192.,_dalomapaodl 22days 0% T"" Mlestone Extemal Tasks Project: Clay Project Plan_v1 Spill Summary Date: rue Extemal Milestone + I I II Ill II I I... Prog"'" Project SUmrnaJY Q ' ' OeadUne./} "" "" ~ "" The Echo Group 56 7/6/2012 RLI Number: R R1 363

364 Page 364 of 379 lu,_ ~ 0 1'-"'"~ = I w,..,... ~ nu ~ m ~.. <W" '"... - '"...,... ~ ON ~ - '""""' ~ >m,.... ~ " '" "' "'' !!1 1!!1,, '"""'" "' -..., "' "" 11!!1 om,. A""c~ on w..,. Fnlll/12 ""' 11!!1,., oo,. '... _... "-' ; ~.., '" _, ~ ~..._... l'nw Oll ~ ~ ~ m ~ ~ ~ '""'"" '""""'' "" "" ~ Fnll/Jioz FnWOIJ{02 "'"""" '""' "" '"""" '"'''"' "" '" "' """ '"""" ""'"""' "" '"""'' "" """ '"""" '"'"""' "" """ '""" m OWOWQO< ow ow I ow ~ " 000,.,., "' '""'....,.,... "' Wo '" ""'""" "m" """""'".I '" '""... ~ "' ~,, ~ ao '""' "' ""''" '"~"" = _,, '""'""I..., '" "" ~~owo '""' '"'""'" 1 ""~'moo ~ w...,.,,. ow""''" "' "' MOO nn oz """""'"".. Plqect: Clay Project Plan V1 Date;Tue6119i12..._...,..,.,. '"" Split ''"'""''''""'' "'""""' ' ' """"'..., prqm summary $ "'""" External MBestone.!) '" '" "' "' "' ~ "' ~ The Echo Group 57 7/6/2012 Rll Number: R R1 364

365 Page 365 of 379 Prcject Clay Project Plan_vt Date: Tue T.,. Spll! Progress!!!!!!!!l!!!!!l!!!l Milestone sumrrnwy Project SUmmary Extemal Tasks $ External Milestone + 4 Oeadnne ~ The Echo Group RLI Number: R R1 58 7/6/

366 Page 366 of 379 J'?tilecho ~o.\!l!l!lroup m 4) Project Team Structure- Proposed project structure for this project, including any subcontractors. If necessary, provide an organizational chart indicating governance for this project. The Echo Group 59 7/6/2012 RLI Number: R R1 366

367 Page 367 of 379 The Echo Group does not utilize Subcontractors. 'ililecho ~-Group Professional &etvi es -!j;p8l:ialis~s Be\1) SC:rim~er s~. Professional svcs Spe~lall$1: I Ja~cm; P_ltzen sr. PiOfessJ~rta_l _:svcs Sp~c;lallsi: (QH) _M~rnre.: _l_o_nes_ Proresslonal. svc:s Speciallst(QA) I w~n~y Gail~nt ProfessiOnal sv:cs speoi~list ' Joal)na B~ll VP, Professional Se.,ices I ProJ!!Ci:. Mana_gei-$.. I 'tiha--dic:kiso n T~mlllad.er.Sr. ProJect Manager I. ' Jaye l.;!llder ProJect Manager I Suci<Bae.r 1. Project Man~gel (0"1). ' I Vacant ProJec!= J\1anager... '(CA).., o~o~-m,t;~r]}~y ;SuppOrt:~pedaliSt I -.-. ;~~:~,~:freritzen _ isuppoit SiJedai!St 'jason_vi~~, St:.pP,()};t_ ~pe'sj~us~ (0~) I DavldAilen tustomer Relatlonsf\lp.. Manager (CA) - The Echo Group RLI Number: R R1 60 7/6/

368 Page 368 of 379 5) Staff Qualifications/Experience - If the consultant will be utilizing other staff in fulfillment of the terms and conditions of this RLI, including subcontractors, who will be assigned to the potential contract, indicate the responsibilities and qualifications of such personnel, and include the amount of time each will be assigned to the project. Provide resumes' for the named staff, which include information on the individual's particular skills related to this project, education, experience, significant accomplishments and any other pertinent information. The respondent must commit that staff identified in its proposal will actually perform the assigned work. Joanna Cameron Bull, Vice President of Professional Services M.A.L.D International Business, The Fletcher School at Tufts University B.A. Wesleyan University Joanna joined The Echo Group in September 2010 as a member of the leadership team responsible for customer success, overseeing implementation and technical support activities. Joanna brings extensive software operations experience, with over 11 years managing the services delivery of complex client-server and hosted software solutions. Joanna's background includes various senior management roles overseeing the successful delivery of project management, training, consulting, integrations, systems engineering/it, and custom data and reporting services. Scott D. Taylor, Senior Account Manager B.S. Johns Hopkins University Mr. Taylor has 25 years experience designing, programming, documenting, implementing and troubleshooting business systems in a variety of settings. He has been a project leader for installation of G/L, NP, NR, Inventory Control and Purchase Order Systems. As Information Systems Manager, Regional Manager and Production Manager for retail and manufacturing companies Mr. Taylor has extensive and detailed knowledge of software products and the human processes they support. An employee of The Echo Group for 14 years, Mr. Taylor has served as Product Manager, Submissions Manager, Special Projects Manager, Customer Service Manager, Build Manager and currently as a Senior Account Manager. He received his BS from Johns Hopkins University in Baltimore, Maryland. Jaye Lauder, Project Manager BS in Computer Engineering, University of New Hampshire Jaye Lauder has nine years of experience working with clients as a technical project manager at Fidelity to transition their HR!benefits record keeping from a combination of a purely paper approach to a mix of both paper and electronic to a fully electronic approach. As a recently certified PMP project manager with a BS in computer engineering and experience in medical billing she also brings technical and organizational capability to her new role at Echo. To support Echo clients and The Echo Group's commitment to certification, she was recently certified in the Medicare and Medicaid EHR incentive program through the Health IT Certification program. The Echo Group 61 7/6/2012 RLI Number: R R1 368

369 Page 369 of 379 Tina Dickison, Project Manager AS, Richland College Tina brings to The Echo Group 18 years of experience in Behavioral Health and Substance Abuse treatment including case management, information technology, medical records, privacy and security. She was the project manager and DBA for Heritage Behavioral Health Center when they won the Nicholas E. Davies Award. Tina is well-versed in Privacy and Security Regulations including HIPAA and 42 CFR Part 2. She brings a strong background in system redesign and applying technology to streamline business process. Tina's combination of end-user and deep technical product experience, make her a valuable asset to The Echo Group and its customers. Hamilton "Buck" Baer, Project Manager Phoenix University and US Army, 10th Mountain Division Buck joined The Echo Group with 5 years of behavioral health experience as Director of Applications, Support and Development at a at an Ohio-based comprehensive counseling agency with expertise in mental health diagnosis and treatment. Buck has an additional 10 years of experience managing software implementations, training, development, report writing, and process mapping in the fields of records management and tracking. He takes a hands-on approach and works hard to understand end-users needs, workflow, and how they can be enhanced with technology; all of which contributes to Buck's effective delivery of services for Echo's customers. Beth Scrimger, Senior Professional Services Specialist University of New Hampshire Beth has been associated with The Echo Group for almost 10 years; six of those years in Technical Support, Training and Implementation. She was employed by an Echo customer as a Database Administrator for three, before recently rejoining the Echo team as a Project Planner. Her end-user experience, combined with her knowledge of the inner workings of the Echo products, make her a valuable resource. Wendy Gallant, Professional Services Specialist AS, University of Maine Wendy brings over 10 years of healthcare and software experience to Echo. Wendy previously worked with Echo for 5 years in a variety of roles, including Technical Support, Quality Assurance, and Professional Services. She took a hiatus to deepen her software services skills elsewhere, and returned to Echo in Spring With her diverse background, from billing and reimbursement for a major commercial insurer, to Senior Director of Customer Support for a startup dot com; Wendy draws from a wealth of experience to ensure success for her Echo customers. The Echo Group 62 7/6/2012 RLI Number: R R1 369

370 Page 370 of 379 ~echo ~-Group ""'" 6) Training - Provide a variety of training options to minimize the cost of training County employees. Course 500a-b- Configuring Clinician's Desktop and Revenue Manager Training Number of Days Location 6 On-site or remote Description This course teaches staff serving in the System Administrator role how to set up and fully configure the Clinician's Desktop rm and Revenue ManagerrM software. Common features of all Echo products are trained. Trainees will learn how to configure the system for general use in the following areas: Adding users and groups Establishing system security Logging in to and exiting the software Navigating the software Configuring windows for data entry Customizing the appearance of the software Keyboard shortcuts Performing and saving searches Building note templates Building activity templates Building staff files Defining Service Components Adding Pay Sources, Rate Tables and Services Who should attend System Administrator/IS staff Agency's Project Manager Clinical department representative Billing department representative (optional) What to bring Configuration worksheets from your Echo project manager Code lists for validated fields Sample demographic data and intake/admission process information System administrator and training manual for Clinician's Desktop rm and Revenue Manager TMfor each attendee The Echo Group 63 7/6/2012 RLI Number: R R1 370

371 Page 371 of 379 '7iilecho,\Waroup Course Creating Custom Forms Number of Days Location 2 (minimum) On-site or remote Description The Window Designer course is a customized training designed to suit the needs of your agency. Your staff will learn to create and configure customized windows in any of the Echo products. Topics include: Identifying the data fields for a window Designing the appearance of the window Creating/modifying tables in the SOL database Building custom windows in the software Linking custom windows Attaching custom windows to the outliner Configuring data entry for the custom windows Who should attend System Administrator/IS staff Agency's DBA!Project Manager Business Office Manager Clinical Director/Program Managers Prerequisites System Administrator Training course #500 "DBA" privileges in Echo's applications Understanding of the features, tables and standard windows in Echo's applications Privileges in SQL Enterprise Manager What to bring Completed Window Designer worksheets for at least two custom windows Sample forms to create Available copy of database schema on Echo's Installation CD The Echo Group 64 7/6/2012 RLI Number: R R1 371

372 Page 372 of 379 Course 510- End User Training 'fiilecho tr.,.-group.. Number of Days Location 3 On-site Description The End User course is designed to train agency staff on how to apply features of Clinician's Desktop TM and Revenue Manager. The following topics are covered: Navigating the software Performing searches and queries in the database Entering staff data Entering and managing client data Entering household and family information Scheduling appointments, utilizing tools/shortcuts Entering activities and client cash receipts Using progress and case notes Generating standard revenue and billing reports Tracking Financial Assistance Entering Client Pay Source data including Service Authorizations Echo Mail and Electronic Signatures Who should attend System Administrator/IS staff Agency's System Administrator/Project Manager Intake, Data Entry, Billing, Clinical staff Clinical Director/Program Managers Prerequisites Database configured according to project worksheets What to bring Client records for each trainee Current staff schedules for two weeks Clinician's Desktop Training Manual Client Pay Source and AR Manager sections of Revenue Manager Training Manual The Echo Group 65 7/6/2012 Rll Number: R R1 372

373 Page 373 of 379 ~echo,.\wgroup o b o Course 515 -Incorporating Custom Reports into Echo Systems Number of Days 2 Location On-site or remote Description This course is designed to train agency staff to create customized reports using the Crystal Report Writing tool. Attendees will learn the following: Report Builder Writing reports Formatting reports Running reports Output options Integrating reports with Echo applications Who should attend System Administrator/IS staff Agency's DBNProject Manager Clinical Directors/Program managers Administrative staff Prerequisites Three months' actual data in the application's database Understanding of the features, tables and standard reports in the Echo applications At least two examples of identified agency reporting needs (samples must be sent to Echo at least 10 business days prior to the start of the training session) What to bring Copies of sample reports that trainees wish to create from scratch Copies of standard Echo reports that trainees wish to modify The Echo Group 66 7/6/2012 RLI Number: R R1 373

374 Page 374 of 379 Course Using revenue manager 'flilecho ;,.\.lagroup.. Number of Days Location 3 On-site Description This course intended to teach agency staff how data will move through the software to produce bills and reports. Trainees will learn how to use the software to process charges and transactions, manage revenue, and monitor receivables. Focus is on the following areas: Desktop review Processing services Producing bills Processing transactions Reporting Who should attend System Administrators /IS staff Agency's DBNProject Manager Business office staff Prerequisites Setup of each trainee to have access to both Clinician's Desktop rm & Revenue Managerr, set up in the Reimbursement user group in both Setup of each trainee as the database owner role in SQL Enterprise Manager Limit of 12 trainees in the training Capability of each trainee to print from the training computer (for paper HCFA) Installation of the paper HCFA & self-pay statement submission paths &.exes Configuration of the pay sources, rate schedules & services in Revenue Managerr Configuration of the setup considerations & global mapping for the paper HCFA Pay source, client, service, staff, activity dates & service cut-off dates for producing bills for each trainee Whatto bring Revenue Managerr training manual Sample billing scenarios and Explanation of Benefit reports The Echo Group 67 7/6/2012 RLI Number: R R1 374

375 Page 375 of 379 -~ I Course Developing Treatment Plans and Using Predefined Content ~ec.ho ~-GI))Up! Number of Days Location 3 On-site Description This course is designed to teach the Treatment Planning and Assessment functionality in the Echo software, and how they will be utilized according to the agency's workflow. Trainees will learn how to use all the features of these options including: Overview of screens Define outline and content Libraries Strength and weakness Assessment authoring Entering treatment plans Entering assessments Who should attend System Administrator/IS staff Agency's DBA/Project Manager Clinical staff Clinical Director/Program Managers Prerequisites Configuring Clinician's Desktop and Revenue Manager training course #500 What to bring Treatment Plan templates Assessment templates The Echo Group 68 7/6/2012 RLI Number: R Rl 375

376 Page 376 of 379 Course #599- Business Intelligence for Your Organization Training '7lilec.ho Group.... Number of Days 3 Location On-site Description This course teaches agency staff serving in the reporting, outcomes or data warehousing roles how to utilize tools such as Rapid Insight and Xcelsius, which offer statistical analyses to better understand trends and the impact of clinical and management decisions, and quick access to how client demographic and clinical variables and treatment decisions are related to outcomes, providing valuable "Meaningful Use" data. Trainees will learn how to use the software in the following areas: Navigating the software Keyboard shortcuts Performing lookups/searches Rapid Insight o Importing and exporting data o Univariate analysis o Multivariate analysis o Means analysis o Variable creation o Reporting options Xcelsius o Exporting data via views o Importing data o Creating and exporting dashboards o Creating charts and graphs o Displaying within application Who should attend System administrators Clinical and Outcomes department representatives Agency's project manager What to bring Sample existing reports, and State or Federal reporting guidelines, as necessary The Echo Group 69 7/6/2012 RL/ Number: R R1 376

377 Page 377 of 379 7) Provide a formula for calculation of the County's Return on Investment (ROI). <Colnpany Name>. Capital budgeting--retum..on-investment IROIJ analysis ~ SAMPLE D-ata c:eij ke-y,!; "~" ~~, ( --~ t~<:>~ ~ ~i~ ~c.o~jr --~~.1. 1~~_. ~ ~~~-~ ~ /.f '" ~ ' jl ~ j, 0:' "-'.! Oi' _ i <'> ~;J cash flow and ROI statemeflt BENEFIT DRIVERS ~ ~ 125,000 ~ion 125, !iO,GOO 2!i , i.IICIIl 125.!100 12~!100 12~0011 ~0011 1n ~1100 3llii,CIIlll 100.UOO GII;Dtlll.12S.Gtlll 12S.OOII 12S.Gtlll 125,ilil S,Gtlll 1CIIl,Gtlll 7S,Gtlll 300, , , ,000 Costs Ye-M 0 Year 1 Y{>.M 2 Year 3 if.~ ~:.'-AL.~~~ "..!" Jl~:~ ~.1f..'~,._X.'2~~~ - :r~.. Tu"~- ;!,_ ~,-t. '"'Z~it~< iij lntij;al 1mresf:rrn!.nl Ye.aJ 0 Year 1 Ye<a:r 2 Ye,;u 3 $1,200, ,0110 $0 0 $ , , ,000!iO,OIIO ~GOO z;,ooo 377

378 Page 378 of 379 Evaluation Criteria - Company Profile 6. DRUG FREE WORKPLACE: 1. Do you have a drug free workplace policy? 2. If so, please provide a copy of your drug free workplace policy in your proposal. BELOW 3. Does your drug free workplace policy comply with Section of the Florida Statutes? 4. If your drug free workplace policy complies with Section of the Florida Statutes, please complete the Drug Free Workplace Policy Certification Form. Attachment N 5. If your drug free workplace policy does not comply with Section of the Florida Statutes, does it comply with the drug free workplace requirements pursuant to Section a.2 of the Broward County Procurement Code? 6. If so, please complete the attached Drug Free Workplace Policy Certification Form. 7. If your drug free workplace policy does not comply with Section a.2 of the Broward County Procurement Code, are you willing to comply with the requirements Section a.2 of the Broward County Procurement Code? If so, please complete the attached Drug Free Workplace Policy Certification Form. DRUG-FREE WORKPLACE: Echo is a drug free workplace. Company hereby certifies that it has or it will within thirty (30) days after execution of this Contract: 1. The unlawful manufacture, distribution, dispensation, possession, or use of controlled substance is prohibited in the workplace and specifying actions that will be taken for violations of such prohibition; 2. Establish a drug-free awareness program to inform employees about (i) the dangers of drug abuse in the workplace, (ii) the Company's policy of maintaining a drug-free workplace, (iii) any available drug counseling, rehabilitation, and employee assistance programs, and (iv) the penalties that may be imposed upon employees for drug abuse violations; 3. Notify each employee that as a condition of employment, the employee will (i) abide by the terms of the prohibition outlines in (a) above, and (ii) notify the Company of any criminal drug statute conviction for a violation occurring in the workplace not later than five days after such conviction; 4. Impose a sanction on, or requiring the satisfactory participation in a drug counseling, rehabilitation or abuse program by, an employee convicted of a drug crime; 5. Make a good faith effort to continue to maintain a drug-free workplace for employees; The Echo Group 71 7/6/2012 Rll Number: R R1 378

379 Page 379 of 379 and '{tech a 1. Group m ' 6. Require any party to which it subcontracts any portion of the work under the contract to comply with the provisions of this Section. The Echo Group 72 7/6/2012 RLI Number: R Rl 379