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Home My WebLink AboutFY16 SRC HCCBG funding revision Interim onlyHewett, Teresa From: Smith, Amber Sent: Wednesday, January 06, 2016 5:33 PM To: Hewett, Teresa Subject: FW: Revised 732 Attachments: 160104150549_000l.pdf l ertSd, Attached is a HCCBG revision for Interim. They are just moving money from one level of service to another, but it needs to be routed for signatures. Thanks. Amber Amber Smith I Senior Resource Center Manager -l" Resource Center New Hanover County 2.222 S. College Road Wilmington, NC 28403 ,1' 6410 p 1 (910) 798 -3492 f www.nhcaov.com From: Bobby Shoemake [ mailto: bshoemake @interimhealthcare.com] Sent: Wednesday, January 06, 2016 12:25 PM To: Smith, Amber Cc: Ginny Brinson; Jane Jones Subject: Fwd: Revised 732 Amber, Attached please find revised 732 form that I submitted to Ginny Brinson. I am moving money in order to get dollars released to us where we are overspent in LVL III. Thanks, Bobby - - - -- Forwarded Message - - - -- From: 'Bobby Shoemake" <bshoemaken interimhealthcare.com> To: "Ginny Brinson" <gbrinson(cr capefearcog org> Cc: "Jane Jones" <jjones�a capefearcog org> Sent: Monday, January 4, 2016 3:14:04 PM Subject: Revised 732 Ginny, Attached is an updated 732 form for New Hanover County. I have the original and can put it in the mail to you. Could you please give me your mailing address. Also, can you make the changes in the system so our money can be released based on the attached form? Thanks, Bobby - - - -- Forwarded Message - - - -- From: sencifaxwhiteville (a)interimhealthcare.com To: "Bobby Shoemake" < bshoemake (ainterimhealthcare.com> Sent: Monday, January 4, 2016 3:05:49 PM Subject: Attached Image[1] To: asrnithQ.nhcgov.com Remove this sender from my allow list From: bshoemake(a interimhealthcare.com You received this message because the sender is on your allow list. Loftin DAME AND ADDRESS Home and Community Care Block Grant for Older Adults ;OMMUNITY SERVICE PROVIDER DOA -732 (Rev. 2/14) nitnm HealtbCare of the County Funding Plan County_ New Hanover :astem Carolinas, Inc. July I, 2015 through June 30, 2016 Provider Services Summary JREVISION# , DATE: A B C D E F G H I icrviccs Ser Dekrm• 1 Block Grant Funding Required Local Match Net• Se, Cost NSIP Subsid\- Total Funding Projected HCCBG Units Projected Reimburse Rate Prcjated HCCBG Clients Projected Total Units (Check 0-) Deed IP.eh I Access In -Home Other Total n -Home Aide Level 1 34003 \ \ \ \ \\U \ \%A \\\ 3778 37781 37781 2225 16.9788 14 2225 n -Home Aide Level 2 104000 \1 \ \UN \ \ \ \ \\1C ^. 11556 115556 115556 6695 172576 28 6695 n -Home Aide Level 3 66000 \ \ \0\ \ \11 \\1 \ \\U 7333 73333 73333 4203 174476 18 4203 \1 \ \ \ \ \ \ \ \1 \ \ \U \\ 0 0 0 \\ \ \Vk \ % \\11 \ \\ 0 0 0 1111 \ \\1 \ \ \1 \ \l' 0r -I \\ 0 0 u\\, 0 0 0 Z%vvv 0 0 m\au\ \\\a\ 0 V11111AAAwmxv u o 0 \\t\1 \\ \a\ \\u\\\ 0 0 ea\\\ n 0 uvnvvmavav 0 0 Total 1111\\\ \ \1 \ \ \\ 0 204003 0 204003 22667 226670 0 226670 13123 \ \ \ \U \ \i \\U1 60 13123 'Adult Day Care & Adult Day Health Care Net Service C-1 ADC ADHC Daily Care Certification of required minimum local match availability. transportation Required local match will be expended simuitanemisly Authnrrze t alure, lle Date Wministrative with Block Grant Funding. Comm en ^ices PPravt j Jet Su, Cost Total c �Vnr, uti: ter' vl ' n� Signature, County Finance Officer Date - na ore, Ch ^ t Boar atunis,"m rs Date Liu Wurizkbr k�r�hie� �'rwncictl [0ctt i0(iu�hanc� e fit- r Una'rMC�n NAME AND ADDRESS Home and Canmunily Care Block Grant fur Older Adults COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 2/14) Interim HealthCHm ofthe County Funding Plan County_ New Hanover Eastem Carolinas, Inc. Only 1, 2015 through June 30, 2016 Provider Services Summary REVISION li 1 , DATE : 12/30/2015 A B C D E F G H I Services Ser. De1—, c One) EEZ Block Grant Funding Required Local Match Net- Sery Cos[ NSIP Subsidy Total Funding Projected HCCBG Units Projected Reimburse Rate Projected HCCBG Clients Projected Total Unite m,M, Purca. Access In -Home Other Total In -Hone Aide Level 1 19234 \6 \1\ \\ \ \ \ \ \ \1t \\ 2137 21371 21371 1259 16.9788 10 1259 In -Hone Aide Level 2 75510 \\N\\\\\\ \ \ \\1\\ 8390 83900 63900 4862 17.2576 20 4862 ht -Home Aide Level 3 109259 116 \ \6 \ \ \ \1 \\ \ \\ 12140 121399 121399 6958 17.4476 30 6958 \\\\\\\\% % \ \ \\ 0 0 0 1 \ \ \ \AA \ \ \ \%\\ 0 0 0 \\ \ \U \ \6 \1 \ \ \ \ \1 0 0 0 \ \ \ \ \ \ \l1 \ \ \ \l \ \\ 0 0 0 \1 \ \1\ \111\ \111 \1\ 0 0 0 \ \ \1l \ \ \6\ \\66\ 0 0 0 \ \W \\%\ \A%\ 0 0 0 \1\ \6111 \ \ \ \\ \1\1 0 0 0 \ \ \ \ \1 \611W1 \ \1 0 0 0 5\ \1 \ \6 \ \ \ \ \1 \6\ 0 0 0 \\ \ \ \ \1\\ \ \ \ \1\ \1\ 0 0 0 Total \ \ \U6 \11111\ 0 204003 0 204003 22667 1 226670 0 226670 13079 16111 \ \11 \61 60 13079 *Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC Daily Care Certification of required minimum local match availability. _ -'� `�•: , 'fransponalion Required local match will be expended simultaneously Aulhorized gnalure, Title Dale Administrative with Block Grant funding. Community Service Provider Net Ser. Cost Total Signature, County Finance Officer Date Signature, Chairman, RoardofCommissionws Date CV'0 -'V warN =0 CD wi Cap IM cn cl 40 401 > LQ N (5 CD > C, 4n > C`. (14 L ac Go%! C-4 — ------------ 00' I.R . C) en •Wl co w m I C14 C-4 a r qCr co 001 CIO ql-r, M 00 C4 <4 cc v cam, .; tn %n C4 t� V3 %0 C'l 40 'It Wi Wi *D a, cIrl I z < < rn C/) C, le 1 -.It; ac. 00 10: Q! 43S i i 0 w CO zzl ! 0 0 z Im CO Ului CA 0 U3 North Carolina Division of Aging and Adult Services Service Cost Computation Worksheet C732A -Ws DoA -732A Provider: Interim HealthCare of the Eastern Carolinas, Inc. 3/89 County: New Hanover Budget Period: July 1, 2015 through June 30, 2016 Revision K _yes, _ no, revision date 12130/2015 Service Service Service Service Service Service Service Service Grand IHA IHA IHA I. Projected Revenues Total Level 1 Level 2 Level 3 A. Fed /State Funding From the Division of Aging 204,003 /1 /lIl /l /I!ll/l 19,234 75,510 109,259 R u!red Minimum Match -Cash lllllllllllll /1/ //llllll /l/1/rl Nllllllllllll/ 1 / /111 /lfllllll rl /l! / /I/! /ll /l 111111/1!1/1111 /llllllll117l11 !I111117l!!!ll 11!lllllllllll! 1/ll1/11/!1/M 1 o uuinnulm 2 0 /llll!lIJIIr!ll 3 0 /llllll /llllll/ Total Required Minimum Match - Cash 22,667 ll111111ill/ll/ 2,137 8,390 12,140 0 0 0 0 0 Required Minimum Match - In -Kind 7ll/ //1/I//72771 lrltl!!!II /111/ 1 /qr //1!! /1l // // /111 /Il/!11/! / /I/1 /1! / /!1!!/ ulu11111mll /I! /lpnunu rmuaanu� 1 0 2 0 /11 /l1 /l1 /!11 /l 3 0 Total Required Minimum Match - In -Kind 0! /! /! /!!I /! /1!! 0 0 0 0 0 0 0 0 B. Total Re uired Minimum Match cash + in -kind 22,667 1Il /J / / /1 /1 /! // 2,137 8,390 12,140 0 0 0 0 0 .Subtotal, Fed/State/Required Match Revenues 226,670 11/111111/11111 21,371 83,900 121,398 0 0 0 0 0 D. NSIP Cash Subsid /Commodi Valuation 0 E. 6 Title V Worker Wages, Fringe Benefits and Costs O lllll /ll1! /l1ll Local Cash, Non -Match !/llllllll!!!ll 11 /f!/!llfll!!I llllll /1lllr! /l lllldlllllllll 1llllllflllllll llNlllllllllll u/m/llllllll Illllllllllllll I11/t/l/ 1 /1111 lNlllllll /11I! 1 0 /Kill //1 /llllll 2 0 Illllllllllllll 3 0 /!Il!llllll!ll1 4 0 /ll1llllllllll! F. Subtotal, Local Cash Non -Match 0 1 /Il /!/!J/! /rr! 0 0 0 0 0 0 0 0 Other Revenues, Non -Match 111I/r/l111I/1l l!/111111!/ll// !f! /Ill! / /ll /l/ 11!! / /U /ll1 /!l / /r / / /1! /111 //! 11lNllllq/11l /llllll/ /l1/ll! I/lllllll/l/Ir/ 1!I /fl /!!r /!1l/ Illll!!I/llll/! 1 0 /J /1!11111 /ll /J 2 0 /111 /llll11111/ 3 0 1111111111/r1/l G. Subtotal, Other Revenues, Non -Match 0 / / /!! / /1l! /! /1/ 0 0 0 0 0 0 0 0 Local In -Kind Resources Includes Volunteer Resources) 1 o unuulnan 2 o rnluuuan 3 H. Subtotal, Local In -kind Resources, Non -Match 0 /llllll!/ /!fill 0 0 0 0 0 0 0 0 I. Client Cost Sharing 0 / / / /! / / / / /! / //! J. Total projected Revenues (Sum I C,D,E,F,G,H, & I) 226 670 / / / / / / / / / / / / //! 21,371 83,900 121,399 0 0 01 0 0 Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. IHA IHA IHA It. Line Item Expense Total Cost Level 1 Level Level 3 Staff Salary From Labor Distribution Schedule /m /11/w/w x/nn/m111 1!!nn /nrml m/m/m/ n /x /m/wnn /rnnn! /u /n nuanumr/ uiunuonu rrouiuiuul nrumunm 1) Full -time Staff 65,830 47,991 3,821 5,014 9,004 2 Part-time staff do not include Title V workers) 116,834 11,414 43,384 62,036 A. Subtotal, Staff Salary 182,664 47,991 16,235 48,398 71,040 0 0 0 0 0 Fringe Benefits l //1 ////!1!/ /I! 1!11/!///1!//!/ t1111111/!///!/ /n/!!11///!//1 /!! //1! /1H /!11 u/m/111/w/ !l /Ull!llll!!l InI11!l1 11/11! lllllllllllllll !II/w/ llllll 1 FICA 7.65 % 13,974 3,671 1,165 3,702 5,435 2 Health Ins. @ 0 3) Retirement @ 0 4) Unemployment Insurance -SUTA .720% 1,315 346 110 348 511 5 Worker's Compensation @ 7% 12,786 3,359 1,066 3,388 4,973 6 Other - FUTA § 0.8% 146 38 12 39 57 B. Subtotal, Fringe Benefits 28,222 7,415 2,354 7,477 10,976 0 0 0 0 0 Local In -Kind Resources, Non -Match /////////1/!//1 fl!//! ///If111/ 1! ///!1/1!!/!1/ ///////!////1// ///N/!!//ll/// /!11(11!111!/!1 111!// /!1111/// ///1///r////!// //!n/I//I/!!!/ 1 0 2 0 3 0 C. Subtotal, Local In -Kind Resources Non -Match 0 0 0 0 0 0 0 0 0 0 D. OAA Title V Worker Wages, Fringe Benefits and Costs 0 Travel WHURr!/n nnnl!/ MI/ I//1111!/!//1// n/nl!/II/nll !/0///118118 HIM/11HUM 111111//!!!!//( 1 Per Diem 0 2 Mileage Reimbursement 0 3) Other Travel Cost 0 E. Subtotal, Travel 0 0 0 0 0 0 0 0 0 0 General Operating Expenses /!//////111//// 11111111/0/111 //1100 /luw /on0IDnn1 U/111IRM/I ///!!//!/!1//// In/lI70IPM //111 /11HI /! /! /Nl ///!nl!/1/ Illll /111/!/!/! 1) Management Information Systems 86 15 23 48 2) equipment depreciation /depreciation 1,116 60 132 924 3 rent/lease 2,758 147 474 2,137 4 insurances 6,074 190 1,298 4,586 5 consumable supplies 2,137 308 615 1,214 6 RN Supervision 1,999 266 633 1,100 7) utilities - computers, phones 1,614 114 345 1,155 8) 0 F. Subtotal, General Operating Expenses 15,784 0 1,100 3,620 11,164 0 0 0 0 A"UHH"MY G. Subtotal, Other Administrative Cost Not Allocated M //1/1//1/11/ I///f!//l111!/1 unifn/ /m/ !0 /n/!nl/fl/ I/1n1INNIN 1111 /1//1//1111 /I/ /l 110!!1 /fl f/11//1!/l/!Il/ nI/r IUMN In Lines ILA throw h F 111 /w/u1n/ !I /1f111l111l11 I/mIll /Ill/!/ ll11rllll! /1111 l /1/1111 /11111/ 011! /1llll /ill n!/!Il!!1l/lll ! /lIl11lIl!!lll ll111ll1111 /Ill 11110/81/Ill1 1!lnl/ll!l8 ll 1111!!11 11!17 /f 07!1/1 /111!!11 111/11!!i!UM UUM1l1l11H NIII/ /l!!nll! H. Total Pro j. Expenses Prior to Admin. Distribution 226,670 65,406 18,689 69,396 93,1801 0 0 0 0 0 I. Distribution of Admininistrative Cost lIrllll!llll!!l 1 •56,406 2,6821 24,6061 28,2191 0 0 0 0 D J. Total Pro j. Expenses After Admin. Distribution 226,670 1!1/1/!//!!!/// 21,3711 83,9001 121,399 D 01 0 0 0 of Aging and Adult Services Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand IHA IHA IHA Total Level f Level 2 Level 3 The Division of Aging ARMS deducts reported program income from reimbursement paid to providers. Line III.D indicates the number of units that will have to be produced in addition to those stated on line III.0 in order to earn the net revenues stated on line I.C. on this form (DOA -732A) corresponds with stated on the Provider Services Summary as follows: DOA -732A DOA -732 Block Grant Funding Line LA Col, A Required Local Match -Cash & In -Kind Line LB Col. B Net Service Cost Line LC Col. C USDA Subsidy Line LD Col, D Total Funding L. I.0 +I.D Col. E Projected HCCBG Reimbursed Units Line III.0 Col. F Total Reimbursement Rate Line 111.8.5 Col. G Projected Total Service Units Line III.F Col. I Grant Document Routing loo Start date: 1/8/16 From: Teresa Hewett, Finance Department (7408) Signatures required: Lisa Wurtzbacher, Chief Financial Officer Beth Dawson, Chairman Return to Teresa Hewett, Finance Department (7408) Type(s) of documents, attached: 1 copy — SRC HCCBG (Home & Community Care Block Grant) revision for in -home aide Explanation of document(s): Interim HealthCare is the provider of in -home aide funded by the HCCBG grant. The attached County Funding Plan will only move funds between different levels of care that is provided by Interim. It does not change the total funding amount. I have included a copy of the original funding plan for Interim for your reference. Please let me know if you have any questions. Thank you --------------------------- - - - - -- for finance department use-------------------------------------------- - - - - -- DATE ADDED TO LASERFICHE PICKED UP BY: Print Name & Date Signature