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FY18 HCCBG Award ContractDAAS -730 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan Identification of Agency or Office with Lead Responsibility for County Funding Plan County New Hanover July 1, 2017 through June 30, 2018 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. New Hanover County Senior Resource Center (Name of agency /office with lead responsibility vn� q t( j ' I'1 u rized signature (date) Avril M. Pinder, Deputy County Manager (Type name and title of signatory agent) DAAS -731 (Rev. 2116) Home and Community Care Block Grant for Older Adults County New Hanover County Funding Plan July 1, 2017 through June 30, 2018 County Services Summary A B C D E F G H I Services Block Grant Funding Required Local Match Net Service Cost NSIP Subsidy Total Funding Projected HCCBG Units Projected Reimbursernen Rate Projected HCCBG Clients Projected Total Units Access In -Home Other Total 18R Case Assist 180093 \ \ \ \ \ \ \ \ \ \ \\ 20010 200103 200103 2150 Congregate Nut 83273 \ \ \ \ \ \ \ \ \ \ \\ 9253 92526 11812 104338 10442 8.86 485 16200 HDM Nutrition 321040 \ \ \ \ \ \ \ \ \1 \\ 35671 356711 64687 421398 59781 5.97 590 82500 Sr. Center ODs 34395 \ \ \ \ \ \ \ \ \ \ \\ 3822 38217 38217 Trans: General 23000 \ \ \ \ \ \ \ \ \ \ \\ 2556 25556 25556 2716 9.41 125 8750 Trans.- Medical 56252 \ \ \ \ \\ \ \ \ \ \\ 6250 62502 62502 6578 9.5 210 9819 Adult Day Care 67603 \ \ \ \ \ \ \ \ \ \ \\ 7511 75114 75114 997 75.31 997 Adult Day Health 31279 % \\\AAA 3475 34754 34754 545 63.76 545 Trans: ADC 1009 \ \ \ \ % \ %\ 112 1121 1121 747 1.5 747 Trans: ADH 1009 %%%% 112 1121 1121 747 1.5 747 In Home Aide 1 12000 \ \ \ \ % \\\\\ 1333 13333 13333 785 16.9851 10 785 In Home Aide II 88003 \ \ \ \ \ \\\ % 9778 97781 97781 5666 17.2575 20 5666 In Home Aide III 114000 % \ \ \AA \\ 12667 126667 126667 7259 17.4496 25 7259 \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total 259345 312885 440726 1012956 112551 1125506 76499 1202005 96263 % \A \ \ \ \ %\ 3615 134015 �,J ,A Z /% Chairman, Woody White I late NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - ATTACHMENT A LABOR DISTRIBUTION SCHEDULE DAAS -732A1 2/16 AGENCY NAME: New Hanover County Senior Resource Center FY: 2017 -2018 SFY 17 -18 STAFF NAME POSITION FULL TIME PART TIME TOTAL SALARY ADMIN. SALARY Case Assist Congregate HDM Sr. Center Gen Trans Med Trans SERVICE SERVICE BRIDGERS, K HDM Packer FULL TIME $48,231 $48,231 BRYANT, M Con g, Mgr. PART TDAE 28,366 28,366 CANNY, B Social Worker FULL TIME 70,298 59,753 10,545 CONNER, E Nutrition Mgr. FULL TDAE 74,843 37,421 37,422 DAVIS, S Activity Asst. FULL TIME 50,332 50,332 DODSON, C Trans Coord. FULL TIME 59,340 19,670 39,670 GILL, K Vol Coordinat FULL TIME 52,996 52,996 HATTEN, V Case Wrk FULL TIME 42,889 42,889 _ HAYES, R Social Worker FULL TIME 59,080 50,218 8,862 HOLMES, J HDM Driver PART TIME 31,477 31,477 LEE, J Social Worker FULL TIME 66,514 56,536 9,977 LOESER, R Admin FULL TIME 60,426 30,213 30,213 NORRIS, H Trans Asst. PART TIME 34,136 34,136 ZELDIN, A SW Supervisor FULL TDAE 78,880 78,880 SUBTOTAL FT: $663,829 $0 $288,276 $67,634 $1.98,246 $50,332 28,366 31,477 0 $19,670 $39,670 $0 $0 SUBTOTAL PT: 93,979 0 0 34,136 0 0 0 TOTAL $757,808 $0 $288,276 $96,000 $229,723 $50,332 $53,806 $39,670 $0 $0 PERCENT FT: 87.60% #DIV /0! 100.00% 70.45% 86.30% 100.00% 36.56% 100.00% #DIV /0! #DIV /0! PERCENT PT: 12.40% #DIV /0! 0.00% 29.55% 13.70% 0.00% 63.44% 0.00% #DIV /0! #DIV /0! Page 1 NAME AND ADDRESS Home and Community Care Block Grant for Older Adults COMMUNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16) NHC Senior Resource Center County Funding Plan County_New Hanover_ 2222 S. College Rd. July 1, 2017 through June 30, 2018 Wilmington, NC 28403 Provider Services Summary JREVISION# , DATE : 8/4/2017 Services A Ser. Delivery (Check One) Block Grant Funding B C D E F G H I Required Local Match Net* Sery Cost NSIP Subsidy Total Funding Projected HCCBG Units Projected Reimburse Rate Projected HCCBG Clients Projected Total Units Direct IPurch. Access I In -Home Other Total I &R Case Assistance x 180093 20010 200103 1 200103 2150 Congregate Nutrition x 83273 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 9253 92526 1 1812 104338 10442 8.86 485 16200 HDM Nutrition x 321040 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 35671 356711 64687 421398 59781 5.97 590 82250 Sr. Center Ops x 34395 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 3822 38217 38217 Transportation - General x 23000 \ \ \ \ \ \ \ \ \ \ \ \\ 2556 25556 25556 2716 9.41 125 8750 Transportation - Medical x 56252 \ \ \ \ \ \ \\ 6250 62502 62502 6578 9.5 210 9819 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 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 \ \ \ \ \ \\ \ \ \ \ \ \\ 259345 0 438708 698053 77562 775615 76499 852114 79517 \ \ \ \ \ \ \ \ \ \ \ \ \\ 3560 117019 *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 Avril M. Pinder, Deputy County Manag Date Administrative I'D Block Grant Funding. C mmunity Service Provider Net Ser. Cost Total ��N�� a U3 L,— C1 I ► 5 l , , g , Lisa Wurtzbacher, County Finance Officer Date Cha)had ody White Date Cost Computation Worksheet c:732AAS r: Senior Resource Center New Hanover Period: July 1, 2017 through June 30, 2018 i _yes, X no, revision date DAAS -732A 3/99 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/Home 2 0 3 0 Total Required Minimum Match - Cash 77,562 / / / / / / / / / / / / /// 20,010 9,253 35,671 3,822 2,556 6,250 0 0 Required Minimum Match - In -Kind llllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll 1 0 2 0 3 0 Total Required Minimum Match - In -Kind 0 / / / / / / / / / / /! /// 0 0 0 0 0 0 0 0 B. Total Required Minimum Match cash + in -kind 77,562 / /! / / / / / / / / / /// 1 20,010 9,2531 35,671 3,822 2,5561 6,250 Of 0 C. Subtotal, Fed/State/Required Match Revenues 1,090,518 / / / / / / / / / / / / /// 200,103 92,526 356,711 38,217 25,556 62,502 100,900 214,003 D. NSIP Cash Subsidy/Commodity Subsidy/Commodity Valuation 0 E. OAA Title V Worker Wages, Fringe Benefits and Costs 0 Local Cash, Non -Match / / / / / / / / / / / / /// 11/!11/!//!1/!/ 1 County Contribution 450,859 / / / / / / / / / / / / /// 94,139 60,334 176,765 37,035 54,286 28,300 2 0 3 0 4 0 1 /lllllllllllll F. Subtotal, Local Cash, Non -Match 450,859 /////////////// 94,139 60,334 176,765 37,035 54,286 28,300 0 0 Other Revenues, Non -Match lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllll /Ill lllllllllllllll lllllllllllllll 1 0 2 0 3 0 lllllllllllllll G. Subtotal, Other Revenues, Non -Match 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 0 0 Local In -Kind Resources Includes Volunteer Resources / / / / / / / / / / / / /// / / / / / / / / / / /I /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// /////////////1/ / / / / / / / / / / / / /// /1/!/!/!1!1/!/! 11//!1///!1//// 2 0 3 0 H. Subtotal, Local In -kind Resources, Non -Match 0 / / / / / / / / / / / / /// 1 01 01 01 01 01 0 0 0 I. Client Cost Sharing 29,500 / / / / / / / / /! / / /// 1 1 2,5001 22,0001 1 2,5001 2,500 J. Total Projected Revenues sum l a i ) zva,zaz 100'joul 000,410 r0,z0z 0z,-J4z "'Juxi 1u218uu zla,uua 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 Item Expense Total Cost I &R Nutrition Nutrition Center General Medical Care /Health Staff Salary From Labor Distribution Schedule 1 Full -time Staff 663,828 288,276 67,634 198,246 50,332 19,670 39,670 2 Part-time staff do not include Title V workers 93,979 28,366 31,477 34,136 A. Subtotal, Staff Salary 757,807 0 288,276 96,000 229,723 50,332 53,806 39,670 0 0 Fringe Benefits included in salary) 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 0 0 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 0 3 Other Travel Cost: 0 E. Subtotal, Travel 0 0 0 0 0 0 0 0 0 0 General Operating Expenses 1 Contract Services- ARMS MIS fee 2,009 0 350 639 0 350 670 2 Contract Services vendors 419,935 0 54,585 287,450 0 25,500 52,400 3 Postage 1,312 200 200 79 490 171 172 4 Printing off site 2,335 260 100 250 1,650 45 30 5 Printing- in house copies 4,586 506 600 600 2,500 190 190 6 Supplies 23,715 600 3,175 2,200 17,500 120 120 7 Dues and Subscriptions 505 0 150 225 130 0 0 8 M & R Equipment 5,450 0 200 2,500 2,650 50 50 9 Cell Phone expense 1,320 0 0 720 600 0 0 10 Supplies-Gas 5,820 0 0 3,900 0 11920 0 11 HDM Volunteer Mileage Reimbusment 26,260 0 0 26,260 0 0 0 12 Training and Travel 3,950 1,400 100 500 1,650 150 150 13 Employee Mileage Reimbursment 3,785 3,000 25 430 250 40 401 1 F. Subtotal, General Operating Expenses 498,167 0 5,966 59,360 325,753 24,920 28,536 53,6321 01 0 G. Subtotal, Other Administrative Cost Not Allocated llIlllllllllll/ Illlll /lll/llll llll /lllllll/Il lllllllllll/Ill lI/IlIIIl1lllll lllllllllllllll lll/lllllllllll Illllllllllllll iffliliffflulu Jill /llllllllllll /I Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Casr Asst Cong HDM Senior Total 1 &R Nutrition Center 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 (DAAS -732A) corresponds with stated on the Provider Services Summary i as follows: DAAS -732A DAAS -732 Block Grant Funding Line LA Col. A Required Local Match -Cash & In -Kind Line I.B Col. B Net Service Cost Line LC Col. C NSIP Subsidy Line LD Col. D Total Funding L. I.0 +I.D Col. E Projected HCCBG Reimbursed Units Line IILC Col. F Total Reimbursement Rate Line 111.6.5 Col. G Projected Total Service Units Line III.F Col. 1 3 DAAS -733 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan July 1, 2017 through June 30, 2018 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 New Hanover County Senior Resource Center County—T! ew Hanover Coun 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. 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. According to the US Census 2016 population estimates, New Hanover County's population was estimated to be 223,483. This is an increase of 10.26% from 202,688 at the 2010 census. The population density equates to approximately 1,058 per square mile and approximately 16.7% over the age of 65 years. According to the 2016 census estimates 17.3% 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: Options Counseling & 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 dignity Health Independence Services: Promoting wellness Caregiver Support Programs: Providing respite and supportive services for caregivers. Community Enrichment: Enhancing quality of life Prescription Assistance Program: assisting seniors enroll in programs to reduce prescription costs. Social Workers assess client 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 senior friendly and promotes the many services and special programs offered at the SRC. The SRC also provides bi- monthly newsletters, bi- weekly Gov Delivery announcements, and social media outreach that promotes all services and programs. 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. Over 60% of the activities offered are at no cost to the participant. 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, 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, essential shopping trips, and day trips. DAAS -734 (revised 2/16) 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 hU://www.ncdhhs.mov/aginWmonitoL/mpolicy.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. 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: Eligibility determination; Client intake/registration; Client assessment/reassessments and quarterly visits, as appropriate; Determining the amount of services to be received by the client; and Reviewing consumer contributions policies with eligible clients. 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. 4143C-6-23, 09 NCAC 03M1 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 Security. Per the requirements in 10A 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. vti �A tist.`DCer- Avril Pinder q (Authorized Signature) (Date) 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: New Hanover County Senior Resource Center Name of Agency Administrator: Amber K. Smith Signature: &. /,Y—, lliy� Date: 8/4/2017 (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. WV Area Agency On A ing C Cape Fear Council of Governments IMPORTANT INFORMATION: HCCBG ALLOCATIONS SFY 2017/2018 TO: Amber Smith, Director New Hanover County Senior Resource Center FROM: Jane Jones, Region O AAA Director JU DATE: July 25, 2017 RE: SFY 2017/2018 HCCBG Allocations NC Division of Aging and Adult Services has notified the Area Agency on Aging of the SFY 18 Home & Community Care Block Grant (HCCBG) funding. Please see attachment for your county's SFY 2017 /2018 allocation. All of the 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. However, due to significant increases in allocations in each county in our region, it would be prudent to convene your HCCBG Committee as quickly as possible and contact me with datel ime/location of meeting. The SFY 2017/2018 HCCBG Budget instructions are available through the NC Division of Aging/Adult Services website httt)s://www.ncdhhs.gov/home- and - community -care- block - grant- hccbg- county - budget- instructions- documents. Since allocations are much later than normal, it would be helpful to complete your budget packets as soon as possible after HCCBG Committee meetings are conducted and submit to your Board of County Commissioners for approval. (Note that form DAAS 735 is for the AAA use only). Please submit completed, signed packet to Ginny Brinson as soon as possible. Please note that non -HCCBG funds including Evidence Based Health Promotion & Senior Center General Purpose allocations will be sent out in the next few weeks along with the proposal packets. Please contact me if you have any questions. Thanks! CC: Ginny Brinson, AAA/COG Chris May, COG Director Dawn Tucker, COG Finance Officer Chris Coudriet, County Manager Avril Pinder, Deputy County Manager Serving Brunswick Columbus, New Hanover and Pender Counties 1480 Harbour Drive • Wilmington, NC 28401 • (910) 395 -4553 • (800) 218 -6575 • Fax: (910) 395 -2684 www.capefearcog.org An Fq,ol Opportunity /Aff,mctie Aotlon /ADA Employer /PPog- New Hanover County Home & Community Care Block Grant Allocation SFY 2018 COUNTY /REGION HCCBG New Hanover July 24, 2017 SFY 2017/2018 Tota I Allocation Local Plus Local Match Match $1,012,956 � $112,551 1 $1,125,507 Minimum Budget Requirement Access 30% $41,988 Minimum Budget Requirement In -Home 25% $34,990 Minimum Budget Requirement Congregate 33% $57,534 Agenda HCCBG Advisory Committee Meeting August 3, 2017 @ 2pm NHC Senior Resource Center • Acknowledge start of the meeting— Elizabeth Grace, HCCBG Chairman • Welcome —Amber Smith • Introductions • HCCBG Fiscal Year 2017 /2018 —Amber Smith • Questions • HCCBG committee recommendations and vote • Close of meeting — Elizabeth Grace Thank you for coming and being a part of making New Hanover County a better place to live, work, and enjoy! Smith, Amber From: Smith, Amber Sent: Thursday, August 03, 2017 4:22 PM To: Hewett, Teresa; Akin, Amy Cc: Heath, Tina; Zeldin, Andrew; Connor, Ellen; Kennedy, Greg Subject: 2017 2018 Recommended Allocation August 03 2017 with increase Attachments: 2017 2018 Recommended Allocation August 03 2017 with increase.docx Teresa and Amy, Attached is the HCCBG allocations with the $35,646 increase. Since the county overmatches, we will not need to include an additional match. I am working on the actual HCCBG budget forms and will hopefully have them ready to you for signatures and the BOCC agenda by Monday, August 7, 2017. The increases will be in in the following project codes (the project number reflects the increase from the adopted budget and the numbers in the ( )'s shows how much it was increased): Adult Day Care /Health: 11068733 302250 G0001- $100,900 (- $7,500 increase) 11068730 780010 G0001 $100,900 ($7500 increase) Congregate: 11068733 302250 G0003 - $83,273 (- $4,000 increase) 11068730 700080 G0003 $54,585($3,700 increase) 11068730 700512 G0003 $600($200 increase) 11068730 700905 G0003 $100 ($100 increase) HDM: 11068733 302250 G0005 - $321,040 (- $8,600 increase) 11068730 700080 G0005 $287,450 ($8,600) In Home Aide: 11068733 302250 G0006 - $214,003 (- $10,000 increase) 11068730 780005 G0006 $214,003 ($10,000 increase) Senior Center: 11068723 300930 G0011 - $34,395 (- $5,546 increase) 11068720 700520 G0011 $17,546 ($5,546 increase) Thank you, Amber MEETING SIGN -IN SHEET HCCBG Committee Facilitator: Amber Smith Name I Title I Company Meeting Date: 8/3/2017 Place /Room: SRC Craft Room 2 6� o� m Phone I E -Mail Page 1 of 1 WC re q10- 795- �qlo Ac ev. a S-Aci N e P, �� SRc- 9ojf SAC q10-- 7 ?23 . &yam .5MAV,s oo,4 ��- � q .kiln ") , "erl *f f �p (L/ �3 17ky0 ✓. co ND� 2� su.� 5 Ge_ Cop �� r�—v [ ��Z - Gl/ 6-4 ck LzM cc 64 1910 --39 - SG rL �✓ �oo Q ` 2b easao S2C S�tG N �' �c, &C Page 1 of 1 County: New Hanover Date: 08/03/2017 SFY 2017/2018 Home & Community Care Block Grant Meeting Worksheet Decisions Is this a budget revision? Yes No X Federal/State Home & Community Care Block Grant Funding: Total $1,012,956 FY 2017/2018 Required Match $112,551 What amount of monies should the identified services receive? 16/17 Recommended Service Provider Allocation Allocation 17/18 Difference Transportation: General SRC 36,500 23,000 < $ 13,500 Medical SRC 64,752 56,252 < $ 8,500 Home Delivered Meals SRC 290,440 321,040 > $ 30,600 Congregate SRC 79,273 83,273 > $ 4,000 Case Assistance/I &R SRC 180,093 180,093 -0- Senior Center Operations SRC 28,849 34,395 > $ 5,546 In Home Aide Services SRC (Interim) 204,003 214,003 > $ 10,000 Adult Day Care/Health SRC (Elderhaus, Inc.) 93,400 100,900 > $ 7,500 HCCBG Total $ $977,310 $ 1,012,956 $ 35,646 HCCBG Advisory Committee Meeting MINUTES 8/3/2017 2:03 PM — 2:30 PM SRC— CRAFT ROOM 2 MEETING CALLED BY Amber Smith — SRC Director TYPE OF MEETING HCCBG Funds Allocation FACILITATOR Amber Smith NOTE TAKER Tina Heath — Administrative Technician TIMEKEEPER Tina Heath Amber Smith, Shantel Davis, lane ]ones, Ginny Brinson, Ellen Connor, Heather Clark, Rick ATTENDEES Richards, Greg Kennedy, Dorothy Grime, Chris Dodson, Andrew Zeldin, Bobby Shoemake, Elizabeth Grace, Carol Bales, Nathan Bales, Susie Springer Agenda topics 1 HOUR FY 18 HCCBG ALLOCATION INCREASE AND VOTE AMBER SMITH AND ELIZABETH GRACE DISCUSSION HCCBG Allocation of reinstated funds increase - $35,646 • At 2:02pm Betty Grace called the meeting to order and welcomed everyone. Introductions were made. • Amber Smith explained that the State reinstated the HCCBG funding and reviewed the funding methodology. As a result, NHC received an increase of $35,646 to the Block Grant budget. This was an increase from 2017. Due to the increase in funds, Amber convened a meeting for the committee members to vote on allocation of those funds. • Amber provided a worksheet with recommended allocations. There would be decreases to Transportation, General $13,500 & Medical $8,500. With the $35,646 Amber recommended the following increases; $8,600 HDM, $4,000 Congregate, $5,546 SRC Ops, $10,000 In Home Aide Services, and $7,500 Adult Day Care /Health. The SRC is in need of a new treadmill and the increased Senior Center Ops funding would be utilized to purchase a new treadmill. The cost for the new commercial treadmill is $5,300 +. The treadmills are the most used pieces of fitness equipment and would be a good use of funds. • Questions /Comments: 1. Betty Grace asked about taking money from Transportation. Amber stated yes, and explained that we were underspent in previous years and it would be better to redirect those funds elsewhere. Also, the SRC receives ROAP and 5310 funds that are specifically used for transportation. 2. Other comments: With the additional funds, over 40 additional HDM clients can be served, Interim can serve 7 extra clients, Elderhaus can provide approximately 100 extra days of service, and the HDM waiting list could be reduced. • No further questions. Betty Grace stated that this is a good use of funds. That it will benefit NHC citizens & the community well. • A vote was taken. Dorothy Grime's motioned to accept the proposed allocations. Nathan Bales seconded the motion. Motion was approved by all voting members in attendance. No further comments or questions. Meeting was adjourned at 2:30 pm. All members voted in favor of proposal to decrease Transportation funds and to redirect to other areas where it is needed. Members voted to allocate the $35,646 HCCBG funding to HDM, Cong., Senior Center CONCLUSIONS Ops, Adult Day Care /Health, and In Home Aide. Members also voted in favor of using funds to purchase a commercial treadmill. Amber will turn proposal into the County for the Commissioners to vote on. Amber will let everyone know when it will be voted on, and if agenda or consent. Motion passed. NAME AND ADDRESS home and COlamunit) Care Block (:rant for Older Adults COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 2/12) Elderhaus, Inc. County Funding Plan County_ New Hanover 2222 S. 17th Street Jul 1, 2017 through June 30, 2018 Wilmington, NC 28401 Provider Services Summary REVISION # , DATE: Services A Ser. Delivery Check One Block Grant Funding B C D E F G H I Required Local Matc Net' Se ry Cost NSIP Subsid Total Funding Projected HCCBG Units Projected Reimburse. Rate Projected HCCBG Clients Projected Total Units Direct JPurcq Access In -Home Other I Total Adult Day Care 67603 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 7511 75114 75114 997 75.3100 Adult Day Health 31279 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 3475 34754 34754 545 63.7600 Transportation-ADC 1009 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 112 1121 1121 747 1.50 Transportation -ADH 1009 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 112 1121 1121 747 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 \ \ \ \ \ \\ \ \ \ \ \ \\ 0 1 98882 2018 100900 11210 1 112110 1 0 112110 30361\\\\\\\\\\\\\\ 0 0 'Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC G Daily Care 33.07 40.00 Certification of required minimum local match availability. ��(y�t�L l.I'� O Transportation Required local match will be expended simultaneously uthorized Signature, Tit at Administrative 42.24 23.76 wi Block Grant Funding. ommu iq Se 'ce Vrod Net Ser. Cost Total 75.3100 63.7600 //�� ignature, County Finance Officer Signature, Chairm of Commi Sion Date Division of Aging and Adult Services Service Cost Computation Worksheet 3/99 Service Service Service Service Service Service Service Service Grand Admin. ADC ADH ADC ADH II. Line Item Expense Total Cost Transp Transp Staff Salary From Labor Distribution Schedule 1) Full -time Staff 199,524 35,516 101,797 50,453 9,167 2.591 2) Part-time staff (do not include Title V workers ) 49,670 13,000 18,720 7,280 8,003 2,667 A. Subtotal, Staff Salary 249,194 48,516 120,517 57,733 17,170 5,258 Fringe Benefits l /ill /lllllllll lllllllllllllll 111111! /1111111 lllllllllllllll Il111111111!lll lllllllllllllll lllllllllllllll lllllllllllllll llllllllll /l!ll lllllllllllllll 1) FICA @ % 19,063 3,711 9,220 4,417 1,314 402 2) Health Ins. Retirement and other benefits 41,324 41,324 41,324 41,324 41,324 41,324 3) Retirement 4) Unemployment Insurance 5) Worker's Compensation 6) Other B. Subtotal, Fringe Benefits 60,387 45,035 50,544 45,741 42,638 41,726 Local In -Kind Resources Non -Match / / // / / / / // / / /// / / / / / / / / / / / / /// /! / / / / / / / / / / /// /11/!////////!/ / / /! /! / / /! / / /// / / / / / / /! / / / / /// /1/111//1!///// / / / / / / / / / / / / /// / / / / / / / / / / / / /// 1//////////!/// 1) 2 3) C. Subtotal, Local In -Kind Resources Non -Match D. OAA Title V Worker Wages, Fringe Benefits and Costs Travel I / / / // / // / / /// / / / / / / // / // /1 // / / / / / / / / / / / / /// !1 /! / / /! / / / / /// / / / / / / / / /I / / /// /1//////1//!1// 1) Per Diem 2) Mileage Reimbursement 3) Other Travel Cost E. Subtotal, Travel General Operating Expenses / / / / /I / / / / / / /I/ / / / / / / / / / / /I /// / / / / / / / / / / / / /// / / / / / / / / / / / / /!/ / / / / / / / / / / / / /I/ 11HIIIIIIII/!/ 1) Gas and Van Maint. 13,763 9,221 4,542 2) Nursing Supplies 3001 2011 99 3) Meals, Snacks and Supplies 44,446 29,779 14,667 4) Activity Supplies 1,980 1,327 653 5) Admin expenses and supplies, commercial insurance 12,758 40,200 8,548 4,210 6) Facility and Utilites 62,943 42,172 20,771 7) Marketing and Information Systems 4,808 3,221 1,587 8 Depreciation and Interest 48,300 32,361 15,939 F. Subtotal, General Operating Expenses 189,298 40,200 126,830 621,11,468 G. Subtotal, Other Administrative Cost Not Allocated /illlll /lI/ /ill /ll /Il/llllllll llllllllll11 /11 l /Illlllll /ll // llllllllll /1111 llllllll /ill /l/ lllllllllllllll lllllllllll /ill ll /I /llllllllll I /ll /llllllllll in Lines ILA through E lllllllllllllll lllllllllllllll I /Il /lIllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll 11 /llllllll /Ill lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll H. Total Proj. Expenses Prior to Admin. Distribution 498,879 133,751 297,890 165,942 59,808 9841 1 North Carolina Division of Aging and Adult Services Service Cost Computation Worksheet c:mudgen732A- 1b1n.as DAAS -732A Provider: 2/16 County: Budget Period: through Revision _yes, _no, revision date Service Service Service Service Service Service Service Service Grand I. Projected Revenues Total A. Fed /State Funding From the Division ofAging 100,900 Required Minimum Match - Cash ll / /l / /l /lllllll lllllllllll /lll lllllllllllllll lllllllllllllll Illlll /llllllll l /l / /l / / /l /!l /! lI / // / / / /l / /l /l lllllllllllllll lllllllllllllll lllllllllllllll 1) HCCBG 10% 11,210 / / / /I / / / / / / / /// 7,511 3,699 2 /llllllllllllll 3 Total Required Minimum Match - Cash 11,210 / / /I! / / / / / / / /1/ 7,511 3,699 Required Minimum Match - In -Kind 1) IlIIIIIIIIIIIII 2) lllllllllllllll 3 Total Required Minimum Match - In -Kind B. Total Required Minimum Match (cash + in-kind) C. Subtotal, Fed /State /Required Match Revenues 112,110 / / / / / / / / / / / / /// 75,114 36,996 D. NSIP Cash Subsidy/Commodity Subsidy/Commodity Valuation E. OAA Title V Worker Wages, Fringe Benefits and Costs Local Cash, Non -Match 1 Public Funding (City & Count) 40,385 / / / / / / / / / / / / /// 27,058 13,327 2) Donations, Rent, Misc 45,400 / / / / / / / / / / / / /// 30,418 14,982 3) 4) F. Subtotal, Local Cash, Non -Match 85,785 / / / / / / / / / / / / /// 57,476 28,309 Other Revenues, Non -Match lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll !!////! 11111 -11 lllllllllllllll ////!//////!/!/ lllllllllllllll lllllllllllllll 1) Private Pay 157,758 / / / /! / / / / / / / /// 105,698 52,060 2) DSS 126,828 / / / / /! / / / / / / /// 84,975 41,853 3) CAP 52,544 / / / / / / / / / / / / /// 35,204 17,340 4) VA 27,0821/1///1///////// 18,145 8,937 5) Family Caregiver Grant 1,200 / / / / / / / / / / / /I // 804 396 G. Subtotal, Other Revenues, Non -Match 365,412 /! / / / / / /! / / / /// 244,826 120,586 Local In -Kind Resources (Includes Volunteer Resources) 1) 2) lllllllllllllll 3) lllllllllllllll H. Subtotal, Local In kind Resources, Non -Match I. Client Cost Sharing 0 J. Total Projected Revenues (Sum I C,D,E,F,G,H, & 1) 1 563,3071/////////////// 1 377,4161 185,891 i. Utstrtbution of Cost Computation Worksheet 3/99 Service Service Service Service Service Service Service Service Grand 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 (DAAS -732A) corresponds with stated on the Provider Services Summary as follows: DAAS -732A DAAS -732 Block Grant Funding Line LA Col. A Required Local Match -Cash & In -Kind Line I.B Col. B Net Service Cost Line LC Col. C NSIP 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.6.5 Col. G Projected Total Service Units Line III.F Col. I NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - ATTACHMENT A LABOR DISTRIBUTION SCHEDULE DOA -732A1 1/98 AGENCY NAME_ :Elderhaus, Inc. FY: 2017 -2018 SFY - - STAFF NAME POSITION FULL TIME PART TIME TOTAL SALARY ADMIN. SALARY Adult Day Care Adult Day Health ADC Tranportation ADH Transportation SERVICE SERVICE SERVICE SERVICE Fox Program Director Full Time 33,280 16,640 11,149 5,491 _ Whitley RN Part Time 26,000 13,000 10,010 2,990 James Receptionist Full Time 18,876 18,876 Cook C N A Full Time 23,400 15,678 7,722 Smith Driver Part Time 10,670 8,003 2,667 McCullough C N A Part Time Full Time Full Time 13,000 8,710 4,290 McLaurin C N A /driver 25,168 12,584 6,286 4,908 1,390 Porter C N A /driver 21,840 10,920 5,460 4,259 1,201 Hankins C N A Full Time 23,400 15,678 7,722 Stevens C N A Full Time 29,120 19,413 9,707 Moss C N A Full Time 24,440 16,375 8,065 SUBTOTAL FT: $199,524 1 $35,516 $101,797 $50,453 $9,167 $2,591 $0 $0 $0 $0 _ SUBTOTAL PT: 49,670 13,000 18,720 7,280 8,003 2,667 0 0 0 0 TOTAL $249,194 $48,516 $120,517 $57,733 $17,170 $5,258 $0 $0 $0 $0 PERCENT FT: 80.07% 73.20% 84.47% 87.39% 53.39% 49.28% #DIV /0! #DIV /0! #DIV /0! #DIV /0! PERCENT PT: 19.93%1 26.80% 15.53% 12.61% 46.61% 50.72% #DIV /0! #DIV /01 #DIV /0! #DIV /0! Page 1 DAAS -733 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan July 1, 2017 through June 30, 2018 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 Elderhaus, 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. Elderhaus' website translates into 15 languages and brochures for services are available online Attached is a brochure for services provided. ELDERHAUS PROGRAM GOALS To provide a professional and appropriate level of care to enable individuals to remain in the community and home setting. To provide supervision, restorative services, therapeutic recreation and socialization to enhance well being. To promote each participant's sense of well -being and optimal level of function in daily living. To provide respite forfamily members from their constant caring roles. To provide an opportunity for family and caregivers to be gainfully employed during the day. h� FOR MORE INFORMATION To obtain additional information about services or program fees, hours of operation and other services, visit our website: www.elderhaus.com or call us at (910) 251 -0660 Hours: Monday - Friday 7:30 - 5:30 _ o f`.� 3 3 n, ' 3 � ry 9 o s s Z Q n N � a O t `�-�),U TOTAL SENIOR CARE 3 ADULT DAY HEALTH CENTER 1950 Amphitheater Drive Wilmington, NC Serving adult citizens of New Hanover, Pender & Brunswick Counties ADULT DAY ENRICHMENT PROGRAM The Adult Day Care program is designed to provide qualified and caring supervision as well as socialization services to adults. ADHC also provides respite or relief for those acting as caregivers in the home setting. PROGRAM SERVICES • Exercise and walking groups • Educational programs • Arts and crafts • Discussion groups • Field trips • Religious programs • Community projects • Special events WHO IS ELIGIBLE? Anyone who is: • 18 years or older • Able to meet basic human needs without constant assistance • Not in need of nursing supervision • Ambulatory or semi - ambulatory y c � 11 T � V ADULT DAY HEALTH PROGRAM The Adult Day Health Program is designed for physically or mentally challenged, frail or at -risk adults. PROGRAM SERVICES In addition to those listed, Adult Day Health provides: • Licensed nurse on duty • Ongoing health monitoring of vital signs, weight control, general nutrition, dental health, and personal hygiene • Medication administration • Assistance with personal care such as feeding, ambulation and toileting • Selected treatments with physician order and minor first aid • Health education /wellness promotion to participants and families • Interagency referrals for specialized services as required by a physician and available in the community WHO IS ELIGIBLE? Anyone who is: • 18 years or older • In need of nursing care and supervision in order to maximize their independence • In need of return to an optimal level of functioning following an acute illness �E. ADDITIONAL AMENITIES • Health and wellness center /exercise program • Fully catered lunch (including special diets) • Field trips • Walking club • Patio overlooking Greenfield Lake • Craft Instruction • Musical program • Spiritual program • Community voluteer opportunities • Approved site for veterans by Veterans Administration • Transportation provided with wheelchair lift- equipped van • Secure environmentwith WiFi FUNDING OPTIONS Include private pay or Long Term Care insurance, Veterans Administration, Government Assistance Programs .w for qualified participants. 1 A f' 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. 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 Security. Per the requirements in I OA 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. Signature) (Date) NAME AND ADDRESS Home and Community Care Block Grant for Older Adults COMMUNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16) Interim Healthcare of the Eastern Carolinas, Inc. County Funding Plan County New Hanover PO Box 2249 July 1, 2017 through June 30, 2018 Whiteville, NC 28472 Provider Services Summary IREVISION 8 , DATE: 08/052017 A B C D E F G H 1 Services Se, Dd,,,p Block Grant Funding Required Local Matc Net- Sery Cost NSIP Subsidy Total Funding Projected HCCBG Units Projected Reimburse Rate Projected HCCBG Clients Projected Total Units (Ch «k one) Dirca Pumh. Access In -Home Other Total In -Home Aide Lev 1 12000 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 1333 13333 13333 785 16.9851 10 785 In -Home Aide Lev 2 88003 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 9778 97781 97781 5666 17.2575 20 5666 In -Home Aide Lev 3 114000 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 1 12667 126667 126667 1 7259 17.4496 25 7259 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \1 \ \ \ \ \1 \ \ \ \\ 0 0 0 \ \ \ \ \ % \ \ \ % \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \1 \ \\ 0 0 0 0 0 0 0 0 0 \\\\%W\\\%\\\ 0 0 0 o\\\\\\\\\\\\ 0 0 0 0 0 0 Total AAAAAAA AAAAAAA 0 214003 0 214003 23778 237781 0 237781 13710 AAAAAAA %AAAA 55 13710 'Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC o Daily Care Certification of required minimum local match availability. Ciro Transportation Required local match will be expended simultaneously Authori ze Signature, Title Date Net Sec. Cost Total Administrative with Block Grant Funding. �Chaia�5`MfCcmonnission d Signature, County Finance Officer Date Signat, ate North Carolina Division of Aging and Adult Services Service Cost Computation Worksheet c:732A.xls Provider: Interim HealthCare of the Eastern Carolinas, Inc. County: New Hanover Budget Period: July 1, 2017 through June 30, 2018 Revision _yes, X no, revision date DOA -732A 3/99 Service Service Service Service Service Service Service Service Grand IHA IHA IHA Total Level Level Level 1 0 2 0 3 0 Total Required Minimum Match - Cash 23,778 / / / / / / / / / / / / /// 1,333 9,778 12,667 0 0 0 0 0 Required Minimum Match - In -Kind lllllllll/llll/l lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll /ll/lll/ll/llll lllllllllllllll lllllllllllllll llllll /llllllll 1 2 0 3 0 Total Required Minimum Match - In -Kind 0 / / / / / / / / / / / / /// 1 0 01 0 01 0 0 0 0 B. Total Required Minimum Match cash + in -kind) 23,778 / / / / / / / / / / / / /// 1,333 9,778 12,667 0 0 01 0 0 C. Subtotal, Fed /State /Required Match Revenues 237,781 f / / / / / / / / / / / /// 13,333 97,781 126,667 0 0 0 0 0 D. NSIP Cash Subsidy/Commodity Subsidy/Commodity Valuation 0 E. OAA Title V Worker Wages, Fringe Benefits and Costs 0 Local Cash, Non -Match 1) 0 2 0 3 0 4 0 F. Subtotal, Local Cash, Non -Match 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 0 0 Other Revenues, Non -Match lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll 1 0 2) 0 3 0 G. Subtotal, Other Revenues, Non -Match 0 / / / / / / / / /I / / /// 0 0 0 0 0 0 0 0 Local In -Kind Resources (Includes Volunteer Resources ) /////////!///// 1 0 2) 0 /////////////// 3) 0 H. Subtotal, Local In -kind Resources, Non -Match 0 / / / / / / / / / / / / /// 0 0 0 0 0 01 0 0 I. Client Cost Sharing 0 / / / / / / / / / / /! /// v. =ro /ecaeu Revenues lawn . a.,v,c,r,u,n, ..I 1 Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. IHA IHA IHA II. Line Item Expense Total Cost Level 1 Level 2 Level 3 Staff Salary From Labor Distribution Schedule 1 Full -time Staff 87,138 53,466 7,091 12,111 14,470 2) Part-time staff do not include Title V workers 95,699 8,880 32,590 54,229 A. Subtotal, Staff Salary 182,837 53,466 15,971 44,701 68,699 0 0 0 0 0 Fringe Benefits /ll / /l / /l1!llll !ll / /l /!ll /l1ll lllllllllllllll ll /l / /l /!l / /lll lllllllllllll /l 1 /lllllllllllll 111111111111111 /lllllllllllll/ lllllllllllllll 1111 //!/!//1/11 1 FICA @ 7.65 % 13,987 4,090 1,222 3,420 5,255 2 Health Ins. @ 0 3 Retirement @ 0 4 Unemployment Insurance -SUTA .720% 1,316 385 115 322 495 5 Worker's Compensation @ 7% 12,799 3,743 1,118 3,129 4,809 6 Other - FUTA @ 0.8% 146 43 13 36 55 B. Subtotal, Fringe Benefits 28,248 6,260 2,468 6,906 10,614 0 0 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 0 3 Other Travel Cost: 0 E. Subtotal, Travel 0 0 0 0 0 0 0 0 0 0 General Operating Expenses lllllllllllllll lllllllllllllll lllllllllllllll !l /l /ll1l! /ll /l ll!ll /llllllll! lllllllllllllll lllllllllllllll lllllllllllllll /llllllllll /lll lllllllllllllll 1 Management Information Systems 98 101 36 52 2 equipment depreciation / depreciation 1,741 157 348 1,236 3 rent/lease 4,304 387 861 3,056 4 insurances 11,148 397 1,045 9,706 5 consumable supplies 3,556 812 1,073 1,671 6 RN Supervision 3,300 700 1,100 1,500 7) utilities -computers, phones 2,549 300 667 1,582 8 0 F. Subtotal, General Operating Expenses 26,696 0 2,763 5,130 18,803 0 0 0 0 0 G. Subtotal, Other Administrative Cost Not Allocated llllll/ll/Il/// lllllll /lllllll lllllll /lllllll llllllll /I /Ill/ / /!llllllll /Ill 111 / / / /l// / /I /I /I///////////ll / /I / /I / / / / / / //I / /lllllllllllll llllll /llllllll in Lines ILA through F lllllllllllllll lllllllllllllll lllllllllllll/ lllllllllllllll lllllllllllllll lllllllllllllll IlIIIIIIIIIIIII /lllllllllllll) lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll H. Total Pro j. Expenses Prior to Admin. Distribution 237,781 61,726 21,202 56,737 98,116 0 0 0 0 0 I. Distribution of Admininistrative Cost 1111 /111111/lll - 61,726 -7,868 41,044 28,551 01 01 01 01 0 J. Total Pro'. Expenses After Admin. Distribution 237,781 / / / / / / / / / / / / /// 13,333 97,7811 126,6671 01 01 01 01 0 Division of Aging and Adult Services Col. B Line LC Col. C Line I.D Col. D Service Cost Computation Worksheet Col. E Line III.0 Col. F Line III.6.5 Col. G Line III.F Col. I Service Service Service Service Service Service Service Service Grand IHA IHA IHA III. Computation of Rates Total Level 1 Level 2 Level 3 A. Computation of Unit Cost Rate: 1. Total Expenses (equals line II.J) 237,781 / / / / / / / / / / / / /// 13,333 97,781 126,667 0 0 0 0 0 2. Total Projected Units / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 785 5,666 7,259 3. Total Unit Cost Rate / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 16.9851 17.2575 17.4496 #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! B. Computation of Reimbursement Rate: / / / / / / / / / / / / / /// llllllllllllllll llllllllllllllll llllllllllllllll llllllllllllllll / / / / / / / / / / / / / /// llllllllllllllll llllllllllllllll llllllllllllllll / / / / / / / / / / / / /// 1. Total Revenues (equals line I.J) 237,781,/////////////// 13,333 97,781 126,667 0 0 0 0 0 2. Less: NSIP (equals line I.D) 0 /////////////// 0 0 0 0 0 0 0 0 Title V (equals line LE and II.D) 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 0 0 Non Match In -Kind (equals line I.H and II.C) 0 / / / / /! / / / / / / /// 0 0 0 0 0 0 0 0 3. Revenues Subject to Unit Reimbursement 237,781 / / / / / / / / / / / / /// 13,333 97,781 126,667 0 0 0 0 0 4. Total Projected Units (equals line III.A.2) /! / / / / / / / / / / /// / / / / / / / / / / / / /// 785 5,666 7,259 0 0 0 0 0 5. Total Reimbursement Rate / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 16.9851 17.2575 17.4496 #DIV /O! #DIV /O! #DIV /01 #DIV /0! #DIV /0! C. Units Reimbursed Through HCCBG / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 785 5,666 7,259 #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! D. Units Reimbursed Through Program Income" / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 0 0 0 #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! E. Units Reimbursed Through Remaining Revenues / / / / / / / / / / / / / /// / / / / / / / / / / / / /// 0 0 0 #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! F. Total Units Reim bu rsed/Tota I Projected Units / / / / /! / / / / / / / /// / / / / / / / / / / / / /// 785 5,666 7,259 #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! 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. Information on this form (DOA -732A) corresponds with information stated on the Provider Services Summary (DOA -732) as follows: DOA -732A DOA -732 Block Grant Funding Line LA Col. A Required Local Match -Cash & In -Kind Net Service Cost USDA Subsidy Total Funding Projected HCCBG Reimbursed Units Total Reimbursement Rate Projected Total Service Units Line I.B Col. B Line LC Col. C Line I.D Col. D L. I.0 +I.D Col. E Line III.0 Col. F Line III.6.5 Col. G Line III.F Col. I NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - ATTACHMENT A LABOR DISTRIBUTION SCHEDULE DAAS -732A 1 2/_16 AGENCY NAME: Interim Healthcare of the Eastern Carolinas, Inc -- - -- - -- FY: 2018 SFY 2018 - -- - STAFF NAME POSITION FULL TIME PART TIME TOTAL ADMIN. SALARY SALARY IHA Level 1 IHA Level 2 IHA Level 3 SERVICE SERVICE SERVICE SERVICE SERVICE Registered Nurse RN 'FULL TIME 43,732 $17,873 $7,091 $12,111 $14,470 Scheduler Scheduler FULL TIME 16,279 10,093 618 21288 3,280 Data Et /Pa roll DE /PR FULL TIME 12,077 11,353 72 268 384 ry Y_ Billing Clerk Billing Clerk FULL TIME 15,050 14,147 90 334 479 In -Home Aide 1HA PART TIME 95,699 8,880 32,590 54,229 I SUBTOTAL FT: $87,138 $53,4.66 95,699 0 $7,871 $15,001 8,880 32,590 $18,613 $0 $0 $0 $0 $0 0 0 0 SUBTOTAL PT: 54,229 0 0 TOTAL $182,837 $53,466 $16,751 $47,591 $72,842 $0 $0 $0 $0 $0 #DIV /0! PERCENT FT: 47.66% 100.00% 46.99 %i 31.52%1 25.55% 0.00% 53.01% 68.48% 74.45% #DIV /0! #DIV /0! #DIV /0! #DIV /0! _ PERCENT PT: 52.34% #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! Page 1 Supplement to Provider Services Summary Interim Healthcare of the Eastern Carolinas, Inc, In -Home Services Detail Name of Community Service Provider DAAS -732 Supplement (Effective: 7/08) July 1, 2017 through June 30, 2018 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 Leven - 235 Respite 0 0 Level I - 041 H Mgmt 12000 1333 13333 785 10 Subtotal Level 1 12000 1333 13333 785 10 Level II - 236 Respite 0 0 Level II - 042 PC 88003 9778 97781 5666 20 Level II - 043 H Mgmt 0 0 Subtotal Level 11 88003 9778 97781 5666 20 Level III - 237 Respite 0 0 Level III - 044 H Mgmt 0 0 Level III -045 PC 114000 12667 126667 7259 25 Subtotal Level H] 114000 12667 126667 7259 25 Level IV - 238 Respite 0 0 Level IV - 046 H Mgmt 0 0 Subtotal Level IV 0 0 0 0 0 Total 214003 23778 237781 13710 !oI ?--7-17 Title Date Community Service Provider DAAS -733 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County Funding Plan July 1, 2017 through June 30, 2018 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: 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. 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 Shoemake COO Signature: Date: (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. DAAS -734 (revised 2/16) July 1, 2017 through June 30, 2018 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 (Name of Provider) and 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 htti)://www.ncdhhs.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). 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 2/16) 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 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 Security. 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.pov/ 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. 0 Signature) (Date)