FY16 SRC FAMILY CAREGIVER GRANT CONTRACTORIGINAL, CON,�`-FR,`%ICT
V-A-Vf
AREA AGENCY ON AGING
GRANT AGREEMENT FOR
FAMILY CAREGIVER SUPPORTGRANT
Jill), 11 2015 - June 305 2016
1. PARTIES TO T"E CONTRACT
This agreement is made and entered into this 14'h day of July 2015 between the Cal-7e Fear Council of
Governments (1480 Harbour Drive, 11,71minglon, NC 2840.7), hereinafter referred to as the "Council of
Governments." and New Hanover Couqv Senior Resource Center (2222 South College R4, Ivihninglon, NC
28403), hereinafter referred to as the "Grantee."
11. EFFECTIVE PERIOD OF CONTRACT
This contract shall be effective July 1, 2015 and shall terminate on June 30, 2016.
Ill. GENERAL PROVISIONS
Subject to the terms and conditions hereinafter set forth, the Council of Governments agrees to grant Family
Caregiver Support program funds per the NC Division of Aging and Adult Services authorized through the
National Family Caregiver Support Act, (The Older Americans Act, as amended in 2000, Title Ill, Part E).
This grant is intended to sustain the efforts of families and other informal caregivers ofolder adults by
providing supportive services (as defined below) under the following Category 2 Access to Services,
Category 3 Training, Counseling & Support Groups Category 4 Respite Care, or Category 5 Supplemental
Services. The objective is to give caregivers relief and provide assistance in finding services allowing them to
keep their older adult in the community f6r as long as possible and/or help support older adult relatives raising
children 18 years of age or below . The services covered under the grant are intended for caregiver not
receiving any other assistance.
Category Services
Grant
Unit Cost
Projected
Projected
(2,3,4 To be
Amount
If applicable
Number of Units
# to be
or 5) provided
If Applicable
Served
2(823) Care Management
$ 20
N/A
N/A
N/A
3 (833) Support Groups
$ 1,200
N/A
n/a
n/a
4(842) In-home/non-medical
$19,200
11$17,00
1129
38
Respite (varies)
4(843) Adult Day Care
$ 1,800
$41/day
43
4
Day Health
5(857) Incontinence Supplies
$ 680
5(859) Liquid Nutritional
$ 100
Supplemental
$23,000
Note: The Cape Fear Council of Governments Area Agency on Aging must approve any changes to the budget.
Category 2 Assistance in Gaining Access to Services (individual, one on one contact to assist caregivers in
gaining access to services)
The Grantee has allocated $20 to this category.
Category 3 Training, Counseling and Support Groups
The Grantee has allocated S 1,200 to Category 3 (33) Support Groups to help with monthly caregiver support
group meetings. They have 2 support groups to assist caregivers.
Category 4 Respite Services (Considered temporary, substitute supports or living arrangements to provide a brief
period of relief to caregivers on an intermittent, occasional or erner 9 ency basis)
*Eligible ear(�fivers inust he curing./or an older adult 60+ ivith tit Icast two ADL (,/Icllivitics ofDaiNLwing i.e .
ealin,g, dressing, bathing) inipairments or individuals frith Atzheinier's diseasc and related dilyordery with
neurological and oi:garzic brain Llj,'sfiinction. /Vo more than $1500.00 in t,, be used per eligible client during grant
period.
The grantee has allocated $19,200 to Category 4 (842) In-Home Respite and $1,800 to Category 4 (843)
Communi", Respite- Adult Day Care which will be used to teinporarily provide some time off for caregivers.
These services will be provided for functionally impaired individuals whose primary caregivers need relief from
everyday caregiving responsibilities in order for impaired individuals to remain at home for as long as possible.
The Grantee will give the caregivers as much choice and flexibility as possible by offering temporary respite
through in-bonie aide (medical and non-i-nedical'), adult day care /day health, group, respite, and institutional respite
in a licensed adult care /nursing facility. Referral for these services will be made after assessments (including
reviewing current services that are being provided to care recipient by completing a comprehensive intake form)
are completed and an appropriate care plan has been developed by the Grantee.
Category 5 Supplemental Services (Services intended as a one-time assistance to caregivers that compliments the
care they are providing. Examples include: purchasing incontinence supplies, home modifications, home safety
interventions) *Eligible euregivers must he caring.1br an older adult 60+ ivith tit least t ADL (Activities (#'Dailj,,
Living i.e, eating, dressing, buthing) in7pairments. No more than $500.00 ma�)7 be used perR eligible client during
grant period.
The Grantee has allocated $680 to Category 5 (857) Incontinence Supplies and $1 ill} to Category 5 (859 Liquid
Nutritional Supplements to help with the financial burden for caregivers purchases these supplies.
Thesc services are to provide temp orary reliet"and iv ill he a bridging inechanisni until consistent services tire
available. The NC Division o 'Aging and Adult Services Home and Farr runny Care Block Grant Service
V
Standards will be used fir provided services. The Faniilv Caregiver ResourccSpecialist and other AAA .staff ivill
provide tech nica I assistance,lbr duration of thee gran t. The terms set forth in this agreenrent for paym en I are
contingent upon availability qffiinding.
IV. GRANT AMOUNT
The total payment tinder this contract shall not exceed $23,000. The North Carolina Division of Aging and
Adult Services is providing the match for the Family Caregiver Support Program; therefore no local match
is required.
In order to qualify for funding, applicants must agree to comply with the following:
All required assurances (which state the organization must comply with Section 504 of the Rehabilitation
Act of 1973, as amended (29 US.C. 794), the Americans with Disabilities Act of` 199(1, and the Department
of Health and Human Services Regulation under Title VI of the Civil Rights Act of 1964) must be signed
prior to receipt of funding under the FCSP.
• Aging Resource Management System (ARMS) Requirements: All program perfonriance and financial
reports must conform to the requirements of the Division of Aging and Adult Services' autornated Aging
Resource Management System (ARMS). The Grantee will be required to participate in the automated
ARMS by supplying the necessary and required input data. The Grantee will also be required to participate
in appropriate training workshops by the Division of Aging and Adult Services and or Area Agency on
Aging. Failure to comply with the reporting requirements inav result in either withholding of funds or
possible suspension /termination of funding. Grantees are required to participate in the ARMS user's fee.
The fee shall apply to each of the categories as the reimbursements are requested through ARMS. It shall
be based on the following formula:
4 of records reimbursement is -_ X S.15 Maintenance cost per service record - Requested for each
service
The Service Code Chart for the Family Caregiver Support Program is as follows:
Non-Unit Services Code
Information/Aissistance
LC., Management
• uor tGroups
Traininig/Education
In-home Respite Care
Community Respite Adult Day Care),_,
Institutional ■ Respite OIL.I.
Med:ical EqWp�pd_As_sistive Technol-
. ... ..... .
Personal EmeTency Response System
incond-ri.e.inceSypplies
IFORIP'llwall -
The whole service code chart for the Aging Resource Management System (ARMS) is available on -line at:
http://www.ncdhhs.gov/"ac[LngLariTis servicecodechart:2015. f
Compensation: Grantees must meet the reporting requirements of the NC Division of Aging and Adult
Services and the Cape Fear Area Agency on Aging Family Caregiver Support Program, Payments will be
made monthly upon request for reimbursement through ARMS by Grantee. Reimbursement forms will be
due monthly to the Area Agency on Aging and must be received no later than the 7th of each month if?
order to be cons ideredfor payment at the end of that month. These forms should reflect the amount of
funds requested through ARMS each month.
Payment of funds will be based upon the Aging Resource Management System (ARMS) Provider
Reimbursement Report (ZGA370-12). The Cape Fear Council of Governments will forward payment of
the approved budget expenditure at the end of each month.
3
Documentation of Expenses: Grantee shall maintain full and complete documentation of all expenses
associated with performing the scope of work under this contract. Documentation in the form of time
sheets or other verification (prior approval required) that services were rendered shall be kept in each client
file. Grantee shall maintain all financial and program records for a period of three (3) years from the date
of final payn-rent under this agreement. Grantee shall maintain records on each caregiver served
including: Family Caregiver In-take Form, Service Cost Sharing form (signed and dated) and
Client/Patient Rights form (signed and dated). The grantee should include their individual
privacy/confidentiality form and a comprehensive intake on the care recipient (see page 2) in
addition to above listed items.
Data Reporting: Grant recipients will keep client inforination updated in ARMS so we can submit a bi-
annual report that will capture required data on caregivers. ARMS will capture client information and
report fund usage monthly. 'The NC Division of Aging and Adult Services and the Cape Fear Area Agency
on Aging will provide training and technical assistance as needed.
Grantees must allow for "consumer contributions"" (caregiver must be given opportunity to contribute to
defray the cost of the service, but inay not be denied service should he/she fail to or choose not to
contribute). The NC Division of Aging and Adult Services Horne and Community Care Block Grant
Service Standards for Consumer Contributions will be followed. The Consumer Contributions Policy and
Procedures can be found on the web at: httl):/iwwN ,,,ncd,litis.i,(.)v,!'$ ibu
igiiic�,l-naiival/consui-net-contr' ti�omjdjj
VIL REALLOCATION OF GRANT FUNDS
It is understood and agreed. in the event that the Grantee's rate of progress on this contract is leading to
underutilization of the funds allocated, and if the Grantee cannot demonstrate how fands will be fully utilized
during the contract period, then, upon notice to the Grantee, the Council of Governments may decrease the total
compensation to be paid hereunder in order to reallocate funds to other Grantees, Family Caregiver Support
Grant expenditures will be reviewed after six months to ensure it is on target. If results find that utilization
of funds is less than 50%, the AAA reserves the right to reduce the original grant amount.
This contract may be modified by written amendment at any time. It is understood and agreed that, in the event
that the amount of funds received from the NC Division of Aging and Adult Services is reduced or increased from
the amount(s) quoted, the Council of Governments may, in turn, decrease or increase the total compensation and
reimbursement to be paid. Such changes, including any increase or decrease in the amount of the Grantee's
compensation shall be incorporated in written amendments to this contract and signed by both parties.
The County agrees to have an annual independent audit in accordance with North Carolina General Statutes, North
Carolina Local Government Commission requirements, Division of Aging and Adult Services Program Audit
Guide for Aging Services and Federal Office of Budget and Management (OMB) Circular A-] 33,
Community service providers, as specified in paragraph one (1), who are not units of local government or
otherwise subject to the audit and other reporting requirements of the Local Government Commission are subject
to audit and fiscal reporting requirements, as stated in NC General Statute 1430 -6-22 and 23 and OMB Circular A-
133, where applicable. Applicable community service providers must send a copy of their year-end financial
statements, and any required audit, to the Area Agency on Aging. Home and Community Care Block Grant
4
providers are not required to submit Activities and Accomplishments Reports. For-profit corporations are not
subject to the requirements of OMB Circular A -133, but are subject to NC General Statute 14310 -6-22 and 23 and
Yellow Book audit requirements, where applicable. Federal funds may not be used to pay for a Single or Yellow
Book audit unless it is a federal requirement. State funds will not be used to pay for a Single or Yellow Book
audit if the provider receives less than $500,000 in state funds. The Department of Health and Human Services
will provide confirmation of fiederal and state expenditures at the close of the state fiscal year. Information oil
audit and fiscal reporting requirements can be found at
ST --_I'
....... . . ..... 51
The following provides a summary of reporting requirements under NCGS 1430 -6-22 and 23 and OMB Circular
A -133 based upon funding L-
received and expended during the service provider's fiscal year,
Annual -Expenditures Repos I.Reqaired to AAA Allowable Cost for Reporting
Less than $25,000 in Certification forin and State N/A
State or Federal funds Grants Compliance Re-
porting <S25,000 (item 4 11,
Activities and Accomplishments
does not have to be completed) OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
Greater than $25,000 Certification form and Schedule of
and less that $500,000 Grantee Receipts >$25,000 and
in State or Federal Funds, Schedule of Receipts and Expendi-
tures OR
Audited Financial Statements in
Compliance with GAO/GAS
(i.e. Yellow Book)
$500,00+ in State funds Audited Financial Statement in
and Federal pass through compliance with GAO/GAS (i.e.
in an amount less than Yellow Book)
$500,000
$500,000+ in State funds
and S500,000+ in Federal
pass through funds (i.e.
at least $1,000,000)
Less than $500,00O in State
Bands and $500,000+ in
Federal pass through funds
Audited Financial Statement in
compliance,x7ith OMB Circular
A-] 33 (i.e. Single Audit)
Audited Financial Statement in
compliance with OMB Circular
A-] 33 (i.e. Single Audit)
N/A
May use State funds, but
not Federal Funds
May use State and Federal
hinds
May use Federal funds,
but not State funds.
Representatives of the Council of Governments and the NC Division of Aging and Adult Services may at any
reasonable times review and inspect the service activities and data collected pursuant to this Agreement. All
reports and computations prepared by or for the Grantee shall be made available to authorized representatives of
the Council of Governments, and the NC Division of Aging and Adult Services for inspection and review at any
reasonable time in the Grantee's office. Approval and acceptance of'such material shall not relieve the Grantee of
its professional obligation to discover and correct, at its expense, any errors found in the work.
To ensure adequate review and evaluation of the work and proper coordination among interested parties, the
Council of Governments shall be kept fully informed concerning the progress of the work and services to be
performed.
Council of Governments staff will conduct on-site assessments and may also make unannounced visits for the
purpose of evaluating the Grantee's work.
X. COMPLIANCE WITH TITLE VI & \1111 OF CIVIL RIGHTS ACT, SECTION 504 OF THE
REHABILITATION ACT, AND AMERICANS WITH DISABILITIES ACT
The Grantee shall comply with Title VI and Vill of the Civil Rights Act of 1964, Section 504 of the Rehabilitation
Act of 1973, and the Americans with Disabilities Act of 1990 (ADA) and all requirements imposed by Federal
regulations, rules and guidelines issued pursuant to these Titles and the ADA for both personnel employed and
clients served.
XI. CONFLICT OF INTEREST
The Grantee expressly states that presently they have no interest and shall not acquire any interest, direct or
indirect, which would conflict in any manner or degree with the performance of services required to be performed
under this contract. The Grantee shall not employ any person having such interest during the performance of this
contract. The Grantee further agrees to notify the AAA in writing of any instance that might have the appearance
of a conflict of interest. See Attachment A for signature.
XII. CONFIDENTIALITY
Any reports, recipient information, data, or other materials given to or prepared or assembled by the Grantee under
this Agreement which the Council of Governments requests to be kept confidential shall not be made available to
any individual or organization by the Grantee without prior written approval of the Council of Governments.
Grantee shall indemnify and hold the Cape Fear Council of Governments, its agents and employees, harmless
against any and all claims, demands, causes of action, or other liability, including attorney fees, on account of
personal injuries or death or an account of property damages arising out of or relating to the work to be performed
by the Grantee hereunder, resulting from the negligence of or the willful act of omission of the Grantee, its agents,
employees, and subcontractors.
XIV. ATTENDANCE AT REGION 0 AREA AGENCY ON AGING MEETINGS
The Grantee, upon request of the AAA Administrator/Designee, will make efforts to attend any committee or
special meeting relating to the project, The Grantee will attend any scheduled regional Family Caregiver Support
Program meetings,
XV. TERMINATION OF AGREEMENT FOR CAUSE
If through any cause, the Grantee shall fail to fulfill in timely and proper manner its obligations under this
Agreement or if the Grantee shall violate any of the covenant, agreements or stipulations of this Agreement, the
Council of Governments shall thereupon have the right to terminate this Agreement by giving written notice to the
Grantee of such termination and specifying the effective date thereof. The date of notice shall be at least fifteen
(15) days before the effective date of such termination.
The Grantee shall have the right to terminate this Agreement by giving the Council of Governments written notice
of such termination at least fifteen (15) days prior to the effective date of the termination. In such event, all
finished documents and other materials collected or produced under this Agreement shall, at the option of the
Council of Governments., become its property.
The Grantee shall be entitled to receive just and equitable compensation for any work satisfactorily performed
under this Agreement,
XV]. APPROVAL OF SUBCONRACTOR OR ASSIGNABILITY
The grantee shall not assign all or any portion of its interests in this contract, nor shall any of the work or services
to be performed under this Contract by the Grantee be subcontracted, without the prior written approval of the
Council of Governments. Any purchase of services with Family Caregiver Support Grant funding shall be carried
out in accordance with the procurement and contracting policy of the community services provider or, where
applicable, the Council of Governments, which does not conflict with Procurement and contracting requirements
contained in 45 CF 92.36. If services are subcontracted, the Grantee remains liable not withstanding such
procedure.
XV11. TAX EXEMPT STATUS
If grantee has tax exempt status they must submit a copy of the tax exempt declaration letter with contract.
0
Ff 89 T W-i MM
W
[OKI Molud 01#119 1 My" Oki MISM M MyTIJ a I My I a my I =a I "Malky Oki I am WHEN IVINIZE
Executive Director
Date
Area Agency on Aging Administrator Date
This instrument has been preaudited in the manner required by the local government budget and fiscal
control act.
Finance Officer
New Hanover County Senior Resource Center
Name of Organization
0
BE
Authorized L Agency Official Da
NV
Attachment A
CONFLICT OF INTEREST POLICY
In accordance with G.S. 143 -6.1 and related legislation, we, the undersigned entity, have
adopted the following policy regarding conflicts of interest:
The undersigned entity is aware that in the process of fund allocation by its
management, employees, members of the board of directors or other governing
body, instances may arise which have the appearance of a conflict of interest or
appearance of impropriety.
In order to avoid conflicts of interest or the appearance of impropriety, should
instances arise where a conflict may be perceived, any individual who may
benefit, directly or indirectly, from the entity's disbursement of funds shall abstain
from participating in any decisions or deliberation by the entity regarding the
disbursement of funds.
The undersigned entity recognizes the possibility that it may be the recipient of
funds which are allocated consistent with the purpose and goals of its programs.
If such allocations are made, the undersigned entity will strive to ensure that funds
are expended in such a manner that no individual will benefit, directly or
indirectly, from the expenditure of such funds in a manner inconsistent with its
program s.
Name of Agency
Chairman, Executive Director, or
other Authorized Official
Sworn to and subscribed before me,
This the day of
Notary Public
My Commission expires:
The National Family Caregiver Support Program (NFCSP), established in 2000 as Title III - E of the
Older Americans Act, funds a range of supports that assist family and informal caregivers to care for
their loved ones at home.
The caregiver is the client for FCSP services and must be registered as the client on the DAAS 101 and
in ARMS.
Eligible Program Participants
The following specific populations of family caregivers are eligible to receive services:
• Adult family members or other informal caregivers age 18 and older providing care to individuals
60 years of age and older;
• Adult family members or other informal caregivers age 18 and older providing care to individuals
of any age with Alzheimer's disease and related disorders-, *
• Grandparents and other relatives (not birth or adoptive parents) 55 years of age and older
providing care to children under the age of 18;
• Grandparents and other relatives (not birth or adoptive parents) 55 years of age and older
providing care to adults age 18-59 with disabilities.
The term "grandparent or older individual who is a relative caregiver" means a
grandparent or step- grandparent of a child, or a relative of a child by blood, marriage, or
adoption who is 55 years of age or older- AND
• Lives with the child;
• Is the primary caregiver of the child because the biological or adoptive parents
are unable or unwilling to serve as the primary caregiver of the child; and
• Has a legal relationship to the child, as such legal custody or guardianship, or is
raising the child informally.
B JI-111
In addition to the eligibility presented above, the Older Americans Act specifies that the caregiver
of an older individual receiving Respite or Supplemental services must be taking care of a
care recipient who meets the definition of "frail." "Frail means that the older individual is
determined to be functionally impaired because the individual—
(A) is unable to perform at least two activities of daily living without substantial human
assistance, including verbal reminding, physical cueing, or supervision; or
(B) due to a cognitive or other mental impairment, requires substantial supervision because
the individual behaves in a manner that poses a serious health or safety hazard to the
individual or to another individual."
* With the assistance of the Duke Family Support Program and the U.S. Administration on Aging, North Carolina
has further clarified that "related disorders" are diagnoses in the family of dementias and are characterized as
being both chronic and progressive.
NORTH CAROLINA
Division of Aging
and Adult Services