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FY18 HCCBG INTERIM REVISED FUNDING PLANNAME AND ADDRESS Home and Community Care Black Grant for Older Adults COMMUNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16) Interim Healthcare ofthe Eastern Curcliass, Inc, County Funding Plan County New Hanover PO Box 2249 July 1, 2017 through June 30, 2018 Whiteville, NC 28472 Provider Services Summary REVISION p 1 , DATE: 02/2612018 A B C D E F G H I sa . Ddrvry Projected Projec¢d Projected Projected Mheck I Block Glint Fundin Required Net• NSIP Total HCCB(i eimbmse HCCBG Total nirtn Pmvn. Anus 1n -Home Other Total Setvioes Lo®I Matd Saw Cost Subsidy Fundin Uaits Rater Clients Units In -Home Aide Lev 1 19000 \\ \ \ \ \ \ \ \ \ \1W1 \\ 2111 21111 211 ❑ 1243 16.9851 10 1243 to,Home Aide 1- 2 78003 \\\\\\\\\\\\\\\1\ 8667 86670 86670 5022 17.2575 20 5022 m "Home Aide Lev 3 117000 \0 \11 \ \ \ \1l \\ \1 \l 13000 130000 130000 7450 17.4496 25 7450 11 \ \1 \ \1 \ \ \ \l1 \ \R 0 0 0 \ \1 \ \ \l \1 \ \1 \ \ \ \ \\ 0 0 0 0 0 0 \1l\l \1 \ \ \ \1 \ \A1 0 0 p \R\\\\\\\\\\\\\\\ 0 0 0 % \\\\\AAAk\\\ 0 0 0 \\\\\\\\\\\\\q\\\ 0 0 0 \\\\\\\\\\\\MM 0 0 01 1 % \\\\\\\\\\\\\\\ 0 0 p \\l \ \ \ % \11\\\\\\ 0 0 p H \ \M \ %\ \AA\ 0 0 0 Total 1 \ \1 \l\ \\l\\\\ 01 214003 0 214003 23778 237781 0 237781 13715 \ \ \ \ \ \11 \111 \\ 55 13715 'Adult Day Care & Adult Day Health Caro Net Service Cost ADC ADHC l Daily Care Certification of required minimum local match availability. Transpottmton Requned local much svi8 he eapmded simultaneously Authorized Signatme, Title Administrative with Block Gant Funding. Community Service Net Set. Cost Total (� Sigoenhre, County Finance Officer Date Signanue, Chairmen, Board ofConmisu 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, 018 Revision # 1. dated: 02/26/2018 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 Level I - 235 Respite 0 0 Level l -041 H Mgmt 19000 1 2111 21111 1 1243 1 10 Subtotal Level 19000 2111 21111 1243 10 Level II - 236 Respite 0 0 Level II - 042 PC 78003 8667 86670 5022 20 Level II -043 H Mgmt 0 0 Subtotal Level 11 78003 8667 86670 5022 20 Level III - 237 Respite 0 D Level III - 044 H Mgmt 0 0 Level III - 045 PC 117000 13000 130000 7450 25 Subtotal Level Ill 117000 13000 130000 7450 25 Level IV - 238 Res pit 0 0 Level IV - 046 H Mgmt 0 0 Subtotal Level IV 0 0 0 0 0 Total 214003 23778 237781 13715 L'Vc� � -, Authorized Signature Community Service Provider bu *tK Title Date ,. n Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. IHA IHA IHA 11. Line Item ense Total Cost Level 1 Level 2 Level 3 Start Sala From Labor Distribution Schedule !l / /l / /!l /l /l!l llllll //llllll! /till/! //llllll l /llllll// Illllllll////// /Ill /I /Il /l /!l! lfllllll /111 //l Illll!/ ///till/ //llllll /l / / /l/ till /l! /Illllll 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 63 466 15,971 44,701 68,699 0 0 O 0 0 Frio a f3enefrts / /l /! /!l /llllll llll /ll //llllll /till //llllll /I 71- ful/!/IJ/!ll !1 /I /1ll /ll /!ll //I/l/l1 / /1 /l /1 /1/ /I /l/l /Il 111 / /1/lJl1 /llllll lllll /ill /! / /l! /Illllll/ //!/Jl 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 1151 322 495 5) Workers Com nsation 7% 12,799 3,743 1,118 3,129 4809 6) Other -FUTA 0.8% 1461 43 13 36 55 B. Subtotal, Fringe Benefits 28,248 8,260 2,468 6,906 10,614 0 01 0 0 0 Local In -Kind Resources, Non -Match /llllll! /llllll /l /ll /l /ll1 /l /! llllll /l111lill I /ill! /11! / /l!1 !/llllll /!J!1 /l //llllAl/ll1!/ 11 /ill / /l! / /lN lllll/l/ll1/l!l 11l//lllllllll/ /ll / /l1 /lf /llll 1) 0 2 0 3) 0 C. Subtotal, Local In -Kind Resources Non -Match 0 D 0 0 0 0 D. OAA Title V Worker Wages, Fringe Benefits and Costs 0 0 0 0 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 O ratio 6q�enses llllll /1/////// / / /1 /1 / / / / / /// /////////!///// 1 Management Information Systems gg 10 38 52 2 uipment depreciation / depreciation 1 741 157 348 1 236 3 rent lease 4.304 387 861 3,056 4 insurances 11,148 397 1045 9,706 51 consumable sup lies 3,556 812 1,073 1.671 6 RN Supervision 3,300 7D0 1,100 1,500 7 utilities - com uters, ones 2,549 300 667 1.582 8) 0 F. Subtotal, General Operating Expenses 28898 0 2,763 5,130 18jw O 0 0 0 0 G. Subtotal, Other Administrative Cost Not Allocated /l1/Illl!/ll!ll 111 /I /fl /Il /!ll / /1111!/1/ /l1/I Illlllllllllll! l!Il/Ifllf!lll! Illll/llllllll/ llll!llllll!lll l!I/llllllll!ll 1!lIlllll/lllll Illllll /l1 /fill in Lines ILA through F INIIl1111111ll llllllIIIIHllf mnNfuml I/IIIIIIIII1111 1111//(//Nllll llllllllllll!!1 !lI!l11lfllf /I! lIIl1/fl!/Il1l/ IM111 /1/ /111/ !lllll/f/l/lll! !lll!!1/llll!ll H. Total Proj. Expenses Prior to Admin. Distribution 237,781 61,726 21,202 56,737 98,116 0 01 01 0 0 I. Distribution of Admininistra0ve Cost //llllll /lfll /I - 61,726 -90 29,933 31,884 0 0 0 0 0 J. Total Proj. Expenses After Admin. Distribution 237,781 /111H 1l1/I /!I 21,111 68,870 130,000 0 0 0 0 0 • ;ion of Aging and Adult Services ice Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand IHA IHA IHA Total Level 1 1-19 1 Avoi a The Division of Aging ARMS deducts reported program income from reimbursement paid to providers. Line IILD indicates the number of units that will have to be produced in addition to those stated on line IILC 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 EA Col. A Required Local Match -Cash & In -Knd Line I.B Col. B Net Service Cost Lire I.0 Col. C USDA Subsidy Line I.D Col. D Total Funding L. I.C.I.D Col. E Projected HCCBG Reimbursed Units Line IILC Col. F Total Reimbursement Rate Line III.B.5 Col. G Projected Total Service Units Line HIT Col. I