FY16 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