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Autism Application Technical Assistance

Autism Application Technical Assistance

Milwaukee County Department of Health and Human Services

Disabilities Services Division

June 12, 2008

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DHHS StaffDHHS Staff

Geri Lyday, Administrator, Disabilities Services Division Liz Kraniak, Supervisor, Disabilities Services Division Dennis Buesing, DHHS Contract Administrator Diane Krager, DHHS Quality Assurance Coordinator Wes Albinger, Contract Services Coordinator Sumanish Kalia, Contract Administration CPA Consultant

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Some minor revisions have been made to the application. If you have already completed the application, simply complete the changed sections on the new application, as indicated by sections with a shaded background.

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Disability Services Division (DSD)

Provider Network

2008 – APPLICATION

General Information

Section A: National Provider Identifier (NPI) Number

Federal Employers Tax ID (FEIN) Number:

Agency Name _______________________________________________

Medicare certified Yes___ No ___ Medicaid Certified Yes ___ No ___

Service Location MA # (if applicable): Site # (if applicable)______________

Service Location Name:

Business Address:

City: State: Zip:

Business Telephone ( ) Fax ( )

Mailing Address if different from above:

Address:

City: State: Zip:

Website Address (if available): http://www. Email Address: _________________________________________ Agency Director Director Telephone ( )

Agency Contact Contact Telephone ( )

Wheelchair Access Yes No Handicapped Parking Yes No DD/TTY Number Yes No (If yes, phone number: )

MA Waiver Manual accessible to all employees at all times. Yes No

(Internet access to Manual: http://www.dhfs.wisconsin.gov/LTC_COP/waivermanual/index.htm) (Internet access to SPC Desk Card: http://dhfs.wisconsin.gov/forms/ddes/dde2018i.pdf

National Provider Identifier: Covered entities under HIPPA are required to use NPIs to identify health care providers in standard transactions. Go to www.nppes.cms.hhs.gov to learn more.

Federal Employer Identification Number. This is the number the IRS issues for filing of payroll tax forms. If you have no employees, use your social security number.

Being Medicare/Medicaid certified means you are able to bill Medicare/Medicaid directly for services.

If Medicaid certified, please provide your number here.

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Section B:

If your agency is a subsidiary of another agency (the parent), please identify it below:

Parent Agency: Parent Agency Telephone ( )

Parent Agency Address:

City: State: Zip:

Parent Agency Contact: Parent Agency Contact Telephone ( )

Additional Locations

If your agency has additional sites that will be utilized to provide services through the DSD, please complete an additional Page 1 (Section A only) of this application for each site: Please attach an agency license for each site, if required per MA Waiver Manual for service(s) provided. Agency Information

Please check all the statements below that best describes your business operation:

Individual Credentialed Provider Partnership For Profit Agency

Service Corporation Corporation Non-Profit Agency

Sole Proprietorship Limited Liability Corporation (LLC) Single Member LLC Is the Agency Incorporated? Yes No (If yes, please enclose articles of incorporation) Is the Agency a LLC? Yes No (If yes, please enclose articles of organization and operating agreement)

Please check all that apply:

Population served: Developmentally Disabled Physically Disabled Child Long-Term Support

Children’s Autism Other_________________________

Days/Office Hours: MINORITY OR DISADVANTAGED BUSINESS ENTERPRISE? MBE Yes No DBE Yes No Certified by UCP? Yes No If No, Minority Vendor? Disadvantaged Vendor? At least 51% of the Board At least 51% of the Board of Directors are minorities Directors are women Organization is owned and Organization is owned and operated by at least 51% minorities operated by at least 51% women

Complete Section A for each site which is currently or proposed to be utilized for services

More than one may apply

Must have one of these boxes checked if your agency is a corporation

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FAITH-BASED ORGANIZATION: Yes No (defined as affiliation with a denomination or church) ORGANIZATION USES VOLUNTEER(s) AS SERVICE PROVIDERS: Yes No BI-LINGUAL STAFF AVAILABILITY Are any of your individual service providers bi-lingual? Yes No If yes, please identify them by name and indicate the language or languages (other than English) that they speak. Name:___________________Language(s): Certification Yes No Name:___________________Language(s): __________________________ Certification Yes No Name:___________________Language(s):___________________________Certification Yes No Name:___________________Language(s):___________________________Certification Yes No Do any of your service providers work with deaf or hearing-impaired clients? Yes No If yes, name of staff:

Individual Providers Currently Working for an Agency in the Long-Term Support (LTS)

Network Applying to Join the Network Sole Providers (individuals in the LTS Network who are one-person agencies) may not simultaneously provide the same services for other agencies in the DSD or CMO without first informing that Agency’s Director, in writing a notification letter, of their intent to do so. A copy of the notification letter must be submitted with the application. Complete the following as applicable:

1. List agencies in the Network that you are employed by or affiliated with (e.g., consultant, Board of Directors, or in an executive/managerial role).

2. List Milwaukee County programs for which you are currently providing services (Wraparound Milwaukee, WIser Choice, Disabilities Services Division, Department on Aging, Children’s Court Center, etc.).

References

Please be advised that DSD or the CMO may require start-up agencies or agencies in business for less than five years to submit two letters of reference to follow a format prescribed by DSD or the CMO.

Please list agency and your position.

For example, you provide in home physical therapy as a physical therapist for ABC agency, and you also work independently as a physical therapist providing in home physical therapy. This must be disclosed to ABC in writing, and a copy of the written notification must be provided with this application.

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REQUIRED DISCLOSURES

1. Has your company or any representative, owner, partner or officer ever failed to perform work awarded or had a contract terminated for failure to perform or for providing unsatisfactory service?

Yes No If yes, on a separate page please provide a detailed explanation. 2. Within the past five (5) years, has your company or any representative, owner, partner or officer

(collectively “your company) ever been a party to any court or administrative proceedings where the violation of any local, state or federal statute, ordinance rule or regulation by your Company was alleged?

Yes No If yes, on a separate page, please provide a detailed explanation outlining the following:

Date of citation or violation Description of violation Parties involved Current status of citation

3. Within the past 5 years has your organization had any reported findings on an annual independent

audit? Yes No If yes, on a separate page please provide a detailed explanation .

4. Within the past 5 years, has your organization been required to submit a corrective action plan by

virtue of review or audit by independent auditor, or any governmental agency or purchaser of services?

Yes No If yes, on a separate page please provide a detailed explanation including if the corrective action has been accepted by the purchasing agency and completely

implemented? If not, please explain remaining action required by purchasing agency.

5. Have you, any principals, owners, partners, shareholders, directors, members or officers of your

business entity ever been convicted of, or pleaded guilty, or no contest to, a felony, serious or gross misdemeanor, or any crime or municipal violation, involving dishonesty, assault, sexual misconduct or abuse, or abuse of controlled substances or alcohol, or are charges pending against you or any of the above persons for any such crimes by information, indictment or otherwise?

Yes No If yes, on a separate page, please provide a detailed explanation.

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Experience/Service Proposal

Briefly address each question identified below. If a topic does not pertain to your type of business, please indicate N/A. For each service that you provide or are proposing to provide, how long have you been providing this service and for what type of population? [Developmentally Disabled (DD)/Physically Disabled (PD)/Child Long-Term Support (CLTS)] Check all that apply (Please use a separate sheet of paper if needed.).

SPC #

(see attached service

descriptions)

Service

Agency Status

regarding service

Length of time providing service

Ages Served

Types of Populations served

Current Proposed

0-2 3-21 Adult DD PD CLTS Other________________________________

Current Proposed

0-2 3-21 Adult DD PD CLTS Other________________________________

Current Proposed

0-2 3-21 Adult DD PD CLTS Other________________________________

1. What agencies/organizations have referred business to you over the past three years?

2. List any agencies/organizations with whom you have had contractual relationships within the previous three years:

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Current Direct Service Providers Every service listed in the proposed table on page 5 of the application must have a provider listed in the following table (If you have more providers than space allows, please attach additional sheets with the additional information). See attached index for SPC Service Code/s. *Bi-lingual ability—Identify all languages spoken fluently other than English **Location—Specify name of locations if agency listed multiple sites on P. 2 of application or state “all.”

SPC Service Code/s

One line each (See Index of

Services)

Direct Service Provider/Employee

Name

*Bi-lingual Ability

**Location

Provider Meets Minimum Credential/Educational/&/or Experience Per Service Description

(For each provider list specific credential/educational/&/or experience and date of completion)

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

Qualifications-_________________________________________________________ Date Completed_______________________________________________________

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Documentation Required

Documentation Required with Application:

1. AGENCY LICENSE A copy of the agency license/s must be submitted with this application as issued to the agency by the State of Wisconsin or Milwaukee County corresponding to the service/s provided or for those services the agency is applying for, such as Adult Day Care, Group Home, Foster Care, Residential Licenses.

2. SERVICE PROVIDER CREDENTIALS (agency must sign and date the attached Certification Statement-

Regarding Individual Service Provider Credential/Educational/&/or Experience as Required per MA Waivers Manual Standards and submit with application) Individual/direct service providers must meet the specific service credentialing/education/and/or experience requirements as set forth in the MA Waivers Manual. The agency is required to maintain in agency file a copy of each service providers corresponding credentialing/education/and/or experience requirements (state licenses or certifications, diplomas, letters of reference).

3. EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATE and EQUAL OPPORTUNITY POLICY Agencies having a Milwaukee County contract and 50 or more employees shall develop and/or update an Affirmative Action Plan as outlined on page 13 of this application. The Equal Opportunity Policy must also be completed and signed (page 14). Plans and/or updates shall be submitted within 120 days of contract award to Mr. Paul Grant, Audit Compliance Manager, Milwaukee County Department of Audit, 2711 West Wells Street, Ninth Floor, Milwaukee, WI 53208 [Phone No: (414) 278-4246]

Information regarding basic statistics on population and labor force may be obtained from the DWD website at www.dwd.state.wi.us/oea/oea_products.htm or by contacting Joe Tumpach, Labor Market Analyst, State Office Building, 201 East Washington Street, Madison, WI 53707, (608) 266-0851.

4. CRIMINAL BACKGROUND CHECKS agency must sign and date the attached Certification Statement

Resolution Regarding Background Checks and submit with application. Documentation Required Upon Initiation of Services Under Contract:

5. INSURANCE COVERAGE

The agency is required to obtain insurance coverage as outlined below prior to the provision of services. The agency must maintain Certificates of Insurance in the agency file.

Contractor agrees to evidence and maintain proof of financial responsibility to cover costs as may arise from claims of tort, statutes and benefits under Workers’ Compensation laws and/or vicarious liability arising from employees, board, or volunteers. Such evidence shall include insurance coverage for Worker’s Compensation claims as required by the State of Wisconsin, Commercial General Liability and/or Business Owner’s Liability (which includes board, staff, and volunteers), Automobile Liability (if the Agency owns or leases any vehicles) and Professional Liability (where applicable) in the minimum amounts listed below.

Automobile insurance that meets the Minimum Limits as described in the Agreement is required for all agency vehicles (owned, non-owned, and/or hired). In addition, if any employees of the Contractor will use their personal

By site, if applicable, per Service Description

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vehicles to transport Milwaukee County employees, representatives or clients, or for any other purpose related to the Agreement, those employees shall have Automobile Liability Insurance providing the same liability limits as required of the Contractor through any combination of employee Automobile Liability and employer Automobile or General Liability Insurance which in the aggregate provides liability coverage, while employee is acting as agent of employer, on the employee’s vehicle in the same amount as required of the Contractor. If the services provided under the contract constitute professional services, Contractor shall maintain Professional Liability coverage as listed below. Treatment providers including psychiatrists, psychologists, social workers) who provide treatment off premises must obtain General Liability coverage (on premises liability and off-premise liability), to which Milwaukee County is added as an additional insured, unless not otherwise obtainable. It being further understood that failure to comply with insurance requirements might result in suspension or termination of the Agreement.

Type of Coverage: Minimum Limits: Wisconsin Workers’ Compensation Statutory or Proof of all States Coverage Employers’ Liability $100,000/$500,000/$100,000 Commercial General Liability Bodily Injury & Property Damage $1,000,000 - Per Occurrence Incl. Personal Injury, Fire, Legal Contractual & Products/Completed $1,000,000 - General Aggregate Operations) Automobile Liability Bodily Injury & Property Damage $1,000,000 Per Accident All Autos - Owned, Non-Owned and/or Hired Uninsured Motorists Per Wisconsin Requirements Professional Liability To include Certified/Licensed Mental $1,000,000 Per Occurrence Health and AODA Clinics & Providers $3,000,000 Annual Aggregate And Hospital, Licensed Physician or any Hospital, Licensed Physician or any other qualified healthcare provider As required by State Statute under Sect 655Wisconsin Patient Compensation Fund Statute Any non-qualified Provider under $1,000,000 Per Occurrence/Claim Sec 655 Wisconsin Patient $3,000,000 Annual Aggregate Compensation Fund Statute State Of Wisconsin (indicate if Claims Made or Occurrence) Other Licensed Professionals $1,000,000 Per Occurrence

$2,000,000 Annual Aggregate, or Statutory limits whichever is higher

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Should the statutory minimum limits change, it is agreed the minimum limits stated herein shall automatically change as well. The Milwaukee County Department Health and Human Services, as its interests may appear, shall be named as, and receive copies of, an “additional insured” endorsement, for general liability, automobile insurance, and umbrella/excess insurance. Milwaukee County DHHS must be afforded a thirty day (30) written notice of cancellation or non-renewal. Disclosure must be made of any non-standard or restrictive additional insured endorsement, and any use of non-standard or restrictive additional insured endorsement will not be acceptable. A certificate indicating the above coverages shall be submitted for review and approval by county for the duration of this agreement. Exceptions of compliance with “additional insured” endorsement are:

1. Transport companies insured through the State “Assigned Risk Business” (ARB). 2. Professional Liability where additional insured are not allowed.

Contractor shall furnish County annually on or before the date of renewal, evidence of a Certificate indicating the above coverages (with Milwaukee County DHHS named as the “Certificate Holder”) shall be submitted for review and approval by County throughout the duration of this Agreement. If said Certificate of Insurance is issued by the insurance agent, it is the Contractor’s responsibility to ensure that a copy is sent to the insurance company to ensure that the County is notified in the event of a lapse or cancellation of coverage. If Contractor’s insurance is underwritten on a Claims-Made basis, the Retroactive date shall be prior to or coincide with the date of this agreement, the Certificate of Insurance shall state that professional malpractice or errors and omissions coverage, if the services being provided are professional services coverage is Claims-Made and indicate the Retroactive Date, Contractor shall maintain coverage for the duration of this agreement and for six (6) years following the completion of this agreement. It is also agreed that on Claims-Made policies, either Contractor or County may invoke the tail option on behalf of the other party and that the Extended Reporting Period premium shall be paid by the Contractor. Binders are acceptable preliminarily during the provider application process to evidence compliance with the insurance requirements. All Coverages shall be placed with an insurance company approved by the State of Wisconsin and rated “A” per Best’s Key Rating Guide. Additional information as to policy form, retroactive date, discovery provisions and applicable retentions, shall be submitted to County if requested, to obtain approval of insurance requirements. Any deviations, including use of purchasing groups, risk retention groups, etc., or requests for waiver from the above requirements shall be submitted in writing to the Milwaukee County Risk Manager (Milwaukee County Risk Manager, Milwaukee County Courthouse, Room 302, 901 N. 9th St. Milwaukee, WI 53233) for approval prior to the commencement of activities under the Contract.

6. Criminal Background Checks (CBCs) are required for all employees who work with or may come into contact 7. with clients. The background check must meet the standards set forth in the State of Wisconsin Caregiver 8. Law and the Milwaukee County Caregiver Resolution. The agency is required to maintain a copy of 9. complete CBCs in the agency file for each service provider/employee.

Background Check requirements are as follows: Complete a State-wide Criminal Background Check. This is a three part process – all three components

are required for a background check to be considered complete. For employees in Wisconsin less than three consecutive years, a Federal background check must be

obtained.

Applies to all coverage types

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The agency shall conduct background checks at its own expense on all employees who provide direct care and services.

Background checks can be completed on-line. Additional information regarding background checks and on-line access to background checks (www.doj.state.wi.us/dles/CIB/forms).

7. DRIVER’S LICENSES agencies are to obtain/maintain the following documents on file at their agency for every

staff who will be transporting clients: Copy of a current, valid Wisconsin Driver’s License Copy of employee’s current automobile insurance A Department of Transportation Driver Record Abstract. Call the Wisconsin DOT at 608-266-2353 or go

online to http://www.dot.wisconsin.gov/drivers/points/abstract2.htm

8. CLIENT FILE DOCUMENTATION Agency agrees to maintain appropriate documentation as described in the MA Waivers manual.

Documentation Required Within 120 days of Contract Award: 9. CIVIL RIGHTS COMPLIANCE PLAN

Agencies which have a Milwaukee County contract shall have a Civil Rights Compliance Action Plan which ensures that no person shall, on the grounds of race, color, national origin, age, sex, religion, or handicap, be excluded from participation in or be subjected to discrimination in any program or activity funded, in whole or in part, by Federal and State funds.

Consistent with the requirements of the U.S. Department of Health and Human Services, the State of Wisconsin Department of Workforce Development (DWD) and the Department of Health and Family Services (DHFS), Contractor is required to complete and submit a copy of a Civil Rights Compliance Plan (CRCP) to include Affirmative Action, Equal Opportunity, and Limited English Proficiency (LEP) Plans, or Contractor may submit a copy of the State approval letter to County in lieu of the CRCP.

Contractors with direct State contracts with DWD or DHFS with fewer than 25 employees, or Contractors receiving less than $25,000 in direct State funding are required to file a Letter of Assurance with DWD or the DHFS, and a copy with County. Contractors with fewer than 25 employees or Contractors receiving less than $25,000 in funding or payment from County are required to file a Letter of Assurance with County. Completion forms, instructions, sample policies and plans are posted on the State website at: www.dwd.state.wi.us/dws/civil_rights/cr0406/cr_plans.htm.

Civil Right Plans or Letters of Assurance shall be submitted within 120 days of contract award to Jane Alexopoulos, Contract Services Coordinator, Milwaukee County Department of Health and Human Services, 1220 West Vliet Street, Suite 109, Milwaukee, WI 53205 [Phone No: (414) 289-5896]

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Submit this Document with Completed Application. Retain a copy in Agency File.

CERTIFICATION STATEMENTRESOLUTION REGARDING INSURANCE COVERAGE

This is to certify that __________________________________________________________(Name of Agency/Organization)

(1)                 Will retain current Certificates of Insurance as required in the agency file as indicated above; and(2)                 Will ensure that Milwaukee County is added as an additional insured on Certificates of Insurance.(3) Will submit a copy of Insurance Certificate to:

Dennis Buesing, DHHS Contract Administrator 1220 West Vliet Street, Suite 109

Milwaukee, WI 53205

(Authorized Signature of Person Completing Form) (Date) _______________________________________________________________________________

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Submit this Document with Completed Application. Retain a copy in Agency File.

MILWAUKEE COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES

Certification Statement-Regarding Individual Service Provider Credential/Educational/&/or Experience as Required per MA Waivers Manual Standards

CERTIFICATION STATEMENT

REGARDING INDIVIDUAL PROVIDER QUALIFICATIONS

This is to certify that __________________________________________________________

(Name of Agency/Organization)

(1)     will ensure that each service provider meets the minimum credential/educational/&/or experience as required per the MA Waivers Manual Standards, and

(2)     will retain proof of providers’ qualifications in respective personnel or agency file.

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Submit this Document with Completed Application. Retain a copy in Agency File.

MILWAUKEE COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES

Certification Statement-Resolution Regarding Background Checks onEmployees of DHHS Contract Agencies and Agencies/Organizations having

Reimbursable Agreements that have Direct Regular Contact with Clients or Provide Direct Services to Children and Youth

CERTIFICATION STATEMENTRESOLUTION REGARDING BACKGROUND CHECKS

This is to certify that __________________________________________________________(Name of Agency/Organization)

(1)       will comply with the provisions of ss.50.065 and ss.146.40 Wis. Stats. and HFS 12 and HFS 13, Wis. Admin. Code State of Wisconsin Caregiver Program (2)       has received and read, “PROVISIONS OF RESOLUTION REQUIRING BACKGROUND CHECKS ON DEPARTMENT OF HUMAN SERVICES CONTRACT AGENCY

EMPLOYEES PROVIDING DIRECT CARE AND SERVICES TO MILWAUKEE COUNTY CHILDREN AND YOUTH;” (3)       has a written screening process in place to ensure background checks on criminal and gang activity for current and prospective employees providing direct care and

services to children and youth; and, (4)       is in compliance with the provisions of the Resolution requiring background checks. (Authorized Signature of Person Completing Form) (Date) _______________________________________ (Title)

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YEAR 2008 EQUAL EMPLOYMENT OPPORTUNITY CERTIFICATE

FOR MILWAUKEE COUNTY CONTRACTS

In accordance with Section 56.17 of the Milwaukee County General Ordinances and Title 41 of the Code of Federal Regulations, Chapter 60, SELLER or SUCCESSFUL BIDDER or CONTRACTOR or LESSEE or (Other-specify),(Hence forth referred to as VENDOR) certifies to Milwaukee County as to the following and agrees that the terms of this certificate are hereby incorporated by reference into any contract awarded. Non-Discrimination VENDOR certifies that it will not discriminate against any employee or applicant for employment because of race, color, national origin, sex, age or handicap which includes but is not limited to the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training including apprenticeship. VENDOR will post in conspicuous places, available to its employees, notices to be provided by the County setting forth the provision of the non-discriminatory clause. A violation of this provision shall be sufficient cause for the County to terminate the contract without liability for the uncompleted portion or for any materials or services purchased or paid for by the contractor for use in completing the contract.

Affirmative Action Program VENDOR certifies that it will strive to implement the principles of equal employment opportunity through an effective affirmative action program, which shall have as its objective to increase the utilization of women, minorities, and handicapped persons and other protected groups, at all levels of employment in all divisions of the seller's work force, where these groups may have been previously under-utilized and under-represented. VENDOR also agrees that in the event of any dispute as to compliance with the aforestated requirements, it shall be his responsibility to show that he has met all such requirements.

Non-Segregated Facilities VENDOR certifies that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not permit its employees to perform their services at any location under its control, where segregated facilities are maintained.

Subcontractors VENDOR certifies that it has obtained or will obtain certifications regarding non-discrimination, affirmative action program and nonsegregated facilities from proposed subcontractors that are directly related to any contracts with Milwaukee County, if any, prior to the award of any subcontracts, and that it will retain such certifications in its files.

Reporting Requirement Where applicable, VENDOR certifies that it will comply with all reporting requirements and procedures established in Title 41 Code of Federal Regulations, Chapter 60.

Affirmative Action Plan VENDOR certifies that, if it has 50 or more employees, it will develop and/or update and submit (within 120 days of contract award) an Affirmative Action Plan to: Mr. Amos Owens, Audit Compliance Manager, Milwaukee County Department of Audit, 2711 West Wells Street, Milwaukee, WI 53208 [Telephone No.: (414) 278-4246]. VENDOR certifies that, if it has 50 or more employees, it has filed or will develop and submit (within 120 days of contract award) for each of its establishments a written affirmative action plan. Current Affirmative Action plans, if required, must be filed with any of the following: The Office of Federal Contract Compliance Programs or the State of Wisconsin, or the Milwaukee County Department of Audit, 2711 West Wells Street, Milwaukee, WI 53208 [Telephone No.: (414) 278-4246].

If a current plan has been filed., indicate where filed and the year covered. VENDOR will also require its lower-tier subcontractors who have 50 or more employees to establish similar written affirmative action plans.

Employees VENDOR certifies that it has (No. of Employees) employees in the Standard Metropolitan Statistical Area (Counties of Milwaukee, Waukesha, Ozaukee and Washington, Wisconsin) and (No. of Employees) employees in total.

Compliance VENDOR certifies that it is not currently in receipt of any outstanding letters of deficiencies, show cause, probable cause, or other notification of noncompliance with EEO regulations.

Executed this day of , 20 by: Firm Name ___________________________________________________________

By: Address

(Signature) City/State/Zip

Applicable to All

Applicable only if you have 50 or more

employees

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SUBMIT THIS DOCUMENT WITH COMPLETED APPLICATION. POLICY SHALL BE POSTED IN A CONSPICUOUS LOCATION

YEAR 2008 EQUAL OPPORTUNITY POLICY

is in compliance with the equal opportunity policy and standards of the Wisconsin Department of Health and Family Services and all applicable Federal and State rules and regulations regarding nondiscrimination in employment and service delivery. EMPLOYMENT - AFFIRMATIVE ACTION & CIVIL RIGHTS It is the official policy of that no otherwise qualified person shall be excluded from employment, be denied the benefits of employment or otherwise be subjected to discrimination in employment in any manner on the basis of age, race, religion, color, sex, national origin or ancestry, handicap, physical condition, developmental disability, arrest or conviction record, sexual orientation, military/veteran status or military participation. We pledge that we shall comply with Affirmative Action and Civil Rights standards to ensure that applicants are employed and that employees are treated during their employment without regard to the above named characteristics. Such action shall include but not be limited to the following: employment, upgrading, demotion, transfer, recruitment, or recruitment advertising, layoff or termination, rates of pay or other forms of compensation and selection for training including apprenticeship. has a written Affirmative Action Plan which includes a process by which discrimination complaints may be heard and resolved. SERVICE DELIVERY - CIVIL RIGHTS It is the official policy of that no otherwise qualified applicant for services or service recipient shall be excluded from participation, be denied benefits or otherwise be subjected to discrimination in any manner on the basis of age, race, religion, color, sex, national origin or ancestry, handicap, physical condition, developmental disability, arrest or conviction record, sexual orientation, military/veteran status or military participation. We pledge that we shall comply with civil rights laws to ensure equal opportunity for access to service delivery and treatment without regard to the above named characteristics. has a written Civil Rights Action Plan which includes a process by which discrimination complaints may be heard and resolved. All officials and employees of are informed of this statement of policy. Decisions regarding employment and service delivery shall be made to further the principles of affirmative action and civil rights. To ensure compliance with all applicable Federal and State rules and regulations regarding Equal Opportunity and nondiscrimination in employment and service delivery, has been designated as our Equal Opportunity Coordinator. Any perceived discrimination issues regarding employment or service delivery shall be discussed with Ms./Mr. . Ms./Mr. may be reached during weekdays at . A copy of the Affirmative Action Plan and/or the Civil Rights Action Plan including the process by which discrimination complaints may be heard and resolved is available upon request. (Director or Chief Officer) (Title) (Date)

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Accuracy of Application Complete and submit this application with a copy of your agency license/s (see page 2 for details) to the Milwaukee County Department of Health and Human Services. SIGNATURE I agree that all information included in this application is true and correct and that I understand and agree to the application information and requirements. I further acknowledge that the information in this application is subject to verification without notice and that any misrepresentation on this form now or in the future may result in disqualification from participation in DSD. Provider Authorized Signature: ______________________________________________ Title: _________________________________ Dated: ___________________________

APPLICATION MUST BE RECEIVED NO LATER THAN: 4:30 p.m., Friday, June 27, 2008

Applications can be mailed or delivered (no fax or electronic submissions) to MILWAUKEE COUNTY DEPARTMENT OF HEALTH and HUMAN SERVICES

Contract Administration 1220 West Vliet Street, Suite 109

Milwaukee, WI. 53205 PHONE: (414) 289-5890 FAX (414) 289-8574

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Other Contract ObligationsOther Contract Obligations HFS 94 Patient Rights and Resolution of Patient

Grievances (http://nxt.legis.state.wi.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=WI:Default&d=codex&jd=top)

Emergency preparedness and notification Right of access and review of service documentation-

agency, provider, client, and fiscal Compliance with all laws and regulations for client

confidentiality, including HIPAA Compliance with Service Descriptions and Billing

procedures in effect during the contract period, including revisions and updates

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Overview of Budget Forms and

Audit & Reporting

Presented By:

Dennis Buesing, DHHS Contract Administrator

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Budget & Other Forms

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Budget and Other Forms

Form 1 Program Volume Data and Unit Rate Calculation

A separate Form 1 and Unit Rate must be developed for each Waiver service

The term Program on all budget forms is inter-changeable with the term Waiver service.

Programs/services funded by site must include separate Form1 for each site.

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Budget and Other Forms Contd…..Form 2 & Form 2A Agency Employee Hours and Salaries

Use Form 2A only if agency has 14 or fewer employees otherwise use multiple copies of Form 2 with Form 2A being the final page.

Column 1 - Position Title

Enter the title of each position with any portion of its time directly allocated to a Waiver service – 1 line per employee.

If a position is vacant, list the title of the position and "vacant" under it.

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Budget and Other Forms Contd…..Budget and Other Forms Contd…..Form 2 & Form 2A Agency Employee Hours

and Salaries, cont’d

Column 2 - Code

Refer to Form 3S Control Acct No. 7000 (Salaries). Use the same number as the last digit of the Sub-Account No. which corresponds to the Acct Description. (e.g., 1 for Executive Salaries, 2 for Professional Salaries, 3 for Clerical Staff Salaries, 4 for Technical Salaries, 5 for Maintenance Employee’s Wages, 6 for Temporary Clerical Help, 7 for Student Stipends, and 8 for Other Staff Salaries

Note:The totals for salaries and employees health and retirement benefits should match respective totals for Control Accts 7000 & 7100 on Form 3S.

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Budget and Other Forms Contd…..Budget and Other Forms Contd…..Form 2 & Form 2A Agency Employee Hours

and Salaries, cont’d

Column 3 - Ethnic/Race and Gender Codes

In column 3 enter the code representing the race or ethnicity of the employee.

 Ethnic/Race Codes: Gender Codes:

A: Asian or Pacific Islander F: Female

B: Black M: Male

H: Hispanic

I: American Indian

W: White

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Budget and Other Forms Contd…Form 2B Employee Demographic Summary (will fill automatically from data on Forms 2 & 2A)

Form 2C Employee Hours Related Information Disclosure (only applies to agencies whose employees work for more than one related organization).

Forms 3 & Form 3S Anticipated Program Expenses

A separate budget tab must me used for each Waiver service.

Fill Form 3S first! For 2007 Budget column use 2007 actual expenses.

Control account subtotals will automatically come forward to corresponding control account on Form 3.

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Budget and Other Forms Contd…

Form 4 & Form 4S Anticipated Program Revenue

A separate budget tab must me used for each Waiver service.

Please Fill Form 4S first! For 2007 Budget column use 2007 actual revenue.

Control account subtotals will automatically come forward to corresponding control account on Form 4.

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Budget and Other Forms Contd…..Form 5 Total Agency Anticipated Expenses Form 5A Total Agency Anticipated Revenue

Report Total Agency expenses on col. B, C and D. For col. C, 2007 budgeted expenses, use 2007 actual expenses

Each respective service’s Form 3 expenses will automatically come forward to its respective column E1 thru E6 of Form 5.

Report Total Agency revenue on col. B, C and D.

Each respective service’s Form 4 revenue will automatically come forward to its respective column E1 thru E6 of Form 5A.

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Budget and Other Forms Contd…

Form 6 and 6D Through 6H Indirect Cost Allocation Plan

To be submitted only if Agency provides more than one service to Milwaukee County, or one or more services to Milwaukee County and one or more services to other purchasers.

Or if expenses are allocated to other functions like fund raising, or allocated between agency and an affiliate.

Allocation Plan document with formulas are also available on the web.

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Budget and Other Forms Contd…Budget and Other Forms Contd…

Linked Budget Forms:

All budget forms Form 1-Form 6 are now available as linked forms with formulas at:

http://www.county.milwaukee.gov/rfpinformation111327.htm

Agency can use these linked form to report up to 6 programs/services or sites without redoing Form 2, 5 and 6. Other forms are also linked so numbers automatically carry forward wherever they are repeated, or whenever calculated based on another form.

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Audit & ReportingAudit & Reporting

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Contract and Audit RequirementsContract and Audit RequirementsContracts are required for Purchase of Care and Services over $10,000 under State

Statute 46.036

Audits are also required by State Statute 46.036(4)(c ), if the Care & services purchased with State funding exceeds $25,000 per year

Statutes require audits to be performed at least every other year. County contracts typically require annual audits

Standards for audits are found in DHFS/DWD/DOC Provider Agency Audit Guide, 1999 Revision (on line at www.dhfs.state.wi.us/grants)

Non-profit providers that receive $500,000 or more in federal awards must also have audit performed in accordance with OMB Circular A-133 Audit of State, Local Governments, and Non-Profit Organizations. Fed audit requirements are for an annual audit

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Audit WaiverAudit Waiver Statutes allow the Dept. to waive audits. Audits may not be waived if the

audit is a condition of state licensure, or is needed to claim federal funding (Group Foster Care or CCI).

Waiver request can only be entertained if agency does not need to have an audit according to Federal Audit requirement.

Waivers need to be approved on case by case basis by regional office based on a risk assessment ( Funding <$75,000 is considered low risk)

DHHS has been approving Audit Waivers for Fee for Service contracts mainly on basis of economic hardship for providers that receive less than $150,000 from state and a county annually.

In case of small residential care providers ( Family Group Home and AFH) county has the authority to grant a waiver.

Waiver Form is available at the bottom of the web page at: http://milwaukeecounty.org/ContractMgt15483.htm

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Allowable Costs & Allowable Profits or ReservesAllowable Costs & Allowable Profits or Reserves

Per State Statute, ultimately, all agreements with Milwaukee County DHHS for client Care & Services paid with dept. funding are cost reimbursement contracts

For-profit providers may retain up to 10% in profit per contract; 7½% of allowable costs, plus 15% of net equity (Allowable Cost Policy Manual, Section III.16)

Nonprofit providers paid on a unit-times-unit-price contract (i.e. FFS) may add surpluses of up to 5% of contract amount to reserves each yr., up to a cumulative maximum of 10%.

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Maintaining Financial RecordsMaintaining Financial Records Both Federal and State contracting guidelines require provider

agencies to maintain orderly books and adequate financial records.

Maintain a uniform double entry accounting system and a management information system compatible with cost accounting and control systems.

Providers should maintain an accurate and up-to-date general ledger and timely financial statements for management & board members

Financial Statements must be prepared in conformity with accounting principles generally accepted in the U.S. (GAAP) and on the accrual basis of accounting. Contractor must request, and receive written consent of County to use other basis of accounting in lieu of accrual basis of accounting.

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Maintaining Financial RecordsMaintaining Financial Records Amounts recorded in the general ledger should be

adequately supported by invoices, receipts or other documentation

Providers should maintain a separate cost center or dept. in their general ledger for each contract, or program/facility within a contract

Whenever possible, costs should be charged directly to a contract, all other costs should be allocated using a reasonable and consistent allocation method and supported by an Indirect Cost Allocation Plan

Providers must not commingle personal and business funds. A separate checking account should be established & providers should not use personal credit cards for agency business

All Provider agencies should maintain and adhere to a board approved, up-to-date Accounting Policy & Procedures Manual

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LINKED FORM WITH SAMPLE DATA

LINKED FORMS TUTORIAL

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Contact Info:Contact Info:Program : Liz Kraniak, Supervisor, Disabilities Services Division (414) 289 6285

Technical : Diane Krager, DHHS Quality Assurance Coordinator (414) 289 5886 Wes Albinger, Contract Services Coordinator (414) 289 5871

Budget: Sumanish Kalia, Contract Administration CPA Consultant (414) 289 6757

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Thank You

Have a nice day

Thank You

Have a nice day