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Home My WebLink AboutSNAP ELIZABETH A. NEVILLE TOWN CLERK REGIST~L/kR OF VIT~KL STATISTICS i~LARRLtGE OFFICER RECORDS A~%-NAC-Ei%IENT OFFICER · ~REEDOi%{ O'F II~FOI{~LiTION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southokitown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF SOUTHOLD Tills IS TO CERTII~ THAT THE FOLLOWING RESOLUTION NO. 697 OF 2004 WAS ADOPTED. AT TIW. REGULAR MEETING OF TI~. sOUTHOLD TOWN BOARD ON SEPTEMBER 2l, 2004: RESOLVED that the Town Board of the Town of Southold hereby authorizes and directs Supervisgr Joshua Y. Horton to execute a.n Agreement with the Suffolk County Office of the Aging for the Supplemental Nutrition Assistance Program (SNAP), IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284 from April 2004 through March 2005, subject to the appro~/al of~he Town Attorney, Elizabeth A. Neville South01d Town Clerk L~,w No. AG004M/0020-07R Rev. 6/22/04 Supplemental Nutrition Assistance Program IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284- Agreement This Agreement (Agreement) is between the County of Suffolk (County), a municipal corporation of the State of New York, having its principal office at the County Center, Riverhead, New York 11901, acting through its duly constituted Office for the Aging (Aging), having its principal office at the H. Lee Dennison Building - 3rd Floor, 100 Veterans Memorial Highway, Hauppauge, New York (Mailing address: P.O. Box 6100, Hauppauge, New York 11788-0099), and the Town of. Southold (Contractor), a New York municipal corporation, having its principal · place of'business at 53095 Main Road, P.O. Box 1179, Southoid, New York 11971. The parties hereto desire to make a senior citizens nutrition program available to the County. Su. fT'icient funding exists in the 2004 Suffolk County Operating Budget. Term of A,g~eement: Shall be April 1,2004 through Maroh 31,2005 with two one- year extensions at the County's option. Total Meals,: Daily Home-Delivered Mea,ls: 105 - 5 days per week - midday Total Cost of Agreement: Shall be on a fee-for- service basis, not to exceed $129,352 for the current contract year, as set forth in Exhibits A, A1 and C attached. Terms and Conditions: Shall be as set forth in Exhibit A through E and the Exhibit entitled "Suffolk County Legislative Requirements Exhibit for Contracts" revised 5/28/04 attached. I~n Witness Whereof, the parties hereto have executed this Agreement as of the latest date written below. Town of S~euthold County of Suffolk ,/J'osh~Ja Y. H0rt6n Paul Sabatino II ~ Supervisor Chief Deputy County Executive Fed. Taxpayer ID #: 11-6091939 Date: bate: '~, ~-") [ 6 ~'~ Approved: Approved as to Leg'aiity: By: Holly S. Rhodes-Teague Date Christine Malafi Director, Office for the Aging ~uffolk County Attorney Recommended: By: Jorzathan Bloom Date By: AssiStant County Attorney Anna Prencipe Date Assistant Food Service Supervisor i]_a~ No. J~GOO4M/00_-OC/7Y IFMS No. SCS EXE 0000000 Rev. 6/10/04 No. 001-6790/6774-4980-95284- I!lC Nutrition Program (Supplemental Nutrition Assistance Program) . Exhibit A Services To Be Performed - Payment By County A. The Contractor shall furnish Aging with one or more nutrition programs for senior citizens of SuffolkCounty (separately or collectively the "Program"), under (i) the Nutrition program for the EIderly pursuant to Title III, Part C of the Federal Older Americans Act (42 U.S.C.A. §3030e et seq.) in accordance with the rules and regulations of the Administration on Aging, United States Departmentof Health and Human Services, or (ii) the New York State Supplemental Nutrition Assistance P~ogram (SNAP), as indicated on the cover pa§~ of this Agreement. The Contractor shall furnish ~he Program as further provided in tt~is Exhibit A, ExhibitA1, the Contractor'sResPonse to 'Section IV, paragraph 3 a through h, to the RFQ Request for iQualifib~ions No. 3/15524VH (~he RFQ) and the following Appendices to the RFQ ,and, a(Jdit[onal Exhibits, which are aftach~d to and made part of this AG 4 (9/00) Agreement: EXHIBIT A1 EXHIBIT B EXHIBIT B1 EXHIBIT C EXHIBIT D EXHIBIT Appendix K Appendix L Appendix M Appendix N Appendix 0 Standard Contract Clauses Program Specifications Special Clauses (if any) Rate Page(s) (Contractors Response to Section ¥ of the RFQ) Grievance Procedures Suffolk County Legislative Requirements Exhibit for Contracts" revised 5/28/04 Technical Assistance Packet (revised 7/03) Policy and Procedure Manuals: Congregate Meals and Home Delivered Meals (revised 7/03) Holiday Schedule Summary Form for each Catchment Area Client Assessment Provider Data System (PBS - Form: revised 5/5/00) The approximate daily number of Congregate and/or Home-delivered Meals included in the Program shall be as set forth on the cover page of this Agreement. Payments will be made in accordance with the Rate Page(s) attached as Exhibit C to this Agreement, but only as provided in Exhibit Al. If, under prior similar agreements with the County, the Contractor has received nonconsumable furniture, equipment or other tangible personal property or funds to purchase any such items, or received any of such items in connection with this Agreement, the Contractor.shall comply with Exhibit D annexed to and made part of this Agreement. The provisions of Exhibit B1 shall prevail over inconsistent provisions of any other Exhibit, the provisions of this Exhibit A and of Exhibits A1 and B shall prevail over inconsistent provision of any other Exhibit except B1, and the provisions of A, A1 and B1 shall prevail over any other document not specifically referred to in this Page 1 of 2 pages of Exhibit A AG4M 03 RFP Model AGRMNT ~La~v No. ~G004M/00__-06/7Y IFMS No. SCS EXE 0000000__ Rev. 4/7/04 No. 00'1-6790/6774-4980-95284- ~'i11C Nutrition Program (Supplemental Nutrition Assistance Program) Agreement or made part thereof by this Exhibit A or by subsequent amendment in writing and signed by both parties except to the extent that provisions of this Exhibit A, or Exhibit A1 or B1 are specifically referred to and amended or superseded by such amendment: Exhibit B is made part of this Agreement for the contract year to which it relates and for any contract period thereafter unless it is modified by Extension Agreement or Amendment. = m = Contract Year The term of this Agreement shall be as set forth on the cover page, unless extended as provided below or terminated as provided in Exhibit Al. Reports The Contractor shall submit reports as reasonably requested by the County, including without limitation those required by the Technical Assistance Packet (Appendix K to the RFQ), and the Policy and Procedure Manuals (Appendix L to the RFQ). Limit Of County's Obligations The maximum amount to be paid by the County as set forth on the cover page of this Agreement or any amendment thereof shall constitute the full obligation of the County in connection with this Agreement and any matter arising therefrom for the contract year to which such cover page relates. Insurance Subparagraph 14.A (1) of Exhibit A1 is deleted and the following provision is substituted in its place: (1) COMMERCIAL GENERAL LIABILITY INSURANCE, including contractual and food products liability coverage, in an amount not less than Two Million Dollars ($2,000,000.00) combined single limit for bodiry injury and property damage per occurrence. Extension Of Term The services of the contractor under this Agreement shall be subject to review by Aging not less often than annually. If Aging, in its sole discretion, is satisfied with the Contractor's services, Aging sha~l notify the Contractor in writing on or before the expiration of the term (as same may have been extended), and the par[les shall negotiate an Extension Agreement, which shall take effect for the extension period specified therein, but in no event beyond the time limits specified on the cover page of this Agreement, upon signature on behalf of the County. Such Extension Agreement shall include the Total Cost of Agreement for the extension period, adjustment of the annual and daily average number of meals, if necessary, and such other modifications of the Agreement as may be agreed upon between the parties. - END OF TEXT OF EXHIBITA- AG 4 (9/00) Page 2 of 2 pages of Exhibit A AG4M 03 RFP Model AGRMNT TABLE OF CONTENTS ~-~Exhibit A1 - Standard Contract Clauses ............................................................... 1. Contractor Responsibilities ......................................................................................... 1 (a) Services ........................................................................................................... 1 ,:: (b) QuaTifications and Licenses .............................................. ' ........... ' .................... 1 : (c) County Review ................................................................................................. 1 (d) Level of Service ............................................................................................... 1 .(e) Compliance with Law ....................................................................................... 1 · 2. Term of Agreement ..................................................................................................... 2 3. Payment for Services :....: ........................................................................................... 2 (a) Claims .............................................................................................................. 2 (b) Final Request for Payment .............................................................................. 2 (c) Payment of Claims .................................................................... :; ..................... 2 (d) Payments Not To Exceed Net Expenditures .................................................... 2 (e) Taxes ............................................................................................................... 3 (f) Agreement Subject to Appropriation of Funds ................................................. 3 (g) Payments Contingent upon State/Federal Funding ......................................... 3 (h) Payments Contingent upon Receipt of State/Federal Aid ................................ 3 (i) Other Governmental Funding .......................................................................... 3 '(j) Post-AUdit ........................................................................................................ 3 4. Accounting Procedures .............................................................................................. 4 5. Financial Statements and Audit Requirements ........................................................... 4 6. Furniture, Fixtures, Equipment, etc ............................................................................. 5 (a) Purchases, Etc. Requiring Prior Approval ........................................................ 5 (b) Purchase Practices .......................................................................................... 6 (c) Proprietary Interest of County .......................................................................... 6 (d) Inventory Records, Controls and Reports ........................................................ 6 (e) Protection of Property in Contractor's Custody ................................................ 7 (f) Disposition of Property in Contractor's Custody ............................................... 7 7. Addresses for Notices, Claims and Repeals ............................................................... 7 8. Statement of Other Contracts ..................................................................................... 7 9. Offset of Arrears or Default ................................................ : ........................................ 7 10. Confidentiality of Records ........................................................................................... 7 11. independent Contractor .............................................................................................. 8 12. Certificate of Incorporation ......................................................................................... 8 AG A1F (5/00) 13. Insurance and Indemnification ...................................................................... : ............ 8 I4. Incident Reporting .................................................................................................... 10 15. Nondiscrimination in Employment ............................................................................ 10 16. Nondiscrimination in Services ........................................................................... ~ ....... 10 17. Nonsectarian/Nonpartisan Declaration ..................................................................... 11 18. Suffolk County Living Wage Law ................................ ~ ................ : ............................ 11 19. Child Sexual Abuse Reporting Policy ......................................................... i ............. 12 -20. Gratuities .................................................................................................................. 12 21. Public Disclosure ...................................................................................................... 12 22. Work Experience Participation .................................................................................. 12 23. Publications, Copyrights and Patents ....................................................................... 12 24. Qualifications of Personnel ....................................................................................... 13 25. Certification Regarding Lobbying .............................................................................. 13 26. Cooperation On Claims ............................................................................................ 13 27. Assignment and Subcontracting ............................................................................... 13 28. Termination ............................................................................................................... 14 29. Severability; No Implied Waiver ................................................................................ 14 30. Merger; No Oral Changes ........................................................................................ 14 AG A1F (5/00) Exhibit A1 - Standard Contract Clauses 1. Contractor Responsibilities (a) Services The Contractor shall perform such services as may be necessary to accomplish the work · required to be performed under and in accordance with this Agreement, as more particularly pro- ¥ided in Exhibits A and B, in a skillful manner and to the best of its ability. (b) Qualifications and Licenses The Contractor specifically represents and warrants that it has and shall p0ssess, and. · that, to'the exteht applicable, [ts employees, agents and subcontractors have and ~hall possess, the req[~ired'education, knowledge, experience and character necessary to qualifythem individu- ally for the particular duties they peri~orm and that the Contractor has and shall have, and, to the extent applica:ble, its employees, agents and subcontractors have ann shall have, all required au- thorizat[on(s)~ registration(s), license(s), certificate(s) or permit, s) required by State, County or local authorities for the Services (hereinafter called "License"). The' Co'ntractor shall immediately notify Aging in writing of any disciplinary proceedings against the holder of any License by the New York State Department of Education or the. New York State Department of Health or other · issuer of a License. In the event that [he Contractor or such other holder of a License is no longer licensed for any one or more of the Services, the Contractor must immediately so notify Aging. Il is understood that the Contractor shah not be. reimbursed for any Services rendered after the ef- fective date of t~rmination of such License. The remainder of this Agreement, or its ~pplication to p'ersons or circumstances other than those as to which said License. has been terminated, shall not be affected thereby, and every other term and provision of this Agreement, shall be va~id and enforceable to the fullest extent permitted by law. (c) County Review It is agreed that the nature and extent of the services provided pursuant to this Agreement shall be subject to the general supervision of Aging and that Aging, through its duly authorized representatives, has the right to monitor and evaluate the program. Aging shall be the sole arbiter as to what constitutes acceptable performance under this Agreement. (d) Level of Service The Contractor agrees that where a minimum level of service is not provided as set forth in Exhibit B, Aging may require the reduction of Contractor staff and costs or terminate this Agreement after giving notice in accordance with the provisions headed, "Termination", of Exhibit ^1. (e) Compliance with Law The Contractor shall comply with all applicable local, County, State and Federal laws, rules and regulations, including without limitation the rules and regulations of the New York State Office for the Aging, Suffolk County local preference and other applicable Suffolk County local laws and resolutions of the Suffolk County Legislature and the rules, regulations, criteria, and guidelines for expenditure controls heretofore adopted or to be adopted by the County, New York State and the Federal government pursuant to law. AG A1F (2/04) Page 1 of 14 pages of Exhibit A1F ~,,,F ;2.. Term of Agreement This Agreement shall cover the period provided on the first page thereof, unless sooner terminated as otherwise provided in this Agreement. Payment-for Services (a) Claims (i) The Contractor shall prepare and present claim forms supplied bythe County (standard Suffolk County Payment Voucher and any other form(s) required by Aging or the Department of Audit and Control) within, eight (8) days after the close of the month in which the expenditure was made', except the claim for the last month of the initial Term of Agreement and of each suc- ceeding E×tensi~n Period, if any, for which the claim sha~l be submitted as provided in Paragraph B below. (ii) All claim forms must be signed in ink by duly authorized persons, and certifica- tion of such authorization with certified specimen signatures thereon must be filed with Aging by a Contractor official empowered to sign this Agreement. (iii)Monthly vouchers shall be submitted directly to the Suffolk County Office for the Aging at H. Lee Dennison Building, 100 Vete~:ans Memorial Highway, P. O. Box 6100, Hauppauge, New York 11788-0099. (iv) No claims shall be payable until the Contractor complies with all require- merits in this Agreement that should have been complied with on or before submission of such claims and also submits evaluative and such other data in the manner and form as shall be required and accepted by Aging, the County, State or Federal Government. (v) The amount of the Total Cost of the Agreement to be paid by the County as set forth on the cover page of this Agreement or of any extension or amend- ment thereof shall constitute the full obligation of the County in connection with this Agreement for the period there indicated. (b) Final Request for Payment A final claim for payment shall be submitted no later than thirty (30) days after the end of the initial Term of Agreement and of each succeeding Extension Period, if any, unless otherwise directed by Aging. (c) Payment of Claims The County agrees to pay the Contractor monthly for services provided and costs in- curred pursuant to this Agreement up to the maximum agreed amount as provided in paragraph 3(a)(5) above, upon receipt of monthly claims in such form as prescribed by the County and after audit and approval by the County. Claims shall be documented by sufficient, competent and evi- dential matter. Payment by the County shall be made within thirty (30) days after approval by the Comptroller of the County of Suffolk. (d) Payments Not To Exceed Net Expenditures The Contractor agrees that if, for any reason whatsoever, the Contractor shall spend dur- ing the term of the Agreement for the purposes set forth herein an amount less than agreed, the AG A1F (2/04) Page 2 of 14 pages of Exhibit A1F ,~,~, total County payment herein shall be reduced to the amount of approved actual Contractor ex- penditures made for such purposes, and that the total amount to be paid by the County during the contract term shall not exceed approved actual net expenditures or the Total Cost of the Agree- ment on the cover page and in the Budget, whichever is less. (e) Taxes The charges payable to the Contractor under this Agreement are exclusive of federal, state and local taxes, the County being a municipality exempt from the payment of such taxes. (f) Agreement Subject to Appropi'iation of Funds This Agreement is subject to the am,,ount of funds appropriated and any subsequenl modifi- cations thereof' by the Suffolk County Legislature, and n(~ liability shall be incurred by the County Under this Agreement beyond the amount of funds appropriated by the Legislature for the program covered by this Agreement. (g) Payments Contingent upon State/Federal Funding Payments under this Agreement are subject to and contingent upon continued funding by tee State and/or. Federal Government(s). If, for any reason, the full amount of such funding is not made available to the County, this Agreement may be terminated in whole or in part, or the amount payable to the Contractor may be reduced, at the discretion of Aging, provided that any such termination or reduction shall not apply to allowable costs incurred by the Contractor prior to such termination or reduction to the extent that funds are available to Aging for payment of such costs. (h) Payments Contingent upon Receipt of State/Federal Aid If any State or Federal government department or agency funding this Agreement in whole or in part should fail to approve aid in reimbursement to the County for payments made here- under by the County to the Contractor for expenditures made during the term of this Agreement because of any act, omission or negligence on the part of the Contractor, then the County may deduct and withhold from any payment due to the Contractor an amount equal to lhe reimburse- ment denied by such department or agency, and the County's obligation shall be reduced by any such amounts. In such an event, if there should be a balance due to the County after it has made a final payment to the Contractor, the Contractor agrees promptly to reimburse the County the amount of the balance due the County by check to the order of the Suffolk CountyTreasurer. The provisions of this subparagraph shall survive the expiration or termination of the Agreement. (i) Other Governmental Funding If the program of the Contractor which is the subject of this Agreement is funded in whole or in part by contracts with other governmental agencies, it is agreed that the funds of the County under this Agreement shall be refunded to the County to the extent that the local funding from all such sources exceeds the total expenditures of the Contractor for the program. (j) Post-Audit All payments made under this Agreement are subject to audit by the Suffolk County Comptrol- ler pursuant to Article V of the Suffolk County Charter. The Contractor further agrees that the County Comptroller and Aging shall have access to and the right to examine, audit, excerpt, copy or tran- scribe any pertinent transactions or other records relating to services under this Agreement. If such an audit discloses overpayments by the County to the Contractor, within thirty (30) days after the issu- AG A1F (2/04) Page 3 of 14 pages of Exhibit A1F ~,,,F ance of an'official audit report by the Comptroller Or his duly designated representatives, the Contrac- tor shall repay the amount of such overpayment by check to the order of the Suffolk County Treasurer or shall submit a proposed plan of repayment to the Comptroller. If there is no response or if satisfac- ~tory repayments are not made, the County may recoup overpayments from any amounts due or be- coming due to the Contractor from the County under this Agreement or otherwise. ~,.' Accounting Procedures '(a) The Contractor shall maintain separate records of account concerning all costs in- curred by the Contractor in the pedormance of this Agreement and all income relating to the pro- gram funded under this Agreement and consents to audit and inspection by the County, New York State and the Federal Government of ail facilities, books and other financial and statistical data, whether related to this Agreement or otherwise (in the case of towns or other municipal cot- porations, only as they relate to this Agreement). Such records shall be maintained for a period of seven (7) years from the date of termination or expiration of this Agreement. Specific records shall be .kept as to the hours of all personnel. (b) The Contractor shall comply, for the program funded under this Agreement, with the "Regulations for Accounting Procedures for Contract Agencies," promulgated by the Department of Audit and Control of Suffolk County, and any amendments during the Term of this Agreement. 5. Financial Statements and Audit Requirements (a) Notwithstanding any other reporting or certification requirements of Federal, State or local authorities, the Contractor shall obtain the services of an independent licensed public ac- countant or certified public accountant (the "Auditor") to audit its financial statements for each Contractor fiscal year in which the Contractor has received, or will receive, $500,000 or more from the County, whether under this Agreement or otherwise, and shall submit a report on the overall financial condition and operations of the Contractor, including a balance sheet and state- merit of income and expenses, attested by the Auditor as fairly and accurately reflecting the ac- counting records of the Contractor in accordance with generally accepted accounting principles. The Contractor is encouraged to solicit requests for proposals (RFPs) from a number of qualified accounting firms and to review carefully the costs of, and qualifications for, this type of work be- fore selecting the Auditor. (b) The Auditor should be required to meet the following minimum requirements: (i) a current license issued by the New York State Education Department; (ii) sufficient auditing experience in the nonprofit, governmental or profit-making areas, as applicable; and (iii)a satisfactory peer review issued within not more than three years prior to the date when the Auditor was selected to conduct the audi[. (c) The audit must be conducted in accordance with generally accepted governmental auditing standards (GAGAS). Financial statements must clearly differentiate between County-funded programs and other programs that the Contractor may be operating. The use of subsidiary schedules should be encouraged for this purpose. The Auditor must als0 prepare a management letter based on the audit. (d) Furthermore, if the Contractor is a non-profit organization or unit of local govern- ment and expends $500,000 or more of Federal monies, whether as a recipient expending awards AG A1F (2/04) Page 4 of 14 pages of Exhibit A1F ~,,, received directly from Federal awarding agencies, or as a subrecipient expending Federal awards . received from a pass-through entity, such as New York State or Suffolk County, during any fiscal period within which it receives funding under this Agreement ("fiscal year"), the audit must be con- ducted, and the audit report ("Single Audit Report") must be, in accordance with 0~1] Circular No. A-133 (revised June 24, 1997). Single Audit Reports must also be submitted to the designated clearinghouse, cognizant agency and/or pass-through entity, to the extent required by the OMB Circular'just referred to. (e) The Contractor mUst submit a statement in writing, certified by its chief financial. officer, which states the amount of Federal funding expended by the Contractor during such fiscal year. The 6ontractor must mail or deliver the certified statement to Agi.ng and to Elizabeth Tesoriero, Executive Director of Auditing Services, Suffolk County Department of Audit and Contro, H. Lee Dennison Building, 100 Veterans Memorial Highway; P. O. Box 6100, Hauppauge, New'York 11788-0099,'.as soon as possible after the end of the Contractor's fiscal year. The Ctatement should include ALL Federal funding reCeived directly'from the Federal government and ALL Federal funds passed through from the County and other pass-through entities (f) Copies of all financial statements, management letters, Single Audit Reports (if-ap- plicable) and other audit reports,' if required, must be transmitted to Aging and to I~s: Tesoriero at the address just set forth. The reports must 5e submitted within thirty (30) days after completion of the audit, but in no event later than nine (9) months after the end of the Contractor's fiscal pe- riod to which the audit relates. (g) These requirements do not preclude Aging or the Suffolk County Comptroller or their authorized representatives or Federal or State auditors from auditing the records of the Con- tractor. Therefore, the records of the Contractor must be made available to authorized represen- tatives of Federal, State or County government for that purpose_ (h) All payments made under this Agreement are subject to audit by the Suffolk County Comptroller pursuant to Article V of the Suffolk County Charter. If the Contractor fails to cooper- ate with an audit by the Comptroller, the County shall have the right to suspend or partially with- hold payments under this Agreement or under any other agreement between the parties until such cooperation is forthcoming. If such an audit discloses overpayments by the County to the Con- tractor, within thirty (30) days after the issuance of an official audit report by the Comptroller or his duly designated representatives, the Contractor shall repay the amount of such overpayment by check to the order of the Sufl'olk County Treasurer or shall submit a proposed plan of repayment to the Comptroller. If there is no response or if satisfactory repayments are not made, the County may recoup overpayments from any amounts due or becoming due to the Contractor from the County under this Agreement or otherwise. (i) The provisions of this paragraph shall survive the expiration or termination of the Agreement. 6. Furniture, Fixtures, Equipment, etc. (a) Purchases, Etc. Requiring Prior Approval Prior to placing any order to purchase, rent or lease any furniture, fixtures, orequipment, (i) valued in excess of five hundred dollars ($500.00) per unit, or (ii) included but not itemized, in the Budget, the Contractor shall submit to the County a written request for approval to make such a proposed purchase, rental, or lease, with a list showing the quantity and description of each item, AG A1F (2~04) Page 5 of 14 pages of Exhibit A1F .,.,F its intended location and.use, estimated unit price or cost, extended price o'r cost and estimated total cost of the proposed order. Written approval of the County is required before the Contrac- tor may proceed with the proposed purchase, rental, or lease of furniture, fixtures, or equipment. All items purchased .will be new unless specifically described otherwise in the Budget. (b) Purchase Practices The Contractor agrees'to follow all of the general practices that are designed to obtain fur- niture, fixtures, equipment, materials or supplies at the most reasonable price or cost possible. The County reserves the right to purchase or obtain for the Contractor furniture, fixtures, equip- merit, materials or supplies which shall be in accordance vyith the programmatic needs of this Agreement. If the County exercises this right, the amount budgeted for the items so purchased'or :obtained by the County for the Contractor shall not be avaJlabie to-the Contractor for a'ny pur- ~)ose whatsoever. Titt~ to any such items purchased or otherwise, obtained by the County for the Program and entrusted to the Contractor shall remain in the County, and, the Contractor shall 'attach labels indicating the County's ownership if the County has not done so. ' (c) Proprietary Interest of County The County shall retain a proprietary interest in_all furniture, removable fixtures, equip- ment, materials or supplies purchased.or obtained by the Contractor and paid for0r reimbursed to the Contractor pursuant to the terms of this Agreement or any prior agreement. Upon the ter- mination of this Agreement, or of any renewal thereof, the discontinuance of the business of the Contractor, the failure of the Contractor to comply with the terms of this Agreement, the bank- ruptcy of the C°ntractor, an assignment for the benefit of its creditors, or the failure of the Con- tractor to satisfy any judgment against it within thirty (30) days of filing, the County shall have the right to take title to and possession of all such furniture, removable fixtures, equipment, materials and supplies, and the same shall thereupon become the property of the County without any claim for reimbursement on the part of the Contractor. As directed by the County, the Contractor shall attach identifying labels on all furniture, removable fixtures and equipment indicating the pro- prietaw interest of the County. (d) Inventory Records, Controls and Reports The Contractor shall maintain proper and accurate inventory records and controls for all such furniture, removable fixtures and equipment acquired pursuant to this Agreement and all prier agreements, if any, covering the Program. Three (3) months before the termination date of this Agreement, the Contractor shall make a physical count of all items of furniture, removable fixtures and equipment in its custody, checking each item against the aforesaid inventory records. A report setting forth the results of such physical count shall be prepared by the Cor~tractor on a form or forms designated by the County, certified and signed by an authorized official of the Con- tractor, and one (1) copy thereof shall be delivered to the County within five (5) days after the date set for the aforesaid physical count. Within five (5) days after the termination date of this Agreement, the Contractor shall submit to the County six (6) copies of the same report updated to the termination date of this Agreement, certified and signed by an authorized official of the Con- tractor, based on a physical count of all items of furniture, removable fixtures and equipment on the aforesaid termination date, and revised, if necessary, to include any inventory changes during the last three (3) months of the term of this Agreement. AG A1F (2/04) Page 6 of 14 pages of Exhibit A1F ~,~F - (e) Protection of Property in Contractor's Custody The Contractor shall maintain vigilance and take all reasonable precautions to protect the furniture, fixtures, equipment, materials or supplies in its custody against damage or Ioss by fire, burglaw, theft, disappearance, vandalism or misuse. In the event of burglary, theft, vandalism or ;disappearance of any item of furniture, fixtures, equipment, materials or supplies, the Contractor shalrimmedi'ately notify the police and make a re~;o~rd thereof, including a record of the results of :any investigation which may be made thereon, In the event of loss of or damage_to any item.of :fumitu~-e, fixtures, equipment, materials or supplies from any cause, the Contractor immediately ~shall send the County a detailed, written report thereon. (f) Disposition of Property in Contractor's Custody Upon termination of the County's funding of the Program covered by this Agreement or by any renewal hereof, or at any other time that the County may direct, the Contractor shall make access available and render all necessary assistance for physical removal by the'County or its designee of any or all furniture, removable fixtures, equipment, materials or Supplies in the Con- tractor's custody in which the County has a proprietary interest, in the same condition as Such · property was received by the Contractor, reasonable wear and ,tear excepted. Any disposition, settlements or adjustments connected with such property Shall be in accordance with the rules and regulations of the County and the State of New York. 7. Addresses for Notices, Claims and Reports The Contractor shall mail any communication, notice, claim for payment, reports, or other submission to: Suffolk County Office for the Aging at its address on the cover page of this Agree- ment, or such other address of which the County shall have given the Contractorwritten notice. The County shall mail any communication, notice, or other submission to the Contractor at its address on the cover page of this Agreement or such other address of which the Contractor shall have given the County written notice. 8. Statement of Other Contracts The Contractor has attached, and in the event of any change, will attach to any extension agreement/amendment of this Agreement, a Statement of Other Contracts in the form annexed to this · Agreement. The Contractor represents and warrants that any such Statement of Other Contracts is and will be a complete list of all other contracts (i) which are currently in effect or (ii) which have ex- pired within the past 12 months and have not been renewed, and under which funds have been, are being or will be received by the Contractor from any department or agency of the County, the United States of America, the State of New York or other municipalities or funding organizations_ 9. Offset of Arrears or Default The Contractor warrants that it is not, and shall not be during the term of this Agreement, in arrears to the County for taxes or upon debt or contract and is not, and shall not be during the term of this Agreement, in default as surety, contractor or otherwise on any obligation to the County, and the Contractor agrees that the County may withhold the amount of any such ar- rearage or default from amounts payable to the Contractor under this Agreement. 10. Confidentiality of Records (a) The Contractor expressly agrees to preserve the confidentiality of all data and in- formation shared, received, collected, or obtained as a result of this Agreement. No disclosure, AG AIF (2/04) Page 7 of 14 pages of Exhibit A1F ,g,,F rediscl0sure or release of such data or information is to be made,.'permitted, or encouraged by the Contractor or its officers or employees, except as expressly authorized by law. It is further under- stood and agreed that no such data or information is to be used for personal benefit. The Con- tractor further agrees that its employees shall be specifically instructed in regard to their obliga- tibn to keep such data ~nd information in confidence and their liability upon breach of confidential- ity to all the penalties' prescribed by law. (b) The Contractor further agrees to implement such procedures for safeguarding in- formation as the Department shall require. The Contractor further agrees to indemnify and hold the County and Aging harmless against any Ioss, damage, cost or expense arising out of any suit, claim .or demand which may be brought or made against the County or Aging by reason of a breach of these provisions. (c)' In addition, the Contractor agrees to maintain the confidentiality of all information in conformity with the provisions of applicable local, State and Federal laws and regulations. 11. Independent Contractor The relationship of the Contractor to the County shall be that of an independent contrac- tot. The Contractor, in accordance with its status as an independent contractor, covenants and agrees that neither the Contractor nor any of its o_fficers, directors or employees will hold itself or themselves out as, or claim to be, an officer or employee of the County by reason of this Agree- merit, and that neither it nor any of them will, by reason thereof, make any claim,, demand or appli- cation to or for any right or privilege applicable to an officer or employee of the County, including, but not limited to, Workers' Compensation coverage, unemployment insurance benefits, Social Security coverage, or retirement membership or credits. 12. Certificate. of Incorporation The Contractor (if not a town or other municipal corporation) shall furnish Aging with certi- fled copies of its Certificate of Incorporation and by-laws, including any amendments thereto, at the time it signs this Agreement, to the extent not already on file with Aging, and any amend- merits thereto during the term of this Agreement promptly upon their adoption, and a list of the board members governing the Contractor from time to time. The Contractor shall not dissolve any existing corporation or establish any new corporation with the responsibility for the operation of the program without the prior written approval of Aging. 13. Insurance and Indemnification (a) The Contractor agrees to procure, pay the entire pre _mium for and r~aintain throughout the term of this Agreement insurance in amounts and types specified by the County. Unless otherwise specified by the County and agreed to by the Contractor, in writing, such in- surance will be as follows: (i) COMMERCIAL GENERAL LIABILITY INSURANCE, including contrac- tual coverage, in an amount not less than Two Million Dollars ($2,000,000.00) combined single limit for bodily injury and property damage per occurrence. (ii) AUTOMOBILE LIABILITY INSURANCE (if any vehicles are used in the · performance of this Agreement) in an amount not less than Three AG A1F (2/04) Page 8 of 14 pages of Exhibit A1F ~g,,, Hundred Thousand Dollars ($300,000.00) combined single limit for bodily injury and property damage per occurrence. (iii)PROFESSIONAL LIABILITY/ERRORS AND OMISSIONS INSUR- ANCE in' an amount not less than Two Million Dollars ($2,000,000.00) on either a per occurrence or claims made basis. (iv) WORKERS' COMPENSATION and EMPLOYER'S LIABILITYINSUR- ANCE in compliance with all applicable New Ybrk s~ate laws and regu- lations and DISABILITY BENEFITS INSURANCE if required by law and shall have furnished to the County prior to its execution of this Agreement the 'documentation required by the State of New York Workers' Compensation Board of coverage or exemption from cover- age pursuant to §§ 57 and 220 of the Workers' Compensation Law. In accordance with General Municipal Law § 108, this Agreement shall be void and of no effect unless the Contractor shall provide and maintain coverage during the term of this Agreement for the benefit of such em- ployees as are required to be covered by th_e provisions of theWork- ers' Compensation Law. (v) FIDELITY BONDS (if a Budget and payment schedule are attached to this Agreement) providing comprehensive coverage, in an amount not less than the greater of (i) Five Thousand Dollars ($5,000) or (ii) the amount of the advance to the Contractor under'this Agreement, against dishonesty, disappearance and destruction or money and se- curities for all personnel who have access to or sign checks, or have care, custody or control of funds or property entrusted to the Contrac- tor under the terms of the Agreement. (b) All policies providing such coverage shall be issued by insurance companies ac- ceptable to the County. (c) The Contractor shall furnish to the County certificates of insurance or, on request, original policies, evidencing compliance with. the aforesaid insurance requirements. In the case of commercial general liability insurance, said certificates or other evidence of insurance shall name the County of Suffolk as an additional insured. All such certificates or other evidence of insurance shall provide for the County of Suffolk to be a certificate holder and to be notified in writing thidy (30) days prior to any cancellation, nonrenewal or material change. Such certificates, policies or other evidence of insurance and notices shall be mailed to Aging at the address al the head of this Agreement or at such other address of which the County shall have given the Contractor no- tice in writing. If the Contractor is a town or other municipal corporation and has a self-insurance program under which it acts as a self-insurer for any of such required coverage, it may provide self-funded coverage and certificates or other evidence of such self-insurance in lieu of insurance issued by insurance companies. (d) Furthermore, to the extent permitted by law, the Contractor shall indemnify and hold harmless the County, its consultant (if any), employees, agents and other persons from and against all losses, claims, costs, judgments, liens, encumbrances and expenses, including attor- neys' fees, by reason of liability imposed by law, for damage because of bodily injury, including death at any time resulting therefrom, sustained by any person or persons, or on account of dam- AG A1F (2/04) Page 9 of 14 pages of Exhibit A1F ,g,,F · age to property, arising out of the acts or omission§ br negligence of the Contractor, its agents, employees or subcontractors or of other persons, in connection with the services described or re- ferred to in.this Agreement, even if such injuries to persons or damage to properly are due, or are claimed to be due, to passive negligence of the County, its employees, agents or subcontractors or'other persons, except only in cases of the County's sole active negligence. 14. Incident Reporting The Contractor agrees to provide Aging with reports of all instances of claims, costs, damages, and injuries to'persons or property of whatsoever kind arising out of services provided under this Agreement. All such notifications should be given to Aging immediately after the inci- dent, if possible., but in no case longer than five (5) days after the incident. The Contractor fur- 'ther agrees to send. Aging copies of all "notices of claim" relating to the program covered in this Agreement. 15. Nondiscrimination in Employment (a) The Contractor agrees in connection with the performance of this Agreement as follows: (i) The Contractor shall not discriminate against employees or applicants for employment because of race, creed, color, national origin, sex, age, disability, Vietnam Era Veteran status or marital status, and will undertake or continue existing programs of affirmative action to ensure that women and minority group members are afforded equal employment opportunities without dis- crimination. Affirmative action shall mean recruitment, employment, job as- signment, promotion, upgradings, demotion, transfer, layoff, or termination and rates of pay or other forms of compensation. (ii) The Contractor shall require each employment agency, labor union or authorized representative of workers, with which it has a collective bargaining or other agreement or understanding, to furnish a written statement that such employment agency, labor union or representative will not discriminate on the basis of race, creed, color, national origin, sex, age, disability, Vietnam Era Veteran status or madtal status and that such union or representative will affirmatively cooperate in the implementation of the Contractor's obligations herein. (iii)The Contractor shall state, in all solicitations or advertisements for employ- ees, that, in the performance of this Agreement, all qualified applicants will be afforded equal employment opportunities without discrimination because of race, creed, color, national origin, sex, age, disability, Vietnam Era Veteran status or marital status. 16, Nondiscrimination in Services (a) Furthermore, the Contractor, in providing services under this Agreement, shall not, on the grounds of race, creed, color, national origin, sex, age, disability or marital status: (i) Deny an individual any services or other benefits provided under the program: (ii) Provide any services or other benefits to an individual which are different, or are provided in a different manner, from those provided to others under the program; (iii)Subject an individual to segregation or separate treatment in any matter related to his/her receipt of any services or other benefits provided under the program; AG A1F (2/04) Page 10 of 14 pages of Exhibit A1F ,g,,F (iv). Restrict an individual in any way in the enjoyment of any advantage or privi- · lege enjoyed by others receiving any services or other benefits provided un- der the program; '(v) Treat an.individual differently from others in determining whether or not the individual satisfies any eligibility or other requirements or conditions which in- dividuals must meet in order to receive any aid, care, services, or other bene- fits provided under the program. (b) The Contractor shall not utilize criteria.or methods ct' administration which have the effect of subjecting individuals to discrimination because of their race, creed, national origin, sex, age, disability o~ r~aritai status or have the effect of defeating or substantially impairing accom- plishment of the objectives, of the program in respect to individi~als of a particular race, creed; na- tional origin, sex, age, 'disability or madtal status, in determining: (i) The types of services or other benefits to be provided under the program, or (ii) The class of individuals to whom, or the situations in which, such services or other benefits will be provided under the program, or (iii) The class of individuals to be afforded an opportunity to participate in the program. (c) The Contractor also agrees to observe all applicable Federal Regulations contained in 45 CFR, Part 84 and Part 85 entitled "Non-Discrimination on the Basis of Handicap in Program Activities Receiving or Benefiting from Federal Financial Assistance." (d) The Oontractor agrees to comply with the requirements of the Civil Rights Act of 1964. (e) In addition (unless otherwise indicated, or not applicable to the Program described, in Exhibit B), pursuant to § 306(a)(5)(A)(ii) of the Older Americans Act, as added by P. L. 100-175, 42 U.S.C.A. § $026(a)(5)(A)(ii), the Contractor shall (i) specify how the Contractor intends to satisfy the service needs of Iow-income minority individuals in the area served by the Contractor; and (ii) attempt to provide services to Iow-income minority individuals in at least the same proportion as the population of Iow-income minority older individuals bears to the population of older individuals of the area served by the Contractor. 17. Nonsectarian/Nonpartisan Declaration The Contractor agrees that all services performed under this Agreement are secular and nonpartisan in nature and that no funds received pursuant to this Agreement will be used for sec- tarian purposes or to further the advancement of any religion, candidate or partisan effort. Fur- thermore, the Contractor agrees that all program services are and will be available to all eligible individuals regardless of religious belief or political affiliation. 18. Suffolk County Living Wage Law The Contractor represents and warrants that it has read and is familiar with the requirements of Section 6 of Chapter 347 of the Suffolk County Code, the Living Wage Law, attached hereto as part of the "Suffolk County Legislative Requirements Exhibit for contracts" and made a part hereof. AG A1F (2/04) Page 11 of 14 pages of Exhibit A1F ,,,,F 19. Child Sexual Abuse Reporting Policy The Contractor agrees to comply with the Suffolk County Child Sexual Abuse RepoKing Policy, Chapter 577, Article IV, of the Suffolk County Code, attached hereto as part of the "Suffolk County Legislative Requirements Exhibit for Contracts" and made a paK hereof, as now in effect or amended hereafter or of any other Suffolk County Local Law that may become applicable dur- ing the term of this Agreement with regard to child sexual abuse reporting policy. 20, Gratuities The Contractor represents and warrants that it has not offered or given any gratuity to any official, employee or agent of Suffolk County or New York State or of any political party, with the p.urpos'e of intent of securing favorable treatment with respect to'the awarding or amending of an 'agreement or the maMng of any determinations with respect to the p .erfo(mance of an agreement, and that the signer of this Agreement has read and is familiar with the provisions of Local Law No. 32-1980 of Suffolk County (Chapter 386 of the Suffolk County Code). 21. Public Disclosure The Contractor represents and warrants that, unless exempt, it has filed wilh the Comptroller of Suffolk County the verified public disqlosure statement, required by Local Law No. 14 of 1976, as amended (§A5-7 of the Suffolk County Code) and acknowledges that such filing is a material, contractual and statutory duty and that the failure to file such statementshall constitute a material breach of this Agreement, for which the County shall be entitled upon a determination that such breach has occurred, to damages, in addition to all other legal remedies, of fifteen per- cent (15%) of the amount of the Agreement. (Such filing is not required if the Contractor is a not-for-profit corporation.) 22. Work Experience Participation If the Contractor is a nonprofit agency or institution, each of the Contractor's locations in Suffolk County at which services are provided under this Agreement shall be a work site for pub- lic-assistance clients of Suffolk County pursuant to Local Law No. 15-1993 at all times during the term of this Agreement. If no Memorandum of Understanding ("MOU") with the Suffolk County Department of Labor for work experience is in effect at the beginning of the term of this Agree- ment, the Contractor, if it is a nonprofit agency or institution, shall enter into such MOU as soon as possible after the execution of this Agreement and failure to enter into orto perform in accor- dance with such MOU shall be deemed to be a failure to perform in accordance with this Agree- ment, for which the Contractor may withhold payment, terminate this Agreementor exercise such other remedies as may be appropriate in the circumstances. 23. Publications, Copyrights and Patents (a) The Contractor shall not issue or publish any book, article, announcement, report or other publication relating to the subject program without prior written permission from the County. Any such publication shall bear a statement acknowledging the cooperation and/orrunding by the County of Suffolk- Steve Levy, County Executive. (b) If the work of the Contractor under this Agreement shouId result in the production of original books, manuals, films or other materials for which a copyright may be granted, the Con- tractor may secure copyright protection. However, the County reserves, and the Contractor hereby gives to the County, and to any other municipality or government agency orbody desig- AG AIF (2/04) Page 12 of 14 pages of Exhibit A1F .g..,, nated by the County, a royalty-free; nonexclusive license to produqe, reproduce, publish, tra'ns- late or otherwise use any such materials. (c) If the Contractor under this Agreement makes any discovery or invention in the course of or as a result of work performed under this Agreement, the Contractor may.apply for and secure for itself patent protection.However, the County reserves, and the Contractor hereby gives to the County, and to any other municipaIity' or government agency o~ body designated by the County, a royalty-free, nonexclusive license to produce or otherwise use any item so discov- ered or patented. 24, Qualifications of Personnel The Contractor agrees that it will provide the County with relevant policies regarding the personnel qualifications for professional employees and that these poIicies shall be subject fo ap- proval by Aging. 25. Certification Regarding Lobbying Together with this Agreement and as a condition precedent to its execution by the County, the Contractor shall have executed and delivered to Aging the Certification Regarding Lobbying · (if payment under this Agreement may exceed $100,000 - SEE FORM ATTACHED) required by 31 U.S.C. Section 1352 and regulations thereunder, shall promptly advise the County of any ma- terial change in any of the information reported, on such Certification and shall otherwise comply with, and shall assist the County in complying with, said regulations as now in effect or as amended during the Term of this Agreement. 26, Cooperation On Claims The Contractor agrees to render diligentry to the County any and all cooperation, without additional compensation, that may be required to defend the County against any claims, demand, or action that may be brought against the County in connection with this Agreement. 27. Assignment and Subcontracting (a) The Contractor shall not assign, transfer, convey, sublet, or otherwise dispose of this Agreement, orany of its right, title or interest therein, or its power to execute this Agreement, or assign all or any portion of the monies that may be due or become due thereunder, to any other person or corporation, without the prior consent in writing of the County, and any attempt to do any of the foregoing without such consent shall be of no effect. (b) The Contractor shall not enter into subcontracts for any of the work contemplated un- der this Agreement without obtaining prior written approval of Aging. Such subcontracts shall be sub- ject to all of the provisions of this Agreement and to such other conditions and provisions as Aging may deem necessary; provided, however, that notwithstanding the foregoing, unless otherwise pro- vided in this Agreement, such prior written approval shall not be required for the purchase of articles, suppIies, equipment and services which are incidental to, but necessary for, the performance of the work required under this Agreement. No approval by Aging of any subcontract shall provide for the incurrence of any obligation by the County in addition to the total agreed upon price. The Contractor shall be responsible for the performance of any subcontractor for the delivery of service. AG A1F (2/04) Page 13 of 14 pages of Exhibit A1F ,,~, 28: Termination (a) If the Contractor fails to fulfill in a timely and proper manner its obligations under this Agreement, or if the Contractor becomes bankrupt or insolvent or falsifies its records or re- ports, or misuses its funds from whateyer source, the County may terminate this Agreement in ' whole or with respect to any identifiable part of the program, effective immediately, or, at its op-- tion. effective at a later date specified in the notice of such termination to the Contracto'r. (b) ]f the County shall deem it in its best interest to terminate this Agreement in whole or with respect to any identifiable part of the program, it shall have the right to do so by giving not less than thirty (30) days' prior written notice to the Contractor. {:c) The Contractor may terminate this Agreement by giving not less than sixty (60) days' prior wr'r[ten notice (or thirty (30) days' pdor writter~ not,ice if substantial breach of contract is involved) to the Director of Aging, specifTing the reasons for termination and the effective date of termination. (a) The C0un, ty shall be released from any and all responsibilities and obligations aris- ing from the Program covered by this Agreement, effective as of the date of termination, but the County shall be responsible for payment of all claims for services provided and costs incurred by the Contractor prior to termination of this Agreement, that are pursuant to. and after the Contrac- tor's compliance with, the terms and conditions of this Agreement. (e) Notice'of termination must be in writing, signed by an authorized official, and sent to the other party by certified mail, or by messenger, and receipt shall be requested. Notice of termi- nation shall be deemed delivered as of the date of its posting by certified mail or at the time it is delivered to the other party by messenger. 29, Severability; No Implied Waiver (a) It is expressly agreed that if any term or provision of this Agreement, or the applica- tion thereof to any person or circumstance, shall, to any extent, be held invalid or unenforceable, the remainder of this Agreement, or the application of such term or provision to persons or cir- cumstances other than those as to which it is held invalid or unenforceable, shall not be affected thereby; and every other term and provision of this Agreement shall be valid and shall be enforced to the fullest extent permitted by law. (b) No waiver shall be inferred from any failure or forbearance of the County to enforce any provision of this Agreement in any particular instance or instances, but the same shall other- wise remain in full force and effect notwithstanding any such failure or forbearance. 30. Merger; No Oral Changes It is expressly agreed [hat this Agreement represents the entire agreement of the parties, that all previous understandings are merged in this Agreement, and that no modification of this Agreement shall be valid unless written and executed by both parties. END OF TEXT OF EXHIBIT A1 AG A1F (2/04) Page 14 of 14 pages of Exhibit A1F ,~,F Law NO. 'AGO'b4~110'O_-O61'rY IFMS No. SCS E×E 0000000 Rev. 417104 No. 001-6790/6774-4980-95284- IIIC Nutrition Program (Supplemental Nutrition Assistance Program) Exhibit B Program Specifications For Nutrition Programs ~i. Goals Of Program The intended outcome of the Nutrition Program for the Elderly is to improve, maintain or delay the decline in the nutritional status of persons 60 years of age and older and help them to remain independent in their own homes and communities. · 2. General. In general, but without limitation, the Contractor shall be required to meet the criteria listed below: A. The Contractor will adhere to the requirements of the Suffolk County Office for the Aging Policy and Procedure Manuals and the Technical Assistance Packet. B. Each meal must meet 1/3 of the recommended dietary allowance. Special Iow salt and basic diabetic diets must be provided to those clients requiring such upon physician's order. The meal pattern and the amounts must follow those set forth by the New York State Office for the Aging. All aspects of food preparation and s~rvice must meet the standards of the Suffolk County Department of Health Services, e.g., safe temperature of food - hot entr6e always served at a minimum of 140°F, salad and other cold items served at 42°F or below, and home-deIivered meals delivered in 2 hours or under_ C. All nutrition programs which cook on site must hold a complete sample of each day's meal(s), including all components except milk and bread, in the refrigerator for 5 days for testing purposes. All nutrition programs which serve catered meals must hold a complete sample of each day's meal(s), including all components except milk and bread, if possible, or hold 3 tablespoons of each meal component, in the refrigerator for 5 days for testing purposes. D. All congregate sites will develop and maintain a Site Council to operate in an advisory capacity for the program. The Site Council shall be composed of participants in the nutrition program. 3. Contributions The Contractor has the obligation to inform each recipient of the service of the opportunity to make a free, willing and anonymous contribution toward the cost of the service. So,ice may not be denied if a person is unable or unwilling to make a contribution. The Contractor must maintain an audit trail of all incoming contributions and make monthly reports of any contributions received. All contributions must be used to enhance services. All printed materials used for the program must include the sources of funding for the Program and must include the following information: Contributions to this (these) service(s) are free and voluntary. Any contribution you wish to make will be used to expand the program and will be greatly appreciated. AG 4 (7/03) Page 1 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT LaW N'o; ~GO'o4MIoo~.o6/7Y IFMS No. SCS EXE 0000000 Rev. 4/7/04 No. 001-6790/6774-4980-95284- IIIC Nutrition Program (Supplemental Nutrition Assistance Program) Each recipient of service must be informed in writing of the opportunity to contribute at least annually. In the congregate setting, the Contractor must provide a locked box and envelopes for the suggested meal donations for the participants in order to protect the confidentiality of program participants' identities and the amount which they contribute. The suggested donation amount will be determined through consultation with the Suffolk County Office for the Aging and the Site Council. (1) All sites must post the suggested contribution for program participants. (2) Pdce of the meal for guests must be posted. (3) The above two amounts are to be posted near the locked box. For home-delivered meal participants, The Contractor must provide envelopes for the suggested meal donations of the participants in order to protect the confidentiality of the program participants' identities and the amount which they contribute. 4, Targeting And Outreach The Contractor must give preference to providing services to older individuals with the greatest economic or social needs with particular attention to Iow-income minority individuals, (42 U.S.C. {}3025 (a) (1) (E)). The term "greatest economic need" is defined as the need resulting from an income at or below the poverty levels as established annually by the Office of Management and Budget. The term "greatest social need" refers to the need caused by non- economic factors which include physical and mental abilities, language barriers, social or geographical isolation including that caused by racial or ethnic status which restricts an individual's ability to perform normal daily tasks or which threatens such individual's capacity to live independently (42 U,S.C.§302(21)). The following four target groups have been identified as having the greatest economic and social needs: minorities, Iow income, frail and vulnerable. In order to comply with Targeting requirements, the Contractor must employ Outreach Strategies which may include, but are not limited to, locating target populations using Census or other resource data, translated printed materials, location of services in catchment areas for targeted populations, publicity to community-based groups, and minority staff/volunteers. 5. Coordination The Contractor must coordinate the delivery of services with other providers and organizations to provide the most suitable outcomes and minimize possible duplication of effort. In order to accomplish this, the Contractor will undertake activities such as, but not limited to, participation in inter-agehcy meetings, coordination of referrals and follow-ups with other local service providers, entering into agreements with other organizations for joint efforts and/or funding, centralized assessment and maintaining up-to-date resource materials both within and outside the Contractor's organization. AG 4 (7/03) Page 2 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT LaW NO. AG004M/00__-06ITY IFMS No. SCS EXI: 0000000__ Rev. 4/7/04 No. 001-6790/6774-4980o95284. IIIC Nutrition Program (Supplemental Nutrition Assistance Program) Congregate Meal Program A. The nutrition site shall be open as stated on the SummarY Sheet, which is attached and made part of this Agreement; fully staffed, dudng regular business hours based on local need and availabie funding, Holiday schedules are to be posted one month in advance at the nutrition site. The Contractor shall submit copies of all holiday schedules and staff vacations to Aging. B. The Contractor must provide participant transportation as needed and supportive services as appropriate to the needs and abilities of each participant. Supportive services mean education and training, information and referral, outreach, public information, recreation, shopping.assistance, socialization and volunteer activities. When viewed as a whole, transportation services must be accessibleto people with disabilities as required by the Americans with-Disabilities Act of 1999 (P.L. 101-336) and the regulati0ns thereunder (49 CFR part 37). C. The Contractor must abide by standards set forth under both Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 (P.L. 101-336) and the regulations thereunder (28 CFR Parts 35 and 36) which require that all programs and facilities (buildings, bathrooms, etc.) must be accessible to the handicapped. D. The site manager shall work closely with Aging's staff and other local agency staff to provide a full array of supportive services for participants. Home-Delivered Meal Program A. Eligibility must be determined prior to the delivery of service by using the standardized Client Assessment Provider Data System (PDS) (see Form - Appendix O and Policy & Procedures Manual - Appendix L). Each client receiving home-delivered meals must be reassessed at appropriate intervals based on each client's situation, but in no instance less frequently than at least once in each twelve-month period. The Contractor will also make a six-month contact in the form of a home visit or a telephone call. B. The packaging of meals must meet the standards of the Suffolk County Department of Health Services. Aluminum foil partitioned containers are recommended. In order to maintain safe food temperatures in delivery, equipment approved by the National Sanitation Foundation must be purchased. Menus, whenever possible and feasible, should be sent to the clients. C. The Contractor must provide supportive services to the homebound client according to his or her specific needs. The frequency of the supportive services will be determined by the individual assessment. Nutritional counseling and education must be included in this service. D. The Contractor shall provide a meal for those holidays and/or weather emergencies that fall on a weekday. The holiday/emergency meals may be frozen or canned and must be delivered the last business day before the holiday AG 4 (7/03) Page 3 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT Law', No. A~G004MI00__-06/TY IFMS NO. SCS EXE 0000000 Rev. 417104' No. 001-679016774-4980-95284- illC Nutrition Program (Supplemental Nutrition Assistance Program) = or weather emergency. In addition, an emergency supply Of shelf-stable food should be made available twice a year for weather related emergencies. A Iist of suggested food items is available from Aging. (see Policy & Procedure Manuals) Reporting Requirements A. The following forms and reports are required by the County to meet the standards of the Nutrition program: (1) Monthly Program Reports Copies of the participant daily sign-in sheets must be received in Aging by · ~the eighth day following month's end. The units of service/und~plicated count repot[, including targeting results,' (Nutrition or S.N.A.P. Services) is. due the eighth day following month's end. The activity report is due one week prior to the month reported. Menu forms are due four weeks prior to the serving cycle. (2) Monthly Fiscal Reports SCOFA Forms NPAG 2 (congregate), NPAG 3 (home-delivered), NPAG 4 and NPAG 5 are due the eighth day following month's end_ NPAG 4 and 5 are to be signed in ink by the site manager where indicated. The forms listed above are found in the Policy and Procedure Manual (Appendix L). (3) Demographics The Contractor must at a minimum determine and maintain the following specific type of demographic information for each individual receiving services: · Name. · Sex. · Age. · Disabled/Frail. Disabled - Any person who has a physical or mental impairment which substantialIy limits one or more major life activities, has a record of such impairment, or is regarded as having such an impairment. This includes alcoholism and drug addiction. Frail - A person with one or more functional deficits in the following areas: physical functions; mental functions; activities of daily living (ADL) (eating, bed/chair transfer, dressing, bathing, toileting and continence); instrumental activities of daily living (IADL) (meal preparation, housekeeping, shopping, medications, telephone, travel and money management). Live Alone. AG 4 (7/03) Page 4 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT Law'No. AG004M/00__-06/7Y IFMS No. SCS EXE 0000000 Rev. 4/7/04 No. 001-6790/6774-4980-95284- IIIC Nutrition Program (Supplemental Nutrition Assistance Program) w B= · Rural. Low Income -The need resulting from an income level at or below the poverty threshold, as established by the Bureau of the Census, a'nd updated annually as follows: Size of Family Unit 1 2 100 % of poverty Threshold 150% of Poverty Threshold (for IIIC Nutrition program(s))(for SNAP Program(s)) $9,310/year $13,965/year $12,490/year $18,735/year · Minority - These individuals belonging to one Of the following groups: Native American/Alaskan Native, Asian, Black, Native Hawaiian/Pacific Islander and Hispanic. · Low Income Minority - Those minority persons whose income is at or below the poverty threshold_ Contractor's Staff A. The Contractor agrees to employ adequate numbers of qualified staff and supervisory personnel to meet all the specifications and responsibilities of the program in a orderly, punctual and reliable manner. Personnel involved in all aspects of food handling and preparation are to be in good health and trained to ensure the safety standards of the food prepared and served. A full-time managedsupervisor will direct and coordinate the daily operations. All meetings and trainings required by the. County are to be attended by the appropriate staff. The Contractor will have on file with Aging the procedures to be followed by workers and other staff in case of emergency. The County shall have the right to prior approval of the filling of any site manager position and shall be advised by the Contractor of the duties and compensation of all personnel assigned to the Nutrition Program for the Elderly Program. 10. Confidentiality A. The Contractor agrees that no personal information obtained from an individual in conjunction with this program shall be disclosed in a form in which it is identified with the individual without such individual's written consent to such disclosure, except to Aging. B. In the case of a request by Aging for names and addresses of individuals participating in the program, the Contractor shall furnish such information as requested. Failure to comply with a request by Aging for such information shall be deemed a material breach of this Agreement and shall result in a freeze on all monies due and owing to the Contractor until compliance by the Contractor. 11. Administration A. Overall administration of this program will be the responsibility of the Contractor. The Contractor or its designee will insure proper implementation and direction of the AG 4 (7/03) Page 5 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT La~-No.',~G004M/00__-06/TY IFMS No. SCS EXE 0000000 Rev. 4/7/04 No. 001-6790/6774-4980-95284- ilIC Nutrition Program (Supplemental Nutrition ASSistance Program) service, act as liaison between Aging and the actual service and insure accuracy and timeliness of submission of all reporting forms and expenditures, B.Program Staff shall attend meetings and training as requested by Aging. C. Attendance by site managers at site managers' meetings and training sessions is mandatory. Transportation to these meetings must be accomplished without decreasing transportation services to the Program. 12. Grievance Procedures In accordance with §306 (a).(6)(P) of the Older Americans Act, as amended (OAA), Aging has established a process for resolving complaints from older persons who are dissatisfied with or denied services funded under Title III of the Act. The Contractor shall comply with the requirements of the Grievance Procedures as set for[h in Exhibit. E - Grievance Procedures. 13. Monitoring A_ Financial Transactions Aging's staff and staff of the New York State Office for the Aging may examine or review evidence regarding the existence, timing and classification of financial ' transactions that are charged to the program for reimbursement. To obtain this evidence, such staff may examine documentary evidence, including financial statements, financial reports, etc., and original records. Such staff may make physical verification by actually observing or counting certain assets (e.g., cash, equipment and supplies) to establish their physical existence. The Contractor shall cooperate in Aging's periodic physical verification of cash, food, equipment, supplies and other assets of the program. B. Program The Contractor agrees to permit Aging's staff and staff of the New York State Office for the Aging to review program records and to monitor training, supervision and services at any time. 14. Miscellaneous A. It is the responsibility of the Contractor to have an identifTing logo in equal sized lettering on any pdnted materials and on all brochures, flyers, and advertisements (including without limitation television graphics), and on Program vehicles, as follows: Purchased with Federal Funding: Funding provided by the Suffolk County Office for the Aging and the U.S. Dept. of Health and Human Services Through the New York State Office for the Aging Purchased with State/County Funding: Funding provided by [the} Suffolk County [Office for the Aging] [through the New York State Office for the Aging]* Any announcement of the Program on radio or television must identify funding by [the] Suffolk County [Office for the Aging]*, the U.S. Department of Health and Human Services and/or through the New York State Office for the Aging, as applicable. AG 4 (7/03) Page 6 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT Lab No. AG004M/00__-06/TY IFMS No. SCS EXE 0000000 iRev. 4~7~04 No; 001-6790/6774-4980-95284- · :lllC Nutrition Program (Supplemental Nutritieo Assistance Program) The Contractor must establish a formal system of soliciting comments from the participants concerning meals, transpor[ation and suppor[ive services. The Contractor shall comply, and shall require its officers and directors, partners, trustees or other members of its governing body and personnel employed to render services under this Agreement, to comply with all applicable rules, regulation and requirements of law, including without limitation, the Americans with Disabilities Act, and the applicable Policy and Procedure manual issued by Aging, and the Technical Assistanoe Packet, which have been made part of this Agreement. Omit the words that are not applicable. AG 4 (7/03) Page 7 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT Law Ro. AG004M/00__-06/7Y IFMS No. SCS EXE 0000000__ Rev. 4/7/04 No. 001-6790/6774-4980-95284- IIIC Nutrition Program (Supplemental Nutrition Assistance Program) GENERAL FOOD SPECIFICATIONS ' FOOD SPECIFICATIONS FOP, CYCLE MENUS Meat or Alternate Meats - USDA Choice or Better Preservatives, tenderizers, or coloring agents may not be added to any fresJ~ meat or fresh meat product. Ve.qetables and Fruits All fresh fruits and fresh vegetables must not contain bisulfates. All fresh fruits and fresh vegetables must be washed. Fresh Fruit Minimum Size Oranges 113 Apples 120 Bananas 150 ½ cup represents drained weight of fruits and vegetables Frozen Vegetables - Grade A - Fancy (USDA) Canned Vegetables - Grade A- Fancy (USDA) Marqarine - from liquid vegetable oil and fortified with Vitamin A Bread/Alternate - whole grain or enriched Instant Mashed Potatoes must be fortified with Vitamin C Milk - Vitamin A & D fortified skim or low-fat milk - 3 days lead time from day of service Desserts Gelatin - fortified with Vitamin C Milk-based puddings used for pudding mix Canned Fruits - Grade A - Fancy (USDA) Canned Fruit Juices - Grade A - Fancy (USDA) - fortified with Vitamin C Frozen Fruits - Grade A- Fancy (USDA) All foods shall be obtained from State or Federal inspected plants. - END OF TEXT OF EXHIBIT B- AG 4 (9/00) Page 8 of 8 pages of Exhibit B AG4M 03 RFP Model AGRMNT L. aw~ No~,/~G'004M/0020~07R Rev. 6~8~04 Supplemental Nutrition Assistance Program IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284- CONTRACTOR'S RESPONSE TO SECTION IV RFQNo. 3115524VH AG 4 (7/03) AG4 sohld 04-05 SC Purchasing RFQ No. 3/15524VH SC LawNo. AG RFQ For Nutrition Programs for the Elderly Section IV Technical Services Response Form PROGRAM DESIGn, FACILITIES, DOCUMENTATION, SERVICES AND ACTIVITIES: This response form will become incorporaled into Exhibi~ B to the Agreement 1. program Design A/B. Southold Town Senior Services is a maltipurpose seninr center that has provided nul~ition and support services to Sonthold Town residgnt's age 60 and older since 1974. The Center is located ia the hamlet of Mattituck and is ia close proximity to Ma~aituck village, public ttausportatian, shopping, banking, etc. The eervice catdunent ar~a for Southold Town's nntritional program ls the lxIoFth Fork of Long Island, · an area of approdmately 70 square miles. Because of its vast rum[nature, vilal h-auspertation is provided to our sen/or participants v/a bus or yam There are 13 vehicles assigned to the Seuier Center for the purpose of delivering meals to the homebound and trafisporting seniors to the C~nter. Southold Town is proposing to annt/nue providing nutrition and supportive services to s6nior ~itlz~m 60 yet of age and older. Our in:tent ia to improve, malniain or delay the dediine in their nuh-/fional sta. iu~ while helping them to remain iadepandent nt home and ia their eemm~ mlty: We curro~l~ serve an average of 69 congreg~e meals and 156 home deliv~edmeals daily. Our center is a licensed food sortie8 eslabliahmant with Suffolk County Deparlment of Health (see attached DOt~ certificate./Sec. IV--3 #1). Our dedicated~ staffis committed'to serving qual~y meals with a high nutritianal value (see attached~nenns/Sea IK3 g4). All meals and supportive services are provided to Soul/told Town residents aged 60~- and meat thc nuix}~'tional requirements set forth ia Exh~%it B Pwgtam Sl~Cificafious. Dietary modifications.a~e provided for special health requirements (diabetic and low sodium diets). We also reasonably accommodate pardclpan~s who have particular die/ary needs arising. from religio~ requirements or eilmic;.backgroends. &It menus are submi~ed to thc Peg/stet'ed Diet/clan with Suffolk County Office for the Aging for prior approval. The Center was recently renovated, fully accessible to persons with disabilities and is in full compliance with the Pm~ericens with Disabilities Act. TheCente~hasamax. knumcepacityallowanceof175andls complete with d~nlng room seating for 1.00. We also tta~e a new, fully equipped commercial kitchen. In addition to the senior nutrition program, Southold Senior Services offur~ a full range o f re~realiona[ and comprehensive supportive servieea ta Town resider~ts 60 years of age and elder. (See attachment IKl..40. B. 1. Congregate Meal Program: Soathold Town Senior Nutrition Center is open 5 days a week, Monday through Friday (except for legal holidays). OurhoursofoperationarefromSam-4:00pm. Our objeetivelstoprovidesedorresidents with a nutritious daily meal, ~ well as a community-meeting place where they can enjoy re~ealional pmgrnm~ and social activities, with full supportive services available on site as needed. (See attachment Sea IK. 3 #5). All meals meet 1/3 of the RDA (Per Exhibit B_ Program Specifica~'ons). Meais are served at 12 noon and Wanspottntion is available. The suggested confidential voluntary contribution is $2.00 pee meal and no one is denied service duc to inability or anwill|ng~leSS to pay. All participant contn3utions are used to expand services. Our professional staffis on site to assist seniors at all times. Since saf~y ia a high priority, the Senior Center is fully equipped with fire and smoke detection alarms and fire suppression equipment. We ~ known to the local fire department and are monitored by £he Central Slat/on of Suffolk Security Systems. Fir* e~acuatinn plans are posted and fire drills are held twice yearly. Our center/s inspected regularly and meets all fire safety standards for areas of public safety. ('See attachedSea IK $ #2/6). ,SC Purchasing RFQ No. 3/15524VH SC Law No. AG RFQ For Nutrition Programs for the Elderly Section IV Technical Services Response Form PRO~RAM DESIGN, FAC~S, DOCUM~3¥rATION, SERVICES AND ACTIVITIES: ~ response form will become incorporated into Exinbit B to the Agreement IV.1. 'B. 2. Home Delivered Meal Program: Southold Town's Nulrition Program furnishes home-delivered meals to senior residents aged 60 + under the Supplemental Nutrition Assistance Program (SNAP). Priority is given to the frail, nulfitionally at-risk elderly. All meals are cooked en site and meet I/3 of the RDA. Our program adheres to all policies, procedures and specifications for Nutrition Programs for the Elderly as set forth in Exhibit B. Eligibility is de~ermined prior ~ the delivery of service by using the standardized Client Assessment~rovider Data System (PDS). Each chant receiving home-delivered meals is reassessed at appropriate ~en,als baseden the individual's silu~5on. At a rnlnim~ml, clients receive a six-month 6ontact by telephone or in person and _ · an in-home aanuaI'review iaeach'12-mrmth period. The'PDS client assessment helps detern~e what . '47 . . suppurtlva serwces are.needed and the frequency of those serve:es. Nutrition screening CffSI), provided to clients as part of the PDS in-berne assessment has greatly assisted us in ideaaffying those hdividuals nulrifionally at risk_ Home_deLiveced meuls are prepared on site and packaged in 3 compar~nent disposable al.minum trays. AR packing and meal delivery procedures meet the safe food haodlin§ standards set forth by Suffolk County Dep~tment of Health and Nutrition Program specifications, (i.e, hot entrde's areserved at minimum of 140 degrees Fahrenheit with salad and other cold items served at 42 degrees Fahrenheit or below. (Exhibit B)). The Town currently has five homebound meal routes throughout our catchment area. _Meals are transported in special carriers to maintain ~emperatures and delivered in lesg than 2 hours. Meals hare provided/'or those holidays and/or weather emergencies tha~ fall on a weekday and are delivered the last business day beforehand. Additionally, emergency shelf stable meals are dislributed at least twice yearly for. wegther related emergencies. 2. Pro,ram Description & Methodology A. Food Service: $outhold Town Senior Services Nutrition Program has over 29 years expetiencein providing institutional food service. Our professional kitchen staffprepares all meals on site. (All meals meet the RDA and all s£eciftcations for nutrition programs set forth in Exhibit ~). Food is aafifomaly portioned and served promptly at noon. The kitchen is a fully equipped commercial kitelien and offers sni~ble storage for food supplies, dry goods, frozen and refifigeraled food pmducls. AR food and supplies are ordered in bulk for optimal pricing and availability. The Center fellows tho Town's procurement policy as set forth in General MunicipalLaw Section 103, relative to formal bidding of food, supplies end equipment The Center zerves aa average of 69 congregate and 156 home delivered meals daily. (Based on 2002 program year). A sample six- week menu cycle is included for your review (see attachment Sec i7($ gl). Southold Town Senior Services employs a foll kitchen staff consisting ofa ~ooI~ assistant cook, five food service workers and one kitchen aide. (Title genrollee). No componentof our food service operation will be subcontracted to outside services. SC Purchasing RFQ No. 3/15524VH SC Law No. AG RFQ For Nutrition Programs for the Elderly Section IV Technical Services Response Form PROGRAM DESIGN, FACI~IT1BS, DOcuM~ENTATION, SERVICES AND ACTIVITIES:' Tiffs response form will become incorporated into Exhibit B to the Agreement IV.2. B. Supportive Services: In addition to our nutrition programs, seniors are provided with a comprehensive array of support services designed to meet their many needs. Recreation programs, activities, trips and special events are offered regularly. Community oulreach and education is provided along with individual case management service and entitlement counseling. Caregiver support programs are offered along with full day Senior Adult Day Care; our Residentm~' 1 Repair Program is available to assist seniors with minor home repairs. We a/so have a Telephone Reassurance Program in which voluhteerS~provide d.iTy phone contact to home~oand seniors. Itt addition to regular route transportation servic~s~ we provide demand responsive h'ansportation for seniors to medical appoinlments, grocery shopping, etc. All support services~activitias are printed on a monthly calendar, posted in the Center and dislributed to all homeb0und meal recipients (See attachment 11(.3 #5). C. Transportation: Southold Town Senior Services provides both "Regular Route" and "Demand Responsive" transportation. Regular route service is provided to and from the Senior Center daffy. Regularly scheduled trips for shopping, senior citizen club meetings and recreational events fall under this service category. Demand Responsive ~anspurlation is reserved for seniors for wed[cai escort/ assistance and is provided on a reservation basis. Transportation services are as~ilable to all seniors 60+ residing in Southold Town. We currently have 13 vehicles dedicated to this program, four of which are handicapped/wheelchair accessible. Service is not restricted ts Town boundaries and we often transport seniors for medical services to Riverhced and points wes!~s far as Stony. Brook University HospitaL We have experienced an increased demand for Wansportafian survices since la.st year and have worked diligently to service the needs of ow senior residents to meet this demand. The average number of one-way passenger trips provided montfdy has i~cr~ased bom 1,073 in2002, to 1,383 in 2003, a29% increase in service. The Southo]d Town Highway Depar[ment maintains and repairs all vehicles as necessary. Our Senio~ Clerk Typist s~hedules all transportation services and maintains our fleet inventory, service records, and mileage reports for all Town and Suffolk County owned vehicles. D. Targeting: Our goal in providing nutrition and support services to the elderly is to reach as many seniors as possible that need and can benefit bom our program particnlarly the frail, low-inmme, minority, elderly who are nutritionally at-risk. We have broadened oar efforts in community ou~ach to include a new web site dedicated to informing seniors, a speaker's bureau and regular announcements in the Town Supervisor's newsletter that klghHgh/s Senior Services. Tkis newsletter is dislributed quaaerly to all Town residents. We also continue existing practices of public service announcements, guest appearances on cable television, dis[xibufion of program and informational brochures and activities calendar throughout the Towe, ongoing program announcements in the Snffolk Times Community Calendar page, and Senior Sourcebook. We also employ ongoing outreach efforts to medical facilities, doctor's offices, senior citizen dub meetings, local churches, and other special groups or orgnnlvatinas that focus anserving our senior gopulatiom Suffolk County Office for the Aging has also assisted us in our outreach effor/s. SC Purchasing RFQ No. 3/15524V]t SC Law No. AG__ RFQ For Nutrition Programs for the Elderly Section IV Technical Services Response Form PROGRAM DESIGN, FACII,ITIES, DOCUY[ENTATION, SERVICES _AND AETIVITHgS: This response form will become incorporated into Exhibit B to the Agreement Targeting the low-income minority elderly living ia Southold Town particularly ia the Village of GreenPort (4% of seniors in our catchment area in this category) is a high priority. ~/e have increased v~ibility and access to our programs, particularly in the Vii/age of G~nport. We have provided additional bus service to the area and have had ~equant contact with church and community leaders, as well as other agencies serving the fen'fl, Iow-income minod[y community_ I ~t on the Board o£Directors of Community Action of Southald Town, located in Greenpo~_ Th'~ · ~ afforded me an opportunity to promote our services in the Greanport V'flinge~ Our efforts have been successful ia tha~ our service delivery to our targeted Iow income, minoritypopulation has ' increased beyond 4% for 2003. Our additional target population is the kosher population. Outreach efforts willlaclude contact with th~ Rabbi Ulrych at the Tifere_.th Israel Synagogue ia Greenport to sdaedule an hfurmafianal presentation to the congregation. Coordination: Southold Town sponsors a monthly meeting of the Town's Comminee on HealthCare Issues and the Elderly. The committee meets regularly and has a diverse group membership representing health care and commu~ty service providers fi.om both the private and public sectors. The meeting provides networking opportunities for professionals and alinws for a valuable exchange of Infun~afien and coordination of the resources available to our senior population. The ¢ornm~e~ also provides a mechanism for mininlizing duplication of programming for improved services to seainrs. Within our agency, the PDS assessments allow us to mn'retain a comprehensive record on each client we serve and assis~ us in optlmi~ng coordination with formal service providers. Our professional s-~ffreviews and discusses our clientele at regular intervals in order to devefop the most appropriate, individualized care plan and follow-up services. Program shaffshares common office space, which provides for optimal information exchange and improved co0rdhation of service. A confidential log sheet is maintained in our main office that reflects drily status changes that 0eeur with each individual client. Program staffaeeesses this log daily and pro~des follow- up accordingly. The log serves as an internal mechanism to reduce duplication of services provided to our program participants by our sta.fl~ Client Assessment Provider Data System (PDS): ' Jeanne Johnson and Philllp Beltz (See attachedresumes, SeclK3 ~7), serve as oar primary PDS assessors. Ms. Johnson holds a BA degree in Behavioral Science/Community Men~l Health and has completed ongoing training in completing client assessments with Suffolk County Office for the Aging ($COFA) and $outhold Senior Services. Ms. Johnson has been wi~ oB agency for four years and has been responsible for overseeing the home delivered meals program. Phillip Bell:r, MSW, has extensive experience in Social Work practice and assists our agency on a part- time basis completing ia-home PDS assessments. In addilion, both Carol Betty and ayself are proficient in completing the PDS and offer assistance as needed to avoid serviceinterruption or delay. $C Purchasing RFQ No. 3/15524VFI SC Law No. AG RFQ For Nutrition Programs br the Elderly Section IV Technical Services Response Form PROGR~AM DESIGN, FACILITIES, DOCUMENTATION, SERVICES AND ACTIVITIES: This response form will become incorporated into Exhibit B to the Agrecmem Client assessments (PDS) are completed on all seninr~ who request home detivered meal service, service. Exceptions axe made for emergency situations or hospital discharges, air&ich time a PDS is completed within 72 hours. Service is initiated when a client, f~mily me~ber or other service provider makes a referral by calling the C6~ter. Pal intake is completed ~ith basic information provided and au initial home visit is scheduled with the family to ceraplete the PDS assessment. Once elig~ility is determined, the client is provided service in a timely manner. Each client is provided with a packet of infntma~on, which inulude~ our p'rogram po[isles and procedures, and a complete list of thesupportive services we offer. Six mouth follow up contact is made by telephone to each client and au in home visit is completed at least once ~nually by our PDS assessors. - Chea3,1Kaswell, Account Clerk Typist, has been with our agency for over a year. She is profidant with the computer and is respaus~le for entering all clients in the PDS database. W~ are currently using the Windows NT application. Technical assistance has been prodded by $COFA on a regular basis. Our computer equipment is suitable for PDS purposes. Other Resources: As a division of Southuld Town government, Senior Services is afforded the many senrices and resources of the Town. Our building cleaning and maintanance~ both interior audexterior is provided by our Department of public works. Our Itighway Deparanant maintains and repairs our vehicle fleet, keeps our parking lot and walkways clear of snow and ice in inclement weather, and provides sanitation services. The Towns Accounting and Finance Department processes all vouchers, revenues, expenses, payroll and_financial records. The Town Police Depa~oncnt provide emergency assistance as needed and maintains regular contact and makes appropriate refen'ais to our department for frail elderly residents at risk. Our Recreation Department provides au array of sanior ~ps and recreational activities that our seniors participate in. They also have two very active Senior Citizen Clubs that meet regularly and are pollticeliy active. Many of our program participants benefit from senior club membership. The Assessors Office provides home visits to assist seniors in completing senior tax exemption and STAR applications. Our Town Supervisor is very supportive of our programs and handles all public notices and features our deparanent in his quarterly town-wide newsletter. Senior Service also coordinates with outside agencies and human service providers that serve the senior pupuiatiau of Sauthold. Our agency hos fi-equent cautact and coordinates many services with the following agencies: San Simeon Nursing Home, Eastern Long Island & Central Suffolk Hospitals, Peermic landing, Dominican Sisters, Lewin, Utopia, Pecenic Bay and Catholic Sisters Rome Health Agencies; Catholic Charities, North Fork Parish Ouh-each, North Fork I~oasing Alliance, Community Action of Southold Town (CAST), American Red Cross, RSVP, Keyspan Energ~r, Family Service League, Pecenic Community Council,.Suflblk County Ott~ce for the Aging Deparanent of Social Services, Adult Protective Services and Mobil~ Crisis Team. Our Center is also a host site for oar local school districts for community service projects and a field placement site for medical interns from Stony Brook University Rospital and Social Work students from the Stony Brook School of Socinl Welfare. Other volautear oppor~ities are provided to seniors through our Telephone ReassUrance/RSVP program. SC Purchasing RFQ No. 3/15524V1t SC Law No. AG__ RFQ For Nutrition Programs for the Elderly. Section IV Technical Services Response Form PROGRAM DESIGN, FACILHIJ~S, DOCUMENTATION, SERVICES AND ACTIVITIES:' This response form will become incorporated into Exhibit B to the Agreement IV.2. H. Contribution Policy: Seniors participating in our nu~ition programn are informed of their opportunityto make a voluntary and confidential eonla'ibution for tho cost of the meal. For congregate meal participants, a contribution sign is posted and visible that states our funding sources, our sponsoring agency (SCOFA), our $2.00 suggested contribution, and that NO one is ever denied a meal due to unwillingness or inability to pay. Envelopes are provided for their anonymous c0aln'butious and phc. ed next to a locked box in a private c~raer outside of the main office. Seniors place their coi~Iribtrtion in the box if they desire. For home delivared manl participants, an ,nmarked. envelope is pm3'ided by their driver on Thursdays with their meaI. Clients haveaia opportanity to return their envelope to theft: driver, who returns it to the. Center staff[ All bomebannd.meal recipients are gi~ven a letter prior to start of service and annually thereafter, exphiaing our eontn-bntion poF~cy and procedures. The letter clearly states that an contribution.rare voluntary and anonymous and that lqo one will be denied service for inability or uaw~ll]nozllOss tO pay. An nutrition program participauts axe also informed that ali conlributions are treed t~ expand services. 3. .Documentation: · The following documentation ir included as attachments and refarred to in our proposal. 1. Permit from Suffolk County Department of Health Services. 2. Permit Southold Town Building Department. 3. Food Handlem' Certificates_ 4. Six-week sample menu. 5. One-month activity schedule & list of support services. 6. Notification to the Mattituck Fire Department_ 7. Project Staffresumes. 8. Ex[fibit B - Program specifications for NuWition Programs. SC l'ur~hasing I~FQ No. 3t15524Vt1 SC LuW N°'AG - For Nutrition Programs for the Elderly Client Assessment Providtr Data System (IDS) PD$ Ass .cs~ents- l:~ufic~:txt ~v~h. ~e com~u~m' n~Jd ts, e~l,ot~s~le for ~g ~I cli~ ~ ~e PDS D~ B~. ~11 ~e h~ ~ ~e f~ ~.~g PDS' ~m 5~ ~ 75%. We also ~ p]~ to ~ up "Oncc thc l:~r-k!og of cases is cnunv..d the numBe~ number of new PDIt' 8~mcnm~l per mont~. SC Purchasing RI~Q N0. 3/15524VH SC Law ~0. AG RFQ For Nutrition Programs f~r ~e Eldcr~ ~on ~' · '...T~hni~l Se~i~ R~nse PR~ DESIGN, FAC~ ~~A~ON, $~CES ~ ACT~rt-~S: B, 1. C. Emergency Management: Thc Senior Seodres Dim~or is part ofth~ Em~c¥ lor~;mcnt Team~ for S~nld T~ ~c H~ ~mci~. KAREN MCLAUGHLIN SENIOR CITIZEN PROGR3~ DIRECTOR Human Services '~0wn of Southold P.O. Box 85 750 Pacific Street Ma~uck, NY 11952 Tel. (631) 298-4460 Fax (63 !) Z98-4462 Attachment W.3 #6 Nulrition Program Home ~livered Meals · Case ~anagement EssentialTmasportafion Senior Adult Day Care Alzheiner's Day Care Telephone Reassurance October 27, 2003 'Chief Edward Hanus Ma~d~uck Fire Depl:. 1000 Pike Street Mattituck, NY 11952 Dear Chief Hanus: In compliance with our regulations from the SuffoLk County Office for the Aging, I am notifying you in wxiting of the nature and location o£ our Senior Center. Southold Town Human Resource Center, located at 750 Pacific Street, Mattituck serves · as a multipurpose center for senior residents of Southold Town. we offer a variety of programs including a congregate dining program, community education and 0uizeach, recreational activities, home delivered meals program and transportations senqces. Our social model Senior Adult Day Care Program operates in our annex called "Katinka House" and serves 20 frail elderly participants. Our.hours of operation are 8am to 4:30pm Monday through Friday. Our center's fire system is monitored at a centxal station and regularly maintained by Suffolk Security System. Our fire suppression system is also closely monitored and maintained by All Island Fire Prot~ztion. Please contact me at 298-4460 ff you have any questions or would like more ir~ormation about the Senior Center. Thank you. Since y, Dh'ecl:or of Senior Services Law No. AG0041~l/0020-07R Rev. 6/8104 Supplemental Nutrition Assistance Program IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284- EXHIBIT C · RATE PAGE (CONTRACTOR'S COST RESPONSE) iTOWN OF SOUTHOLD · HOME-DELIVERED MEAL PROGRAM Proposed Schedule of Fees for Services First Contract Year Second Contract Year Third Contract Year Home Delivered Meals $4.72 $4.86 $5.02 AG 4 (7/03) AG4 sohJd 04-05 Exhibit D Grievance Procedures 1. Purpose In acc(~rdance with §306 (a) i6) (P) of the Older Americans Act, as amended (OM), the Suffolk County Office for the Aging has established a process for resolving .complaints from older persons who are dissatisfied with or denied services funded under Title III of the A-ct. 2. Notifying Participants of the Right to File a Grievance (a) The Contractor shall inform all paKicipants in the program of the right to file a grievance. A summary of the procedures, including a statement that assistance to file shali be provided tO eider [3erso[~s, .must be prominently posted at Service'delivery sites or offices at which participants and service applicants apply for services. Summaries must be in a format approved by Aging'and shall als0 be written in languages other than.English Where required to serve the client/applicant population. Service participants shall be informed of the grievance procedures through written and verbal statements provided to them upon assessment and/or reassesSm~nt for services. (b) A participant or applicant who is denied Title II1 services by the Contractor and the Aging program monitor must be given the reasons for the denial. The denial shall be confirmed in writing and the applicant informed of the right to file a grievance and to whom the grievance shall be addressed. For services which are applied for by telephone or verbally, in person, the client may be told of the right to file a grievance verbally. 3. Grievance Process (a) Filing of grievances must follow the following process: i. Participants must submit their grievances in writing to Aging's Program Administrator. ii. The grievance should be filed within thirty (30) days of denial, reduction or termination of services, or of the event or circumstances with which the participant is dissatisfied. Aging's Program Administrator maygrant an extension for good cause shown. iii. The grievance should be filed on the form approved by Aging, which shall include a written statement setting forth in detail the date, time and circumstances that are he basis of the complaint. (b) Investigation and Response to Grievance: i. The designated reviewer who performs the initial review shall investigate the grievance, including, as appropriate, meeting with the grievant and other persons involved in the action(s) complained of or in the denial of services. ii. The reviewer shall review all pertinent facts and/or documents, and shall determine whether the agency action was made in accordance with lawful procedures (that is, consistent with applicable OAA and or State laws, regulations and policies) and supported by the facts. R~v, 5/21/03 Page 1 of 2 pages of Exhibit D iii. The designated reviewer shall prepare and send a written response to the grievant and to Aging's Director within fifteen (15) days after [he grievance is filed. The response shall set forth the circumstances relating to the grievance, the action requested by the grievant, the findings of the reviewer, a proposed remedial action, if any, and reason(s) f0r and facts relied on in the determination. (c) Appeal of Initial Response/Decision i. The grievant may initiate a request for subsequent review by Aging's Director within twenty (20) calendar days following receipt of notification by the Program Administrator of the decision. ii. Aging's Director shall request copies of the initial file on the complaint in question. Aging's Director will review the materials to ensure that pertinent policies and procedures have been applied and followed. If appropriate, Aging's Director or his/her designee will meet with the older person to allow the grievant an opportunity to present information about the grievance. iii. If the policies and procedures have been adhered to~ Aging's Director wiil not overturn the decision of the Program Administrator. If proper policies and procedures have not been applied, Aging reserves the right to overturn the decision. The subsequent review shall be completed within forty-five (45) days of receipt of the request by the older individual and the grievant will be notified in writing of the result of the subsequent review. 4. Record Keeping Aging shall keep the records of the grievance and its handling for six years following the conclusion of the calendar year of the occurrence. The file shall contain, at a minimum, but not limited to the initial grievance, any investigative reports; any written response submitted by Aging or the service provider aging; any documents or other records submitted by any party; the written initial Response of the agency, and, if applicable, the notice to the grievant of the right to an appeal. 5, Confidentiality No information, documents or other records relating to a grievance shall be disclosed by program staff or volunteers in a form that identifies the grievant without the written informed consent of the grievant, unless the disclosure is required by court order or for program monitoring by authorized agencies. -- End of Text -- Rev, 5/21/03 Page 2 of 2 pages of Exhibit D Exhibit E' Client Assessment Date: 04/2112003 Assessor's Name: Initial Assessment Date: Agency Name: Intake Date: Reason for Assessment: Agency Code: Source of Info.: (Re)Assessment Date: CLIENT INFORMATION Soc Sec #: Name: Address: Apt. Cf: City: State: Zip: CD Code: Floor: Elevator: Cross Street: Phone: Steps: Homeless: Borough/County: DOB: Age: Gender: E-maih Num in house: Marital Status: [] Divorced Living Status: [] Alone Race / Ethnicity: [] Amer. lndian/Nal. Alas [] Married [] With Non-Relat [] Asian/Pacific [slandel [] Separated [] With Relatives [] Blac~ no[- Hispanic [] Single [] With Spouse [] Hispanic [] Widowed [] Other [] Whitdnon-Minority Veteran Status: Lanquaqes (Rate ability Fluent, Ability Moderate, or Basic.) Veteran? Primary: Speaks If yes, Disabled? Reads: Understands: Spouse a Veteran? Secondary: Speaks Reads: Understands: Language Comments: Country of Origin: Does Client Have A Medicare Card? [] Yes [] No Does Client Have A Medicaid Card? [] Yes [] No I$ the Client Receiving Medicaid Homecare? [] Yes [] No ~CONTACT LIST ] Please note lhe following contact classifications here: Emergency, Informal Support, Lives With, Neighbor, Who Has the Key? 'contact list con,hUed:) Emerqency Contact: Name: Address: Phone Number: Relationship: Classifications: EmerRenc¥ Contact: Name: Address: Phone Number: Relationship: Crassifications: Classifications: Name: Address: Phone Number: Relationship: Classifications: Address: Phone Number: Relationship: Classifications: Address: Phone Number: Relationship: Classifications: I Name: Address: Phone Number; Relationship: Classifications: Address: Phone Number:, Relationship: Classifications: Address: Phone Number: Relationship: Contact Notes: IMEDICATIONS Medication Dose/Frequency Comments Client Assessment Date: 04/21/2003 Does the client have any probtems with medication? [] Adverse Reaction/Allergies [] Cost of Medication [] None [] Obtaining Medications [] Other How is medication administered? [] Admin by Health Professional [] Admin/Monitored by Lay Person [] Other [] Without Assistance If client cannot administer medication, who will? Name: Address: Phone Number: Relationship: Who obtains medication? Name: Address: Phone Number: Relationship: Pharmacy: Phone: Medication Comments: ~EALTH Does the client have any chronic illnesses or impairments? [] Alcoholism ~] Co]ostomy [] Hyperglycemia [] Recent fractures [] Alzheimers [] Congestive head failure[] Hypoglycemia [] Renal disease [] Anemia [] Dental pmbrems [] Incontinence [] Respirator/problems [] Anorexia [] Diabetes [] Liver disease [] Smelling impairment [] Arthritis [] DJvedicu]itis [] Lowblood pressure [] Speech problems [~-Cancer [] Gallbladder disease [] Osteoporosis [] Stroke [] Chronic constipation [] Hearing impairment [] Other [] Ulcer [] Chronic diarrhea [] Heart disease [] Parkinsons [] Urinary tract infection [] Colitis [] Hiatal hernia [] Visualimpairment [] High blood pressure Doctor/Health Care Provider: Name: Address: Phone Number: Health Care Proxy: Address: Phone Number: Client Assessment Date; 0.4/21/2003 Current Problems: Significant History: Health Care Events within the Last Six Months Events Date Reason for Service Comment Clinic Visit Emergency Room PRJ Hospital Visit DMS-1 Physician Visit Other Does the client visit the doctor less than once a year? [] Yes [] No Does the client require a comprehensive medical exam? [] Yes [] No Frail I Disabled: [] Yes [] No Assistive Devices.'? [] Cane [] Dentures [] Hearing aid [] Walker [] Eyegrasses [] Wheelchair Does the client require trainin on assistive devices? [] Yes [] No ~COGNITIVE STATUS Profile: [] Alert [] Appears lonely [] Cooperative [] Dementia [] Depressed [] Diagnosed mental health prob. [] Disruptive socially [] Evidence of substance abuse [] Hallucinations [] History of mental health treat Other (specify): [] Impaired decision making [] Memory deficit ~ Other [] Physical aggression [] Problem behavior reported [] Sleeping problems [] Suicidal thoughts [] Verbal disruption ~ Worried or anxious Client Assessment Date: 04/21/2003 Any stressful life events within the past year? Comments: Does the client require a mental health evaluation? [] Yes [] No ~IJTRiTION Height: Weight: Body Mass Index: Any weight changes within the last six months? [] Yes: Howmuch?: ~ No H(;w many meals does the client eat daily? Does the .client ever go without food? [] Yes: Specify#~: L.J No Does the client have adequate food in the house? [] Yes [] No Does the client have a modified/therapeutic or ethnic diet? [] Yes: Specify: [] No If client has modified therapeutic diet, does the client follow it? [] Yes [] No Nutrition Problema: Select all that apply) [] Ap.petite [] Chewing/Swallowing [] Dehydration [] Dental [] Digestive problems [] Overweight [] Taste impairment [] Underweight Nutrition Profile: (Selecfallfhatapply.) [] inadequate refrigerator/freezer and cooking facilities [] Unable to open containers/cartons and cut up food [] Requires nutritional supplements [] Has a physician-diagnosed food a]rergy [] Has a physician-prescribed modified/therapeutic diet Nutrition Risk Screeninq [] Client has an illness or condition that changes the kind and/or amount of food eaten. [] Eats fewer than 2 meals/day, Eats fewer than two daily servings of the following food groups. [] Fruits [] Vegelables [] Milk Product [] Has 3 or more drinks of beer, liquor or wine almost everyday. [] Has tooth or mouth problems that make it hard to eat. [] Does not always have enough money to buy food needed_ [] Eats alone most of the time. [] Takes 3 or more prescribed or over the-counter drugs a day. [] Without wanting to, lost or gained 10 pounds in the past six months. [] Not always physically able to shop, cook and/or feed self. 2 3 2 2 2 2 4 1 1 2 2 Nutritional Risk Status: Nutrition Index: Client Assessment Date: 04/21/2003 Comments/Additional Notes: --UNCTiONAE STATUS Status Codes: 1. Totally Able 2. Needs some a~st. 3. Needs maximal asst. 4. Unwilling to perform Needs Met: -U Unmet -I Informal supports -F Formal service -A Assistive Device nstrurnental Activities of Daily Living ~Status ~-Needs [Contact rJADLS) ~Code ~Met? ~Name/Relationship ~Hand]e personal business/Finan Housework/Cleaning L~-aundry Prepare end Cook meals Prepare light mealslReheat ,Se[f-admin. of Medication Shopping Jse telephone !Use Transportation --~__ I. ] I / -I ~-- I_ I __ I---- I 1 I I 1 ~_ · J ~_J_ I 1 I _T--I I T I IHours I I I I [ I Frequency IADL Comments: IADL's: Impaired Activities: Met by informal Support: Met by Formal Supports: Met by Assistive Device: Unreel Needs: ~.ctivities of Daily Living [ADLS) B~hing [Dressing Eating [Mobilil~, personal Hygiene c tatus Needs Contact ode IMet? [Name/Relationship I I I I _ I -I ] -I I tHours IFrequency I I [l'oileting ~ransfer~ I r I I ~ Client Assessment Date: 04/21/2003 I1 ADL Comments: ADL's: Impaired Activities: Met by Informal Suppor~s: Met by Formal SuppoCs: Met by Assistive DevicE: Unmet Needs: [A~L/ADL CAREGIVER' LIMITATIONS Activity Name: Contact name: Does the client appear to have a good relationship with this caregiver? [] Yes [] No Any factors which might limit involvement?. Iscareglverreliefnee~ied? [] Yes [] No' If yes. when? Could other informal supports provide relief? ActivityName: . . Contact name: Does the client appea~::[o have a good relationship with this caregiver? [] Yes [] No Any factors which might limit involvement? Is caregiver relief needed? [~ Yes [] No If yes, when? Could ether informal supports provide relief? - Activity Name: Contact name: Does the client appear to have a good relationship with this caregiver? [] Yes [] No Any factors which might limit involvement? Is caregiver relief needed? [] Yes [] No If yes. when? Could other informal supports provide relief? HOUSING Type of Housing: Ownership Stalus: [] Multi family Unit [] Single Family Unit ~j Own dwelling [] Rent dwelhng [] Other Nome Safety Problem? [] Accumulated garbage/dirb/living areas [] Loose scaEter rugs [] No working C0detectors [] Bedroom-bath traffic lane has obstacle.. [] No access to telephone/emergency numbers [] No working smoke detectors [] Cluttered stairs/walkways [] No grab bar at toile'dbathtub [] Odors [] Cords/wires across walkways [] No handrails on stairways [] Plumbing problem [] Doorway widths too narrow ~] No light in reach of bed [] Poor lighting in bathroom [] Exposed widng/electriccords [] No locks on doors/windows [] Poor lighting inhallway [] Inadequate heating/cooling [] No rubber mat/decals in bathtub [] Stairs are notwell lighted [] Inadequate hot/cold water [] Stairs in poorcondition [] Inadequate lighting in living areas [] Insects/vermin Other (specify): Client Assessment Date: 04/2112003 Is neighborhood safety an issue? [] Yes [] No Landlord: (if available) Name: Address: Phone Number: Super: (if available) Name: Address: Phone Number:. Housinq. Comments: BENEFITS Cod~ Status as follows: HB = Has Benefit ME = May Be Eligible RA = Refuses to Apply AP = Application Pending D = Denied NE = Not Eligible Benefit [ Status code II Benefit Status code --_PiC -i I'[QMB [ %od Stamps I ItRailroad Retirement Health Insurance I I,[Real Prop. Tax Exemption HEAP -- 1 t!Reverse Modgage IT214 { IfSCRIE [I..ife~lin~e [ {~Section 8 I Long term care insurance I [[SLIMB I [Medicaid I~ocfal Security IMedicare I I~SSD [Medigap Insurance/HMO L [Private Health Insurance I public Assistance I pther I ILwRAP i'_~ Benefits ----l~/eteran Tax Exemption [Other Notes: Does the client require counseling on entitlements and benefits? [] Yes [] No dEALTH INSURANCE INFORMATION Insurance Company Identification Plan # Client Assessment Date; 04/21/2003 I~U RRENT SERVICES (List any service cfient received wilhin the last 6 months, regardless of whether ar net it was authorized,/arranged by your agency.) Service Funding erg. Provider/Contact Units Freq. Auth. Date End Date [AssE.SSMENT S.UMMAR¥ Evaluate Informal Support System: [] Adequate Can Expand [] Adequate Not Expand [] Inadequate/Limited [] Other [] Temp Unavailable Would client accept help from the family? Rate client's motivation to stay in the community?: [] Cannot Rate [] Highly Motivaled [] Motivated with Support [] Needs Supped [] Resistive Disposition: [] Never [] Oti~er [] Short Term [] Uncertain Could neighborhood/community/religious affiliations Summary: [] Eligible for AAA in-home [] Other [] Refer lo CHHA [] Refer to Medicaid Homecare [] Referte Nursing Home ~-] Refer ia Sell-Pay service 3rovide assistance? [] Yes [] No ~CARE PLAN Care Plan Goals: Care Plan Objectives: Client Outcomes: Date: 04/21/2003 Client Assessment Proposed Time Frame: Client self-dir~cting/abIe to direct home care staff? Client Preferences Regarding Service: Yes [] No IP~AN N ED SERVICES To include services provided by Informal supports in the Care Plan, put Contact name under Provider and Est Informal as the Funding Org. Service Funding Org. Provider/Contact Units Freq. Sta~ Date End Date PLANNED TASKS Task Comments Due Date OK to discuss plans with informal suppods? Plans discussed and[or accepted by client]informal supports? [] Yes [] No [] Yes [] No Supervisor's Name: Date of Review: Assessor Supervisor Client Assessment Date: 04/21/2003 [FINANCIAL ~nfo Received From: [] [Agency [~Agent L~ ~Aunt ~iBrother ~/Brother-in-law ~ [Daughter [] r, Da ug h~er-in-law [] [DFTA [] [Domestic Partner ~ IFather ~ jFather-in-law [] JFriend [] ~Grand Daughter ~ ~Grand Son ~ '~Grandfather ~_~, ,G[G~randmother [] ~fospital [] JHousing L ushand ~ ~_andlord [][Mother [] IMother-imlaw ~ ENeighbor ~__~ [Nephew INieoe pthCr ~ [Relative ~ ]Religious erg. ~elf ~ ~ister ~ ~ister-in-law [] ~Social Serv Agc L~ ~Social Worker [] Son ~] ~on-in-law [] IStep Daughter []~Step Father [] JStep Mother ~] IStep Son ~:inanJcial Information: Monthly Housin.q Exp, SSNI: SSI12: !Electricity [$ l$~ JHeating/Cooking Fq$ iS. IOther [$ I'$ I JRentJModgage/Co-~_ Faxes L~_Phone j~_ IWa(~r/Sewage ~$ Monthly Income SSNI: SSN2: [Dividends from Inv¢$ ~- ~nterest ~_ ~. JNon-client Inc.not ,~$ [$_ ] IOther sL Ps I JPensian/Retiremen($ J,$ SalaryArCages fromks [Social Security [$ ~ IS:upplemental Sect,S I$ ] I Monthly Medical Exp. SSNI: SSN2: JH,ealth Ins. Premiur~ J$_ JH'ome Care J?.4edication ~_ ~_ Obther A ~hysician kS ~J~ SSNI: SSN2: 3hecking ~ ~ Life Insurance - Ca($ [$ Life Insurance - Fa~$ [$ Other (IRAs) ~ l$ Other Cash Accts. I$ sL Real Property [Savings JStocks,Bonds,Mulu[$ ~lSuper [] no e Client Assessment Date: 04/21/2003 [] ~/is~ing Nurse Dthers Information: $.$.iq Name Relation IEvent: I~ [Event Based []'poi[ow-up Assessment. [] Ilnitial Assessment E~ R~opening' [] [Review prior to Discharge []lp, outine Reassessment ~ommen[s: Client's Signature Case Worker's Signature SEC. 20. HOLIDAYS 20.1 Full-time employees shall be entitled to the following hoiidays offwith.pay, to .wit: .. the first day o£.Ianuao,, known as New. Year's Day the third Monday of lanuary, lc~.~ ~wn as Martin Luther King, Jr. Day the twelfth day of February, kn6wn as Lincoln's Birthday (dekte, effective January 1, .2000). the third Monday in February, known as (President's Day) Washin~on's Birthday the last Monday in May, known as Memorial Day the fourth:daY of July, knoTM as Independetice Day the first IV~onday in Septin'nber, known as Labor Day tho seeand Monthyin' October, known as Columbus Day the Tuesday next succeeding the first MOnday in November, known as Election Day the elevei~th day of November, known as Veteran's Day the fourth Thttrsday in November, known ~s Thanksgiving Day the day.~fter Thanksgiving Day, except for employees assigned to the Landfill, who shall receive a floating holiday to be icheduled as though it Were a personal day (effective January 1, 2000) the twenty-fifth day of December, known as Christmas Day the eve of Thanksgiving Day, ~ day the eve of Christmas Day, ~ day the eve of New Year's Day, kl day SU MI 1ARY - RFQ FOR NUTRITION PROGRAMS 2003 PROPOSER:-Town of Southold -(S~nidr' S~r~i~es) GEOGRAPHI~ CATCHMENT AREA: ..... : Town of So~thold [ 2000· US Census Tracts t700.01, 1700.'02,'1701.01, 17.02.02) PROV DE ONE COPY OF THIS SUMMARY SHEET FOR EACH P~ROGRAM CATCHMENT AREA YOU MAY MAKE PHOTOCOPIES.OF THIS FORM. TARGETCOMMUNI/Y: Southold Town ( includes Village of Greenport (1701.01) "Elderly Low Income Minority and Kosher Commu~litie$. 52 105 ' 5 8AM-4PM Number of meals to be served each day7 congregate Number of meals to be served each day-Home-Delivered Number of days per wee~'-.~r program Circle days of program':.' ~. ' Q Hours ofoperatign each d~y Location for congregate site: Southold To%rn }{uman Resource Center, 750 Pacific ~t~eet, Mattituck N.Y. 11952' Locatior~ of program administration, if.difference from_ congregate site: .. Same PI.ease state any additional information afl'ecting service delivery: OFFICE USE ONLY: Southold Town Senior Services · 750 Pacific Street ~Lattitu~k, New York 11952 l~hone # 631 298-4460 Revised 9]25/03 SUMI~U~.Y SHEET 03 last rev. 5/28104 Suffolk County Legislative Requirements Exhibit for Contracts This exhibit is attached to and is made part of the contract executed with the County. Suffolk County Living Wage Requirements "Suffolk County Living Wage Requirements Exhibit As Last Revised by the Suffolk County Depar[ment of Labor on 5/12J04" (2 pages). Child Sexual Abuse Reporting Policy Chapter 577, Article IV, of the Suffolk County Code entitled "Child Sexual Abuse Reporting Policy" (3 pages). III Gratuities Chapter 386 of the Suffolk County Code, entitled "Political Parties, Gifts to Officials Off' (2 pages). IV Contractor's/Vendor's Public Disclosure Statement Form SCEX 22; rev. 3/30/04 (form consists of three pages; requires signature & notarization) Note: The Contractor's/Vendor's Public Disclosure Statement Form SCEX 22; rev_ 3/30/04, references the following law, which is included with this Exhibit. Suffolk County Administrative Code Section A5-7 (consists of 3 pages). I Suffolk County Living Wage DocumentS .Suffolk Co,unty Living Wage'Requirements'Exhibit As LC, st Revised by the Suffolk County Department of Labor on 5/12/04 Suffolk County Living Wage Requirements Exhibit ' As Last Revised by the Suffolk County Department of Labor on 5/12/04 Pursuant to Section 6 of Chapter 347 of the Suffolk County Local Law No. 12-2001, "A Local Law to Implement Living Wage Policy for the County of Suffolk" ('[he "Living Wage Law"), all RFPs, County contracts and financial assistance agreements subject to the law shall contain the following two paragraphs or substantially equivalent language: This Agreement is subject to the Living Wage Law of the County of Suffolk. The law requires that, unless specific exemptions apply all employers (as defined) under service contracts and recipients of County financial assistance, (as defined) shall provide payment of a minimum wage to employees as set for[h in the Living Wage Law. Such rate shall be adjusted annually pursuan~ to the terms of the Suffolk. County Living Wage Law of the County of Suffolk. Under the provisions of the Living Wage Law, the County shall have the authority, under appropriate circumstances, to terminate this Agreement and to seek other remedies as set forth therein, for violations of this Law, Suffolk County Local Law No. 18-2002, "A Local Law to Implement Living Wage Policy for the County of Suffolk" provided for certain amendments to the Living Wage Law. Forms for Completion and/or Signature (as applicable) Suffolk County Department of Labor- Living Wage Unit Notice of Application for County Assistance (Contract) Form LW-1 (consists of 1 page) Suffolk County Department of Labor - Living Wage Unit Certification/Declaration - Subject to Audit Form LW-38 (consists of 1 page) (Replaces LW2, LW3 and LW33) Suffolk County Department of Labor- Living Wage Unit Request for General Living Wage Exemption Form LW-4 {consists of 1 page) Suffolk County Department of Labor- Living Wage Unit Request for Specific Living Wage Exemption Form LW-5 (consists of 2 pages) 1 of 2 pages Suffolk Co, unty Living Wage' Requirements Exhibit As Last Revised by the Suffolk County Department of Labor on 5/12/04 · Note: Pursuant to Section 7 of Local Law No.18- 2002, "A Local Law to implement Living Wage Policy for County of Suffolk", all covered employers subject to the provisions of the Living Wage Law shall Submit a completed and sworn (under penalty of perjury) Cer[ification/Declaration - Subject to Audit Form LW-38, signed by an authorized representative, as part of an executed contract with the County of Suffolk. The complete Certification/Declaration -Subject to Audit Form LW-38 shall be made a part of any executed contract or project agreement and made available to the public upon request. To certify Living Wage compliance: Return Forms LW-1 and LW-38. or To certify non-applicability of Living Wage law: Return Form LW-38. or To request and document a general living wage exemption: Return Forms LW-1, LW-38 and LW-4. or · To request and document a specific living wage exemption: Return Forms LW-I, LW-38 and LW-5. in the event that there is a change in circumstances, it is the Contractor's responsibility to submit to the County additional Living Wage forms which either replace or supplement prior submissions of Living Wage forms. Living Wage Law information Fact Sheet, text of the Local Law, Frequently Asked Questions, Forms, and Rules and Regulations can be found on the Suffolk County web site at www.co.suffolk.ny us Click: Department Directory Labor Living Wage Law Info Suffolk County Department of Labor Living Wage Unit Tel. (631) 853-3808 End of Text for Suffolk County Living Wage Requirements Exhibit As Last Revised by the Suffolk County Department of Labor on 5/12/04 2 of 2 pages II Child Sexual Abuse Reporting Policy C~L~PTER 577, ARTICLE IV, Child Sexilal ~bu~e Reporting Policy [Adopted 6-11- '2002 ~y Res. NO. 543-2002] 577-16. Policy establlshed. The County of Suffolk hereby establishes a formal child sexual abuse reporting policy as follows: Each County Department that ham a contract or agreement with any individual, partnership, corporation, joint venture, business organization, or other entity which receives pa~en~s'~rom the County of Suffolk, either directly or as a conduit for payment from aaothar leYel of government, shall notify such individual, partnership, co~oration, joint venture, business organization, or other-entity that Suffolk County requires full compliance with the reporting and disclosure provisions of Subsection C of this section, as a condition precedent Ko receipt of such pa}~ent and continuing receipt of such paymentf in chose instances in which an allegation has been made of sexual abuse of a minor by any employee or member of such contract vendor, including any member 0f the clergy, involvin9 any of the following sex offenses: (1)Rape in the third degree, ~ 130.25 (less than 17 },ears old) of the New York Penal Law; (2)Rape in the second deBree, § 130.30 (less than 14 },ears old) of the-Hew York Penal Law; (3) Rape in the first degree, ~ 130.35 (less than 11 years old) of the ISew York Penal Law; (4)Sodomy in the third de~ree, ~ 130.40 · York Penal Law; (5)Sodomy in the second degree, ~ 130.45 York Penal Law; (6)Sodomy in the first York Penal Law; (7)Sexual abuse in the New York Penal Law; (8)Sexual abuse in the New York Penal Law; (9)Sexual abuse in the ~ew York Penal Law; (10)Aggrax~ated sexual abuse in old) of the New York Penal (ll)D. ggravated sexual abuse in old) of the New York Penal (12)Aggravated sexual abuse in old) of the New York Penal Law; (13}Course of sexual conduct a~ainst a child in the first degree, § 130.75 (less than 11 years old) of the New York Penal Law; and (14)Course of sexual conduct against a child in the second dsgrse, § 13D.S0 (less than 11 years old) of the New York Penal Law; (15)Sexual misconduct, § 130_20 (sexual intercourse without consent) of the New York Penal Law; (16)Forcible touching, § 130.52 [ssxual or intimate parts) of the New York Penal Law; (17)Persistent sexual abuse, § 130.53 (two or more convictions within tbs past 10 years for less than 17 years old or 14 years old) of the New York Penal Law; (lB)Aggravated sexual abuse in the fourth de~ree, § 130.65a (less than 17 years old) of the New York Penal Law; (19)Female genital mutilation, Section 130.85 (less than 18 years old, nonmedical procedure) of the New York Penal Law; (20)Facilltating a sex offense with a controlled substance, § 130.90 (without consent to commit a felony) of the New York Penal Law. (less than 17 years old) of the 1;aw (less than 14 years old) of the New degree, § 130.50 (less than 11 }'ears old) of the third degree, § 130.55 (less than 17 },ears old) of She second degree, ~ 130_60 (less than 14 years old) of the first degree, § 130_65 (less than 11 years old) of the the third degree, § 130.66 (less than 11 years Law; the second degree, § 130_67 (less than ii years Law; the first degree, [ 130.7~ (less than 11 },ears B. Definitions. For the purposes of this article, the following terms shall have the meanings indicated: CLERGY -- A doly authorized bishop, pastor, rector, priest, rabbi, minister, imam, nun, or a person having authority from, or in accordance with, the rules and regulations of the governing ecclesiastical body of the denomination or order, if any, to which the church D~lcngs, or otherwise from the church, synagogue, or mosque to preside over and direct the spiritual affairs of the church, synagogue, or mosque, as the case may be. MINOR -- ~yone under the age of 18 years of age; C. All supervisory, administrative, or management employees of any individual, partnership, corporation, joint venture, business organization, or other enuicy receiving pay~nent from the County of Suffolk, either directly or as a conduit for payment from another level of government, under agreement or contract with the County of Suffolk, shall report or cause a report to be made to 911 or the pertinent village, town, or county Police Department when he/she, or it has reasonable cause to suspect Ehat a minor coming before them is or has been the victim of sexual · abflse, or when another person or clergy person comes before them and states from personal knowledge facts, conditions, or circumstances which, if correct, would render the minor a victim of sexual abuse under amf of the following sex offenses. said reporting to occur within 2i hours after forming.the reasonable cause or first learning of the allegations: [Amended 8-28-2002 by'Res. No. 819-2002] (1)Rape in the third degree, § 130.25 Penal Law; (2)Ra~e in the second degree, § 130.30 Penal Law; (3}Rape in the first degree, § 130.35 Penal Law; (4)Sodomy in the third degree, § 130_40 (less than 17 years o/d) of the ~Iew York Penal Law; (5)Sodomy in the second degree, § 130.45 (less than 14 }'ears old) o~ the New York Penal Law; (6)Sodomy in the firs5 degree, ~ 130_50 (less than 11 years old) of the New York Penal Law; (7)Sexual abuse in the third degree, § 130.55 (less than 17 years old) of the l~ew York Penal Law; (8)Sexual abuse in the second degree, ~ 130.60 ('less ~han 14 years old) of the New York Penal Law; (9)Se×ual abuse in the first dsgree, ~ 130.65 (less than 11 years old) of the New York Penal Law; (10)Aggravated sexual abnse in old) of the New York Penal (il)Aggravated sexual abnse in old) of the New York Penal (12)Aggravated sexual abuse in (less than 17 }-ears old) of the New York (less than 14 years old) of the New York (less than 11 years old) of the New York old) of the New York Penal Law; (13)Course of sexual conduct against a child in the first degree, ~ 130_75 (less than 11 years old) of the New York Penal Law; and (14)Course of sexual conduct against a child in the second degree, ~ 130.80 (less than 11 years old) of the New York Penal Law; (15)Sexual misconduct, § 130.20 [sexual intercourse without consent) of the ~ew York Penal Law; (16)Forcible touching, § 130_52 (sexual or intimate parts[ of the New York Penal Law; (17)Persistent sexual abuse, § 130.53 (two or more convictions within the past 10 years for less than 17 years old or 14 years old) of the New York Penal Law; (10)Aggravated sexual abuse in the fourth degree, ~ 130.65a (less than 17 years old) of the New York Penal Law; (19)Female genital mutilation, § 130.85 (less than 18 years old non-medical procedure[ of the New York Penal Law; (20)Facilitating a sex offense with a controlled substance, § 130.90 [without consent to commit a felony) of the New York Penal Law; the third degree, § 130.66 (less than ]1 years Law; the second degree, ~ 130_67 (less than 11 years Law; the first degree, § 130_70 (less than 11 years D- Whenever a clergy person is required to repo~t under this article, in his or her c~pacity as a men, er of the clergy, he or she shall immediately notify the person in charge of such church, synagogue, or mosque, or his or her designated agent, who shall then also become responsible to report or cause reports to be made to 911 or the pertinent village, town, or county Police Department when he or she has reasonable cause to suspect that'a minor coming before 5hem is or has been the victim of sexual abuse, or when another clergy person comes before them and states from personal knowledge facts, conditions, or circumsgances which, if correct, would render the minor a victim of sen{ual abuse_ [Amended 8-28-2002 by Res. No. 819-2002] No information derived from a confession or confidential communication to a clergyman shall be disclosed pursuant to the requirements of this article if the confession or confidence is made to the clerg}~an in his or her professional capacity as a spiritual advisor, unless the person so confessing or confiding ' waives this privilege. F. Ail contract vendors covered by this article shall inform all of their emplo~ees in writing as to the disclosure requirements of this article and shall also inform them that each of them must report any allegations of child abuse covered in paragraph (A) of the 1st RESOLVED clause of this article to supsrvisory, management, or designated administrative personnel of the employer. 577-17. Failure to comply; penalties for offenses. Failure to comply with the terms and conditions of this article shall result in the following: First violation: the contract vendor shall be issued a warning and all supervisory, administrative, and management employees of such contract vendor shall be required to attend a child sexual abuse prevention/education workshop provided by a contract agency approved by the County of Suffolk via duly enacted resolution, which workshop shall include specific skills for adults to help prevent childhood sexual abuse; skills that adults can teach childrea to help protect themselves from childhood sexual abuse; skills for detectinS the signs of childhood sexual abuse; and how to report allegations of childhoad sexual abuse. The cost of this training shall be paid for by the contract vendor. In addition, the contract vendor shall submit a corrective plan of action to the Suffolk County office of Labor Relations_ B. Second violation within a three-year period subsequent to a first violation: the contract ~endor shall be subject to a fine of 10% percent of Khe contracts that the pertinent violating individual supervisor, manager, or administrator oversees, not to exceed $50,800. In addition, the contract vendor shall be put on probation for three years. D~ annual review shall be conducted by the Suffolk County Department of Audit and Control. C. Third violation within a three-year period subsequent to a first violation: the termination of the agreements with such individual, partnership, corporation, joint venture, business organization, or other entity overseen by the pertinent violating individual supervisor, manager, or administrator and the withholding of all payments to said individual, partnership, corporation, joint venture, business organization, or other entity for such agreements regardless of whether such pa}~ents are for past or future goods or services. The contract vendor shall not be eligible for funding from the County for three years fr01n the date of such termination. ~ 577-18. Authority to issue rules and regulations. The Suffolk County Department of Law is hereby authorized, empowered, and directed to issue and promulgate such rules and regulations as shall be deemed necessary and appropriate to implement the provisions of this article. III Gratuities §386-1 GIFTS T© pAtRTY OFFICIALS §386-1 CHAPTER 386 POLITICAL PARTIES, GIFTS TO OFFICIALS.OF § 386-1. § 386-2. § 386-3. § 386-4_ § 386-5. Definitions. Prohibited acts. Clause required in all contracts. Penalties for offenses. Excepted contributions. [HISTORY: Adopted by the Suffolk County Legislature.12-9-80 as L.L_ No. 32-1980. Amendments noted where applicable.] §386-1. Definitions. As used in this chapter, the following terms shall have meanings indicated: AGREEMENT-Any written or oral contract or any implied contract, including but not limited to a contract for the sale of goods or services, a construction contract or a lease or contract relating to real or personal property. The term "agreement" shall also include any transaction whereby a person agrees to sell goods or services, or both, to the county pursuant to a successful bid. GRATUITY -Any money, benefit, enter[ainment, gift or any other consideration whatsoever. OFFICIAL OF A POLITICAL PARTY -A party officer as defined by §1-104, Subdivision 5, of the Election Law. PERSON -Any individual, partnership, firm, corporation or other legal entity, as well as their employees, agents or representatives. POLITICAL PARTY -A party as defined by § 1-104, Subdivision 3, of the Election Law. § 386-2. Prohibited acts. It shall be a crime for any person to offer or give any gratuity to an official of any political party with the purpose of intent of securing or obtaining an agreement with the County of Suffolk or securing favorable treatment with respect to the awarding or amending of such agreement or the making of any determination with respect to the performance of an agreement. Page 1 of 2 B. It shall be a crime for an Official. of a ~0iitical party to solicit, receive or'accept a gratuity in connection with securing or obtaiging an agreement with the County of Suffolk or securing favorable treatment with respect to the awarding or amending of such agreement or the making of a determination With respect to the performance of such agreement. § 386-3. Clause required in all contracts. In all agreements with the County of Suffolk made after the effective date of this chapter, there shall be written representation by the person entering the agreement with the county that he has not offered or given any gratuity to any official, employee or agent of Suffolk County or New York State or of any political party, with the purpose or intent of securing an agreement or securing favorable treatment with · respect to the awarding or amending of an agreement or the making of any determinations with respect to the performance of an agreement, and that such person has read and is familiar with the provisions of this chapter. § 386-4. Penalties for offenses. criminal. A violation of §386-2 of this chapter shall be a Class A misdemeanor and shall be punishable by a sentence of not more than one (1)yearin prison or a fine of not more than one thousand dollars ($1,000) or by both such fine and imprisonment. Civil remedies. A violation of § 386-2 or 386-3 of this chapter shall give the county the option, among other civil remedies, of either terminating the agreement or deducting the value of the gratuity from any amount due or to become due from the county thereunder. §386-5. Excepted contributions. This chapter shall not apply to contributions to political parties, committees or candidates as defined by § 14-100, Subdivision 9, of the Election Law. Such contributions shall be excluded from and shall not be in violation of this chapter. Page 2 of 2 IV ..Contractor's/Vendor's. Public. DisClosure .Statement Documents Suffolk County Fonn 22 Contractor's/Vendor's Public Disclosure Statement Pursuant to Section A5-7 of the Suffolk County Administrative Code, this Public Disclosure Statement must be completed by all contractors/¥endors that have a contract with Suffolk County. In the event contractor/vendor is exempt from completing para~aphs numbered 1 tltrough 11 below, so indicate at paragraph number I2 below setting forth the reason for such exemption. Notwithstanding such exempt status, you must execute this fom~ beloxv before a notary public. 5.b Contractor's/Vendor's Name Address City and State Contracting Department's Name Address Zip Cod~ Payee Identification or Social Security No. TypeofBusiness~Corporation Partnership~SoleProprietorship__Other Is contractoffvendor entering into or has contractor/vendor entered into a contract with Suffolk County [n excess of $1,0007 Yes No. Has contractor/vendor entered into three or more contracts, including the one for which you are now completing this form, with Suffolk County, any three of which, when combined, exceed $1,0007 Yes No. Table of Organization. List names and addresses of all principals; that is, all individuals serving on the Board of Directors or comparable body, names and addresses of all partners, and names and addresses of all corporate officers. Conspicuously identify any person in this table of organization who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary.) List all names and addresses of those individual shareholders holding more than five percent (5%) interest in the contractor/vendor_ Conspicuously identify any shareholder who is also an officer or an employee of Suffolk County. (Attach additional sheet if necessary). 10. Does contractor/vendor derive 50% or more of its total revenues from its contractual or vendor relationship with Suffolk County? Yes__ No. If you answered 3res to 8 above, you nmst submit with this disclosure staternent, a complete financial statement listing ail assets and liabilities as well as a profit and loss statement. These statements must be certified by a Certified Public Accountant. (Strike this out if not applicable.) The undersigned shall include this Contractor's/Vendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.). Page 1 of 3 Public Disclosure Form 1l. 12. Remedies. The failure to file a. verified public disclosure statement as required under local law shall constitute a material breach of contract. Suffolk County may resort, use or employ any remedies contained in Article II of the Uniform Commercial Code of the State of New York. hi addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contfacL If you are one of the entities listed below at a) through c) or you qualify under d) below, you are exempt, from completing para~aphs numbered 1 tl~rough 11 herein: __ a) Hospital __ b) Educational or governmental entities __ c) Not-for-profit corporations __ d) Contracts providing for foster care, family day-care providers or child protective sentices Please check to the left side of the appropriate ex.eruption. 13. Verification. This section must be sigt~ed by an officer or principal of the contractor/vendor authorized to sig-a for the company for the purpose of executing contracts. The undersi~mled being sworn, affinns under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to hisser own knowledge, true. Printed Ndme of Signer: Title of Signer: Name o f Contractor/Vendor: UNIFOR3I CERTIFICATE OF ACKNOWLEDGMENT (Within Ne~v York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the ~__7 ?day of~ in the year 2004 betbre me, the undersized, personally appeared x_7'6~,.c~',9 g' M~ personally Maown to me or proved to me on the basis of satisfactoD~ evidence to be the individual(s) whose name(s)js (are) subscribed to the within instrument and ac~owledged to me that he/she/they executed the same in his/her/their capacity(les) and that by his/her/their si~ature(s) on the instrument, the individual(s), or the person upon behalf or,ich the individual(s) acted, executed 'signatUre and office of individual taking ac~owledgement) Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) )SS.: COLrNTY OF ) On the day of in the ),ear 2004 before me, the undersigned, personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and ac ~knowledged to me that he/shq/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the individual(s), or th6 person upon behalf of which the individual(s) acted, executed the mstmmenk and that such individual(s) made such appearance before the undersigned in (Insert the city or other political subdMsion and the state or country or other place the acknowledgement was taken) (signature and office ofiudividual tak/ng acknowledgement) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:',Documents and Setfings\mvalerie-kempinski\My Documcnts\LEGAD,Standard Contract clauses\SCEX 22 Disel 5-04.doc SUFFOLK COUNTY ADMINISTRATIVE CODE SECTION A5-7 § A5-7. Contractors and vendors required to submit full disclosure statement. [Derived from L.L, No. 14-1976, as amended 2-27-'1979 by L.L. No. 6-1979] A. Definitions. As used in this section, the following terms shall have the meanings indicated: CONTRACT ~ Any written agreement between Suffolk County and a contractor or vendor to do or perform any kind of labor, service, purchase, construction or public work, unless the contract is for a federally or state- aided, in whore or in part, program required to be bid pursuant to § 103 of the New York General Municipal Law. [Amended 6-29-1993 by L.L No. 28:19934] NOTE: L.L No. 28-1993 also provided as follows: Section 1. Legislative Intent. This Legislature hereby, finds and determines that Suffolk County's comprehensive Contractor/Vendor Public Disclosure Statement Law currently applies to a broad array of contracts that exceed one thousand dollars ($1,000.) in value, subject [o exemptions for contractors doing business with the County Department of Social Services; hospitals; educationa], medical,'and governmental entities; and not-for-profit corporations. This Legislature further finds and determines that these exemptions prevent full disclosure of important information that may he useful to elected county officials in determining whether or not specific types of contracts are in the public interest, especially in light of recent trends towards privatization and use of outside consultants on an increased basis by municipalities. Therefore, the purpose of this law is to eliminate many of the exemptions from completing and filing verified public disclosure statements with the County Comptroller availeble to certain contractors providing social services or health services contracts. CONTRACTOR or VENDOR [Amended 12-18-1990 by L,L, No. 41- 19902; 6-29-1993 by L;L. No. 28-19933] - Any proprietorship, partnership or closely held corporation which has a contract with Suffolk County in excess of one thousand dollars ($1,000.) or which has three (3) or more contracts with Suffolk County, any three (3) of which, when combined, exceed one thousand dollars ($1,000.), except: (1) Hospitals. (2) Educational or governmental entities. 1 Editor's Note: This local law was adopted by the legislature after disapproval by the Executive on 5-26-1993. 2 Editor's Note: This local law was adopted by the Legislature after disapproval by the Executive on 12-13-1990. See the note at § A4-12. 3 Editor's Note: This local law was adopted by the Legislature after disapproval by Executive on 5-26-1993. See note above. Page I of 3 (3) Not-for-profit corporations. (4) Contracts providing for foster care, family day-care 2roviders or child protective consulting services. · FULL DISCLOSURE CLAUSE - A proviso f_o be included as a material part of a contract imposing upon the contractor or vendor a material, contractual and statutory duty to file a verified public disclosure statement. VERIFIED PUBLIC DISCLOSURE STATEMENT - A declaration, the contents of which are acknowledged before a notary public, containing information required under this section. A full disclosure clause is to be included in all future contracts between Suffolk County and a contractor or vendor. Such full disclosure clause shall constitute a material part of the contract. C.. Notice of the full disclosure clause shall be included and made a part of the specifications, if any, which are submitted to interested potential bidders. Each contractor or vendor shall file a verified public disclosure statement with the Comptroller of Suffolk County as soon. as practicable prior to being awarded the contract. An updated disclosure statement shall be flied by the contractor or vendor with the Comptroller by the 31st day of January in each year of the contract's duration. It shall be the duty of the Comptroller to accept and file such statements. No contract shall be awarded to any contractor or vendor, as defined in this section, unless prior to such award a verified public disclosure statement is filed with the Comptroller as provided in this section. Any verified public disclosure statement containing fraudulent information shall constitute, for all purposes, a failure to file such statement in the first instance. F. The verified public disclosure statement required by this section shall include: (1) A complete list of the names and addresses of those individual shareholders holding more than five-percent interest in the firm. ' (2) The table of organization for the company shall include the names and addresses of all individuals serving on the board of directors or comparable body, the names and addresses of all partners and the names and addresses of all corporate officers. The contractor or vendor shall conspicuously identify any such person in this table of organization who is an officer or an ernployee of Suffolk County. Page 2 of 3 (3) A complete financial statement listing all assets and liabilities as well as a profit-and-loss statement, certified by a certified public accountant. Such statement shall be the most current available and in no event shall have been prepared more than six (6) months prior to the date of the filing of the bid. No financial statement or profit-and-loss statement shall be required from any contractor or vendor having fifty percent (50%) or more of their gross revenues from sources other than the County of Suffolk. A separate folio for each company shall be maintained alphabetically for public inspection by the Comptroller. Remedies. The failure to file a verified public disclosure statement as required under this section shall constitute a material breach of contract. Suffol. k County may resort, use or employ any remedies contained in Adicle 2 of the Uniform Commercial Code of the State of New York. In addition to all legal remedies, Suffolk County shall be entitled, upon a determination that a breach has occurred, to damages equal to fifteen percent (15%) of the amount of the contract. Under no circumstances shall the county be precluded from invoking any remedy contained in the preceding section by reason of its failure to invoke promptly its remedies. Page 3 of 3 Certification Regarding Lobbying For Contracts, Grants, Loans and Cooperative Agreements The undersigned certifies, to the best of his or her knowledge and belief, that: (1) No State or Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence legislatior~ or appropriation actions pending before local, State and Federal executive and/or legislaCve bodies in connection with the awarding of any contract, the making of any grant, the'making of any loan, the entering of any cooperative agi-eement, and the extension, cont!nuation, renewal, amendment, or modification of any contract, grant loan, or cooperative agreement. (2) If 8ny.funds other than State or Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence legislation or ~ppropriation actions pending before local, State and Federal executive and/or legislative bodies in connection with this contract, grant, loan or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "'Disclosure Form to Report Lobbying", in accordance with its instructions. (3) The uhdersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts, under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by Section 1352, Title 31, U.S. Code. Failure to file the required certification shall be subject to civil penalty by the Federal government of not less than $10,000 and not more than $100,000 for each such failure. Signature of Official Authorized To Sign Application For: Name of Grantee Certification Regarding Lobbying 04 0 r~ ROY H ~ AGENt, ~C. ONLY ~D CONF~S No RIGH~ U~ ~E CE~ PO ~X ~, 1~ ~N RD. HO~ F~ 63t-~8~850 I~RE~ A~O~ING ~V~GE ~IC~ INSU~D INSU~R~ I~u~ Co~o~'on ~ Hann~er TO~ OF SO~O~ P.O. BOX 11~ ]NSU~ C: I~u~ ~o~o~ of H~n~v~ ~5 M~ ROAD rHE'POUC~E~ OF IN~URANCE. L~D ~O~N i~AVE B~=~ I~ TO I-HE,INSURED ~ ~ FOR~E PO~yp~l~ ]ND~D, NO~ ~E~ H~ -~1~ - J~t 05 ' ~U~CE, * 1,~,~ X ~ GEN~ ~IL~ ~; ~' $ ~,0~ -- ~'~. $ 3,~,~ c ~zuu~ ~ ~UB~ J~ t ~ J~ 1 ~ ~ ~E 10,~0,~ B X ~ :.~E S~ ~LT DAY C~ CERTIFICATE HOLDER A~m'noN,~. ~4~u~-~; i~ ~ COUNTY OF SUFFOLK OFFICE FOR THE AGING P.O- BOX 6'100 HAUPPAUGE, NY 117'88-0099 Affent]on: .. FAX: 2984462 KAREN MCLAUGHUN ACORD 25 (2001108) Certificate # CANCELLATION 4158 Thomas A. Dickerson .