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FY16 HCCBG Final Funding PlansADDRESS Y SERVICE PROVIDER 'source Center 180093 Home and Community Care Block Grant for Older Adults JI f DOA -732 (Rev. 2115) V County Funding Plan County lgew Hannve July 1,2813 through June 30, 2016 Provider Services Summary REVISION # 2 , DATE : 07/14/2016 B C I D E F G I H I Projected �9- P 'undin Required Net* NSIP Total HCCBG Other Total Local Match Sery Cos[ Subsidy Funding Units \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 20010 200103 200103 CONG NUTRIT X 88821 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 9869 98690 10688 109378 11652 8.4696 445 1 14249 HDM NUTRIT. X 339652 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 37739 377391 55500 432891 65197 5.8019 509 74000 SR. CTR. OPS. X 28849 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 3205 32054 32054 TRANSPORT. -GEN \ \ \ \ \ \\ X 26681 0 457322 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 2965 29646 66188 29646 3413 8.6862 138 8500 TRANSPORT. MED. Day Health Care Net Service Cost X 31796 ADC ADHC \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 3533 35329 Certification of required minimum local match availability. 35329 4246 8.3205 249 9564 Administrative with Block Grant Funding. Community Service Provider b+,it( CGUAh( 11 Net Stt. Cost Total \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 A ' I � Signature, County Finance Officer Dare Signature, Chairman, Board of Commissioners Da}� e , F 7 - -a7-� \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 2016 01 ni 1 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total \ \ \ \ \ \\ \ \ \ \ \ \\ 238570 0 457322 695892 77321 773213 66188 839401 84508 \ \ \ \ \ \ \ \ \ \ \ \ \\ 2749 1 106313 *Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC Daily Care Certification of required minimum local match availability. (% Transportation Required local match will be expended simultaneously Authorized Signature, Title qf-(` fA, ji&r -Date Administrative with Block Grant Funding. Community Service Provider b+,it( CGUAh( 11 Net Stt. Cost Total , n ` -71ZIIIIP 6;20-051� A ' I � Signature, County Finance Officer Dare Signature, Chairman, Board of Commissioners Da}� e , F 7 - -a7-� 0 2016 Cli ID IQ °/ °R ■\ /$ \;/ /m / 2 - f9)R/ #/ �/ ®■« 4\ ~5 /)) /4 / k\��\ MM cO 3 ;E/ ~ Li 22 \{|k§ )\ § ) E (\ =2 E0 -_ ;� \__ \\ {,2: ;�E / { §£� - -\ r :{ §§ at! -!!£ _ 2($ /\� !7, :{ =�@J) !! -_{2 fƒ a! ° ®^ !!� F };■&° |) § �- %! -- 2 -!a § § »)) t!a =f» �:0m za2 /2I %a �Dau)�,,,33,�,aa� „ a =e Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. Case Asst Cong HDM Senior Transport Transport Adult Day IHA II. Line hem Expense Total Cost I &R Nutrition Nutrition Center General Medical Care/Health Staff Salary From Labor Distribution Schedule / / / / / / / / / / / / /// !/////HHH /// 1 Full -time Staff 625,680 272,436 61,687 199,079 43,883 24,297 24,298 2 Part-time staff do not include Title V workers 70,143 18,192 29,813 22,138 A. Subtotal, Staff Salary 695,823 0 272,436 79,879 228,892 43,883 46,435 24,298 0 0 Fringe Benefits included in total sale / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / /I / / / / / / / / /// / / / / / / / / / / / / /// /////!HMI /// / / / / / / / / / / / / /// ///////HHH // 1 FICA % 0 2 Health Ins. 0 3 Retirement @ 0 4 Unemployment Insurance 0 5 Worker's Compensation 0 6 Other 0 B. Subtotal, Fringe Benefits 0 0 0 0 0 00 0 0 0 Local In -Kind Resources, Non -Match 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 1 Per Diem 0 2 Mileage Reimbursement 2,380 1,505 25 400 250 100 100 3 Other Travel Cost: 3,250 1,250 500 900 300 300 E. Subtotal, Travel 5,630 0 2,755 25 900 1,150 400 400 0 0 General Operating Expenses 1 Contract Services- ARMS -MIS 1,230 400 630 301 170 2 Contract Services 368,119 1 47,025 244,200 23,068 53,826 3 Postage 1,897 306 0 135 606 425 425 4 Printing-off site 1,566 300 144 300 678 72 72 5 Print Copier 4,554 400 274 500 3,000 190 190 6 Supplies 13,275 500 3,175 2,200 7,000 200 200 7 Dues & Subscriptions 0 180 50 0 0 0 0 8 M &R Equipment 4,100 0 400 850 2,650 200 0 9 Cell Phone Expense 600 0 0 600 0 0 0 10 Supplies-Gas 8,451 0 01 5,634 0 2,817 0 11 0 0 0 0 0 0 0 F. Subtotal, General Operating Expenses 404,022 0 1,686 51,468 255,049 13,934 27,002 54,883 0 0 G. Subtotal, Other Administrative Cost Not Allocated / / / / //I//////// /I/ // / / // /I / /// / / / / / / /// / / / /// / / //// / // / / /I /I /// / / / / / // / / //I / /I / / / / /// / / /// //I /lllllllllll /I /I / //I / / /ll // ll////I///I/ /// /I/ ///////// /// in Lines ILA through F 1111111llIIII11 lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll Iln/w ///1111 Illllllllllllll lllllllllllllll HIllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll Illllllllllllll Illllllllllllll lllllllllllllll Prior to Admin. Distribution Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Case Asst Cong HDM Senior Transport Transport Adult Day IHA Total I &R Nutrition Nutrition Center General Medical Care/Health 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 III.B.5 Col. G Projected Total Service Units Line III.F Col. I NAME AND ADDRESS Home and Community Care Block Grant for Older Adults COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 4/14) County Funding Plan County_ New Hanover Elderhaus, Inc. July 1, 2015 through June 30, 2016 1950 Amphiteater Dr. Provider Services Summary REVISION # 2, DATE: 7/16 Wilmington, NC 28401 Services A Set. Delivery (check one) Block Grant Funding B C D E F G H I Required Local Minct Net" Sery Cost NSIP Subsidy Total Funding Projected HCCBG Units Projected Reimburse Rate Projected HCCBG Clients Projected Total Units Direct Parch, I Access In -Home Other Total Adult Day Care 70841 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 7871 78712 78712 1231 63.96 Adult Day Health 27493 3055 30548 30548 436 70.0925 Transportation- ADC 823 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 91 914 914 609 101 1.50 Transportation- ADH 137 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 15 152 152 1.50 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \\ 0 0 0 \ \ \\ 0 0 0 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total \ \ \ \ \ \\ \ \ \ \ \ \\ 1 0 1 98334 960 99294 11032 110326 0 110326 2377 \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 "Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC - Daily Care 33.07 40.00 Certification of required minimum local match availability. \0 Transportation Required local match will be expended simultaneously Authorized Signature, Title Date Administrative 30.89 30.09 with Block Grant Funding. nCommunity Service Provider Net Ser. Cost Total 63.96 70.09 \ ( �� [ 466nk� \� Signature, County Finance Officer Date Signature Chairman Board of Commissioners Date tr K '& JgvJSo� NAME AND ADDRESS I onu• and ('omnumitc ('arc Black Grant for OW, Adults COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 2/14) Interim HealthCme of the County Funding Plan County Hanover Eastern Carolinas, Inc. Jul 1, 2015 through Juoe 30, 2016 Provider Services Summary REVISION # 1 , DATE : 07/15/2016 A B C I D E F G H I Ser. Deliver Projected Projected Projected Projected Icneel<argil Block Grant Funding Required Net- NSIP Total HCCBG Reimburse HCCBG Total Dir Pares. Access In -Home Other Total Services Local Match Sery Cost Subsidy Funding Units Rate Clients Units In -Home Aide Level 1 13233 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 1470 14703 14703 866 16.9788 9 866 In -Home Aide Level 2 70335 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 7815 78150 78150 4540 17.2576 27 4540 In -Home Aide Level 3 98599 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 10955 109554 109554 6282 17.4476 29 6282 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 %%\\\\\\\\A\\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \\\\\\\ \ %W \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total \ \1 \ \ \\ \ \ \ \ \ \\ 0 182167 0 182167 20240 202407 0 202407 11688 \ \ \ \ \ \ \ \ \ \ \ \ \\ 65 11688 •Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC Daily Care Certification of required minimum local match availability. Transportation Required local match will be expended simultaneously Authorized S' lure, Title Date Administrative wr Block Grant Funding. Community Service Provider Net Ser. Cost Total N Signature, County Finance Officer Date Signature, Chairman, Bo d of Commissioners Date e '�