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Home My WebLink AboutSC Office of Aging SNAP ELIZABETH A. NEVILLE TOWN CLERK REGISTRAR OF VITAL STATISTICS MARRIAGE OFFICER RECORDS MANAGEMENT OFFICER FREEDOM OF INFORMATION OFFICER Town Hall, 53095 Main Road P.O. Box 1179 Southold, New York 11971 Fax (631) 765-6145 Telephone (631) 765-1800 southoldtown.northfork.net OFFICE OF THE TOWN CLERK TOWN OF $OUTHOLD THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 697 OF 2004 WAS ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON SEPTEMBER 21, 2004: RESOLVED that thc Town Board of the Town of Southold hereby authorizes and directs Supervisor Joshua Y. Horton to execute an Agreement with the Suffolk CounW. Office of the Aging for the Supplemental Nutrition Assistance Program (SNAP), IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284 ~rom April 2004 through March 2005, subject to the approval of the To~vn Attorney. Elizabeth A. Neville Southold Town Clerk COUNTY OF SUFFOLK SUFFOLK COUNTY E~XECUTIVE OFFICE FOR THE AGING HOLLY $. RHODES-TEAGU~' October 27, 2004 The Honorable Joshua Y. Horton Supervisor Town of Southold 53095 Main Road P.O. Box 1179 Southold, New York 1197I RE: Supplemental Nutrition Assistance Program IFMS No, SCS EXE 00000009442 Dear Supervisor Horton: The fully executed agreement referenced above is enclosed for your files. Also enclosed find the Notice of Rights, which must be posted as part of your compliance with Local Law No. 12-2001, the Living Wage Law. Sincerely, Leonor Hunter Fiscal Administrator II LH:MVK:ny Enclosure cc: Karen McLaughlin NOTIFICATION OF RIGHTS UNDER THE LIVING WA GE LAW According to the provisions of Local Law #12-2001 (the Living Wage law) enacted by Suffolk County in July of 2001, a living wage rate has been established. The Living Wage shall be adjusted each year in proportion to the increase of the area Consumer Price Index. The increase in the area Consumer Price Index, for 2003, is 3.2%. Effective July 1, 2004 the Living Wage will increase to $9.29 per hour with health benefits and $10.58 per hour without health benefits for covered employees of an agency receiving financial compensation through the County. The law also mandates that these workers receive at least 12 compensated days off per year through any combination of sick, vacation or personal leave and includes paid holidays provided by the employer. The Suffolk County Department of Labor has been designated as the agency to administer this law and to this end has established a Living Wage Unit. Further information concerning the parameters of the Living Wage law may be obtained by contacting this Unit (631 853-3808) or accessing the Suffolk County web page at ww~v.co.suffolk.ny.us/labor and following the link to the Living Wage section. All inquiries will remain confidential. Law No. AG004M/0020-07R Rev. 6/22104 Supplemental Nutrition Assistance Program IFMS No. SCS EXE 0000000~u~u,2- No. 001-6774-4980-95284- ~Ju~ur2. 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 - 3~d 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, Southold, New York 11971. The parties hereto desire to make a senior citizens nutrition program available to the County. Sufficient funding exists in the 2004 Suffolk County Operating Budget. Term of Agreement: Shall be April 1, 2004 through March 31,2005 with two one- year extensions at the County's option. Total Meals: Daily Home-Delivered Meals: 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. In Witness Whereof, the parties hereto have executed this Agreement as of the latest date written below. Town of~uthold s oshua Y.'Hort6n upervisor Fed. Taxpayer I~,#: 11-~01939 Date: ~ l~&~ County of Suffolk Paul Sabatino II Chief Depu, ty County Executive Date: Approved: Approved as to Leg~ality: ' _ .... ..~ By: ~, x~ '"/"~-_-¢-d~',~ t'/~.~ 1~/~ / ~ Holly S~hode~Teague--~ ~- 'Date ~h~istine Mal~fi / [ ~ Director~Office for the Aging~ ~u.olk ~un[y AttQ~( ~ ~'l ~ ~ ~ ~ ]. ~ I0/~ Recomm~ed: ,/ -- - ~ Date By: - Samantha ~'~cgachin /nna Prencipe ' Da(e Assistant County Attorne~ Assistant Food Se~ice Supe~isor i~a~v Ne. ,~,G004M/00 -06/7Y IFMS No. SCS EXE 0000000 er. 6/10/04 -- No. 001-6790/6774-4980-95284- IIIC 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 Suffolk County (separately or collectively the "Program"), under (i) the Nutrition Program for the Elderly 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 Program (SNAP), as indicated on the cover page of this Agreement. The Contractor shall furnish the Program as further provided in this Exhibit A, Exhibit Al, the Contractor's Response to Section IV, paragraph 3 a through h, to the RFQ Request for Qualifications No. 3/15524VH (the RFQ) and the following Appendices to the RFQ and additional Exhibits, which are attached to and made part of this Agreement: EXHIBIT EXHIBIT EXHIBIT EXHIBIT C EXHIBIT D EXHIBIT A1 Standard Contract Clauses B Program Specifications B1 Special Clauses (if any) Rate Page(s) (Contractor's Response to Section V of the RFQ) Grievance Procedures Suffolk County Legislative Requirements Exhibit for Contracts" revised 5/28/04 Appendix K Technical Assistance Packet (revised 7/03) Appendix L Policy and Procedure Manuals: Congregate Meals and Home Delivered Meals (revised 7/03) Appendix M Holiday Schedule Appendix N Summary Form for each Catchment Area Appendix O 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 I of 2 pages of Exhibit A AG4M 03 RFP Model AGRMNT AG 4 (9/00) ~a~v 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) 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 pedod thereafter unless it is modified by Extension Agreement or Amendment. 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 bodily 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 shall notify the Contractor in writing on or before the expiration of the term (as same may have been extended), and the padies 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 EXHIBIT A- AG 4 (9/00) Page 2 of 2 pages of Exhibit A AG4M 03 RFP Model AGRMNT Exhibit A1 1. 7. 8. 9. 10. 11. 12. TABLE OF CONTENTS - Standard Contract Clauses ............................................................... Contractor Responsibilities ......................................................................................... 1 (a) Services ........................................................................................................... 1 (b) Qualifications and Licenses ............................................................................. 1 (c) County Review ................................................................................................. 1 (d) Level of Service ............................................................................................... 1 (e) Compliance with Law ....................................................................................... 1 Term of Agreement ..................................................................................................... 2 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 Subiect 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 0) Post-Audit ........................................................................................................ 3 Accounting Procedures .............................................................................................. 4 Financial Statements and Audit Requirements ........................................................... 4 Furniture, Fixtures, Equipment, etc ............................................................................. 5 (a) Purchases, Etc. Requiring Prior Approval ........................................................ 5 (b) Purchase Practices .......................................................................................... 6 (c) Proprietary Interest of County .......................................................................... (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 Addresses for Notices, Claims and Reports ............................................................... 7 Statement of Other Contracts ..................................................................................... 7 Offset of Arrears or Default ......................................................................................... 7 ConfidentJality of Records ........................................................................................... 7 Independent Contractor .............................................................................................. 8 Certificate of Incorporation ......................................................................................... 8 AG A1F (5/00) 13. Insurance and Indemnification .................................................................................... 8 14. 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 ....................................................................... 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. Cedification 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 padicularly pro- vided 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 possess, and that, to the extent applicable, its employees, agents and subcontractors have and shall possess, the required education, knowledge, experience and character necessary to qualifythem individu- ally for the particular duties they perform and that the Contractor has and shall have, and, to the extent applicable, its employees, agents and subcontractors have and shall have, all required au- thorization(s), registration(s), license(s), certificate(s) or permit(s) required by State, County or local authorities for the Services (hereinafter called "License"). The Contractor 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 the 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. It is understood that the Contractor shall not be reimbursed for any Services rendered after the ef- fective date of termination of such License. The remainder of this Agreement, or its application to persons 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 valid 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 Al. (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 .~,. 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. 3. Payment for Services (a) Claims (i) The Contractor shall prepare and present claim forms supplied by the 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 Extension Period, if any, for which the claim shall 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 Veterans Memorial Highway, P. O. Box 6100, Hauppauge, New York 11788-0099. (iv) No claims shall be payable until the Contractor complies with all require- ments 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 Appropriation of Funds This Agreement is subject to the amount of funds appropriated and any subsequent modifi- cations thereof by the Suffolk County Legislature, and no 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 the 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 pad of the Contractor, then the County may deduct and withhold from any payment due to the Contractor an amount equal to the 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 Charier. The Contractor fudher 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 ,ga,F anco 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. 4. Accounting Procedures (a) The Contractor shall maintain separate records of account concerning all costs in- curred by the Contractor in the performance 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 all facilities, books and other financial and statistical data, whether related to this Agreement or otherwise (in the case of towns or other municipal cor- 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- ment 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 Depadment; (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 audit. (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 a,,,F 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 OMB 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 Contractor must mail or deliver the certified statement to Aging and to Elizabeth Tesoriero, Executive Director of Auditing Services, Suffolk County Depadment of Audit and Control, 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 statement 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 Repods (if ap- plicable) and other audit reports, if required, must be transmitted to Aging and to Ms. Tesoriero at the address just set forth. The reports must be submitted within thirty (30) days after completion of the audit, but in no event Iater 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 6ontractor 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 Countyto the Con- tractor, within thidy (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 Suffolk 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 ~,, its intended location and use, estimated unit price or cost, extended price or cost and estimated total cost of the proposed order. Written approval of the County is required before the Contrac- for 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, fi×tures, equip- ment, materials or supplies which shall be in accordance with 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 available to the Contractor for any pur- pose whatsoever. Title 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 Contractor, 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 properly 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- prietary 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 prior 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 Contractor 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, cedified 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 ,~,, (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 loss by fire, burglary, 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 shall immediately notify the police and make a record 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 furniture, 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, repods, 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 shalt 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 notbe 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 A1F (2/04) Page 7 of 14 pages of Exhibit AIF Cg~ redisclosure 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- tion to keep such data and 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 Bepartment shall require. The Contractor further agrees to indemnify and hold the County and Aging harmless against any loss, 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- tor. The Contractor, in accordance with its status as an independent contractor, covenants and agrees that neither the Contractor nor any of its officers, directors or employees will hold itself or themselves out as, or claim to be, an officer or employee of the County by reasonof this Agree- ment, 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- fied 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- ments 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 forthe operation of the program without the prior written approval of Aging. 13. Insurance and Indemnification (a) The Contractor agrees to procure, pay the entire premium for and maintain 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, includingcontrac- 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 a~,F Hundred Thousand Dollars ($300,000.00) combined single limit for bodily injury and properly 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 LIABILITY INSUR- ANCE in compliance with all applicable New York State 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 the provisions of the Work- 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 of 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 thirty (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 atthe 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 cedificates 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 ~,a,¢ age to property, arising out of the acts or omissions or 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 odgin, 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 underthe program; AG A1F (2/04) Page 10 of 14 pages of Exhibit A1F .ga,, (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 of administration which have the effect of subjecting individuals to discrimination because of their race, creed, national origin, sex, age, disability or marital status or have the effect of defeating or substantially impairing accom- plishment of the objectives of the program in respect to individuals of a particular race, creed, na- tional origin, sex, age, disability or marital 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 Contractor 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. § 3026(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 low-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 aga,F 19. Child Sexual Abuse Reporting Policy The Contractor agrees to comply with the Suffolk County Child Sexual Abuse Reporting 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 part 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 purpose of intent of 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 the signer of this Agreement has read and is familiar with the provisions 0f 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 with the Comptroller of Suffolk County the verified public disclosure statement, required byLocal 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 or to 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 Agreement or 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/orfunding by the County of Suffolk - Steve Levy, County Executive. (b) If the work of the Contractor under this Agreement should 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 or body desig- AG A1F (2/04) Page 12 of 14 pages of Exhibit AIF a~,,F nated by the County, a royalty-free, nonexclusive license to produce, reproduce, publish, trans- 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 municipality or government agency or body designated by the County, a royalty-free, nonexcIusive 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 policies shall be subject to 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 diligently 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, supplies, 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 A1 F (2/04) Page 13 of 14 pages of Exhibit A1F ,ga,, 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 whatever 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 Contractor. (b) If 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 written notice (or thirty (30) days' prior written notice if substantial breach of contract is involved) to the Director of Aging, specifying the reasons for termination and the effective date of termination. (d) The County 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 shafl be requested. Notice of termi- nation shall be deemed delivered as of the date of its posting by certified mail or atthe 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 padicular 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 that 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 a~,, L, aw 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) Exhibit B Program Specifications For Nutrition Programs 1. 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 service 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-delivered 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. 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. Service 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 No. AG004MI00_-06/7Y IFMS No. SCS EXE 0000000__ Rev. 417104 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) Price 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 resoume 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-agency 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__-06/7Y IFMS No. SCS EXE 0000000 Rev. 4/7/04 No. 001-6790/6774-4980-95284. 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, during regular business hours based on local need and available 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 accessible to people with disabilities as required by the Americans with Disabilities Act of 1990 (P.L. 101-336) and the regulations 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 Pads 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 L~w No. A~G004M/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) or weather emergency. In addition, an emergency supply of shelf-stable food should be made available twice a year for weather related emergencies. A list 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/unduplicated count report, 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 substantially 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 La~v' No..AG004M/00__-06/7Y IFMS No. SCS EXE 0000000 Rev. 4/7/04 No. 001-6790/6774-4980-95284- IllC Nutrition Program {Supplemental Nutrition Assistance Program) · Rural. w Low Income - The need resulting from an income level at or below the poverty threshold, as established by the Bureau of the Census, and updated annually as follows: 100 % of poverty Threshold 150% of Poverty Threshold Size of Family Unit (for IIIC Nutrition program(s))(for SNAP Program(s)) 1 $9,31 O/year $13,965/year 2 $12,490/year $18,735/year · Minority - Those 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 L~w 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) 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 forth 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 identifying logo in equal sized lettering on any printed 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 Lav~ 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) The Contractor must establish a formal system of soliciting comments from the participants concerning meals, transportation and supportive 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 Assistance 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 No. AGOO4MIOO__-O617Y 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 FOR CYCLE MENUS Meat or Alternate Meats - USDA Choice or Better Preservatives, tenderizers, or coloring agents may not be added to any fresh meat or fresh meat product. Veqetables 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 ¼ cup represents drained weight of fruits and vegetables Frozen Vegetables - Grade A - Fancy (USDA) Canned Vegetables - Grade A - Fancy (USDA) Margarine - 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 Iow-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) - for-tiffed 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 LaW No, .~G004M/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 RFQ No. 3/15524VH AG 4 (7/03) AG4 sohld 04-05 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, FACILITIES, DOCUMENTATION, SERVICES AND ACTIVITIES: This response form will become incorporated into Exhibit B to the Agreement 1. Pro,ram Desilm A/B. Southold Town Senior Services is a multipurpose senior center that has provided nutrition and support services to Southold Town residgnt's age 60 and older since 1974. The Center is located in the hamlet of Mattituck and is in close proximity to Mattituck village, public transportation, shopping, banking, et*. The service catchment area for Southald Town's nutritional program is the North Fork of Long Island, an area of appmxlmately 70 square miles. Because of its vast rural nature, vital transportation is provided to our senior participants via bas or van. There are 13 vehicles assigned to the Senior Center for the purpose of delivering meals to the homeboand and transporting seniors to the Center. Southold Town is proposing to continue providing nutrition and supportive services to senior citizens 60 years of age and older. Our intent is to improve, maintain or delay the decline in their nutritional status while helping them to remain independent at home and in their commlmity. We currently serve an average of 69 congregate meals and 156 home delivered meals daily. Our center is a licensed food service establishment with Suffolk County Deparlment of Health (see attached DOH certi, ficam/Sec, lg3 #1). Our dedicated staff is committed to serving qualiiy meals with a high nutritional value (see attached menus/Sea IK3 g4}. All meals and supportive services are provided to Southold Town residents aged 60+ and meet the nutritional requirements set forth in Exlfibit B Program Specifications. Dietary modifications are provided for special health requirements (diabetic and Iow sodium diets). We alsu eensonably accommodate partlcipants wha have particular dletaty needs arising from religious requirements or ethnic backgrounds. All means are submitted to the Registered Dietician with Suffolk County Office for the Aging for prior approval. Tho Center was recently renovated, fully accessible to persons with disabilities and is in full compliance with the Americans with Disabilities Act. The Center has a maximum capacity allowance of 175 and is complete with dining room seating for I00. We also have a new, fully equipped commercial kitchen. In addition to the senior untxition program, Sonthold Senior Services offers a full range of recreafiunal and comprehensive supportive services to Town residents 60 years of age and older. (See attachment 1K I.A.). B. 1. Congregate Meal Program: Southold Town Senior Nutrition Center is open 5 days a week, Monday through Friday (except for legal holidays). Our hours of operation are from gem- 4:00pm. Our objective is to provide senior residents with a nutritious daily meal, as well as a commlmity-mecting place where they can enjoy recreational programs and social activities, with full supportive services available on sit~ as needed. (See attachment Sea IK. 3 #5). All meals meet 1/3 of the RDA (Per Exhibit B. Program Specifications). Meals are served at 12 noon and transportation is available. The suggested confidential volantmy contribution is $2.00 per meal and no one is denied service due to inability or unwillingness to pay. All participant contributions are used to expand services. Our professional staffis on site to assist seniors at all times. Since safety is a high priority, the Senior Center is fully equipped with fire and smoke det~don alarms and fire suppression equipment. We ure known to the local fire deportment and are monitored by the Cuntral Station of Suffolk Security Systems. Fire evacuation plans are posted and fire drills are held twice yearly. Our center is inspected regularly and meets all fl~ safety standards for areas of public safely. (See attachedSe~ IE$ #2/6). SC Purchasing RFQ No. 3115~24VH SC Law No. 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 incorporated into Exhibit B to the Agreement IV.I.B. 2. Home Delivered Meal Program: Southold Town's Nuffition Program furnishes home-delivered meals to senior residents aged 60 + under the Supplemental Nutrition Assistance Program (SN.4J'). Priority is given to the frail, nuOtionally at-risk elderly· All meals are cooked on site and meet 1/3 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 determined prior to the delivery of service by using the standardized Client Assessment/Provider Data System (PDS). Each client rceeiviag home-delivered raeals is re, assessed at appropriate intervals based on the individual's situation. At a mlnlmtlm, clients receive a six-month conhact by telephone or in person and an in-home annual review in each 12-raonth period. The PDS client assessment helps determine what suppomve sermces are needed and the frequency of those services. Nntrition screening ~SI), provided to clients as part of the PDS in-home assessment has greatly assisted us in identifying those ~clividuais nutritionally at rislc Home-delivered meals are prepared on site and packaged in 3 compamnent disposable ah,mlnum trays. All packing and meal delivery procedures meet the safe food handling standards set forth by Suffolk County Department of Health and Nutrition Program specifications, (i.e., hot entrde's areserved at minimum off40 degrees Fahrenheit with salad and other cold items served at 42 degrees Fahrenheit or below. (Exhibit B)). The Town currantly has five homeboundmeal routes throughout oureatctanent area. Meals are transposed in special carriers to maintain temperatures and delivered in less than 2 hours. Meals are provided for those holidays and/or weather emergencies that fall on a weekday and an delivered the last business day beforehand. Additionally, emergency sbeff stable meals are dlslxibuted at least twice yearly for. weather related emergencies. 2. Program Desc..ripfion & Methodology A. Food Service: Southold Town Senior Services Nu~ition Program has over 29 years experience in providing institutional food service. Our professional kitchen staffprepares all meals on site. (All meals meet the RD.4 and all specifications for nutrition programs set forth in Exhibit ~). Food is uniformly portioned and served promptly at noon The kitchen is a fully equipl~d commercial kitchen and offers suitable storage for food supplies, d~ goods, frozen and refrigerated food products. All food and supplies are ordered ia bulk for optimal pricing and availability. The Center follows the Town's procurement policy as set forth ia General Municipal Law Section 103, relalive to formal bidcllng of food, supplins und eqnipment. The Center serves a~ avurage of 69 congregate and 156 home delivered meals daily. (Based on 2002program year). A sample six- week menu cycle is included for your review (see attachment Sec ~3 #4). Sonthold Town Senior Servioos employs a full kitchen staffconslsting of a cook, assistant cook, five food sendce workers and one kitchen aide. (Title Venrollee). No component of 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, FACILITIES, DOCUMENTATION, SERVICES AND ACTIVITIES: This response form will become incorporated into Exhibit B to the Agreement IV.2. B. Supportive Services: In addition to oar nutrition programs, seniors are provided with a comprehensive an'ay of support services designed to meet their many needs. Recreation programs, activities, ~gs and special events are offered regularly. Community outreach 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; oar Residential Repair Program is available to assist seniors with minor home repairs. We also have a Telephone Reassurance Program in which volunteers provide daily phone contact to homeboued seniors. In addition to regular route IranspoOation services, we provide demand responsive waasporlation for seniors to medical appointments, grocery shopping, etc. All support services/activities are printed on a monthly calendar, posted in the Cen~r and distributed to all homeb0tmd meal recipients (See attachment lK 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 daily. Regularly scheduled trips for shopping, senior citizen club meetings and recreational even~ fall under this service category. Demand Responsive transportation is reserved for seniors for medical escorff assistance and is provided on a reservation basis. Transportation services are available 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 to Town boundaries and we often transport seniors for medical services to Riverheed and points west as far as Stony Brook University Hospital. We have experienced an increased demand for transportation services since last year and have worked diligently to service the needs of our senior residents to meet this demand. The averagu numbor of one-way passenger trips provided monthly has increased fi-om !,073 in 2002, to 1,383 in 2003, a 29% increase in service. The Southold Town Highway Department maintains and repairs all vehicles as necessary. Our Senior Clerk Typist schedules all transportation services and maintains our fleet inventory, service records, and mileage reporLs for all Town and Suffolk County owned vehicles. D. Targeting: Oar goal in providing nutrition and support services to the elderly is to reach as may seniors as possible that need and can benefit from our program particularly the frail, low-income, minority, elderly who are nutritionally at-risE We have broadened our efforts in eommtmity 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 highlights Senior Services. Tiffs newsletter is distributed quarterly to all Town residents. We also continue existing practices of public service announcements, guest appearances on cable television, distribution ofpr0gram and informational brochures and activities calendar throughout the Town, ongoing program announcements in the Suffolk Times Community Calendar page, and Seulor Sou~eboolc We also employ ongoing outreach efforts to medical fanilifi~ doctor's offices, senior citizen club meetings, local churches, and other special groups or organizations that focus on serving oar senior population. Suffolk County Office for the Aging has also assisted us in ot~ ou~each efforts. ~C Purchasing RFQ No. 3/15524VH SC Law No. 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 incorporated into Exhibit B to the Agreement [Vo2. Targeting the low-income minority elderly living in Southold Town particularly in the Village of Greenport (4% of senlors in our catchment area in this category) is a high priority. We have increased vis~ility and access to our programs, particularly in the Village of Greenport. We have provided additional bus service to the area and have had frequent contact with church and community leaders, as well as other agencies serving the frail, low-income mino6ty community. I sit on the Board of Directors of Community Action of Southuld Town, located in Greenport This has afforded me an opportunity to promote our services in the Greenport Village. Our efforts have been successful in that our service delivery to our targeted Iow income, minority popalation has increased beyond 4% for 2003. Our additional target population is the kosher population. Ou~each efforts will include contact with the Rabbi Ul~ch at the Tifereth Israel Synagogue in Graenport to schedule aa informational presentation to the congregation. E. Coordination: Southold Town sponsors a monthly meeting of the Town's Comminee on Health Care Issues and the Elderly. The committee meets regularly and has a diverse group membership representing health care and community service providers from both the private and public sectors. The meeting provides networldng opportunities for professionals and allows for a vainable exchange of infurmation and coordination of the resources available to our sen/or popolafi0n. Yhe committee also provides a mechanism for minimizing duplicalion of programming for hnproved services to seniors. Within our agency, the PDS assessments allow us to maintain a comprehensive record on each client we serve and assists us in optimizing coordination with formal service prodders. Our professional staffraviews and discusses our clientele at regular intervals in order to develop the most appropriate, individualized care plan and follow-up services. Program staffshares common office space, which provides for optimal information exchange and improved coordination of service. A confidential Icg sheet is rna'retained in our main office that reflects daily status changes that occur with each individual client. Program staffaccesses this log daily and pro~ides follow- up accordingly. The log serves as an internal mechanism to reduce duplication ofservices provided to our program participants by our stag F. Client Assessment Provider Data System (PDS): Jnanne Johnson and Phililp Beltz (See attached resumes, Sec IV. 3 #7), serve as our primary PDS assessors. Ms. Johnson holds a BA degree in Behavioral Science/Community Mental Health and bas completed ongoing ~rninlng in completing client assessments with Suffolk Count, Office for the Aging ($COFA) and Southold Senior Services. Ms. Johnson has been with our agency for four years and has been respans~le for overseeing the liome delivered meals program. Phlillp Beltz, MSW, has extensive experience in Social Work practice and assists our agency ena part- time basis completing in-hame PDS assessments. In addition, both Carol Bet~y and myself are proficient in completing the PDS and offer assistance as ne, eded to avoid service inten-uption or deiny. ~;C Purchasing RFQ No. 3/15524VH SC Law No. 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 incorporated into Exhibit B to the Agreement IVo2o Client assessments (PDS) are completed on all seniors who request home delive~d meal service, service. Exceptions are reade for emergency situations or hospital discharges, at which time a PDS is completed within 72 hours. Service is initiated when a client, family member or other service provider makes a referral by calling the Center. An intake is completed ~th basic information provided and an initial horee visit is scheduled with the family to complete the full PDS assessment. Once eligibility is determined, the client is provided service in a timely manner. Each client is provided with a packet of information, which includes our progra~ poticies and procedures, and a complete list of the supportive services we offer. Six month fo~ow up contact is made by telephone to each client and an in home visit is completed at least once annually by our PDS assessors. Cheryl Kaswell, Account Clerk Typist, has been with our agency for over a year. She is proficient with the computer and is responsible for entering all clients in the PDS database. We are currently using the Windows biT application. Technical assistance has been provided by SCOFA on a regular basis. Our computer equipment is suitable for PDS purposes. Other Resources: As a division of Southold Town government, Senior Services is afforded the many services and resources of the Town. Our building cleaning and maintenance, both interior ande~erior is provided by our Deparanent of pablic works. Our Highway Department mai~tai,~ and repairs our vehicle fleet, keeps our parking lot and walkways clear of snow and ice in incleramt weather, and provides sanitation services. The Towns Accounting and Finance Department processes all vouchers, revenues, expenses, payroll and fmanelal records. The Town Police Depamnent provide emergency assistance as needed and maintains regular contact and makes appropriate referrals to our department for fi~il elderly residents at risk. Our Recreation Department provides an array of senior trips and recreational activities that our seniors participate im They also have two very active Senior Citizen Clubs that meet regularly and are politically 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 applicatiore. Our Town Supervisor is very supportive of our programs and handles ali public notices and features our deparlment in his quarterly town-wide newsletter. Senior Service also coordinates with outside agencies and human service providers that serve the senior population of Southold. Our agency has frequent contact and coordinates many services with thc following agencies: San Simeon Nursing Home, Eastern Long Island & Central Suffolk Hospitals, Peconic Landing Dominican Sisters, Lewin, Utopia, Peeon]c Bay and Catholic Sisters Home Health Agencies; Catholic Charli~es, No~h Fork Parish Oua~each, North Fork Housing Alliance, Community Action of Southold Town (CAST), American Red Cross, RSVP, Kcyspan Energy, Family Service League, Peeonic Community Council, Suffolk County O~ce for the Aging, Deparmaant of Social Services, Adult Protective Services and Mobile Cri$~ Team. Our Center is also a host site for our local school districts for community service projects and a field placement site for medical interns from Stony Brook University Hospital and Social Work studenla from the Stony Brook School of Social Welfare. Other volunteer opportunities are provided to seniors through our Telephone Reassurance/RSVP program. 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, FACILITLES, DOCUMENTATION, SERVICES AND ACTIVITIES: This response form will become incetporated into Exhibit B to the Agreement Contribution Policy: Seniors participating in our nu~ition programs are informed of their opportuni~ to make a volanta~ and confidential contribution for the cost of the meal. For congregate vaeal participants, a conUibution sign is posted and visible that states our funding sources, our sponsoring agency (SCOFA), our $2.00 suggested conlfibution, and that NO one is ever denied a meal due to unwillingness or inability to pay. Envelopes are provided for their anonymous c0nuibutioa~ and placed next to a locked box in a private comer out~ide of the main office. Senior~ place their contribution in the box if tboy desire. For home delivered meal participants, an unmarked envelope i~ provided by their driver on Thursdays with their meal. Clients have m opportunity to retom their envelope to their driver, who returns it to the Center staff. All bometound meal recipients are given a letter prior to start of service and annually thereafter, explainiag our contribution policy and procedures. The letter clearly states that all con~butiom are volantary and anonymous and that NO one will be denied service for inability or unwillingness to pay. Ail nutrition program participants are aiso informed that all contributions are used to expand services. 3. Documentation: The following documentation is included as attachments and referred to in our proposal. 1. Permit from Suffolk County Department of Health Services. 2. Permit Southold Town Building Deparlment~ 3. Food Handlers' Cerfffiuates. 4. Six-week sample menu. 5. One-munth activity schedule & list of support services. 6. Notification to the Mattituck Fire Deparlment 7. Project Staffresumes. 8. Exhibit B - Program specifications for NuhSfion Programs. ~C P'ur~hasing RI~Q No. 3/15524VEI SC Law No. AG RFQ For Nutrition Programs forthe Elderly IV.2.. Addendum: ' · .... Client Assessment Provider Data System (PDS) PD$ A~sessments .As s;~.~rl in RFQ, Cheryl Kas,,~ll has he~ v6th our c~c'nt for over a y~r. Sk is pmt~cicnt with the ¢ompulm' ~nd fa respons~lo for cnler~g all clic"nt~ in the PD$ I~I~ Brae. For l~ogram year 20011, we ham enm't~d. ?0% of our c. ns~s. To impmv~ our ra~, M~. Kas~ll will increase her work time for eating PDS' thom 50% In 75%. We also are plan~g to ~ up nnoti~er computer for ~*- enby so other support s'laff c~n assist with the worklead, n~eded. Sou~old Town will en~r a m;nlmurn of 25" client files Ina the PDS ~ base mo~dy to m'~sore full compliance. I am confid~nt h'uit we will t~.ach our 1~ mrlt~ for PDS enlry, SOncc the backlog of caseS is cnu:md the numi~- of cues cntx-~d will ¢olncld¢ witt thc number of new PDS' gtmc-nami per month. Purchasing RFQ No. 3/15524VH SC Law No. AG__ RFQ For Nutrition Prol~r'ams for the Elderly Section IV' Technical Services Response Form PROGRAM DESIGN, FACILI'rlXS, DOCUMENTATION, SERVICES AND ACTI~I-I'I~S: This rc~'pon~e form will become ine. orpor~led into F. xb, ibit B m thc Agreement IV.I.B. 1. C. Emergency Manngement: The Senior Services Director is part of the Emerge:ney M~%oemcnt Teton for Southold Tc~m. The Human Rcsou~.~ Cen~ter is a desi~n~,.d non-medical special needs eva~uatlon shelter for the Tmon. The Senior Center is equipped with ~m e~ne~cncy gcnernmr and om' on.call staffis well trained in working w~th thc elcL"rly. 'l'be American Red Cross n. lso provldcs tznined shelter voluntee~ for additlon~l suppm during emergencies. In the even! ofnn ~nne~gency (weather related or other, i.e.: ~nodsm alert, c~c). The Town Supervisor Act~ the Emergency Mene~er for the Town. He declares a ~'~/~ of emergency, and mobiliz:.s theemer~ency numagcmcnt ~ Thc local Emc~,,cncy Olx:r~ions C, cnter (EOC) is a clearing hous~ for il c~ls. The EOC identifies the nccd and dhr. cts individuals to the appro~ services. The Sen~or Cmer s~affhes a list of seniors th~ ar~ identified es high priority for e~-ua~Jon m~c] lhe Senior Center Direc~0r ~d staff ceil the seniors md n~d~ thc loc. al EeC. The volontcer fire depa,-~sents coordin~e U~mlx~etinn m the evn~'ua~lon centers. Senior~ with special medical needs ~re ~w. sported to Ce~zni Suffolk ~10spt~l. Thos~ For all seniors, the Iocel radio s~ions broedce.s't inst~,vctions for emergency preparedness end ~ them to the app~x:~,riam ev~uetion centers. In rant, this pa~t August our cerm~ ~ oiled a~ an ~a~-'r~cncy shel~'r dm`ing the blackout. If the Cen~er is c]o~l e,~rly for a wether rel~d emergency, ell ~j~ ~ ~;~ to ~e~ ho~. If Se ~ is c[o~ ~inn ~ al~ ~a ~e I~ ~o s~fi~s. All ~ on b~ &li~ ~d co~ m~ ~s ~ ~vi~d ~ · ~k~ of ~om ~ follow ~ ~ ~e ~ clos~g. ~ m~y ~, o~ ~ ~ ~n wi~ no ~s~ ~i~. All home deliv~ m~l ~ci~ ~e ~vi~ ~ ~ ~ me~s m ~ ~v~ ~m ~ely ~li~ ~e m ~e ~. ~ ~ ~ ~l c~lcd ~ ~e ~ly m~g ~d n~fied when ~ ~not ~liv~. ~ ~ is ~ ~nd~ ~ ~e l~nl KAREN MCLAUGHLIN SENIOR CITIZEN PROGRAIVl DIRECTOR Human Services ~gwn of Southold P,O. Box 85 750 Pacific S~reet Mattituck, NY 11952 Tel. (631) 29g-4460 Fax (631) 29g-4462 Attachment W.3 #6 Nulrition Pwgram Home Delivered Meals Case Management Essential Transportation Senior .Adult Day Care Alzheh~r's Day Care Telephone Reassurance October 27, 2003 Chief Edward Hanus Mattituck Fire Dept. 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 writing of the nature and location of 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 outreach, recreational activities, home delivered meals program and transportations services. Our social model Senior Adult Day Care Program operates in our annex called 'Kafinka 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 central station and regularly maintained by Suffolk Security System. Our fire suppression system is also closely monitored and maintained by All Island Fire Protection. Please contact me at 298 ~60 if you have any questions or would like more ir~ormation about the Senior Center. Thank you. Director of Senior Services Levi No.'AG004M/0020-07R Rev. 6/8/04 Supplemental Nutrition Assistance Program IFMS No. SCS EXE 0000000 No. 001-6774-4980-95284- EXHIBIT C RATE PAGE (CONTRACTOR'S COST RESPONSE) TOWN 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 sohld 04-05 Exhibit D Grievance Procedures 1. Purpose In accordance with {}306 (a) (6) (P) of the Older Americans Act, as amended (OAA), 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 Act. 2. Notifying Participants of the Right to File a Grievance (a) The Contractor shall inform all participants in the program of the right to file a grievance. A summary of the procedures, including a statement that assistance to file shall be provided to older persons, 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 also 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 reassessment for services. (b) A participant or applicant who is denied Title III 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 may grant 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 fodh 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. Rev. 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 the grievance is filed. The response shall set fodh 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)for 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 will 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 fody-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: 04/21/2003 Assessor"s Name: Initial Assessment Date: Agency Name; Intake Date: Reason for Assessment: Agency Code: Source of Info.: (Re)Assessment Date: ~,LIENT INFORMATION Soc Sec #: Name: Address: Apt. #: 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. lndJan/Nat. A[as [] Married [] With Non-Relat [] Asian,~Pacific Islandel L~ Separated ~] With Relatives [] Black eot Hispanic [] Single [] With Spouse [] Hispanic [] Widowed [] Other [] White/non-Minority Veteran Status: I Languages (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 Is the Client Receiving Medicaid Homecare? [] Yes [] No i:O. AC Please note the following conlact classifications here: Emergency, Informal Support, Lives With, Neighbor, Who Has the Key? Client Assessment Date: 04/21/2003 bontact fist continued.') Emer.qency Contact: Name: Address: Phone Number: Relationship: Classifications: Emer.qency Contact: Name: Address: Phone Number: Relationship: Classifications: Classifications: Name: Address: Phone Number: Relationship: Classifications: Name: Address: Phone Number: Relationship: Classifications: Name: Address: Phone Number: Relationship: Classifications: Name: Address: Phone Number: Relationship: Classifications: Name: Address: Phone Number: Relationship: Classifications: Name: Address: Phone Number: Relationship: Contact Notes: MEDICATIONS Medication Dose/Frequency Comments Client Assessment Date: 04/21/2003 Does the client have any problems 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: Medication Comments: Who obtains medication? Name: Address: Phone Number: Relationship: Pharmacy: Phone: HEALTH Does the client have any chronic illnesses or impairments? [] Alcoholism [] Colostomy [] Hyperglycemia [] Recent fractures [] Alzheimers [] Congestive heart failure [] Hypoglycemia [] Renaldisease [] Anemia [] Dental problems [] incontinence [] Respiratory problems [] Anorexia [] Diabetes [] Liver disease [] Smelling impairment [] Arthritis [] Diverticulitis [] Low blood pressure [] Speech problems [] Cancer [] Gallbladder disease [] Osteoporosis I[~ Stroke [] Chronic constipation [] Hearing impairment [] OtherI[] 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: Name: Address: Phone Number:. Client Assessment Date: 0412112003 Current Problems: Significant History: Health Care Events within the Last Six Months Events Date Reason for Service Comment Clinic Visit Emergency Room PRI Hospital Visit DMS-1 Physician Visit Other Does the client visit the doctor less than once a year? [] Yes [] No Frail I Disabled: [] Yes [] No Does the client require a comprehensive medical exam? [] Yes [] No Assistive Devices? [] Cane [] Dentures [] Hearing aid [] Walker [] Eyeglasses [] Wheel chair Does the client require training 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 [] Impaired decision making [] Memory deficit [] Other [] Physical aggression [] Problem behavior reported [] Sleeping problems [] Suicidal thoughts [] Verbal disruption [] Worried or anxious Other (specify): Client Assessment Date: 04/21/2003 Comments: Any stressful life events within the past year? Does the client require a mental health evaluation? [] Yes [] No qUTRITION Height: Weight: Body Mass Index: Any weight changes within the last six months? [] Yes: Howmuch?: [] No How many meals does the client eat daily? Does the client ever go without food? [] Yes: Specify'i~: [] Ne 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 Problems: [] Appetite 'Select all that apply) Chewing/Swallowing Dehydration Dental Digestive problems Overweight Taste impairment Underweight Nutrition Profile: (Select all that apply.) [] Inadequate mfrigeratoflfreezer and cooking facilities [] Unable to open containers/cations and cut up food [] Requires nutritional supplements [] Has a physician-diagnosed food allergy [] 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 [] Vegetables [] 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 2 2 2 2 4 1 1 2 2 Nutritional Risk Status: Nutrition Index: Client Assessment Date: 04/21/2003 Comments/Additional Notes: FUNCTIONAL STATUS Status Codes: 1. Totally Able 2. Needs some asst, 3. Needs maximal asst. 4. Unwilling to perform Needs Met: -U Unmet -I Informal supports -F Formal service -A Assistive Device Instrumental(IADLS) Activities of Daily Living Hours Frequency 4andle personal business/Finar~ I I I [ I IH_°usew_°rldCleaning I I I _ I .aundry ~repare and Cook meals =repare light meals/Reheat ~elf-admin. of Medication ~hoppir~.g_ Jse telephone Jse Transpodation Status Needs ~Contact Code Met? IName/Re ationship IADL Comments: IADL's: Impaired Activities: Met by Informal Suppods: Met by Formal Suppods: Met by Assistive Device: Unmet Needs: Activities of Daily Living (ADLS) B~thing ID~essing ~E~tin~g ~~. ~obility IPersonal Hygiene Status Needs Contact Code Met? Name/Re at onsh p I I I I I I I I I I I I I I I Hours Fre~quency t J ~,DL Comments: ADL's: impaired Activities: Met by Informal Supports: Met by Formal Supports: Met by Assistive Device: Unmet Needs: ADL/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? Is caregiver relief needed? [] Yes [] No If yes, when? Could other informal suppods 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? 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 suppods provide relief? lOUSING Type of Housing: Ownership Status: [] Multi family Unit [] Single Family Unit [] Own dwel]ing [] Rent dwelling [] Other Home Safety Problem? [] Accumulated garbage/didy living areas [] Loose scatter rugs [] No working C0detectors [] Bedroom-bath traffic lane has obstacles [] No access to telephone/emergency numbers [] No working smoke detectors [] Cluttered stairs/walkways [] No grab bar at toilet/bathtub [] Odors [] Cords/wires across walkways [] No handrails on stairways [] Plumbing problem [] Doorway widths too narrow [] No light in reach of bed [] Poor lighting inbathraom [] Exposed wiring/electric cords [] No locks on doors/windows [] Poor lighting inhallway [] Inadequate heating/cooling [] No rubber mat/decals in bathtub [] Stairs are not well lighted [] Inadequate hot/cold water [] Stairs in poor c0ndition [] 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 Code Status as follows: HB = Has Benefit ME = May Be Eligible P,A = Refuses to Apply AP = Application Pending D = Denied NE = Not Eligible Benefit I Status code II Benefit EPIC =ood Stamp__s Health Insurance HEAP Status code I~ailroad Retirement _ _ [IReal Prep. Tax Exemption JlReverse Modgage _ liT 214 I i;SCRIE [Lifeline I I[Section 8 ILong term care insurance [Medicaid I I I~SLIMB I I~Social Security IMedicare I I~ssD IMedigap Insurance/HMO ~Private Health Insurance I r~VA Benefits I [Public Assistance I !~/eteran Tax Exemption I pther I I~P~P I_ ~Other I Notes: Does the client require counseling on entitlements and benefits? [] Yes [] No -IEALTH INSURANCE INFORMATION Insurance Company Identification Plan # ti' Client Assessment Date: 04/21/2003 ~URRENT SERVICES (List any service client received within the last 6 months, regard/ess of whether or not it was authorized/arranged by your agency.) Service Funding Org, Provider/Contact Units Freq. Auth. Date End Date ASSESSMENT SUMMARY Evaluate Informal Support System: [] Adequate Can Expand [] Adequate Not Expand [] Inadequate/Limited [] Other [] Temp Unavailable Would client accept help from the family? [] Never [] Other [] Short Term [] Uncertain Rate client's motivation to stay in the community?: [] Cannot Rate [] Highly Motivated [] Motivated with Support [] Needs Support [] Resistive Dieposition: [] Eligible for AAA in-home [] Other [] Refer to CHHA [] Refer to Medicaid Homecare [] Refer to Nursing Home [] Refer to Self-Pay service Could neighborhoodlcommunitylreligious affiliations provide assistance? Summary: Yes [] No ~CARE PLAN Care Plan Goals: Care Plan Objectives: Client Outcomes: Client Assessment Date: 04121/2003 Proposed Time Frame: Client self-directing/able to direct home care staff? Client Preferences Regarding Service: [] Yes [] No ~PLANNED SERVICES To include services provided by Informal suppotls in the Care P/an, put Contact name under Provider and list/nfomal as the Funding Org. Service Funding Org, ProvidedContact Units Freq, Start Date End Date =LANNED TASKS Task Comments Due Date OK to discuss plans with informal supports? Plans discussed and/or accepted by client/informal supports? [] Yes [] No [] Yes [] No Reassessment Due; Supervisor's Name: Date of Review: Assessor Supervisor Client Assessment Date: 041211200:3 IFINANCIAL Ilnfo Received From: [] ~Agency [] ~gent [] ,unt rq[ rother [] IBrother-in-law []~OHHA [][oousi. ~ ~D~ugh~r ~ ~Dnught~r-in-lnw ~ ~FTA ~ ~octor ~ ~omestic Pa~ner ~ ~ather ~ ~ather-in-law [] ~Grand Daughter [~rand Son [] ~3randfather [] ~Grandmother [] iHospital [] [Housing []~usband [] [internal [] ~_andlord [] IMedicaid [] [Mother [] [Mother-in-law [] ~Neighbor []~ephew []Niece [] [Officials [] [Other [] jRelative [] JReligious Org. [] ~Sister [] [Sister-in-law [] ~Social Serv Agc [] ~Social Worker [~on [] ~Son-in-law [] ]Step Daughter [] ]Step Father [] ]Step Mother [] ]Step Son Financial Information: Monthly HousinFI Exp. SSNI: SSr42: JElectricit¥ [$ ~Heating/Cuoking F~$ [$ pther ~ ~_ ~RentJModgage/Co-($ Faxes Ih'elephone ~$ ~ ~Nater/Sewage ~$ ~ Monthly Income SSNI: SSi'I2: 1Dividends from Inv¢; ~ Ilnterest ~$ iNch-client Inc.not ~$ J$ IOther J$ ~ JPension/Retiremen~$ ~5 JSalaryNVages fmm~$ ~ ]Social Security ~Supplemental Secu~$ IS Monthly Medical Exp. SSN 1: SSN2: JHea]th Ins. Premiu~ [Medication ~ther ~ ]Physician ~ Resources SSNI: SSN2: ~Checking ~$ ~ JLife Insurance - Ca~$ ILife Insurance - Fa~ [other (IRAs) ~$ }Other Cash Accts. ~$ IReal Property ~$ ~avings ~ ~Stocks,BondslMutu~$ [~ ~uper ~] ~.lncle Client Assessment Date: 04/21/2003 [] [Visiting Nurse [] ~Wife ;)thers Information: S.S.N Name Relation IEvent: [] [Event Based [] IFollow-up Assessment [~ Ilnitial Assessment ~ ~Reopening [] IReview prior to Discharge E~ ~outine Reassessment 1Comments: Client's Signature Case Worker's Signature SEC. 20. HOLIDAYS Full-time employees shall be entitled to the following holidays offwith.pay, to the fa'st day of Ianuary, known as New. Year's Day the third Monday of lanuary, known as Martin Luther King, Jr. Day the twelfth day of February, known as Lincoln's Birthday (delete, effective January 1, 2000) the third Monday in Febma~-3,, known as (President's Day) Washington's Birthday the last Monday in May, known as Memorial Day the fourth day of July, known as Independence Day the first Monday in September, known as Labor Day the second Monday in October, known as Columbus Day the Tuesday next succeeding the fu-~t Monday in November, known as Election Day the eleventh day of November, known as Veteran's Day the fourth Thursday in November, known kq Thanksgiving Day the day after Thanksgiving Day, except for employees assigned to the Landfill, who ~hall receive a floating holiday tO be ~cheduled as though it ? 3/2 were a personal day (effective January I, 2000) the twenty-fifth day of December, known as Christmas Day the eve of Thanksgiving Day, ~ day the eve of Christmas Day, t//day the eve of New Year's Day, ¼ day APpenDiX' N SUMMARY - RFQ FOR NUTRITION PROGRAMS 2003 PROPOSER: .Town of Soutnold -(Senior' Services) GEOGRAPHIC CATCHMENT AREA: ' ' ' Town of Southold ( 2000 US Census Tracts 1700.01, ~?00.02,'~70~.0Z, ~7~2.02) PROV DE ONE COPY OF THIS SUMMARY SHEET FOR EACH PROGRAM CA'fOHMENT AREA. YOU MAY MAKE PHOTOCOPIES .OF THIS FORM. TARGET COMMUNITY: Southold Town ( includes Village of Greenport (1701.01) Elderly Low Income Minority and Kosher Communities. [~ 'CONGBEGATE ~'~ HOME-D.ELIVERED E~' CATERED-:F~. cook ON SITE 52 105 · 5 8AM-4PM Number of meals to be served each day- congCegate Number of meals to be served e¢c~ day- Home-Delivere~ Number of days per week-for pr0pram Circle days of programiO. 'Q (~ Hours ofoperatkm each d'~y SA SU Location for congregate site: Southold Town Human Resource Center, 750 Pacific 'Street, Mattituck N.Y. 11952' Location of program administration, if difference from congregate site: Same Please state any additional information affecting service delivery: OFFICE USE ONLY: Revised ~'25/03 Southold Town Senior Services ' 750 Pacific Street Mattituck, New York 11952 Phone # 631 298-4460 SUMMARY SHEET 03 last rev. 5128104 Suffolk County Legislative Requirements Exhibit for Contracts This exhibit is attached to and is made part of the contract executed with the County. II Suffolk County Living Wage Requirements "Suffolk County Living Wage Requirements Exhibit As Last Revised by the Suffolk County Department of Labor on 5/12/04" (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 Of'' (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 Dl)cuments ,Suffolk Co,unty Living Wage Requirements Exhibit As I.est 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" (the "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 forth in the Living Wage Law. Such rate shall be adjusted annually pursuant 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 I page) Suffolk County Department of Labor - Living Wage Unit Certification/Declaration - Subject to Audit Form LW-38 (consists of I 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 County Living Wage Requirements Exhibit As .Last E~vised 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) Certification/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-1, 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~LRPTER 577, ARTICLE IV, Child Sexual Abuse Reporting Policy (Adopted 6-11- '2005 ~y Res. No. 543-2002] ~ 577-16. Policy established. The County of Suffolk hereby establishes a formal child sexual abuse reporting policy as follows: Each County Department that has a contract or agreement with any individual, partnership, corporation, joint venture, business organization, or other entity which receives payments from the County of Suffolk, either directly or as a conduit for payment from another level of government, shall notify such individual, partnership, corporation, 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 to receipt of such payment and continuing receipt of such payment, in those 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 of the clergy, involving any of the following sex offenses: (1)Rape in the third degree, § 130.25 (less than 17 }'ears old) of the l~ew York Penal Law; (2)Rape in the second degree, ~ 130.30 (less than 14 years old) of the l~ew York Penal Law; (3)Rape in the first degree, § 130.35 (less than 11 years old) of the New York Penal Law; (4)Sodomy in the third degree, ~ 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 New York Penal Law; (10)Aggravated sexual abuse in the third degree, § 130.66 (less than 11 years old) of the New York Penal Law; (Il)Aggravated sexual abuse in the second degree, § 130.67 (less than 11 }'ears old) of the New York Penal Law; (12)Aggravated sexual abuse in the first degree, § 130.70 (less than 11 years old) of the New York Penal Law; (13)Course of sexual conduct against a child in the first degree, § 130.75 (less than ll 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 New 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; (18)Aggravated sexual abuse in the fourth degree, ~ 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)Facilitating 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 New (less than 14 years old) of the l~ew degree, ~ 130.50 (less than 11 years old) of the New third degree, ~ 130.55 (less than 17 }'ears old) of the second degree, § 130.60 (less than 14 years old} of the first degree, ~ 130.65 (less than 11 years old) of the B. Definitions. For the purposes of this article, the following terms shall have the meanings indicated: CLERGY -- A duly 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 belongs, 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. ~INOR -- Anyone under the age of 18 years of age; All supervisory, administrative, or management employees of any individual, partnership, corporation, joint venture, business organization, or other entity receiving payment from the County of Suffolk, either directly or as a conduit fcr 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 that a minor coming before them is or has been the victim of sexual abuse, 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 any of the following sex offenses, said reporting to occur within 24 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 (less than 17 years old) of the New York Penal Law; (2)Rape in the second degree, § 130.30 (less than 14 }'ears old) of the New York Penal Law; (3)Rape in the first degree, ~ 130.35 (less than 11 }'ears old) of the New York Penal Law; (4)Sodomy in the third degree, § 130.40 (less than 17 years old) of the l]ew York Penal Law; (5)Sodomy in the second degree, § 130.45 (less than 14 years old) of the New York Penal Law; (6)Sodomy in the first degree, § 130.50 (less than 11 years old) of the New Yerk Penal Law; (7)Sexual abuse in the third degree, ~ 130.55 (less than 17 years old) of the New York Penal Law; (8)Sexual abuse in the second degree, ~ 130.60 (less than 14 years old) of the New York Penal Law; (9)Sexual abuse in the first degree, § 130.65 (less than 11 years old) of the New York Penal Law; (10)Aggravated sexual abuse in the third degree, § 130.66 (less than 11 years old) of the New York Penal Law; (il)Aggravated sexual abuse in the second degree, § 130.67 (less than 11 years old) of the New York Penal Law; (12)Aggravated sexual abuse in the first degree, § 130.70 (less than 11 }'ears 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 New York Penal Law; (16)Forcible touching, ~ 130.52 (sexual er 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 Mew York Penal Law; (18)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 }'ears 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; Whenever a clergy person is required to report under this article, in his or her capacity as a member 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 them is or has been the ¥ictim o~ sexual abuse, or when another 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. [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 clergyman 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 employees 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 let RES05VED clause of this article to supervisory, 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 children to help protect themselves from childhood sexual abuse; skills for detecting the signs of childhood sexual abuse; and how to report allegations of childhood 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. Second violation within a three-year period subsequent to a first violation: the contract vendor shall be subject to a fine of 10% percent of the contracts that the pertinent violating individual supervisor, manager, or administrator oversees, not to exceed $50,000. In addition, the contract vendor shall be put on probation for three years. An 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 payments are for past or future goods or services. The contract vendor shall not be eligible for funding from the County for three },ears from 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 TO PARTY 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, entertainment, 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 Ejection Law. § 386-2. Prohibited acts. A. 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 political party to solicit, receive or accept a gratuity in connection with 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 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. A. 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)year in prison or a fine of not more than one thousand dollars ($1,000) or by both such fine and imprisonment. B. 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 Coullty Fom~ 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/vendors that have a contract with Suffolk County. hq the eveut contractor/vendor is exempt from completing paragraphs numbered I tlu'ough 11 below, so indicate at paragraph number 12 below setting forth the reason for such exemption. Notwithstanding such exempt status, you must execute this £orln below before a notary public. $.b Contractor's/Vendor's Name Address Town of Southold City and State Contracting Department's Name Address Zip Code Payee ldentificatiou or Social Security No. Type of Business__Corporation__Partnership__Sole Proprietorship__Other Is contractor/vendor entering into or bas contractor/vendor entered into a contract with Suffolk County iu excess of $1,0007 Yes No. Has contractor/vendor eutered into three or more contracts, including the one for x, bich you are now completing this form, with Suffolk County, any tlu'ee of x~.hich, when combined, exceed $1,0007 Yes No. Table of Organization. kist names and addresses of all principals; that is, all indMduals 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 ~bis 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 indMdual 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). I0. 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 yes to 8 above, you must submit with this disclosure statement, a complete financial statement listing all 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 inclnde this Contractor's/Vendor's Public Disclosure Statement with the contract. (Describe general nature of the contract.). Page I of 3 Public Disclosure Form i 1. 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. 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. 12. If you are one of/lie entities listed below at a) through c) or you qualify under d) below, you are exempt from completing paragraphs numbered 1 through 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 serx'ices Please check to the left side of the appropriate exemption. 13. Verification. This section must be signed by an officer or principal of tile contractor/vendor authorized to sign for the company for the purpose of executing contracts. The undersigned being sworn, affirms under the penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his~ler own knowledge, true. Dated: ~1 ~1,'} I [ 4 Signed: Printed Ndme of Signer: ~o,~ Title of Sider: Name of ContractoffVendor: UNIFORM CERTIFICATE OF ACKNOWLEDGMENT (Within New York State) STATE OF NEW YORK) COUNTY OF ) ss.: On the o77 _~ay of~ in the 3'ear 2004 before me, the undersigned, personally appeared ,.70.Clfun V: ~d),~ro~-2 personally kmown 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 alld acknowledged to me that be/she/they executed the same in his/her/their capacity(les) and that by his/her/their signature(s) on the instrument, the indMdual(s), or tile person upon behalf of x~ich the indMdual(s) acted, executed UNDA J. COOPER the instrument. NOTARY PUBLIC, State of New Yo~ ~(~,~..~.. No. ~822563, ,Suffolk County (signature and o ff~'e of indivic~ual taking acknowledgement) Page 2 of 3 Public Disclosure Form UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT (Without New York State) STATE OF ) COUNTY OF ) On the .day of in the year 2004 before me, the undersigned, personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the indMdual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/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 the person upon behalf of which the individual(s) acted, executed the instrument, and that such individual(s) made such appearance before the undersigned in (Insert the city or other political subdivision and the state or country or other place the acknowledgement was taken) (signature and office of individual taking acknowledgement) Contractor's/Vendor's Public Disclosure Statement Form (Rev. 3/04) Page 3 of 3 Public Disclosure Form C:~.Documents and Settings\mvalerie-kcmpinski\M} Documents',LEGAL\Sta~dard Contract clauses\SCEX 22 Discl 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 whole 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. 28-1993~] 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 to exemptions for contractors doing business with the County Department of Social Services; hospitals; educational, 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 be 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 available 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. ~ 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 the Executive on 5-26-1993. See note above. Page l of 3 (3) Not-for-profit corporations. (4) Contracts providing for foster care, family day-care providers or child protective consulting services. FULL DISCLOSURE CLAUSE - A proviso to 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. B. 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 partof the specifications, if any, which are submitted to interested potential bidders. D. 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 filed 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. E. 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 employee 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. Suffolk County may resort, use or employ any remedies contained in Article 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 legislation or appropriation actions pending before local, State and Federal executive and/or legislative bodies in connection with the awarding of any contract, the making of any grant, the making of any loan, the entering of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any contract, grant loan, or cooperative agreement. (2) If any 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 appropriation 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 undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 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. By: ignature of Official Authorized To Sign Application For: Name of Grantee Certification Regarding Lobbying 04 CERTIFICATE OF LIABILITY INSURANCE J ' UAY26. ' PRODUCE~ ll-IIS CERT1RCATE IS ISSUED AS A MATI'cR OF INFORMATION ROY HREEVLa~GENCY, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE PO BOX 64, 13400 MAIN RD. HOLDER. 1HIS CERTIFICATE DOES NOT A~END, EXTEND OR PHONE: 63t-298-4700 FAX: 631-298-3850 INSURERS AFFORDING COVERAGE NAIC # TOW~ OF $OU'FHOLD INSURER B: American Alternative Insurance Company P.O. BOX '1 t79 INSURER C: Insurance Corporation of Hannover 63096 MAIN ROAD $OU')'HOLD NY ¶'197~-0959 IRSURERD: ~ ~ H63X0000~8 JAN 1 04 JAN 1 05 ~ ~ t ' 1,~,~ A ~ ~&~ I$ 1,~,~ ~ ~ H~ ~ 1 ~ J~ 1 OS ~D S~ ~ ~o ~Y: ~ I ~ ~ ~U~ J~ 1 ~ J~ 1 OS ~ ~ t0,~,~ B ~S~N OF ~~~~CL~ ~D~ ~E~I SPEC~ PRO~S~ ~: ~E ~ ~ULT DAY ~ COUNTY OF SUFFOLK n~s~m, ms ~c.E NTS OR mmf~F-SEm'A'm~S. OFFICE FOR THE AGING I , P.O. BOX IS100 .~Lmmlu~) ~'~ATIVt; ~{}~]~ ~ HAUPPAUGE, NY 11788-0099 Atta~lon: · FAX: 298-4482 KAREH MCLAUGHLIN ACORD 26 (20~1/08) 'Certificate#' 4158 Thomas A. Dickerson