Document:

Exhibit 10.21

 

SECTION 9

ATTACHMENT A

APPLICATION AND QUALIFIED VENDOR
AGREEMENT AWARD

 

	
  APPLICATION
  and

  	
   

  	
  ARIZONA
  DEPARTMENT OF

  
	
   

  	
   

  	
  ECONOMIC
  SECURITY

  
	
  QUALIFIED
  VENDOR AGREEMENT AWARD

  	
   

  	
   

  
	
   

  	
   

  	
  DIVISION
  OF

  
	
  RFQVA
  NO. DDD 704011

  	
   

  	
  DEVELOPMENT
  DISABILITIES

  

 

APPLICATION

 

	
  TO: THE STATE OF ARIZONA

  
	
   

  
	
  The undersigned hereby
  applies and agrees to provide the service(s) in compliance with the RFQVA 

  For clarification of this application, contact:

  

 

	
   

  	
   

  	
   

  
	
  Greg Torres

  	
   

  	
  04-2893910

  
	
  Name

  	
   

  	
  Federal Employer Identification Number

  
	
   

  	
   

  	
   

  
	
  (617) 790-4800

  	
   

  	
  National Mentor Healthcare, Inc. DBA Arizona Mentor

  
	
  Phone Number

  	
   

  	
  Company Name

  
	
   

  	
   

  	
   

  
	
  (617) 790-4901

  	
   

  	
  3724 N. 3rd
  St. Suite 200

  
	
  Fax Number

  	
   

  	
  Mailing Address

  
	
   

  	
   

  	
   

  
	
  greg.torres@TheMentorNetwork.com

  	
   

  	
  Phoenix

  	
  AZ

  	
  85012

  
	
  Email Address

  	
   

  	
  City

  	
  State

  	
  Zip

  
	
   

  	
   

  	
   

  
	
  If awarded a Qualified Vendor Agreement,

  	
   

  	
  602-200-9494

  
	
  all notices should be sent to:

  	
   

  	
  Phone Number

  
	
   

  	
   

  	
   

  
	
  Kay S. Moore

  	
   

  	
  kay.moore@TheMentorNetwork.com

  
	
  Name

  	
   

  	
  E-Mail Address

  
	
   

  	
   

  	
   

  
	
  3724 N. 3rd
  St. Suite 200

  	
   

  	
  /s/ Greg Torres

  
	
  Mailing Address

  	
   

  	
  Signature & Person Authorized to Sign
  Application

  
	
   

  	
   

  	
   

  
	
  Phoenix

  	
  AZ

  	
  85012

  	
   

  	
   

  
	
  City

  	
  State

  	
  Zip

  	
   

  	
  Greg Torres

  
	
   

  	
   

  	
  Printed Name

  
	
  602-200-9494

  	
  602-200-8588

  	
   

  	
   

  
	
  Phone Number

  	
  Fax Number

  	
   

  	
  CEO

  
	
   

  	
   

  	
   

  	
  Title

  
	
  kay.moore@TheMentorNetwork.com

  	
   

  	
   

  
	
  EMail Address

  	
   

  	
   

  
								

 

APPROVAL OF APPLICATION AND
AGREEMENT AWARD (FOR STATE OF ARIZONA USE ONLY)

 

Your application is hereby approved. 
The Qualified Vendor is now bound to provide the service (s) listed in
the attached award notice based upon the RFQVA, including all terms,
conditions, service specifications, scope of work, amendments, etc., and the
Qualified Vendor’s application as accepted by the State.

 

This agreement shall henceforth be referred to as Qualified Vendor
Agreement No. 00455. The begin date and the effective date of this agreement
is either the date that this award is signed by the Procurement Officer or
July 1, 2003, whichever is later.

 

	
   

  	
  State of Arizona

  	
   

  
	
   

  	
  Awarded this Date:

  	
  7/1/03

  	
   

  
	
   

  	
  /s/ Antonia Valladares

  	
   

  
	
   

  	
  Procurement Officer

  	
   

  
					

 

A-1

 

SECTION 1

NOTICE
OF REQUEST FOR QUALIFIED VENDOR APPLICATIONS (RFQVA)

State of
Arizona

Department
of Economic Security (DES) or (Department) 

Division
of Developmental Disabilities (DDD) or (Division)

 

RFQVA
Number: DDD 704011

 

o Time Limited

ý Open and Continuous

 

Application Due Date:

 

Pursuant to Arizona Revised Statutes (A.R.S.) § 36-557 and
rules adopted thereunder (R6-6-2101 et seq.), which are incorporated
herein by reference, Applications for the services listed below will be
accepted by the Division at the time and manner specified below. Through this
Request for Qualified Vendor Applications (RFQVA) the Arizona Department of
Economic Security (DES or Department), Division of Developmental Disabilities
(DDD or Division) will execute Qualified Vendor Agreements with providers for
the provision of services.

 

Applications must be submitted electronically using the Qualified
Vendor Application and Directory System as well as submitting a printable hard
copy with signatures and necessary additional documentation. See Section 3
and Section 9.

 

Applications will be accepted from current contracted
providers beginning April 7, 2003. To assure service continuation
effective July 1, 2003 Applications should be submitted by May 1,
2003 at 5 p.m. Arizona time. Applicants new to DDD may submit
Applications beginning May 5, 2003. All Applicants shall not expect to be
awarded an agreement sooner than 60 days after the submittal of a complete
Application. [NOTE: Applications from independent providers as defined in
Section 6 will not be processed or result in an agreement until the
statewide published rates for independent providers have been adopted in the
fall of 2003.]

 

Submittal
Location:

 

ELECTRONICALLY
GENERATED HARD COPY WITH ORIGINAL SIGNATURE 

AND
NECESSARY DOCUMENTATION

 

In Person or By Courier
to:

 

DDD Contract Unit, 4th
Floor Southwest

Business Operations —
Site Code 791A

Division of Developmental
Disabilities

Arizona Department of
Economic Security

1789 West Jefferson
Street

Phoenix, Arizona 85007

(602) 542-6874

 

I-1

 

By Mail to:

 

DDD Contract Unit

Business Operations -
Site Code 791A

Division of Developmental
Disabilities

Arizona Department of
Economic Security

P.O. Box 6123

Phoenix, Arizona 85005

 

Services:

 

Home-Based Services: Attendant Care; Habilitation, Community Protection
and Treatment Hourly; Habilitation, Support; Housekeeping; and Respite. Day Treatment and Training Services:
Day Treatment and Training, Adult; Day Treatment and Training, Children
(After-School); and Day Treatment and Training, Children (Summer). Developmental Home Services:  Habitation, Vendor Supported Developmental
Home (Child and Adult); and Room and Board, Vendor Supported Developmental
Home (Child and Adult). Independent Living
Services: Habilitation, Individually Designed Living
Arrangement. Group Home Services:
Habilitation, Community Protection and Treatment Group Home; Habilitation,
Group Home; Habilitation, Nursing Supported Group Home; and Room and
Board, All Group Homes. Professional Services:
Home Health Aide; Nursing; Occupational Therapy; Occupational Therapy Early
Intervention; Physical Therapy; Physical Therapy Early Intervention; Speech
Therapy; and Speech Therapy Early Intervention. Other
Services: Transportation.

 

First
Pre-Application Conference:

 

Date: March 19, 2003, Arizona Time: 10 a.m.
to 2 p.m.

 

Location:                      Sheraton Crescent Hotel

2620 West Dunlap Avenue 

Phoenix, Arizona 

(602) 943-8200

 

Second
Pre-Application Conference:

 

The second pre-Application conference will be held
after the electronic application is released. The purpose of the conference
will be to answer specific questions about the electronic application, referred
to as the Qualified Vendor
Application and Directory System.

 

Date: March 28, 2003, Arizona Time: Session
1 - 9 a.m. to Noon; Session 2 - 1 p.m. to 4 p.m.

 

These two sessions will provide the same information. Applicants whose
Federal Employer Identification Number (FEIN) or Social Security Number (SSN)
ends with an odd number shall attend the morning (9 am to noon) session, and
Applicants whose FEIN or SSN ends with an even number shall attend the
afternoon (1 p.m. to 4 p.m.) session.

 

I-2

 

Location:                      Auditorium in the basement of the Arizona
Land Department 

1616 West Adams Street 

Phoenix, Arizona 

(602) 542-4631

 

Persons with a disability may request a reasonable
accommodation by contacting the RFQVA contact person. (For TDD/TTY call
through the Arizona Relay Service at 800 367-8939). Requests should be made
as early as possible to allow time to arrange the accommodation.

 

Agreement Type: Qualified Vendor Agreement with
Published Rate

 

Agreement Term: 12 months beginning no sooner than 7/1/03, with five
one-year options for the Division to extend or renew the agreement, with all
agreements ending 6/30/09. The agreement can be terminated as specified in
Section 6, DES/DDD Terms and Conditions.

 

RFQVA Contact Person (Phone/email)

 

Cathie Rodman (602)
542-6896 /CRodman@azdes.gov

 

 

	
   

  	
   

  	
   

  	
   

  
	
  DDD Procurement Specialist

  	
  Date

  

 

AN EQUAL
EMPLOYMENT OPPORTUNITY AGENCY

 

I-3Exhibit 10.22

 

Attachment 1

 

STATE OF
NEW JERSEY 

DEPARTMENT
OF HUMAN SERVICES

 

STANDARD
LANGUAGE DOCUMENT 

FOR
SOCIAL SERVICE AND TRAINING CONTRACTS

 

This CONTRACT is effective as of the date recorded on
the signature page between the Department and the Provider Agency
identified on the signature page.

 

WHEREAS the New Jersey Department of Human Services
(the “Department”) has been duly designated under the authority of N.J.S.A.
30:1A-1, 30:1-11, 30:1-12, and 30:1-20 to administer or supervise the administration
of social service and training programs and has, in turn, designated the
Departmental Component to be directly responsible for the funding,
implementation and administration of certain social service and training
programs, including the program(s) covered by this Contract; and

 

WHEREAS the Department desires that the Provider
Agency provide services and the Provider Agency has agreed to provide services
in accordance with the terms and conditions contained in this Contract;

 

THEREFORE the Department and the Provider Agency agree
as follows:

 

I.              DEFINITIONS

 

For the purposes of this document, the following
terms, when capitalized, shall have meanings as stated:

 

Additional Insured means an endorsement to an insurance
policy extending the coverage to the State of New Jersey against loss in
accordance with the terms of the policy. 
Designating the State as an additional insured permits the Department to
pay the premium should the insured fail to do so.

 

Annex(es) means the attachment(s) to this document
containing programmatic and financial information.

 

Contract means this document, the Annex(es), any
additional appendices or attachments (including any approved assignments,
subcontracts or modifications) and all supporting documents.  The Contract constitutes the entire agreement
between the parties.

 

Expiration means the cessation of the Contract
because its term has ended.

 

March  2002

 

1

 

 

Notice means an official written communication
between the Department and the Provider Agency. 
All Notices shall be delivered in person or by certified mail, return
receipt requested, and shall be directed to the persons and addresses specified
for such purpose in the Annex(es) or to such other persons as either party may
designate in writing.

 

The Notice shall also be sent by regular mail and
shall be presumed to have been received by the addressee five Days after being
sent to the last address known by the Department.

 

Termination means an official cessation of this
Contract, prior to the expiration of its term, that results from action taken
by the Department or the Provider Agency in accordance with provisions
contained in this Contract.

 

II.            BASIC
OBLIGATIONS OF THE DEPARTMENT

 

Section 2.01 Payment. As established in the Annex(es),
payment for Contract services delivered shall be based on allowable
expenditures or the specified rate per unit of service delivered. Such
payment(s) shall be authorized by the Department in accordance with the
time frames specified in the Annex(es). Total payments shall not exceed the
maximum Contract amount, if any, specified in the Annex(es). All payments
authorized by the Department under this Contract shall be subject to revision
on the basis of an audit or audits conducted under Section 3.09 Audit
or on the basis of any Department monitoring or evaluation of the Contract.

 

Section 2.02
Referenced Materials.
Upon written request of the Provider Agency, the Department shall make
available to the Provider Agency copies of federal and State regulations and
other material specifically referenced in this document.

 

III.           BASIC
OBLIGATIONS OF THE PROVIDER AGENCY

 

Section 3.01
Contract Services.  The Provider Agency shall provide services to
eligible persons in accordance with all specifications contained in this
Contract.

 

Section 3.02
Reporting. The
Provider Agency shall submit to the Department programmatic and financial
reports on forms provided by the Department. The reporting frequency and due
date(s) are specified and sample forms to be used are included in the
Annex(es), or otherwise made available by the Departmental Component.

 

Section 3.03
Compliance with Laws.
The Provider Agency agrees in the performance of this Contract to comply with
all applicable federal, State and local laws, rules and regulations
(collectively,

 

2

 

“laws”), including but not limited to the following:
State and local laws relating to licensure; federal and State laws relating to
safeguarding of client information; the federal Civil Rights Act of 1964 (as
amended); P.L. 1975, Chapter 127, of the State of New Jersey (N.J.S.A. 10:5-31 et
seq. ) and associated executive orders pertaining to affirmative action
and nondiscrimination in public contracts; the federal Equal Employment
Opportunity Act; Section 504 of the federal Rehabilitation Act of 1973
pertaining to non-discrimination on the basis of handicap, and regulations
thereunder; the Americans With Disabilities Act (ADA), 42 U.S.C. 12101 et:
seq.  Failure to comply with the
laws, rules and regulations referenced above shall be grounds for
Termination of this Contract for cause.

 

If any provision of this Contract shall conflict with
any federal or State law(s) or shall have the effect of causing the State to be
ineligible for federal financial participation in payment for Contract
services, the specific Contract provision shall be considered amended or
nullified to conform to such law(s). All other Contract provisions shall remain
unchanged and shall continue in full force and effect.

 

Section 3.04
Business Registration.  According to P.L. 2001, c. 134
(N.J.S.A. 52:32-44 et  seq. ) all profit and non-profit
corporations (domestic and foreign), as well as, all limited partnerships,
limited liability companies, and limited liability partnerships must submit
annual reports and associated processing fees (annual business registration) to
the Division of Revenue, Department of the Treasury commencing with the year
after they file for their Certificate of Incorporation with the State of New
Jersey. No State agency (the Department) may Contract with a Provider Agency if
the Provider has not filed for its incorporation papers or filed its annual
business registration.  Furthermore, no
Provider Agency that Contracts with the Department shall enter into any
subcontract unless the subcontractor can demonstrate that it is incorporated in
the State of New Jersey or its annual business registration is current.  Failure to comply with this paragraph or the
citation referenced above shall be grounds for the Department to Terminate this
Contract for cause.

 

Section 3.05
Set-off for State Tax.  Pursuant to P.L. 1995, c. 159,
effective January 1, 1996, and notwithstanding any provision of the law to
the contrary, whenever any taxpayer (Provider Agency), partnership or S
corporation under contract to provide goods or services or construction
projects to the Department is entitled to payment for those goods or services
at the same time a taxpayer, partner or shareholder of that entity is indebted
for any State tax, the Director of the Division of Taxation shall seek to set
off so much of that payment as shall be necessary to satisfy the

 

3

 

indebtedness.  The amount of the
set-off shall not allow for the deduction of any expense or other deductions
which might be attributable to the taxpayer, partner, or shareholder subject to
set-off under this Act.

 

The Director of the Division of Taxation shall
give notice of the set-off to the taxpayer, partner or shareholder and provide
an opportunity for a hearing within 30 Days of such notice under the procedures
for protests established under R.S. 54:49-18. No request for conference,
protest or subsequent appeal to the Tax Court from any protest shall stay the collection
of the indebtedness.  Interest that may
be payable by the State, pursuant to P.L. 1987, c. 184 (c. 52:32-32 et  seq.)
to the taxpayer shall be stayed.

 

Section 3.06
Affirmative Action.
During the performance of this Contract, the contractor (Provider Agency)
agrees as follows:

 

The contractor or subcontractor, will not discriminate
against any employee or applicant for employment because of age, race, creed,
color, national origin, ancestry, marital status, affectional or sexual
orientation, sex or disability. Except with respect to affectional sexual
orientation, the contractor will take affirmative action to ensure that such
applicants are recruited and employed.

 

The contractor will also take affirmative action to
ensure that employees are treated during employment, without regard to their
age, race, creed, color, national origin, ancestry marital status, affectional
or sexual orientation, sex or disability. Such action shall include, but not be
limited to the following: employment, upgrading, demotion, or transfer;
recruitment or recruitment advertising; layoff or termination; rates of pay or
other forms of compensation; and selection for training, including
apprenticeship. The contractor agrees to post in conspicuous places, available
to employees and applicants for employment, notices to be provided by the
Public Agency Compliance Officer setting forth provisions of this
non-discrimination clause.

 

The contractor or subcontractor, where applicable, in
all solicitations or advertisements for employees placed by or on behalf of the
contractor, shall state that all qualified applicants will receive
consideration for employment without regard to age, race, creed, color,
national origin, ancestry, marital status, affectional or sexual orientation, sex
or disability.

 

The contractor or subcontractor, where applicable,
will send to each labor union or representative or workers with which it has a
collective bargaining agreement or other contract or understanding, a notice,
to be provided by the agency contracting officer advising the

 

4

 

labor union or workers’ representative of the contractor’s commitments  under this Act and shall post copies of the
notice in conspicuous places available to employees and applicants for
employment.

 

The contractor or subcontractor, where applicable,
agrees to comply with the regulations promulgated by the Treasurer pursuant to
P.L. 1975, c. 127, as amended and supplemented from time to time.

 

The contractor or subcontractor agrees to attempt in
good faith to employ minority and female workers consistent with the applicable
county employment goals prescribed by N.J.A.C. 17:27-5.2 promulgated by the
Treasurer pursuant to P.L. 1975, c. 127, as amended and supplemented from time
to time or in accordance with a binding determination of the applicable county
employment goals determined by the Affirmative Action Office pursuant to
N.J.A.C. 17:27-5.2 promulgated by the Treasurer pursuant to P.L. 1975, c. 127,
as amended and supplemented from time to time.

 

The contractor or subcontractor agrees to inform in
writing appropriate recruitment agencies in the area, including employment
agencies, placement bureaus, colleges, universities, and labor unions, that it
does not discriminate on the basis of age, creed, color, national origin,
ancestry, marital status, affectional or sexual orientation, sex or disability,
and that it will discontinue the use of any recruitment agency which engages in
direct or indirect discriminatory practices.

 

The contractor or subcontractor agrees to revise any
of its testing procedures, if necessary, to assure that all personnel testing
conforms with the principles of job-related testing, as established by the
statutes and court decisions of the State of New Jersey and as established by
applicable federal law and applicable federal court decisions.

 

The contractor and subcontractor agree to review all
procedures relating to transfer, upgrading, downgrading and layoff to ensure
that all such actions are taken without regard to age, creed, color, national
origin, ancestry, marital status, affectional or sexual orientation, sex or
disability, and conform with the applicable employment goals, consistent with
the statutes and court decisions of the State of New Jersey, and applicable
federal law and applicable federal court decisions.

 

The contractor and its subcontractors shall furnish
such reports or other documents to the Affirmative Action Office as may be
requested by the Office from time to time in order to carry out the purposes of
these regulations, and public agencies shall furnish such information as may be
requested by the Affirmative Action Office for 

 

5

 

conducting a compliance investigation pursuant to Subchapter 10 of
the Administrative Code (N.J.A.C. 17:27).

 

Section 3.07
Department Policies and Procedures. In the administration of this Contract, the Provider
Agency shall comply with all applicable policies and procedures issued by the
Department including, but not limited to, the policies and procedures contained
in the Department’s Contract Reimbursement Manual (as from time to time
amended) and the Department’s Contract Policy and Information Manual (as
from time to time amended). Failure to comply with these policies and
procedures shall be grounds to terminate this Contract.

 

Section 3.08
Financial Management System. The Provider Agency’s financial management system
shall provide for the following:

 

(a)                                  accurate, current and complete disclosure
of the financial results of this Contract and any other contract, grant,
program or other activity administered by the Provider Agency;

 

(b)                                 records adequately identifying the source
and application of all Provider Agency funds and all funds administered by the
Provider Agency.  These records shall
contain information pertaining to all contract and grant awards and
authorizations, obligations, unobligated balances, assets, liabilities, outlays
and income;

 

(c)                                  effective internal control structure over
all funds, property and other assets. The Provider Agency shall adequately
safeguard all such assets and shall ensure that they are used solely for
authorized purposes;

 

(d)                                 comparison of actual outlays with
budgeted amounts for this Contract and for any other contract, grant, program
or other activity administered by the Provider Agency;

 

(e)                                  accounting records supported by source
documentation;

 

(f)                                    procedures to minimize elapsed time
between any advance payment issued and the disbursement of such advance funds
by the Provider Agency; and

 

(g)                                 procedures consistent with the provisions
of any applicable Department policies and procedures for determining the
reasonableness, allowability and allocability of costs under this Contract.

 

Section 3.09 Audit. The Department requires submission of
the Provider Agency’s annual organization-wide audit.

 

6

 

Audits shall be conducted in accordance with the Federal Single Audit Act of 1984,
generally accepted auditing standards as specified in the Statements on Auditing
Standards issued by the American Institute of Certified Public Accountants
and Government Auditing Standards issued by the Comptroller General of
the United States.

 

At any time during the Contract term, the Provider
Agency’s overall operations, its compliance with specific Contract provisions,
and the operations of any assignees or subcontractors engaged by the Provider
Agency under Section 5.02 Assignment and Subcontracts may be
subject to audit by the Department, by any other appropriate unit or agency of
State or federal government, and/or by a private firm or firms retained or
approved by the Department for such purpose.

 

Whether or not such audits are conducted during the
Contract term, a final financial and compliance audit of Contract operations,
including the relevant operations of any assignees or subcontractors, may be
conducted after Contract Termination or Expiration.

 

The Provider Agency is subject to audit up to four years after
Termination or Expiration of the Contract. 
If any audit has been started but not completed or resolved before the
end of the four-year period, the Provider Agency continues to be subject to
such audit until it is completed and resolved.

 

Section 3.10 Federal
Davis-Bacon Act and New Jersey Prevailing Wage Act. Any Department Contract containing
federal funds in excess of $2,000 utilized for the construction, alteration,
renovation, repair or modification of public works or public buildings to which
the federal government is a party, or any contract for similar work on public
works financed with federal funds must comply with the federal Davis-Bacon Act,
40 U.S.C. section 276a et  seq.  The Davis-Bacon Act requires that the
contractor must pay the prevailing wages to each designated worker class
engaged under the contract at wage rates determined by the U.S. Secretary of
Labor.

 

In addition, any State funds in excess of $2,000 utilized through a
subsequent Provider Agency contract or subcontract for any public work in which
the Department is a party, or for public work to be done on property or
premises leased or to be leased by the Department shall comply with the NJ
Prevailing Wage Act, N.J.S.A. 34:11-56.27. Such contracts or subcontracts shall
contain a provision stating that the prevailing wage rate, as designated by the
New Jersey Commissioner of Labor, must be paid to all designated classes of
workers employed through said contracts or subcontracts.  The Provider Agency must determine if the New
Jersey Prevailing Wage Act applies and follow all directives per N.J.S.A.
34:11-56 et seq.

 

7

 

Section 3.11
Contract Closeout.
The Provider Agency shall comply with all requirements of Policy Circular P7.01,
Contract Closeout, including the timely submittal of the Final Report of
Expenditures and any other financial or programmatic reports required by the
Department. All required documentation is due within 120 Days of Contract
Expiration or Termination.

 

IV.         TERMINATION

 

The Department may terminate or suspend this Contract
in accordance with the sections listed below.

 

Section 4.01 Default
and Termination for Cause. If the Provider Agency fails to fulfill or comply with any of the terms or conditions of the Contract,
in whole or in part, the Department may by Notice place the Provider Agency in
default status, and take any action(s) listed in accordance with Department
Policy Circular P9.05, Contract Default. Notice shall follow the
procedures established in the Policy Circular.

 

The above notwithstanding, the Departments may
immediately upon Notice terminate the Contract prior to its expiration, in
whole or in part, whenever it is determined that the Provider Agency has
jeopardized the safety and welfare of the Department’s clients, materially
failed to comply with the terms and conditions of the Contract, or whenever the
fiscal or programmatic integrity of the Contract has been compromised. The
Notice of Termination shall state the reason for the action(s); the
Provider Agency’s informal review options, time frames and procedures; the
effective date of the Termination; and the fact that a request for a review of the decision for action(s) does
not preclude the determined action(s) from being implemented.

 

Section 4.02
Termination by the Department or Provider Agency. The Department or provider Agency may terminate this
Contract upon 50 Days’ advance written Notice to the other party for any reason
whatsoever, including lack of funding by the Department.

 

The parties expressly recognize and agree that the Department’s
ability to honor the terms and conditions of this Contract is contingent upon
receipt of federal funds and/or appropriations of the State legislature. If
during the term of this Contract, therefore, the federal and/or the State
government reduces its allocation to the Department, the Department reserves the right, upon Notice to the
Provider Agency, to reduce or terminate the Contract.

 

Section 4.03
Termination Settlement. When a Contract is terminated under any section of
Article IV of this Contract or Policy

 

8

 

Circular P9.05, Contract Default, the Provider
Agency shall be prohibited from incurring additional obligations of Contract
funds. The Department may allow costs that the Provider Agency could not
reasonably avoid during the Termination process to the extent that said costs
are determined to be necessary and reasonable.

 

The Provider Agency and Department shall settle or
adjust all accounts in a manner specified by the Department and shall be
subject to a final audit under Section 3.09 Audit.

 

V.            ADDITIONAL
PROVISIONS

 

Section 5.01
Application of New Jersey Law. This Contract shall be governed, construed and
interpreted in accordance with the laws of the State of New Jersey including
the New Jersey Contractual Liability Act (N.J.S.A. 59:13-1 et seq.).

 

Section 5.02
Assignment and Subcontracts. This Contract, in whole or in part, may not be
assigned by the Provider Agency or assumed by another entity for any reason,
including but not limited to changes in the corporate status of the Provider
Agency, without the prior written consent of the Department.  Upon prior written notice of a proposed
assignment, the Department may: (1) approve the assignment and continue
the Contract to term; (2) approve the assignment conditioned upon the
willingness of the assignee to accept all contractual modifications deemed
necessary by the Department; or (3) disapprove the assignment and either
terminate the Contract or continue the Contract with the original Provider
Agency.

 

The Provider Agency may not subcontract any of the
services that it has committed to perform or provide pursuant to this Contract
without the prior written approval of the Department.  Such consent to subcontract shall not relieve
the Provider Agency of its full responsibilities under this Contract.  Consent to the subcontracting of any part of
the services shall not be construed to be an approval of said subcontract or of
any of its terms, but shall operate only as an approval of the Provider Agency’s
request for the making of a subcontract between the Provider Agency and its
chosen subcontractor. The Provider Agency shall be responsible for all services
performed by the subcontractor and all such services shall conform to the
provisions of this Contract.

 

Section 5.03 Client
Fees.  Other than as provided for in the Annex(es)
and/or Departmental Component specific policies, the Provider Agency shall
impose no fees or any other types of charges of any kind upon recipients of
Contract services.  

 

Section 5.04
Indemnification.  The Provider Agency shall assume all risk of
and responsibility for, and agrees to indemnify, defend

 

9

 

and hold harmless the State of New Jersey and its employees from and against
any and all claims, demands, suits, actions, recoveries, judgments and costs,
and expenses in connection therewith on account of the loss of life, property
or injury or damages to the person, body or property of any person or persons,
whatsoever, which shall arise from or result directly or indirectly from
(1) the work, service or materials provided under this Contract; or
(2) any failure to perform the Provider’s obligations under this Contract
or any improper or deficient performance of the Provider’s obligations under
this Contract. This indemnification obligation is not limited by, but is in addition to, the insurance
obligations contained in this Contract.

 

Furthermore, the provisions of this indemnification
clause shall in no way limit the obligations assumed by the Provider under this
Contract, nor shall they be construed to relieve the Provider from any
liability nor preclude the State of New Jersey, its Agencies, and/or the
Department of Human Services from taking any other actions available to them
under any other provisions of this Contract or otherwise in law.

 

Section 5.05
Insurance.  The Provider Agency shall maintain adequate
insurance coverage. The State shall be included as an Additional Insured on any
insurance policy applicable to this Contract. Should the Provider Agency fail
to pay any premium on any insurance policy when due, the Department may pay the
premium and, upon Notice to the Provider Agency, reduce payment to the Provider
Agency by the amount of the premium payment.

 

Section 5.06
Modifications and Amendments. If both parties to this Contract agree to amend or
supplement this Contract, any and all such amendments or supplements shall be
in writing and signed by both parties. The amendment or supplement shall
incorporate the entire Contract by reference and will not serve to contradict,
amend or supplement the Contract except as specifically expressed in the
amendment or supplement.

 

Section 5.07
Statement of Non-Influence. No person employed by the State of New Jersey has
been or will be paid any fee, commission, or compensation of any kind or
granted any gratuity by the Provider Agency or any representative thereof in
order to influence the awarding or administration of this Contract.

 

Section 5.08
Exercise of Rights.  A failure or a delay on the part of the
Department or the Provider Agency in exercising any right, power or privilege
under this Contract shall not waive that right, power or privilege.  Moreover, a single or a partial exercise
shall not prevent another or a further exercise of that or of any other right,
power or privilege.

 

10

 

Section 5.09
Recognition of Cultural Sensitivity.  The Provider
Agency agrees in the performance of this Contract to be sensitive to the needs
of the minority populations of the State of New Jersey. This sensitivity
includes the employment, if possible, of a culturally diverse staff that can
communicate with, and be representative of, the community it serves.

 

The Provider Agency shall make programs linguistically
appropriate and culturally relevant to underserved minority groups within the
community.  Appropriate accommodations
for services shall be developed and maintained for those minority individuals
who are deprived of reasonable access to those services due to language
barriers or ethnic and cultural differences. 
In addition, Provider Agencies shall make certain that all programs and
services are reflective of the demographic needs of the community, while
providing all minorities the opportunity to experience any and all available
social services irrespective of their ethnic or cultural heritage.

 

Section 5.10
Copyrights.  The State of New Jersey reserves a
royalty-free, nonexclusive and irrevocable right to reproduce, publish or
otherwise use any work or materials developed under a Department or federally
funded contract or subcontract.  The
Department also reserves the right to authorize others to reproduce, publish or
otherwise use any work or materials developed under said contract or subcontract.

 

Section 5.11
Successor Contracts.  If an audit or Contract close-out reveals
that the Provider Agency has failed to comply with the terms and/or conditions
of this Contract, the Department reserves the right to make all financial
and/or programmatic adjustments it deems appropriate to any other Contract
entered into between the Department and the Provider Agency.

 

Section 5.12
Sufficiency of Funds.  The Provider Agency agrees that this Contract
is contingent upon availability of appropriated funding and fulfillment of the
following procedure(s):

 

A separate Contract confirmation letter may be sent by
the Department’s Contract Policy and Management Unit to the Provider Agency
prior to the effective date of the Contract. 
The confirmation shall include the Contract term and the negotiated
Contract reimbursable ceiling.  The
confirmation letter shall be signed by the authorized Provider Agency signatory
and returned to the Contract Policy and Management Unit.  The Contract shall not be valid or binding
and no payment(s), other than the Initial Advance Payment will be approved
until the Contract Policy and Management Unit is in receipt of a properly
executed confirmation letter.

 

Whenever a Contract ceiling is revised (increased or
decreased) during the Contract term, a Contract Modification confirmation
letter

 

11

 

may be initiated that follows the same procedure as the Contract
confirmation letter.

 

The Contract term and reimbursement ceiling specified
in the Contract confirmation letter(s) are hereby incorporated into and made a
part of this Contract.

 

Section 5.13
Collective Bargaining. State and federal law allow employees to organize themselves into a
collective bargaining unit.

 

Funds provided under this Contract shall not be utilized to abridge the
rights of employees to organize themselves into a collective bargaining
organization or preclude them from negotiating with Provider Agency management.
Funds may be utilized for legitimate and reasonable management purposes at the
direction of the Provider Agency during the process of collective bargaining
organization.

 

Section 5.14
Independent Employer Status. Employees of Provider Agencies that Contract with
the Department of Human Services are employees of the Provider Agency, not the
State.

 

In accordance with the National Labor Relations Act,
29 U.S.C.A. 152(2) and State law, N.J.S.A. 34:l3A-l et  seq.,
Provider Agencies are independent, private employers with all the rights and
obligations of such, and are not political subdivisions of the Department of
Human Services.

 

As such, the Provider Agency acknowledges that it is
an independent contractor, providing services to the Department of Human
Services, typically through a contract-for-services agreement. As independent
contractors, Provider Agencies are responsible for the organization’s overall
functions which includes the overseeing and monitoring of its operations,
establishing the salary and benefit levels of its employees, and handling all
personnel matters as the employer of its workers.

 

The Provider Agency acknowledges its relationship with
its employees as that of employer. While the Department has an adjunct role
with Provider Agencies through regulatory oversight and ensuring contractual
performance, the Provider understands that the Department is not the employer
of a Provider Agency’s employees.

 

The Provider Agency further acknowledges that while
the Department reimburses Provider Agencies for all allowable costs under the
Contract, this funding mechanism does not translate into the Department being
responsible for any of the elements of any collective bargaining agreements
into which Provider Agencies may enter. Moreover, each Provider Agency
understands that it is responsible for funding its own programs and is not
limited to the

 

12

 

amount of funding provided by the Department, and, in
fact, is encouraged to solicit non-State sources of funding, whenever possible.

 

Section 5.15
Executive Order No. 189.  Executive
Order No. 189 establishes the expected standard of responsibility for all
parties that enter into a contract with the State of New Jersey.  All such parties must meet a standard of
responsibility that assures the State and its citizens that such parties will
compete and perform honestly in their dealings with the State and avoid
conflicts of interest.

 

In compliance with Paragraph 3 of Executive Order
No. 189, no Provider Agency shall pay, offer to pay, or agree to pay,
either directly or indirectly, any fee, commission, compensation, gift,
gratuity, or other thing of value of any kind to any State officer or employee
or special State officer or employee, as defined by N.J.S.A. 52:13D-l3b and e,
in the Department of the Treasury or any other agency with which such Provider
Agency transacts or offers or proposes to transact business, or to any member
of the immediate family, as defined by N.J.S.A. 52:13D-l3i, of any such officer
or employee, or any partnership, firm, or corporation with which they are
employed or associated, or in which such officer or employee has an interest
within the meaning of N.J.S.A. 52:13D-13g.

 

The solicitation of any fee, commission, compensation,
gift, gratuity or other thing of value by any State officer or employee or
special State officer or employee from any Provider Agency shall be reported in
writing forthwith by the Provider Agency to the Attorney General and the
Executive Commission on Ethical Standards.

 

No Provider Agency may, directly or indirectly, undertake
any private business, commercial or entrepreneurial relationship with, whether
or not pursuant to employment, contract or other agreement, express or implied,
or sell any interest in such Provider Agency to, any State officer or employee
or special State officer or employee having any duties or responsibilities in
connection with the purchase, acquisition or sale of any property or services
by or to any State agency or any instrumentality thereof, or with any person,
firm or entity with which he is employed or associated or in which he has an
interest within the meaning of N.J.S.A, 52:13D-13g.  Any relationships subject to this provision
shall be reported in writing forthwith to the Executive Commission on Ethical
Standards, which may grant a waiver of this restriction upon application of the
State officer or employee or special State officer or employee upon a finding
that the present or proposed relationship does not present the potential,
actuality or appearance of a conflict of interest.

 

No Provider Agency shall influence, or attempt to
influence or cause to be influenced, any State officer or employee or special

 

13

 

State officer or employee
in his official capacity in any manner which might tend to impair the
objectivity or independence of judgment of said officer or employee.

 

No Provider Agency shall cause or influence, or
attempt to cause or influence, any State officer or employee or special State
officer or employee to use, or attempt to use, his official position to secure
unwarranted privileges or advantages for the Provider Agency or any other
person.

 

The provisions cited above shall not be construed to
prohibit a State officer or employee or special State officer or employee from
receiving gifts from or contracting with Provider Agencies under the same terms
and conditions as are offered or made available to members of the general
public subject to any guidelines the Executive Commission on Ethical Standards
may promulgate.

 

14

 

CONTRACT SIGNATURES AND
DATES

 

The terms of this Contract have been read and
understood by the persons whose signatures appear below. The parties agree to
comply with the terms and conditions of the Contract set forth on the preceding
pages in Articles I through Articles V, and any related Annexes.

 

This contract contains 15 pages and is the entire
agreement of the parties. Oral evidence tending to contradict, amend or
supplement the contract is inadmissible; the parties having made the Contract
as the final and complete expression of their agreement.

 

	
  BY:

  	
  /s/ Lisa A
  Coscia

  	
   

  	
   

  	
  BY:

  	
   

  
	
   

  	
  (signature)

  	
   

  	
   

  	
  (signature)

  
								

 

	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Lisa A Coscia

  	
   

  	
   

  	
   

  	
  Muriel Brantley

  	
   

  
	
  (type name)

  	
   

  	
   

  
								

 

	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TITLE:

  	
  Executive Director,

  	
   

  	
  TITLE:

  	
  Regional Assistant
  Director,

  
	
   

  	
  Eastern Division

  	
   

  	
   

  	
   

  	
  Metropolitan Region

  	
   

  
								

 

 

	
  PROVIDER AGENCY:

  	
  National Mentor Healthcare Inc.

  	
   

  	
  COMPONENT:

  	
  DEPARTMENTAL DYFS

  
	
   

  	
  (type)

  	
   

  	
   

  	
   

  

 

	
   

  	
   

  
	
  DATE:

  	
  9/10/04

  	
   

  	
   

  	
   DATE:

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Contract Effective Date:

  	
  10/01/04

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Contract Expiration Date:

  	
  9/30/05

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Contract Number:

  	
  05DDMM

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Contract Ceiling:

  	
  N/A

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  Federal ID#:

  	
  04-2893910/00

  
													

 

	
   

  	
   

  
	
  Provider contract Individual:

  	
   

  	
  Lisa Coscia

  	
   

  	
   

  
	
   

  	
   

  	
  (print name)

  	
   

  	
   

  

 

 

Attachment A

 

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN
SERVICES

CONTRACT MODIFICATION
FORM

 

Provider Agency Name National Mentor Healthcare, Inc.
Modification # 2

 

Fiscal-Year End 09/30/06
Contract Term
                                         thru                       

 

Contract # 05DDMM Cognizant Contract: Yes   ý       No  o

 

Division(s) affected by
the Modification        DYFS/CENTRAL AND
METRO REGION; CAMDEN

•              Date of most recently approved Contract Modification:

•              Requested effective date for this Contract
Modification:        04/01/05

•              Check applicable area(s) for modification:

 

Revisions applicable to all Contracts

 

o       Changes to the Reimbursable Ceiling: from
                                              to

 

o       Contract term: from
                                                  to                                 

 

o       Change in payment methodology

 

o       Change that alters the target population,
negotiated performance standards, lowers the level of service, lowers staff
client ratio, or violates licensing and other State established minimum
standards.

 

o       Change in payment rate

 

Revisions to Cost-Related
Contracts only

 

o       Transfer of funds from one Cluster to
another or, in the absence of a Cluster, from one Program to another.

 

o       Addition of a Budget Category or addition
of a Line Item.

 

o       Line Item increase in Personnel/Fringe
Benefits greater than 5% or the addition or deletion of a staff position.

 

o       Line Item increase of $2,000 or 15% of
the Budget Category total, whichever is greater for: Consultants and
Professional Fees, Materials and Supplies, Facility Costs, Specific Assistance to
Clients, and Other. 

 

o       Addition of an Item of Equipment not
included in the approved budget and/or an increase greater than $2,000 of 15%
of the Equipment Budget Category totals, whichever is greater. 

 

o       General and Administrative (G&A):
Line Item increase or change in G&A costs as stated above for
Personnel/Fringe Benefits and all other Budget Category totals, (i.e., as
G&A costs are subject to the same controls as the Direct cost Budget
Categories) and/or change to the method of allocating G&A costs.

 

o       Change greater than 10% in a previously
approved donor match, or negotiated cost sharing.

 

o       Change in the fee schedule which
directly impact clients served by the Contract.

 

o       Change of subcontractors or subcontracted
services.

 

o       Change to the method of allocating
G&A, the indirect cost rate and/or its application.

 

	
  ý   Other

  	
  7 Slots

  	
  (EMERGENCY TREATMENT HOMES Regular)

  
	
   

  	
   5 Slots

  	
   (EMERGENCY TREATMENT HOMES
  Camden)

  

 

Level 2 Treatment Homes slots are being increased
from 40 slots to 45 slots- (5 slots SRO YES/CPAC) 

 

On a separate sheet, specify the provisions to be modified, explain why
the Modification is needed, and how the Modification will effect the Contract.

 

Expansion of the contract
to include seven Emergency Treatment home (Regular) Beds for the Central and
Metro Regions only. 5 Emergency Treatment homes (Camden) are dedicated as a
detention alternative for Camden youth ages 5-17. Level 2 Treatment Homes slots
are being increased from 40 slots to 45 slots (5 slots SRO YES/CPAC)

 

This form, its
attachments and/or revised section(s) of the programmatic annex and/or the
revised itemized budget or Rate Information Summary, constitute this entire
Contract Modification. The persons whose signatures appear below agree to this
Contract Modification.

 

	
  BY:

  	
  /s/ Lisa Coscia

  	
   

  	
  BY:

  	
  /s/ Alfred
  Sambataro

  
	
   

  	
  (signature)

  	
   

  	
   

  	
  (signature)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Lisa Coscia

  	
   

  	
   

  	
  Alfred Sambataro

  	
   

  
	
   

  	
  (type name)

  	
   

  	
   

  	
  (type name)

  
	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
  Executive
  Director

  	
   

  	
   

  	
  Title

  	
  Administrator,
  Business Operations

  
									

 

	
  Provider Agency:

  	
  National Mentor Healthcare, Inc

  	
   

  	
  Component:

  	
  Departmental MRO

  	
   

  
	
   

  	
   

  	
   

  
	
  Date:

  	
  6/2/05

  	
   

  	
  Date:

  	
  6/15/05

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  DATE EFFECTIVE:

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
  (To be completed by the
  Department)

  	
   

  
								

 

 

STATE OF
NEW JERSEY

DEPARTMENT
OF HUMAN SERVICES 

ANNEX
B-2: CONTRACT RATE INFORMATION SUMMARY

 

	
  PROVIDER:

  	
  National Mentor Healthcare, Inc.

  	
  DATE: 04/01/05

  
	
   

  
	
  CONTRACT No:

  	
  05DDMM

  	
  THIS ANNEX B-2 SUPERCEDES THE 

  ANNEX B-2 DATED:

  
	
  FEDERAL I.D. No: 04-2893910

  
	
  NEW o RENEWAL o CONTRACT MODIFICATION ý MOD # 2  

  
				

 

SECTION I: RATES

 

	
   

  	
   

  	
  MEDICAID

  	
   

  	
  PCIS
  LOCATION

  	
   

  	
  UNIT OF

  	
   

  	
  CONTRACT

  	
   

  	
  LICENSED

  	
   

  	
  RATE
  PER

  	
   

  	
  TYPE OF

  	
   

  	
  EFFECTIVE
  PERIOD

  	
   

  	
  CONTRACT

  	
   

  
	
  PROGRAM/SERVICE

  	
   

  	
  PROVIDER
  #

  	
   

  	
  &
  PROGRAM CODE

  	
   

  	
  SERVICE

  	
   

  	
  SLOTS

  	
   

  	
  SLOTS

  	
   

  	
  SERVICE
  UNIT*

  	
   

  	
  RATE

  	
   

  	
  FROM

  	
   

  	
  TO

  	
   

  	
  CAPACITY

  	
   

  
	
  Treatment Home Level 1

  	
   

  	
  8884803

  	
   

  	
  00/01

  	
   

  	
  Days

  	
   

  	
  173

  	
   

  	
  173

  	
   

  	
  $

  	
  155.81

  	
   

  	
  Fixed

  	
   

  	
  10/01/04-01/31/05

  	
   

  	
  21,279

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Days

  	
   

  	
  188

  	
   

  	
  188

  	
   

  	
  $

  	
  155.81

  	
   

  	
  Fixed

  	
   

  	
  02/01/05-9/30/06

  	
   

  	
  114,116

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Treatment Home Level 2

  	
   

  	
  8884901

  	
   

  	
  00/02

  	
   

  	
  Days

  	
   

  	
  40

  	
   

  	
  40

  	
   

  	
  $

  	
  134.09

  	
   

  	
  Fixed

  	
   

  	
  10/01/04-03/31/05

  	
   

  	
  7,280

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  45

  	
   

  	
  45

  	
   

  	
  $

  	
  134.09

  	
   

  	
  Fixed

  	
   

  	
  04/01/05-09/30/06

  	
   

  	
  24,660

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Special Needs

  Sex Offender Program*     (Second Chance)

  	
   

  	
  9075003

  	
   

  	
  00/08

  	
   

  	
  Days

  	
   

  	
  15

  	
   

  	
  15

  	
   

  	
  $

  	
  320.85

  	
   

  	
  Fixed

  	
   

  	
  10/01/04-01/30/05

  	
   

  	
  1,845

  	
   

  
	
     *Polygraph, Abel Assessment and
  P1eythemograh included in rate

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Days

  	
   

  	
  16

  	
   

  	
  16

  	
   

  	
  $

  	
  320.85

  	
   

  	
  Fixed

  	
   

  	
  02/01/05-09/30/06

  	
   

  	
  9,712

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Treatment

  Homes(regular)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Days

  	
   

  	
  7

  	
   

  	
  7

  	
   

  	
  $

  	
  200.00

  	
   

  	
  Fixed

  	
   

  	
  04/01/05-09/30/06

  	
   

  	
  3,836

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Treatment

  Homes (Camden)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  Days

  	
   

  	
  5

  	
   

  	
  5

  	
   

  	
  $

  	
  200.00

  	
   

  	
  Fixed

  	
   

  	
  04/01/05-09/3006

  	
   

  	
  2,740

  	
   

  

 

Contract Reimbursable Ceiling: $30,401,993.00

 

* THESE RATES ARE SUBJECT TO THE CONDITIONS IN SECTION II AND III.

 

SECTION II: CONTRACT
STIPULATIONS

 

A.                                   The service capacity of the Provider
Agency is (contracted service days ( See
above Under “Contract Capacity”)  for the term of this Contract.
(Check here if not
applicable:                 .)

 

B.                                     The Provider Agency shall submit to the
Department a o monthly, o
quarterly, o semi-annual, ý
annual report certifying to the actual program expenditures consistent with the
Provider’s approved budget set forth in the Contract Budget. This report is due
120 days after the end of the reporting period. (Check here if periodic
expenditure reporting is not
applicable:           .)
See  Section III;
Part D # 5

 

C.                                     The Provider Agency shall submit to the
Department a o monthly, o
quarterly, o semi-annual, ý annual report certifying to the actual units
of service delivered during the reporting period. This report is due
    days after the end of the reporting period. (Check here if
periodic level of service reporting is not applicable    .)
See  Section
III; Part D # 5

 

Other: (Specify reporting requirements if B and C are not applicable.)

 

D.                                   These slots will hence forth be dedicated
“Special Needs Service Sex Offender Program slots. Authorization for
utilization will require approval through the DCBHS residential placement unit.
Note: There will be in the near future a specialized confirmation number which
will be utilized to identify children appropriated for the level of clinical
care associated with the utilization of these service days/slots.

 

SECTION III: GENERAL

 

A.                                   Limitations: Use of the rate(s) contained
in this Annex is subject to any statutory or administrative limitations.
Acceptance of the rate(s) agreed to herein is predicated on the condition that
no information furnished by the Provider Agency and used in the establishment
of the rate(s) as applicable is found to be materially incomplete or
inaccurate.  In addition, if the rate(s)
agreed to herein was/were calculated based on costs contained in the Contract
Budget (Annex B), acceptance of the rate(s) is predicated on the conditions
that: (1) no costs other than Provider Agency costs were included in the
Annex B as finally accepted; (2) all costs reflected in the Contract’s
Reimbursable Ceiling are allowable under the governing cost principles; and
(3) similar types of costs were accorded consistent accounting treatment.

 

B.                                     Types of Rates:

 

1.                                       Provisional: A provisional rate is a
temporary or interim rate and is subject to adjustment on the basis of a final
rate calculated when actual costs are reported.

 

2.                                       Fixed: A fixed rate is a permanent rate,
not subject to adjustment, which is agreed to for a specified future period,
usually one year.

 

C.                                     Notification of State agencies: Copies of
this document may be furnished to other State agencies as a means of notifying
them of the information it contains.

 

D.                                    Other:

 

1.                                      This contract is conditional
based on the program(s) that is/are listed above has/have been approved by the
New Jersey Medicaid Program as a Medicaid Provider under the Partnership for
Children.

 

2.                                      Billing under this contract will
be processed directly to the New Jersey Medicaid Program for reimbursement
through the Medicaid payment system.

 

1

 

3.                                      The unit rate specified in this
contract includes $2.46 per diem rate for clothing. The clothing rate is a
component of the Personal Needs Allowance (PNA) which includes clothing,
personal allowance, and personal care items to meet the needs of children in
placement.

 

4.                                      The provider must maintain at a
minimum, a system that tracks your cumulative level of service, billings sent
to Medicaid, payments received for Medicaid billings and an account receivable
for pending billings related to the contract.

 

5.                                      The provider is required to
submit an annual report of expenditures in the DHS Annex B Budget format within
120 days of the end of each provider fiscal year during the contract period,
which shall be prepared in accordance with the governing cost principles set
forth in the Department of Human Services Contract Reimbursement Manual (CRM). Where
the contract covers portions of more than one provider fiscal year, the first
report shall be from the beginning of the contract to the end of the providers
first fiscal year. The second report shall cover the full provider fiscal year.

 

Under separate cover we will be
providing a reporting format for you to use with the DHS expenditure reporting
document. The Information will contain instructions on the classification of
expenses in terms of room, board and treatment.

 

The aforementioned documents will
also report units of service for the applicable time period.

 

The purpose of this report is to
provide the Department with cost data that may be used to determine costs
associated with “Rehabilitation Services” and “Room and Board” These
reported costs shall not retrospectively effect the Provider’s “Fixed” payment
rates.

 

 

ANNEX A

 

PROGRAM DESCRIPTION

 

Instructions

 

The following Program Description form must be
completed in full by all agencies signing a Model Agreement for Residential
Services with the Department of Institutions and Agencies, Division of Youth
and Family Services.

 

The form is self-explanatory and agencies are
requested, in-so-far as possible, not to exceed space provided on form in
answering questions, unless a more detailed response is specifically requested
for the item.

 

Agencies having questions should telephone or write: 

 

I - AGENCY INFORMATION

 

	
  PROGRAM:

  	
  Mentor - New Jersey - Treatment Homes

  

 

A.           Name of agency which will be responsible for the
operation of the program specified herein.

 

	
  NAME

  	
  National Mentor Inc. - D.B.A.

  	
   MENTOR - NEW JERSEY

  
	
  ADDRESS

  	
  80 Cottontail Lane

  	
   

  	
   

  
	
   

  	
  Somerset, New Jersey 08873

  
	
  COUNTY  Somerset

  	
   

  	
  TELEPHONE

  	
  (732) 627-9890

  
							

 

B.             Addresses of facilities in which contract services are
to be provided (if different from “A”)

 

	
  NAME

  	
  Various Mentor Homes in the community

  	
   

  	
   

  
	
  ADDRESS

  	
  on file in office and available upon request

  	
   

  	
   

  
	
  NAME

  	
   

  	
   

  	
   

  
	
  ADDRESS

  	
   

  	
   

  	
   

  

 

C.             Name and title of Chief Executive Officer responsible
for the administration of the Program. 

 

	
  Name

  	
   

  	
  Title

  	
   

  	
  Telephone
  (include area code)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lisa Coscia

  	
   

  	
  Executive Director, Eastern Division

  	
   

  	
  (732) 627-9890 ext. 210

  

 

D.            Name of individual or officer to who referrals should
be sent.

 

	
  Name

  	
   

  	
  Title

  	
   

  	
  Telephone
  (include area code)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Barbara Wetzel

  	
   

  	
  Program Manager

  	
   

  	
  (732) 627-9890 ext. 213

  

 

 

E.              Attach in appendix a Certificate of Incorporation

 

	
  F.     Board of
  Directors:

  	
   

  	
  Attach in appendix a list with names, addresses,
  occupations, responsibilities, by-laws, election dates and terms.

  

 

 

G.             Are there minutes of meeting?       ý No      o Yes

 

H.            Type of Corporation:ý
Profit                        o
Non-Profit                      o Religious Non-Profit

 

I.                 Date of most recent Financial Statement (attach to
Annex B):       September 30, 2003

 

J.                Date(s) of most recent Fire and Health Inspections:
Mentor homes are licensed by DDD -Office of Licensing and Inspections when
approved by the MENTOR Recruiting Department

 

K.            History of Applicant Agency

 

1.               In a brief narrative, describe the history and
background of your agency from its founding to the present including as you see
the, its most significant accomplishments:

 

NATIONAL MENTOR HEALTHCARE, Inc. is a national behavioral health
company serving more than 18,000 individuals with special needs. MENTOR
operates some 90 programs in 30 states including New Jersey. MENTOR - New
Jersey has been a DYFS provider for more than ten years. MENTOR - New Jersey
received its original Certificate of Approval from DYFS - Division of Licensing
in May of 1992. In addition to serving children through the DYFS, MENTOR
also provides services to the Department of Human Services - Division of
Developmental Disabilities and the Division of Medical Assistance under the TBI
Medicaid Waiver program. MENTOR - NJ also provides children psychiatric and
adult brain injury treatment services to a number of private health insurance
companies.

 

L.              Area Served

 

1.               Describe briefly the geographic area currently served
by your program. Please note if your program serves a specific catchment area
and, if so, describe it specifically.

 

MENTOR - New Jersey is a statewide service
organization.  At present we have
certified homes in most counties of New Jersey except for Cape May. It is
difficult to indicate where we might have an opening at any given time, but we
currently have homes throughout the state.

 

M.         Name and Title of Individual or Officer Authorized to
Sign Contract

 

	
  Name

  	
   

  	
  Title

  	
   

  	
  Telephone
  (include area code)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lisa Coscia

  	
   

  	
  Executive Director, Eastern Division

  	
   

  	
  (732) 627-9890 ext. 210

  

 

 

II - ADMISSIONS AND DISCHARGE
POLICIES

 

A.           Admissions Requirements and Capacity

 

1.              Age range
accepted:           3 yoa through 70
+             Male     Yes      Female      Yes

 

2.              I.Q. range
accepted:    MR/DD Services - Not under 30

 

3.              Capacity: Total Average 1:8 clinician to client ratio -
no maximum capacity Male    Yes    Female    Yes

 

4.              Describe your agency’s policy
concerning pre-placement visits.

 

We strongly encourage pre-placement visits between the
client and the potential mentor. This will include an initial meeting
preferably at the current place of residence of the child and then will include
day visits if clinically indicated, and overnight visits to the mentor homes.
All of this is done with the cooperation of the client, their family or guardian
and treatment team.

 

5.              Describe the identifying evaluative
reports and records required for each referral.

 

At a minimum, the following is required for each
client: current DYFS assessment, psychosocial history,
psychiatric/psychological evaluations, immunization records, school records,
referral summary from the DYFS caseworker, medication records. Additional
information may be requested if the evaluating clinician feels it is necessary.

 

6.              List the agencies and individuals
from whom your agency will accept referrals or applications for admission.

 

*                 NJ - Department of Human Services:

*                 The Division of Youth and Family Services

*                 The Division of Developmental Disabilities

 

*                 County Human Service and Mental Health Organizations

 

*                 Managed Health Care and Health Insurance Programs

 

7.              Describe any physical limitations
which would preclude admissions.

 

Each case is evaluated on an individual basis. If
there is an available mentor home which can accommodate a client and the client
meets admission criteria (see guidelines), he or she will be considered. MENTOR
- NJ will also consider modifying a mentor home if funding is available and the
mentor is favorably inclined to do so. Also, MENTOR - NJ can conduct
specialized recruitment to meet special needs. As much as three months advanced
planning may be required to identify and secure an accessible home.

 

8.              Child Study classifications approved
for Beadleston Special Education payments:

 

	
  ý

  	
   

  	
  Auditorily handicapped

  	
   

  	
  ý

  	
   

  	
  Multiply handicapped

  

 

 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ý

  	
   

  	
  Chronically ill

  	
   

  	
  ý

  	
   

  	
  Neurologically impaired

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ý

  	
   

  	
  Communication handicapped

  	
   

  	
  ý

  	
   

  	
  Orthopedically handicapped

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ý

  	
   

  	
  Emotionally disturbed

  	
   

  	
  ý

  	
   

  	
  Perceptually impaired

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ý

  	
   

  	
  Mentally retarded

  	
   

  	
  ý

  	
   

  	
  Socially maladjusted

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  ý

  	
   

  	
  Visually impaired

  

 

* Please be advised that we evaluate each case on an
individual basis. Admission into the program will also depend on the
availability of a suitable mentor home. The matching of the client and the
mentor is an important piece of the evaluation.

 

9.              For the list of characteristics and
behaviors below, give an indication as to the acceptability of each in terms of your
admission criteria, acceptable (yes), not acceptable (no). If there is a need to qualify
certain entries, please briefly do so in the space provided.

 

	
   

  	
   

  	
   

  	
   

  	
  YES

  	
   

  	
  NO

  	
   

  
	
  a)

  	
   

  	
  Incarcerated delinquent

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  b)

  	
   

  	
  Adjudicated delinquent

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  c)

  	
   

  	
  Adjudicated JINS

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  d)

  	
   

  	
  Physically aggressive

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  e)

  	
   

  	
  Drug experience

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  f)

  	
   

  	
  Drug addiction

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  g)

  	
   

  	
  Alcoholic

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  h)

  	
   

  	
  Runaway

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  i)

  	
   

  	
  Controlled epilepsy

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  j)

  	
   

  	
  Uncontrolled epilepsy

  	
   

  	
  o

  	
   

  	
  ý

  	
   

  
	
  k)

  	
   

  	
  Enuretic

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  l)

  	
   

  	
  Stealing

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  m)

  	
   

  	
  Destructive to property

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  n)

  	
   

  	
  Fire setting (within past 2 years)

  	
   

  	
  o

  	
   

  	
  ý

  	
   

  
	
  o)

  	
   

  	
  Fire setting (more than 2 years ago)

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  p)

  	
   

  	
  Suicide attempts

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  q)

  	
   

  	
  Psychotic

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  r)

  	
   

  	
  Overt homosexuality

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  s)

  	
   

  	
  Promiscuity

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  t)

  	
   

  	
  Dependent and / or neglected

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  u)

  	
   

  	
  Diabetic

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  v)

  	
   

  	
  Married (Client only in placement)

  	
   

  	
  ý

  	
   

  	
  o

  	
   

  
	
  w)

  	
   

  	
  Pregnant

  	
   

  	
  o

  	
   

  	
  ý

  	
   

  
	
  x)

  	
   

  	
  Other (identify)

  	
   

  	
  o

  	
   

  	
  o

  	
   

  

 

f &g- Individual must be involved in a drug or
alcohol treatment program and agree to complete the program to
remain in the MENTOR MR/DD residential program.

 

 

STATE OF
NEW JERSEY

DEPARTMENT
OF HUMAN SERVICES

ANNEX
B-2: CONTRACT RATE INFORMATION SUMMARY

 

	
  PROVIDER:     National
  Mentor Healthcare, Inc.

  	
   

  	
  DATE: 9/7/04

  
	
   

  	
   

  	
   

  	
   

  
	
  CONTRACT
  #:           05DDMM

  	
  THIS ANNEX B-2 SUPERCEDES THE

  
	
   

  	
   

  	
  ANNEX B-2 DATED:

  
	
   

  	
   

  	
   

  	
   

  
	
  FEDERAL I.D.
  #:      04- 2893910

  	
   

  	
   

  
					

 

SECTION II RATES

 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  RATE PER

  SERVICE
  UNIT*

  	
   

  	
   

  	
   

  	
  REIMBURSABLLE

  CEILING

  	
   

  	
  EFFECTIVE
  PERIOD

  	
   

  
	
  PROGRAM/SERVICE

  	
   

  	
  UNIT OF
  SERVICE

  	
   

  	
  SLOTS

  	
   

  	
   

  	
  TYPE OF
  RATE

  	
   

  	
   

  	
  FROM

  	
   

  	
  TO

  	
   

  
	
  Treatment Home

  Level 1 

  ID/LOC 00

  Prg. 01

  	
   

  	
  Days

  	
   

  	
  173

  	
   

  	
  155.81

  	
   

  	
  Fixed

  	
   

  	
  $

  	
  9,838,622.45

  	
   

  	
  10/01/04-9/30/05

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Treatment Home

  Level 2 

  ID/LOC 00

  Prg. 02

  	
   

  	
  Days

  	
   

  	
  40

  	
   

  	
  134.09

  	
   

  	
  Fixed

  	
   

  	
  $

  	
  1,957,714.00

  	
   

  	
  10/01/04-9/30/05

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Special Needs

  Sex Offenders Program*

  (Second Chance)

  ID/LOC

  Prg. 08

  	
   

  	
  Days

  	
   

  	
  15

  	
   

  	
  320.85

  	
   

  	
  Fixed

  	
   

  	
  $

  	
  1,756,653.75

  	
   

  	
  10/01/01-9/30/05

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *Polygraph, Abel Assessment and Pleythsmograph
  included in rate*

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Total Contract Ceiling
  will not exceed

  	
   

  	
  $

  	
  13,552,990.20

  	
   

  	
   

  	
   

  

 

*THESE RATES ARE SUBJECT TO THE CONDITIONS IN SECTION II AND III.

 

SECTION II: CONTRACT
STIPULATIONS

 

A.           The service capacity of the Provider Agency
is                 for
the term of this Contract. (Check here if not applicable :)

 

B.             The Provider Agency shall submit to the Department a o monthly, o quarterly, o
semi-annual, ý annual report certifying to the actual
program expenditures consistent with the Provider’s approved budget set forth
in the Contract Budget. This report is
due      days after the end of the reporting
period. (Check here if periodic expenditure reporting is not applicable:)

 

C.             The Provider Agency shall submit to the Department a o monthly, o quarterly, o
semi-annual, o annual report certifying to the actual
units of service delivered during the reporting period. This report is due
      days after the end of the reporting period,
(Check here if periodic level of service reporting is not applicable ý.)

 

D.            Other: (Specify reporting requirements if B and C
above are not applicable).

 

SECTION III: GENERAL

 

A.           Limitations: Use of rate(s) contained in this Annex is
subject to any statutory or administrative limitations. Acceptance of the
rate(s) agreed to herein is predicated on the condition that no information
furnished by the Provider Agency and used in the establishment of the rate(s)
subsequently found to be materially incomplete or inaccurate. In addition, if
the rate(s) agreed to herein was/were calculated based on costs contained in
the Contract Budget (Annex B), acceptance of the rate(s) is predicated on the
conditions that:

 

1

 

(1) no costs other than Provider Agency costs
were included in the Annex B as finally accepted; (2) all costs reflected
in the Contract’s Reimbursable Ceiling are allowable under the governing cost
principles; and (3) similar types of cost were accorded consistent accounting
treatment.

 

B.             Types of Rates:

 

1.               Provisional: A provisional rate is a temporary or
interim rate and is subject to adjustment on the basis of a final rate
calculated when actual costs are reported.

 

2.               Fixed: A fixed rate is a permanent rate, not
subject to adjustment, which is agreed to for a specified future period,
usually one year.

 

C.             Notification of State Agencies: Copies of this document may be furnished
to other agencies as a means of notifying them of the information it contains.

 

D.            Other:

 

1.               This contract is conditional on the approval of
programs noted in Section I by the New Jersey MEDICAID Program as a
“Medicaid Provider” program under the Department of Human Services Children’s
System of Care Initiative (CSOCI).

 

2.               Reimbursement under the CSOCI will be through the NJ
Medicaid Program. Billing under this contract will be processed directly to the
NJ Medicaid Program or an appropriate billing agent.

 

3.               This contract does ( ) does not (X) allow for a
      month advance payment in the amount
of                 .
The advance payment represents a prospective payment for services that will be
delivered, and therefore the advance payment will be recouped through the
MEDICAID payment process.

 

4.               The unit rate specified in this contract includes a
per diem rate for clothing that is necessary to meet the needs of children in
placement. The clothing per diem for the period 1/1/02-6/30/02 is $2.41; for
the period 7/1/02-12/31/02 the clothing rate is $2.46.

 

5.               The contracted slots and unit per diems identified in
Section I represent the maximum per diems that are reimbursable under the
terms of the contract. Any slots/per diem billed beyond those specified in
Section I will result in an over billing. Reimbursement received for units that exceed the above maximum per diem
units will be subject to recovery by Medicaid.

 

6.               You must maintain at a minimum a system that tracks
your cumulative level of service, billings sent Medicaid, payments received for
Medicaid billings and an account receivable for all pending billings related to
the contract.

 

2

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00092-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00092-of-00352.parquet"}]]