CTR076896_Contract_Amendment_One__1_.pdf
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- Attached to
- Master Agreement AZ|CTR076896
- Contract number
- CTR076896
- Issued by
- Arizona
About this file
This document is a Contract Amendment issued by the Arizona Department of Economic Security for Contract Number CTR076896, involving Baraka House, LLC. The amendment modifies an existing contract for Nursing and Habilitation Services for Individuals with Intellectual Disabilities at Intermediate Care Facilities and State-Owned Group Homes, and extends the contractor's scope to include services for the Arizona Department of Veterans' Services (ADVS).
The amendment adds new provisions for Baraka House, LLC to provide nursing services at four Veterans' Homes in Maricopa and Pima Counties, including healthcare and active treatment services for residents. The contract revision includes detailed incident reporting requirements, specifically mandating the submission of incident reports through the AHCCCS QM Portal within one business day of occurrence, with sentinel events requiring immediate reporting via designated phone lines. The amendment maintains all other existing contract terms and specifications, with the new services to be further defined through mutually approved Task Orders that will outline specific service requirements, deliverables, timelines, and payment terms.
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Text version
CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR076896 One (1)
DESCRIPTION/ LABEL: Nursing and Habilitation Services for Individuals with Intellectual Disabilities at Intermediate Care Facilities and State-Owned Group Homes
CONTRACTOR NAME: Baraka House, LLC.
THE ABOVE-REFERENCED CONTRACT IS HEREBY MODIFIED AS FOLLOWS:
1. In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, the Scope of Work is being revised to add Subsection 2.1.1 as follows:
2.1.1 Provide nursing services at the Arizona Department of Veterans’ Services (ADVS) four (4) Veterans’
Homes (ASVHs) in Maricopa and Pima County. Services include providing healthcare and supporting active treatment services to residents at the Veterans’ Homes.
2. In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, the Scope of Work is being revised to add Subsection 4.9 as follows:
4.9 Arizona Department of Veterans’ Services (ADVS): provides direct services to Veterans, service members, and their families through several state and federally funded programs and initiatives.
3. In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, the Scope of Work is being revised to add Subsection 6.14 as follows:
6.14 Provide services to ADVS as defined in the Scope of Work and as further detailed in mutually approved
Task Orders, which shall outline the service requirements, deliverables, timelines, and payment terms.
4. In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, Section 11 Incident Reporting Requirements is hereby added to the Scope of Work.
11. Incident Reporting Requirements
The Contractor Shall
11.1 Submit Incident Reports as defined in the DDD’s Medical Policy Manual 961, DDD Provider
Manual Chapter 70, and AHCCCS Medical Policy Manual -Chapter 96 as may be amended.
Division Medical Policy Manual 961 Division Provider Manual Chapter 70
AHCCCS AMPM 961
11.1.1 Sentinel Events shall be reported to the Division immediately at 602-375-1403 or 1-855- 375-1403 (phone lines are available 24 hours a day, weekdays, weekends, and holidays) and shall then be submitted via the AHCCCS QM Portal within one (1) business day of the occurrence of the event.
AHCCCS QM Portal Migration User Guide https://des.az.gov/sites/default/files/media/Division_Medical_Policy_Manual_961_Incident_Accident_and_Death_Reporting.pdf?time=1761096186787 https://des.az.gov/sites/default/files/media/DDD_Provider_Policy_Manual_Chapter_70_Qualified_Vendor_Incident_Reporting.pdf?time=1717792726488 https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/900/961.pdf https://docs.google.com/document/d/17V9leTt-Mf9lPUSaOFTqQRz_7jGNutPfKi4m9WcQ6IA/edit?tab=t.0%23heading=h.arsfm1vhtwua
11.1.2 The AHCCCS QM Portal can be accessed through the following links:
AHCCCS QM Portal login page AHCCCS QM Portal FAQ page
11.1.3 The AHCCCS QM Portal User Guides can be found at the links below:
AHCCCS Provider User Guide AHCCCS IAD Submit User Guide AHCCCS Return IAD User Guide AHCCCS Approve IAD User Guide
ALL OTHER REQUIREMENTS, SPECIFICATIONS, AND TERMS AND CONDITIONS REMAIN UNCHANGED
ACKNOWLEDGEMENT AND AUTHORIZATION
This Amendment shall be fully executed by means of electronic approval in APP.
https://qmportal.azahcccs.gov/Account/Login.aspx https://qmportal.azahcccs.gov/Account/Login.aspx https://qmportal.azahcccs.gov/Account/Login.aspx https://qmportal.azahcccs.gov/Account/FAQ.aspx https://qmportal.azahcccs.gov/UserGuides/QuickStart_RegistrationAccountMgmt_Provider.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Submit.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Return.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Approve.pdf
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