FY17 SRC TITLE IIID EVIDENCE BASED HLT PROM APPLICATIONDAAS -734
(revised 2/16)
Attachment A
July 1, 2016 through June 30, 2017
Home and Community Care Block Grant for Older Adults
Community Service Provider
Standard Assurances
NHC Senior Resource Center agrees to provide services through the Home and
(Name of Provider)
Community Care Block Grant, as specified on the Provider Services Summary (DAAS -732)
in accordance with the following:
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 httv://www.nedhhs.gov/aging/monitor/mpolicy.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).
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 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 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 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 2/16)
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 Securi ty. 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.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.
lol3lr
(Authorized Signature) (Date)
i
MM
Cape Fear Area Agency on Aging
FY 2017 FUNDING APPLICATION PACKAGE
TITLE IIID
EVIDENCE BASED HEALTH PROMOTION
J
Geri -Fit at NHCSRC BSRI
NC Division of Aging and Adult Services
Health Promotion Disease Prevention (IIID)
Service Standards are located on the website:
httt)s: / /nedhhs. s3.amazonaws.com/s3 fs- public /documents /files /iiid.pdf
FUNDING NARRATIVE
EVIDENCE BASED HEALTH PROMOTION (EBHP)
Statement of Philosophy and Purpose
Title IIID of the Older Americans Act (OAA) was established in 1987. It provides grants
for education and activities that support healthy lifestyles and behaviors for those 60
and older. In 2012, Congress mandated that Title IIID funding be used only for
programs and activities that have been demonstrated to be evidence - based. Evidence -
based Health Programs are those which have been developed, researched, and
rigorously tested in order to yield consistent, desired results. They reduce the need for
costly medical interventions and enable older adults to live independently longer.
Funding support is provided to states under Health Promotion and Disease Prevention
Services (Title IIID), to empower older adults to take control of their health. Through
these programs, seniors learn to maintain a healthy lifestyle through increased self -
efficiency and self- management behaviors. Classes are provided to older adults in their
own communities, in familiar non - clinical settings, such as community centers, and in
peer learning groups which provide support, socialization and reinforcement of positive
behavior changes.
In keeping with the directive to promote and implement Evidence Based Health Promotion
(EBHP) Programs in the North Carolina aging network, the following funding will be
distributed per the intrastate funding formula to Lead - agencies within Region O.
Title IIID standards for SFY 2016/2017 have changed to meet the federal
requirements that only evidence -based programs meeting the highest tier criteria
shall be offered and supported with Title IIID funds, effective July 1, 2016.
FY 16/17 Evidence Based Health Promotion Allocation
County
Health Promotion Funds
Required
County
Match
Grand Total
Brunswick
9,698
1,078
10,776
Columbus
4,991
555
5,546
New Hanover
10,176
1,131
11,307
Pender
4,135
459
4,594
Page 2 of 5
Application Requirements
1. Complete EBHP Proposal Spreadsheet found on page 5.
2. Consumer Contributions Requirement
a) Describe how your agency will notify participants and solicit consumer
contributions for participants of EBHP.
b) Provide a copy of your Agency Policy and Procedures governing the
collection of voluntary contributions.
The NC DAAS Health Promotion and Disease Prevention Program Standards,
(Section VII. B. Records, Reports and Reimbursement, page 8) states:
"Voluntary Contributions: In accordance with the requirements of the Older
Americans Act, agencies must provide individuals receiving service the
opportunity to contribute to the cost of the service. Eligible persons receiving
Health Promotion and Disease Prevention services are subject to these
requirements. Agencies must establish written policies and procedures
governing the collection of voluntary contributions."
➢ Agencies providing EBHP services with Title IIID funding cannot charge
participants 60 and older for classes or services.
3. Sign the Standard Assurances — Attachment A
4. Sign the Conflict of Interest Policy (for non - profits only) — Attachment B
5. Reporting — Providers shall submit to the AAA each quarter the number of
persons served for each program or activity offend with Title IIID funds.
Additionally, Falls Prevention Programs data (such as A Matter of Balance),
Living Health Programs data, and soon, Tia Chi for Arthritis data must be
reported to the N.C. Center for Health and Wellness at UNC Ashville. Program
data may be submitted to the AAA to be forwarded to UNC Ashville.
Use of grant funds
Title IIID funds cannot be used for:
• Indirect costs or administrative salaries
• Any program other than highest -tier criteria
Title IIID funds can be used to
• Support staff salary when they conduct training or attend meetings where they
are sharing information about Evidence Based Programs
• Any highest -tier program
Page 3 of 5
Reimbursement Methodology
Agency will submit expense records, including invoices, purchase orders,
employee /instructor time records, stipend, travel, etc to the AAA.
• Receipts will show allowable expenditures and request for reimbursement for
non -unit services.
• Service Code 401 must be used to report Title IIID activities in the DAAS Aging
Resource Management System (ARMS).
• Title III -D expenditures shall be tracked separately from Title III -D Surplus
expenditures.
Helpful References
Administration for Community Living — EBHP background information, frequently asked
questions and more:
http: / /www.aoa.acl.gov /AoA Programs /1-110W/Title IIID /index.aspx
Federally- approved list of highest tier programs:
https:// www. ncoa .org /wp- content/uploads/Title -I IID- Highest- Tier - Evidence- FINAL-
7.27.16. pdf
Page 4 of 5
EBHP Proposal Spreadsheet
Name of Program, Event or
Projected Number of
Instructor/
Method for
Method for
Purpose of
Budget
Line Items
Activity You Plan to
Activities /Classes/
Credentialed
Recruiting
Tracking
Funds
for
Attend /Conduct
Seniors Served
Practitioner,
Participants
Attendance
Activity
if known
A Matter of Balance
Four sessions. Each
Shantel Davis,
Flyer, SRC
Sign -in
Instructor
$2860
Instructor fees
session is 8 classes (16
Mary Konicki,
newsletter, and
sheet
fees,
total
and supplies
hours) with two coaches.
Tina Wood,
SRC web -site
supplies, and
Gayla
healthy
$2560
8 -12 seniors per session
MacMillan,
snacks
instructor
fees
Linda Carlsen,
Greg Kennedy
$300
supplies /sna
cks
Geri -Fit
Approximately 364 classes
Mary Konicki,
Flyer, SRC
Sign in
Instructor
$13,332
Instructor fee,
both onsite and offsite
Gayla
newsletter, SRC
sheet
fees,
total
supplies, and
locations. 10 -35 seniors
MacMillan,
website
equipment,
license fee
per session.
Annette
license fee,
$12,560
Crumpton,
additional
instructor
Shantel Davis,
instructor fee
fee, $322
additional
Fran Tabor
instructor
certification,
$150 annual
license,
$300
equipment
Tai Chi for Arthritis
3 classes per week.
Marty Gregory
Flyer, SRC
Sign in
Instructor
$6,240
Instructor fee
Approximately 156 total
newsletter, SRC
sheet
fees
classes. 8 -10 seniors per
website
class.
Page 5 of 5