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FY17 SRC HCCBG Award Documents
LEAD AGENCIES ONLY: Home and Community Care Block Grant (HCCBG) Check List 6SR1, Columbus County DOA, New Hanover County SRC, Pender Adult Services, Inc. Allocation received from County Manager or AAA Or Due to Late Allocations... V HCCBG Meeting scheduled and AAA notified Date of Meeting: M" �Z3I st` Meeting held and minutes completed Budget Worksheet from HCCBG Meeting signed by Provider Agency (can be obtained from AAA and must be submitted to AAA with forms below) The following forms are required by AAA before County Grant Agreements can be sent to the County Manager. V" DAAS 730 P,"'DAAS 731 (check for appropriate signatures and date) s� DAAS 732 (check for appropriate signatures and date) DAAS 732A (check for your approximate unit rate on last page) V DAAS 732A1 V DAAS 733 V DAAS 734 ❑ DAAS Standard Assurance & In Home Clients' Rights Sub-Contractor's Required Forms to be included in packet: • DAAS 732 (check for appropriate signatures and date) LYI*W • DAAS 732 Supplement for In Home Aide Services • DAAS 732A (check for approximate unit rate on last page) T rk{ ri tY+ U 1 dkrk#,t, S • DAAS 732A1 J A- .W m t E.1 tu5 ❑ DAAS 733 T-inl P A M ) e lo-tf'�"A S ❑ DAAS 734 -T44".U'i M E f jt.YkC5 All of the above forms, with the exception of the Budget Worksheet, can be obtained through the NC Division of Aging and Adult Services website at http: / /www.nedhhs. Gov /azine/cobud2et/cobudadn.htm If you have a subcontractor providing service through HCCBG that agency will have a separate checklist and will have forms to complete. Please check all the above forms for accuracy and completeness before submitting to the Area Aaencv on Aging. Thank You M Area Aggp c On A ' } Cape Fear- Gbuiuii of f Gaverianwnts IMPORTANT INFORMATION: HCCBG ALLOCATIONS SFY 2016/2017 TO: Amber Smith, Manager New Hanover County Senior Resource Center FROM: Jane Jones, Region O AAA Director J$f DATE: May 27, 2016 RE: SFY 2016/2017 HCCBG Allocations NC Division of Aging and Adult Services has notified the Area Agency on Aging regarding the SFY 17 Home & Community Care Block Grant ( HCCBG) funding estimates. Please see attachment for your county's allocation. Since the NC General Assembly is currently in session, it is possible that funding awards may have to be revised when DAAS receives a certified budget after the legislature adjourns. All of our counties in the region have already held their HCCBG meetings based on earlier guidance and estimates provided to the AAA by NC Division of Aging/Adult Services. Please complete the HCCBG Forms that can be found at NC DAAS website http: / /www.ncdhhs.gov /ate cobudget/cobud dg n.htm and submit to your Board of County Commissioners for approval. (Note that form DAAS 735 is for the AAA use only). Please submit your completed, signed packet to Ginny Brinson as soon as possible and no later than July 6, 2016. Please contact me if you have questions or need assistance. CC: Ginny Brinson, AAA/COG Chris May, COG Director Cheri Smallwood, COG Finance Officer Chris Coudriet, County Manager Avril Pinder, Assistant County Manager Serving Brunswick. Columbus, New Hanover and Ponder Countle3 1480 Harbour Drive • Wilmington, NC 26401 • (910) 395 -4553 • (800) 218 -6575 , Fax: (910) 395 -2684 www.copefearcog.org A-, Fc{rrul Opporlunity /Arrhmcitive Ac'ionfADA Fmplayer /Pragra- Aging and Adult Services HEALTH AND HUMAN SERVICES DAAS Administrative Letter No. 16 -06 To: County Managers RICHARD O. BRAE ER Secr Wy SUZANNE P. MERRILL Director, D1 vfslon ofAging and Adu@ SarWccrs From: Suzanne P. Merrill, Director Subject: SFY 16-17 County Funding for the Home and Community Care Block Grant (HCCBG) Date: May 11, 2016 Attached please find the SFY 16 -17 Home and Community Care Block Grant funding for your county. SFY 16 -17 KCCBG program information is posted on the Division of Aging and Adult Services (DAAS) website at ft://www.nedhhs.gQv/a&Lnp-/cobudgetloobgdgdn.htm . With the NC General Assembly legislative session currently underway, it is possible that county awards may have to be revised when DAAS receives a certified budget after the legislative session adjourns. Intrastate Funding Formula factors and weights remain unchanged from previous years. Formula factors are as follows: Age 60+ general population (500/0); 60+ low income (30 0/0); 60+ minority population (10010); and 60+ rural (10 %). Please contact your Area Agency on Aging director with any questions concerning the Home and Community Care Block Grant. Thank you. SPM/ma cc: AAA Directors Nothing Cornpares�.,_ DeparmentafHealth andHuman SwvfcesI Dfvlslen afRgingandAdultServices 693 PaimerDrfve, TaylorHal112101 Mail Service Center (Raleigh, NC27699 -2101 919 8553400 T 1 919 733 0443F co C 0 Co m p '`— E a O g0= C V m - CD co V _rte c Q ° M C N V ` \ N to cr _ _O ° 7■ � � m acoi o m _ N as � � E U6 ° V %A C v fj ca b ba 0 o Q r O t m b cc J � O = r 3 O ° Nom= w O C m = Z O_ W � Z w W O Z Q = o V W Z Amber Smith Director NEW HANOVER COUNTY SENIOR RESOURCE CENTER 2222 S. COLLEGE ROAD WILMINGTON, NORTH CAROLINA 28403 Telephone (910) 798-6400 Fax (910) 798-6411 www.nhcgov.com HCCBG Advisory Committee Meeting MINUTES MEETING CALLED BY FACILITATOR NOTE TAKER TIMEKEEPER ATTENDEES Agenda topics MAY 5, 2016 2:03PM 3:02PM Amber Smith -- SRC Director Betty Grace — HCCBG Chair Tina Heath — SRC Administrative Technician Tina Heath — SRC Administrative Technician SRC — CRAF7 ROOM 1 Betty Grace (member), Amber Smith, Andrew Zeldin (member), Ellen Connor, Ginny Brinson, Jane Jones, Nathan Bales (member), Carol Bales (member), Dorothy Grimes (member), Avril Pinder ** *Emma Saunders came late ** *Richard Hayes was excused for an out of town emergency DISCUSSION HCCBG Allocation of Funds FY 16/17 • Betty Grace welcomed everyone and called the meeting to order. Introductions were made. • Amber Smith covered HCCBG Allocation Recommendation worksheet. Amber Smith recommended a decrease in Adult Day Care/Health by $5894.00, and to redirect those funds to Transportation. NHC DSS receives state funding to serve adults 18 and older. There are currently unspent day care /health funds. There is currently no waiting list for Adult Day care/Health. It was proposed to transfer the $5894.00 to increase the general and medical transportation allocation. The SRC lost the DOT 5310 funding due to a 2010 census that classified NHC as a large, urbanized area. NHC Board of County Commissioners allocated the SRC a larger percentage of ED -TAP. With this increase from ED -TAP, the SRC is still lacking funding to serve seniors needing transportation services. In FY 16/17, transportation will be managing HCCBG and ROAP (seniors and disabled). Trips consist of medical appointments, dialysis, SRC nutrition, and essential shopping. These services are an important and overall benefit to the health and welfare of the senior population. All SRC program budgets were covered. HDM, Congregate, Case Assistance/I &R, SRC Operations, and In -Home Aide Services, will all remain the same. No increase or decrease from FY 15/16. ■ Questions/Comments'. 1. Is USER a viable prospect to pursue? Jane ]ones is looking into Senior UBER services to see if this could be an option in the future. Not an option as this time. 2. Where is Adult Day Care located? Elderhaus/Greenfleld area 3. How many people in Elderhaus? Day Care = 15 clients. Health r 7 clients. There is no waiting list for services at this time. 4. What transportation services are we currently utilizing? Taxi's, Wave, and SRC van. Everyone agreed that transportation could most benefit from the increase in funds. ■ A vote was taken. Nathan Bales motioned for decreasing Adult Day Care/Health by the proposed amount of $5894.00, and redirecting to General and Medical Transportation. Andrew Zeldin seconded the motion. Motion was approved by all voting members in attendance. No further comments or questions. Meeting was adjourned at 3:02pm. All voting members voted in favor of Amber's proposal to redirect funds from Adult Day Care /Health to General /Medical Transportation in the amount of $5894.00. The NHC HCCBG advisory committee unanimously voted and approved the Fiscal Year 16/17 allocation. Motion passed. No further questions or concerns. DAAS -730 (Rev. 2116) Home and Community Care Block Grant for Older Adults County Funding Plan Identification of Agency or Office with Lead Responsibility for County Funding Plan New Hanover County July 1, 2016 through June 30 2017 The agency or office with lead responsibility for planning and coordinating the County Funding Plan recommends this funding plan to the Board of Commissioners as a coordinated means to utilize community -based resources in the delivery of comprehensive aging services to older adults and their families. 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LL (D t comm �4E) a�i ZH�(A -a E U m I �e Z WID E o U) U, m V In U m o S H ' N CO E a CO `m m cr o � ❑a m o o w o .M.• w O w ;� D O A FCC 4 a�q O O c c ❑ M Dom➢ A, W o 0 0 W Q o CD W A A � y M M O M e e F, 00 T 00 ON 00 0 O O O 4 H V'i N v'i N eq N 4 O O r�6] fA 69 --� w N OO O e IR ON ti0 W1 V M N M N tN ae 4n v`ni y 6'3 69 4 N ko kn C O d 0 O O p en N U V It O O ti 59 fs4 cn N M Vt N N O to v] C1 N •--� 0 n 0 M M M N .--i v) N ko M W% C* --i bR N N 6P3 to N N N _M N •� m � Co O N N W n N Lp 00 n N N 0% d n ON N 64 59 W N 'D �Qcq n on V'li o �Q %Q ao M E� n W d O M n O n l 01 01 0 0 0 0 v� v� env C7 00 ncr 00 v 00 00 0 H � L6 6Ns 6Ns eC>C os o0 U VyJ a N N O� qT N to O V7 m �D n n d �p N �o N 00 O N O to W' �o N to -� N M n o N 00 r- to 1.0 N In OO .-� M N l� W) w m It �D to r- v) M [- In vi �o 00 �o ON n oo f W O cn O H z! fps fA O 80 HH HHF FF�I HHHHHHH1 -4HHH OO W Z O ,aaaF aa4 a-4 E-aH OH UU w a s VI Z E- u 0U� to u >4aaQ� A U U CA H n z�zN z��oz�ow��WW� En Dom➢ A, DAAS -733 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan July 1, 2016 through June 30, 2017 Methodology to Address Service Needs of Low Income (Including Low- Income Minority Elderly), Rural Elderly and Elderly with Limited English Proficiency (Older Americans Act, Section 305(a)(2)(E)) Community Service Provider NHC Senior Resource Center County New Hanover The Older Americans Act requires that the service provider attempt to provide services to low- income minority individuals in accordance to their need for aging services. The community service provider shall specify how the service needs of low income, low - income (including low income minority elderly), rural elderly and elderly with limited English proficiency will be met through the services identified on the Provider Services Summary (DAAS -732). This narrative shall address outreach and service delivery methodologies that will ensure that this target population is adequately served and conform with specific objectives established by the Area Agency on Aging, for providing services to low income minority individuals. Additional pages may be used as necessary. Although New Hanover County is second smallest in area (328 Sq. miles) in the State, it is one of the most populous as its county seat, Wilmington, is one of the state's largest cities. At the 2010 census, the population was 202,667, an increase of 26.4 percent from 160,367 at the 2000 census. The population density equates to approximately 1,058 per square mile and approximately 15.8% over the age of 65 years. According to the 2010 census 15.9% live below the poverty level. The NHC Senior Resource Center (NHC- SRC) has a case assistance program (Life Enrichment Program) committed to identifying all the needs of the individuals that come in contact with our staff and volunteers. The mission of the Life Enrichment Program is to provide quality and responsive services to older adults and their families. It is the goal of this program to promote social, physical, economic and emotional well- being, while encouraging maximum independence and improving the quality of life for older adults and their caregivers. Services provided by LEP include five areas of focus: Information Services: The gateway to assistance (no wrong door policy) Home Based Services: Bringing resources to the home Protection & Advocacy: Ensuring the right to safety and Health Independence Services: Promoting wellness Community Enrichment: Enhancing quality of life Prescription Assistance Program: assisting seniors enroll in programs to reduce prescription costs. Social Workers assess needs and link individuals with the most appropriate services. The intake process begins with an inquiry from a prospective client, family member, a member of the community, or an agency. Our friendly social workers are very knowledgeable about not only services provided directly by the SRC, but those offered by other community agencies. We act as a community liaison between the client, family and multiple community organizations. Our team responds to the growing needs of our Older Adult Community, and advocates on their behalf. We evaluate potential clients for program eligibility and participate in the development of community resources and services. The SRC has a Case Worker located at the building entrance who is dedicated to providing service or triage to the appropriate individual to provide assistance. A kiosk for E -Pass has been installed in the SRC lobby for senior access and hands -on assistance (if needed) from a case worker to make the use of the system less frustrating and still private. Home visits are offered to engage and assist families, who are in the process of planning for loved ones. The Center continues to maintain connections with local community sites (churches, senior housing, etc.) in low income and rural communities for presentations and educational events for all outreach programs. Transportation assistance is also publicized for these events when funding is available. The Center is also a site for early voting and primary elections with access to candidate forums and transportation as available for many on -site events. Our website is being is senior friendly and promotes the many services and special programs offered at the SRC. The SRC has a robust nutrition program that includes Home Delivered Meals, Congregate Nutrition, raised bed garden, on site nutritionist, and a variety of healthy cooking and wellness support groups. The SRC activities and recreation program consists of approximately 50 different exercise, education, and socialization programs for a diverse group of older adults to enjoy. The variety of classes keeps seniors engaged and promotes wellness, encourage independence, and enhance the quality of life of all older persons. The SRC has an active Retired and Senior Volunteer Program (RSVP) and Foster Grandparent Program (FGP) that engages approximately 900+ seniors to volunteer their time, skills, and talents in the community. Some of the volunteer programs include; Home Delivered Meals drivers, Volunteer Income Tax Assistance, Senior Health Insurance Information Program, hospital, food banks, cultural arts, schools, etc. The SRC Transportation Program provides transportation services to seniors for nutrition, socialization, non - emergency medical appointments, dialysis, employment services, and essential shopping. The SRC uses a variety of contracted vendors who meet the federal and state contract standards. The SRC has one van that is used for nutrition and essential shopping trips. DAAS -734 (revised 2116) July 1, 2016 through June 30, 2017 Home and Community Care Block Grant for Older Adults Community Service Provider Standard Assurances New Hanover County Senior Resource Center agrees to provide services through the Home and Community Care Block Grant, as specified on the Provider Services Summary (DAAS- 732) in accordance with the following: 1. Services shall be provided in accordance with requirements set forth in: a) The County Funding Plan; b) The Division of Aging and Adult Services Home and Community Care Block Grant Procedures Manual for Community Service Providers; and C) The Division of Aging and Adult Services Standards Manual, Volumes I through IV or at http://www.nedhhs.jzov/apingLmonitor/m-polia.htm. Community service providers shall monitor any subcontracts with providers of Block Grant services and take appropriate measures to ensure that services are provided in accordance with the aforementioned documents. 2. Priority shall be given to providing services to those older persons with the greatest economic or social needs. The service needs of low- income minority elderly will be addressed in the manner specified on the Methodology to Address Service Needs of Low - Income (Including Low Income Minority Elderly), Rural Elderly and Elderly with Limited English Proficiency format, (DAAS -733). 3. The following service authorization activities will be carried out in conjunction with all services provided through the Block Grant: a) Eligibility determination; b) Client intake /registration; c) Client assessment/reassessments and quarterly visits, as appropriate; d) Determining the amount of services to be received by the client; and e) Reviewing consumer contributions policies with eligible clients. 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant DAAS -734 (revised 2116) Services will be maintained by the community service provider and any contracted providers. 5. As specified in 45 CFR 75, Subpart D -Post Federal Award Requirements, Procurement Standards, community service providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community service provider. 6. Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and Community Care Block Grant Manual for Community Service Providers, dated February 17, 1997. 7. Community service providers are responsible for providing or arranging for the provision of required local match, as specified on the Provider Services Summary, (DAAS -732). Local match shall be expended simultaneously with Block Grant funding. 8. Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for the Provision of County -Based Aging Services (DAAS -735). 9. Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in paragraph fourteen (14) of the Agreement for the Provision of County -Based Aging Services (DAAS -735) shall be maintained. 10. Providers of In -Horne Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act. 11. Subcontracting — All HCCBG community service providers must assure that subcontractors (for -profit and non -profit entities only) meet the following requirements: a. The subcontractor has not been suspended or debarred. (N.C.G.S. §143C-6-23, 09 NCAC 03M) b. The subcontractor has not been barred from doing business at the federal level. c. The subcontractor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts." CLIENT /PATIENT RIGHTS 1. You have the right to be fully informed of all your rights and responsibilities as a client/patient of the program. 2. You have the right to appropriate and professional care relating to your needs. 3. You have the right to be fully informed in advance about the care to be provided by the program. 4. You have the right to be fully informed in advance of any changes in the care that you may be receiving and to give informed consent to the provision of the amended care. 5. You have the right to participate in determining the care that you will receive and in altering the nature of the care as your needs change. 6. You have the right to voice you grievances with respect to care that is provided and to expect that there will be no reprisal for the grievance expressed. 7. You have the right to expect that the information you share with the agency will be respected and held in strict confidence, to be shared only with your written consent and as it relates to the obtaining of other needed community services. 8. You have the right to expect the preservation of your privacy and respect for your property. 9. You have the right to receive a timely response to you request for service. 10. You shall be admitted for service only if the agency has the ability to provide safe and professional care at the level of intensity needed. 11. You have the right to be informed of agency policies, changes, and costs for services. 12. If you are denied service solely on you inability to pay, you have the right to be referred elsewhere. 13. You have the right to honest, accurate information regarding the industry, agency and of the program in particular. 14. You have the right to be fully informed about other services provided by this agency. Standard Assurance To Comply with Older Americans Act Requirements Regarding Clients Rights For Agencies Providing In -Home Services through the Home and Community Care Block Grant for Older Adults As a provider of one or more of the services listed below, our agency agrees to notify all Home and Community Care Block Grant clients receiving any of the below listed services provided by this agency of their rights as a service recipient. Services in this assurance include: • in -Home Aide • Home Care (home health) • Housing and Home Improvement • Adult Day Care or Adult Day Health Care Notification will include, at a minimum, an oral review of the information outlined below as well as providing each service recipient with a copy of the information in written form. In addition, providers of in -home services will establish a procedure to document that client rights information has been discussed with in -home services clients (e.g. copy of signed Client Bill of Rights statement). Clients Rights information to be communicated to service recipients will include, at a minimum, the right to: • be fully informed, in advance, about each in -home service to be provided and any change and any change in service(s) that may affect the wellbeing of the participant; • participate in planning and changing any in -home service provided unless the client is adjudicated incompetent; • voice a grievance with respect to service that is or fails to be provided, without discrimination or reprisal as a result of voicing a grievance; « confidentiality of records relating to the individual; • have property treated with respect; and • be fully informed both orally and in writing, in advance of receiving an in -home service, of the individual's rights and obligations. Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above listed services prior to the onset of service. For all existing clients, the above information will be provided no later than the next regularly scheduled service reassessment. Agency Name: g'Ve Ki 110yo' Y' AsS ra CLiIr Name of Agency Administrator:tt,M W:% Signature: 2b.e.& Date: (Please return this form to your Area Agency on Aging and retain a copy for your files.) DAAS -734 (revised 2116) d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services will be maintained by both the community service provider and any subcontractors. e. The subcontractor is registered as a charitable, tax - exempt (5016) organization with the Internal Revenue Service (non -profit subcontractors only). 12. Confidentiality and SecuritX. Per the requirements in l0A NCAC 05J and Section 6 of the Home and Community Care Block Grant Procedures Manual, client information in any format and whether recorded or not shall be kept confidential and not disclosed in a form that identifies the person without the informed consent of the person or legal representative. Community service providers, including subcontractors and vendors, must adhere to all applicable federal, state and departmental requirements for protecting the security and confidentiality of client information including but not limited to appropriately restricting access, establishing procedures to reduce the risk of accidental disclosures from data processing systems, and developing a process by which the Division of Adult Aging Services is notified of suspected or confirmed security incidents and data breaches. 13. Record_ Retention and Disposition. All community service providers are responsible for maintaining custody of records and documentation to support the allowable expenditure of funds, service provision, and the reimbursement of services. Service providers must adhere to the approved record retention and disposition schedule posted semiannually on the website of the NC Department of Health and Human Services Controller at http:// www. ncdhhs. govl controVretention/retention.htm. Service providers are not authorized to destroy records related to the provision of services under this Agreement except in compliance with the approved DHHS retention and disposition schedule, which allows for the proper destruction of records based on a schedule by funding source and fiscal year. The agency agrees to comply with 07 NCAC 04M .0510 when deciding on a method of record destruction. Confidential records will be destroyed in such a manner that the records cannot be practically read or reconstructed. 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Name of Community Service Provider Revision # Supplement to Provider Services Summary In -Home Services Detail DAAS -732 Supplement (Effective: 7108) July 1, 2016 through June 30, 2017 In -Home Services A B C F G H HCCBG In -Home Funding Required Local Match Net Service Cost Projected HCCBG units Projected Reimbursement Rate Projected HCCBG Clients Level I - 235 Respite 0 0 Level I -041 H Mgmt 19234 2137 21371 1259 15 Subtotal Level I 19234 2137 21371 1259 15 Level Il - 236 Respite 0 0 Level 11 - 042 PC 75510 8390 83900 4862 30 Level 1I - 043 H Mgrnt 0 0 Subtotal Level 11 75510 8390 83900 4862 30 Level III - 237 Respite 0 0 Level III - 044 H Mgmt 0 0 Level III - 045 PC 109259 12140 121399 6958 25 Subtotal Level III 109259 12140 121399 6958 25 Level IV - 238 Respite 0 0 Level IV - 046 H Mgmt 0 0 Subtotal Level IV 0 0 0 0 0 Total 204003 22667 226670 13079 Authorized 56ature Title Date Community Service Provider i w U o o O 0 0 � A 0 0 0 7� Q �A W o 0 0 sfi sfr A A w O 69 O O 64 I � O O O n U v3 6s olc ? N �r- n tn - of cc to 'ni " y a O N M't O E� M bR M h tz 6A h% 64 cc 00 00 00 � M 00 M N Q� --� 00 N %10 N M M M V w O�r en N kn N b [� ri N N M H 6�A V% m Nr OO � N w _ Q Q N ^y in oa N O v� ON Ln e e ? M n O� �--� � O O� O O� O� Z �cc V 4V4 KOo 1.0 e O c+1 � � � O O b9 n ti 6R kn 5R ` w Q U} w �o�n G U ;✓ z N ON N 10 o N d to vM %D I I N- N �o O� I C O� t- Go" O � li mr tn U Fv, w AUAHHH 0 ww z 0,4 a��� �'�o ww �°� a � L E z u 14 z cu Q V� V7 QCi C/l A FQ � DAAS -733 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan July 1, 2016 through June 30, 2017 Methodology to Address Service Deeds of Low Income (Including Low - Income Minority Elderly), Rural Elderly and Elderly with Limited English Proficiency (Older Americans Act, Section 305(a)(2)(E)) Community Service Provider: Interim Healthcare of the Eastern Carolinas, Inc. County: New Hanover The Older Americans Act requires that the service provider attempt to provide services to low- income minority individuals in accordance to their need for aging services. The community service provider shall specify how the service needs of low income, low- income (including low income minority elderly), rural elderly and elderly with limited English proficiency will be met through the services identified on the Provider Services Summary (DAAS -732). This narrative shall address outreach and service delivery methodologies that will ensure that this target population is adequately served and conform with specific objectives established by the Area Agency on Aging, for providing services to low income minority individuals. Additional pages may be used as necessary. Interim HealthCare of the Eastern Carolinas, Inc. shall provide In Home Aide Level services to qualified consumers in New Hanover County as outlined in the Home and Community Care Block Grant for Older Adults. Those determined to be in need of In Home Aide services will be eligible for services regardless of their income although some recipients will be asked to voluntarily participate in the consumer contributions program. Interim will share information about the In Home Aide program with local doctors, hospital discharge planners, hospice agencies, skilled agencies, senior advocacy groups, Adult Protective Services and the Community Alternatives Program agency (CAP). The program information will be disseminated via written and oral education as well as through weekly marketing visits and phone calls made by Interim. Interim will admit low - income, including low income minority elderly consumers, rural elderly and rural elderly and elderly with limited English proficiency as well older adults (age 60 and over) using the following priorities: *Older adults for whom the need for Adult Protective Services has been substantiated by the Department of Social Services and the service is needed as part of the adult protective services plan. * Older adults who are at risk of abuse, neglect, and/or exploitation. * Older adults with extensive impairments in activities of daily living (ADL's), or instrumental activities of daily living (IADL's), who are at risk of placement or substitute care. Older adults with extensive ADL or IADL impairments. * Older adults with less extensive (1 -2) ADL or IADL impairments. * Well older adults. Interim HealthCare of the Eastern Carolinas, Inc. complies with Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973. And the Americans with Disabilities Act of 1990. DAAS -734 (revised 2116) July 1, 2016 through June 30, 2017 Home and Community Care Block Grant for Older Adults Community Service Provider Standard Assurances Interim Healthcare of the Eastern Carolinas, Inc agrees to provide services through the Home Fame of Provider) and Community Care Block Grant, as specified on the Provider Services Summary (DAAS- 732) in accordance with the following: 1. Services shall be provided in accordance with requirements set forth in: a) The County Funding Plan; b) The Division of Aging and Adult Services Home and Community Care Block Grant Procedures Manual for Community Service Providers; and C) The Division of Aging and Adult Services Standards Manual, Volumes I through IV or at h=://www.ncdhhs.gov/agingJmonitoL/mpoligy.htin. Community service providers shall monitor any subcontracts with providers of Block Grant services and take appropriate measures to ensure that services are provided in accordance with the aforementioned documents. 2. Priority shall be given to providing services to those older persons with the greatest economic or social needs. The service needs of low- income minority elderly will be addressed in the manner specified on the Methodology to Address Service Needs of Low - Income (Including Low Income Minority Elderl y), Rural Elderly and Elderly with Limited English Proficiencx format, (DAAS -733). 3. The following service authorization activities will be carried out in conjunction with all services provided through the Block Grant: a) Eligibility determination; b) Client intake /registration; C) Client assessment/reassessments and quarterly visits, as appropriate; d) Determining the amount of services to be received by the client; and e) Reviewing consumer contributions policies with eligible clients. DAAS -734 (revised 2116) 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant Services will be maintained by the community service provider and any contracted providers. 5. As specified in 45 CFR 75, Subpart D -Post Federal Award Requirements, Procurement Standards, community service providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community service provider. 6. Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and Community Care Block Grant Manual for Community Service Providers, dated February 17, 1997. 7. Community service providers are responsible for providing or arranging for the provision of required local match, as specified on the Provider Services Summary. (DAAS -732). Local match shall be expended simultaneously with Block Grant funding. 8. Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for the Provision of County -Based Aging Services (DAAS -735). 9. Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in paragraph fourteen (14) of the Agreement for the Provision of County-Based Aging Services (DAAS -735) shall be maintained. 10. Providers of In -Home Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act. 11. Subcontracting — All HCCBG community service providers must assure that subcontractors (for - profit and non -profit entities only) meet the following requirements: a. The subcontractor has not been suspended or debarred. (N.C.G.S. §143C -6 -23. 09 NCAC QM b. The subcontractor has not been barred from doing business at the federal level. c. The subcontractor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts." DAAS -734 (revised 2116) d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services will be maintained by both the community service provider and any subcontractors. e. The subcontractor is registered as a charitable, tax- exempt (5016) organization with the Internal Revenue Service (non -profit subcontractors only). 12. Confidentiality and Security. Per the requirements in 1 O XCAC 05J and Section 6 of the Home and Community Care Block Grant Procedures Manual, client information in any format and whether recorded or not shall be kept confidential and not disclosed in a form that identifies the person without the informed consent of the person or legal representative. Community service providers, including subcontractors and vendors, must adhere to all applicable federal, state and departmental requirements for protecting the security and confidentiality of client information including but not limited to appropriately restricting access, establishing procedures to reduce the risk of accidental disclosures from data processing systems, and developing a process by which the Division of Adult Aging Services is notified of suspected or confirmed security incidents and data breaches. 13. Record Retention and Disposition. All community service providers are responsible for maintaining custody of records and documentation to support the allowable expenditure of funds, service provision, and the reimbursement of services. Service providers must adhere to the approved record retention and disposition schedule posted semiannually on the website of the NC Department of Health and Human Services Controller at Service providers are not authorized to destroy records related to the provision of services under this Agreement except in compliance with the approved DHHS retention and disposition schedule, which allows for the proper destruction of records based on a schedule by funding source and fiscal year. The agency agrees to comply with 07 NCAC 04M .0510 when deciding on a method of record destruction. Confidential records will be destroyed in such a manner that the records cannot be practically read or reconstructed. Standard Assurance To Comply with Older Americans Act Requirements Regarding Clients Rights For Agencies Providing In -Home Services through the Home and Community Care Block Grant for Older Adults As a provider of one or more of the services listed below, our agency agrees to notify all Home and Community Care Block Grant clients receiving any of the below listed services provided by this agency of their rights as a service recipient. Services in this assurance include: • In -Home Aide • Home Care (home health) • Housing and Home Improvement • Adult Day Care or Adult Day Health Care Notification will include, at a minimum, an oral review of the information outlined below as well as providing each service recipient with a copy of the information in written form. In addition, providers of in -home services will establish a procedure to document that client rights information has been discussed with in -home services clients (e.g. copy of signed Client Bill of Rights statement). Clients Rights information to be communicated to service recipients will include, at a minimum, the right to: • be fully informed, in advance, about each in -home service to be provided and any change and any change in service(s) that may affect the wellbeing of the participant; • participate in planning and changing any in -home service provided unless the client is adjudicated incompetent; • voice a grievance with respect to service that is or fails to be provided, without discrimination or reprisal as a result of voicing a grievance; • confidentiality of records relating to the individual; • have property treated with respect; and • be fully informed both orally and in writing, in advance of receiving an in -home service, of the individual's rights and obligations. Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above listed services prior to the onset of service. For all existing clients, the above information will be provided no later than the next regularly scheduled service reassessment. Agency Name: Interim Healthcare of the, Eastern Carolinas Inc. Name of Agency Administrator: Bobby S. Shoemake, COO Signatures Date: /a --A (Please return this form to your Area Agency on Aging and retain a copy for your files.) CLIENT/PATIENT RIGHTS 1. You have the right to be fully informed of all your rights and responsibilities as a clientlpatient of the program. 2. You have the right to appropriate and professional care relating to your needs. 3. You have the right to be fully informed in advance about the care to be provided by the program. 4. You have the right to be fully informed in advance of any changes in the care that you may be receiving and to give informed consent to the provision of the amended care. 5. You have the right to participate in determining the care that you will receive and in altering the nature of the care as your needs change. 6. You have the right to voice you grievances with respect to care that is provided and to expect that there will be no reprisal for the grievance expressed. 7. You have the right to expect that the information you share with the agency will be respected and held in strict confidence, to be shared only with your written consent and as it relates to the obtaining of other needed community services. 8. You have the right to expect the preservation of your privacy and respect for your property. 9. You have the right to receive a timely response to you request for service. 10. You shall be admitted for service only if the agency has the ability to provide safe and professional care at the level of intensity needed. 11. You have the right to be informed of agency policies, changes, and costs for services. 12. If you are denied service solely on you inability to pay, you have the right to be referred elsewhere. 13. You have the right to honest, accurate information regarding the industry, agency and of the program in particular_ 14. You have the right to be fully informed about other services provided by this agency. ,d o o c L A A > n o �o 4� N en I eq N W Y � C A U ti Q4 rA W U on n 0 0 0 o o 0 o 0 0 00 ai W �o m `rnn o Eo w o ¢ vn 0 T r A zCO) 9 d .d J q Y 01 a, tO 0 0 0 0 0 0 0 0 4 4 00 n U n n tn 7 � S 1. 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County—!! ew Hanover The Older Americans Act requires that the service provider attempt to provide services to low- income minority individuals in accordance to their need for aging services. The community service provider shall specify how the service needs of low income, low - income (including low income minority elderly), rural elderly and elderly with limited English proficiency will be met through the services identified on the Provider Services Summary (DAAS-732). This narrative shall address outreach and service delivery methodologies that will ensure that this target population is adequately served and conform with specific objectives established by the Area Agency on Aging, for providing services to low income minority individuals. Additional pages may be used as necessary. Elderhaus Inc. will make every attempt to locate and provide services for low income, minority elderly, rural elderly and elderly with English proficiency by utilizing the following methods: Place brochures in various churches in New Hanover, Pender and Brunswick Counties. We advertise our services quarterly in a minority owned paper that is distributed in the African- American community. Outreach to the Hispanic community through advertisements/brochures and promotion at local festivals. Continue to work with Department of Social Services and Adult Protective Services to provide solutions whenever needed. Meet with different groups on an ongoing basis to pass out information and assist with questions. DAAS -734 (revised 2116) July 1, 2016 through June 30, 2017 Home and Community Care Block Grant for Older Adults Community Service Provider Standard Assurances _Elderhaus, Inc. agrees to provide services through the Home and (Name of Provider) Community Care Block Grant, as specified on the Provider Services Summar (DAAS -732) in accordance with the following: 1. Services shall be provided in accordance with requirements set forth in: a) The County Funding Plan; b) The Division of Aging and Adult Services Home and Community Care Block Grant Procedures Manual for Community Service Providers; and c) The Division of Aging and Adult Services Standards Manual, Volumes I through IV or at http: / /www.ncdhhs. ovg /ayingJmonitor /mpolia.htm . Community service providers shall monitor any subcontracts with providers of Block Grant services and take appropriate measures to ensure that services are provided in accordance with the aforementioned documents. 2. Priority shall be given to providing services to those older persons with the greatest economic or social needs. The service needs of low- income minority elderly will be addressed in the manner specified on the Methodology to Address Service Needs_ of Low - Income {Including Low Income Minority Elderly ), Rural Elderly and Elderly_ with Limited English Proficient format, (DAAS -733). 3. The following service authorization activities will be carried out in conjunction with all services provided through the Block Grant: a) Eligibility determination; b) Client intake /registration; c) Client assessment/reassessments and quarterly visits, as appropriate; d) Determining the amount of services to be received by the client; and c) Reviewing consumer contributions policies with eligible clients. 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant DAAS -734 (revised 2/16) Services will be maintained by the community service provider and any contracted providers. 5. As specified in 45 CFR 75, Subpart D -Post Federal Award Requirements, Procurement Standards, community service providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community service provider. 6. Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and Community Care Block Grant Manual for Community Service Providers, dated February 17, 1997. 7. Community service providers are responsible for providing or arranging for the provision of required local match, as specified on the Provider Services Summary, (DAAS -732). Local match shall be expended simultaneously with Block Grant funding. 8. Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for the Provision of Co= -Based Aging Services (DAAS -735). 9. Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in paragraph fourteen (14) of the Agreement for the Provision of Count -Based Aging Services (DAAS -735) shall be maintained. 10. Providers of In -Home Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act. 11. Subcontracting — All HCCBG community service providers must assure that subcontractors (for - profit and non -profit entities only) meet the following requirements: a. The subcontractor has not been suspended or debarred. I T.C.G.S. § 143C -6 -23, 09 NCAC 03M} b. The subcontractor has not been barred from doing business at the federal level. c. The subcontractor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts." DAAS -734 (revised 2116) d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services will be maintained by both the community service provider and any subcontractors. e. The subcontractor is registered as a charitable, tax- exempt (5010) organization with the Internal Revenue Service (non -profit subcontractors only). 12. Confidentiality and Securi . Per the requirements in l0A NCAC 05J and Section 6 of the Home and Community Care Block Grant Procedures Manual, client information in any format and whether recorded or not shall be kept confidential and not disclosed in a form that identifies the person without the informed consent of the person or legal representative. Community service providers, including subcontractors and vendors, must adhere to all applicable federal, state and departmental requirements for protecting the security and confidentiality of client information including but not limited to appropriately restricting access, establishing procedures to reduce the risk of accidental disclosures from data processing systems, and developing a process by which the Division of Adult Aging Services is notified of suspected or confirmed security incidents and data breaches. 13. Record Retention and Dis osition. All community service providers are responsible for maintaining custody of records and documentation to support the allowable expenditure of funds, service provision, and the reimbursement of services. Service providers must adhere to the approved record retention and disposition schedule posted semiannually on the website of the NC Department of Health and Human Services Controller at http• / /www.nedhhs.gov/ control /retention/retention.htm. Service providers are not authorized to destroy records related to the provision of services under this Agreement except in compliance with the approved DHHS retention and disposition schedule, which allows for the proper destruction of records based on a schedule by funding source and fiscal year. The agency agrees to comply with 07 NCAC 04M .0510 when deciding on a method of record destruction. Confidential records will be destroyed in such a manner that the records cannot be practically read or reconstructed. / X?/ ire t (Date) ELDERHAUS, INC. Scope of Work: The organization's mission is to provide Day Care Services for the elderly citizens of our county which will ensure they are kept in the community in a safe and secure environment during the daytime hours. Their caregivers will in turn, have the support they need and an option for not raving to leave the work force to stay home with their elderly relatives. Our goals are to become the premier health system for frail adults who have very little or any support when they become a liability to their families and are threatened with institutionalization which taxpayers have to support financially when they need a Medicaid bed. Service Fee Schedule Daily Rate: Adult Day Care $62.25 Adult Day Health $73.10 Transportation $1.50 per ride A� V CERTIFICATE OF LIABILITY INSURANCE a /19 /zo s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER First Citizens Znsurance Services P O Box 29611 Raleigh NC 27626 -8611 CONTACT Sabrina Cox NAME: PHONE (919) 833 -9761 FAIL (919)716 -2226 LAI ADD IL .mabrina.cox0firstcitizens.com INSURE S AFFORDING COVERAGE NAIC N INSURER A Cincinnati Insurance Company MPMIDICY EXP INSURED Elderhaus, Inc. 2222 South 17th Street Wilmington NC 28401 INSURER B:S ner Coverage Solutions, LLC X INSURERC: INSURERD: INSURER E: INSURERF: $ 1, 000, 000 COVERAGES CERTIFICATE NUMBER CLI581920466 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INra TYPE OF INSURANCE J= BR POLICY NUMBER MP�CY EFF MPMIDICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR EACH OCCURRENCE $ 1, 000, 000 PREMISES P ES ES Ea occurrence) $ MED EXP (Any one person) $ 10,000 X ETD /ETA 0344078 8/7/2015 8/7/2016 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY F-1 JECTT LOG PRODUCTS - COMPNDPAGG $ 3,000, 000 Employee Benefits 5 1,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LMI Ea accident $ 1,000,000 X BODILY INJURY (Per person) $ A ANY AUTO ALL AUTOS ED SCHEDULED AUTOS X ETD /ETA 0344078 8/7/2015 8/7/2016 BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE PeracddeM $ Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 A EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ X ETD /ETA 0344078 8/7/2015 8/7/2016 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/D(ECUTIVE ❑NIA (Mandatory In H) EXCLUDED? (Mandatory In NH) WC522- 000409 -115 8/7/2015 8/7/2016 I PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYE $ 1,00 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A social Service Prof Liab ETD /ETA 0344078 8/7/2015 8/7/2016 Claim Limit 1,000,000 Aggregate Limit 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) New Hanover County is listed as additional insured as required by contract. GANGELLA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE New Hanover County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 230 Government Center Drive ACCORDANCE WITH THE POLICY PROVISIONS. suite 125A Wilmington, NC 28403 AUTHORIZED REPRESENTATIVE r W Connolly CIC, AAI /S 91VUS- ZUT4AGUKUGUKrUKAIIVN. All ngntsreserVea. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025ramamti Rev $AS OVEROM TAM for the SWOOM Per tm arfai. OED t ! to "Ch ow ofi of I"wm 10-0. 1054M33 dbf4ws: or hw�wm. d d kft are aunt fw � uo& r J","7 f Of *"M 0909MMO w0s wall6d mod hm rut fww to nuke iY P 'Y! ►der 9.0 Pap 32 kv 8/15 ATTACHWNT E STATE OF NORTH CAROLINA CpVNTy OF New Hanover AFFIDAVIT OF CO L1ANM wrrH H.C. E-WAIFy STATU rM (ro be, sidwhus Wft of odds) I, Rick Richards t �f'the `�rM"), duty hind by and on bet cSf Elde aus, nc. _ after. toms, ofW ve as tint day swmxs 1. I am +e _CEO (President. a CEO, eto.) of d.* Emploiyer tW fUP " to 'sp far wW on be C Of the EMPkW k6ndfied above: Z. Empbyter underret is -E-VW MeAm the *KWOI E;Yeritfc pW= wed by the t kWed statas 00A df rity and odw fedma! . or any SUCOOSSOr or SWIvalient Pry used to "Nify the *wk 94OW&MIOn Of newly h I en*Ms PWSUW to 101kral lsvr. 3. X Eto 0 Germw 8W* ; 2 or mtwe WnpkjOes, OW Is In rMpliance wo the of N.C. 484-26 * Ennpl r his � worts E- Verify and shall Fatain the. nrcofft d for a 'st In eyew. sea t POW of 8# �� one year. DERVIOW bys low #+en 28 Employees brct is #Wekm W subje,�k to the ins of N.C. Geri StMUW §6446. 4, All sutmftwtom wWW by or to be wqspd tY Etrt*y hens or wl# have use Complied 5. EMPIOW 81189 kW; the ate of North mss. wed of any djanp in ft stales pint to ArWe 2 of .Chapter 64 of the foam C+ to was. This 15thdayof June �} 16 of Affivit Rick Richards, CEO Stste of North Carolina Pt►OW Na" mid Ti Gouty of Pender Sul itred and awomto byre tee #ft 15tFd8y d. June ry � 16 tsrulwo (SEAL) !,Gu'J arsb t 3/ �o 0 r z C., . 0� 'C N NC Rev 8/35 ATTACHMENT B CERT"CATION REGAR(N G DEBARMENT,, SUSPENSION, iNELiMBjLrrY and VOLUNTAFty F.XCLUSf0N L R TIER COVERM TRANSACTION (1) The Pro vs IWW tier pnVdOW { ) , by sbxnlssion of this. bid or proposal. that remit It nor f b ' ; suspended dect tl RW19 as , Pm Posed � debarment went tar .may_ Y +ode# �i1 t#es � by any Federal t2'1 The proWeadve SrddetXOnba also WAYWo by w*nIstW of thit lid or the ,all estrus wd wpp! (GIs mq*Wn r'it flpivs dom W OR subcontraft et all levefa j are not Pr i debeh ad, , Ppc ed fear d$W ment; , l7il ; Or vole r Y excluded f PsrW;*ffm In 04 ft .by my FeftW depoftwo aw may ` (3) Where the pmepeewe Ivwser tjer Pant (� ) u� to certNy to any of the sue* kv this (xa , such gift m Shen aftech an atiary _ or The lower tier padVpant (f3i ACorrt dor), Elderhaus, Inc ftWuW*w end ate try of. ft statement of and d' , if y, SIGNATURE TrrLE CEO COMPANY Elderhaus, Inc oATE 6115116 North Carolina Cpurty of Pender Subscribed and sworn to tire. me the 15ttbay of June 216 Nd*yr Public My Appointment Expires Nge.28 of 32 Standard Assurance To Comply with Older Americans Act Requirements Regarding Clients Rights For Agencies Providing In -Home Services through the Home and Community Care Block Grant for Older Adults As a provider of one or more of the services listed below, our agency agrees to notify all Home and Community Care Block Grant clients receiving any of the below listed services provided by this agency of their rights as a service recipient. Services in this assurance include: • In -Home Aide • Home Care (home health) • Housing and Home Improvement • Adult Day Care or Adult Day Health Care Notification will include, at a minimum, an oral review of the information outlined below as well as providing each service recipient with a copy of the information in written form. In addition, providers of in -home services will establish a procedure to document that client rights information has been discussed with in-home services clients (e.g. copy of signed Client Bill of Rights statement). Clients Rights information to be communicated to service recipients will include, at a minimum, the right to: • be fully informed, in advance, about each in -home service to be provided and any change and any change in service(s) that may affect the wellbeing of the participant; • participate in planning and changing any in -home service provided unless the client is adjudicated incompetent; • voice a grievance with respect to service that is or fails to be provided, without discrimination or reprisal as a result of voicing a grievance; • confidentiality of records relating to the individual; • have property treated with respect; and • be fully informed both orally and in writing, in advance of receiving an in -home service, of the individual's rights and obligations. Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above listed services prior to the onset of service. For all existing clients, the above information will be provided no later than the next regularly scheduled service reassessment. Agency Name: ` Name of Agency Administrator: Signature: Date: l (Please return this form to your Area Agency on Aging and retain a copy for your files.) CLIENT/PATIENT RIGHTS 1. You have the right to be fully informed of all your rights and responsibilities as a client/patient of the program. 2. You have the right to appropriate and professional care relating to your needs. 3. You have the right to be fully informed in advance about the care to be provided by the program. 4. You have the right to be fully informed in advance of any changes in the care that you may be receiving and to give informed consent to the provision of the amended care. 5. You have the right to participate in determining the care that you will receive and in altering the nature of the care as your needs change. 6. You have the right to voice you grievances with respect to care that is provided and to expect that there will be no reprisal for the grievance expressed. 7. You have the right to expect that the information you share with the agency will be respected and held in strict confidence, to be shared only with your written consent and as it relates to the obtaining of other needed community services. 8. You have the right to expect the preservation of your privacy and respect for your property. 9. You have the right to receive a timely response to you request for service. 10. You shall be admitted for service only if the agency has the ability to provide safe and professional care at the level of intensity needed. 11. You have the right to be informed of agency policies, changes, and costs for services. 12. If you are denied service solely on you inability to pay, you have the right to be referred elsewhere. 13. You have the right to honest, accurate information regarding the industry, agency and of the program in particular. 14. You have the right to be fully informed about other services provided by this agency.