FY18 HCCBG SRC AND INTERIM FUNDING PLAN ADJNAME 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 IREVISION t I , DATE: 6/19/2018
A
B
C
D
E
F
G
H
I
Services
Sec Decay
(Check0 -)
Block Grant Funding
Required
Local Match
Net*
Sery Cost
NSIP
Subsidy
Total
Funding
Projected
HCCBG
Units
Projected
Reimburse
Rate
Projected
HCCBG
Clients
Projected
Total
Units
Direct
Punch.
Access
In -Home
Other
Total
I&R Case Assistance
x
180093
11 \ \ \UI\\111\NI\
20010
200103
200103
2150
Congregate Nutrition
x
84940
11 \ \I \II \ \I \ \ \I \I
9438
94378
11812
106190
10442
8.86
485
16200
HDM Nutrition
Ix
x
323040
1 \ \I \\\11\11\11\1\
35893
358933
64687
423620
59781
5.97
590
82250
Sr. Center Ops
34395
\\II \ \II \II \ \I \ \II
3822
38217
38217
Transportation - General
x
23000
\AAA\\\AAA \\
2556
25556
25556
2716
9.41
125
8750
Transportation - Medical
x
59052
\ \A \ \AA \ \I\\ \A
6561
65613
65613
4719
13.9
210
8750
\11111 \111 \\11111
0
0
0
1\1 \AA\ 1111111
0
0
0
1 \\\ \\\1111 \\11111
0
0
0
\\\\11N11111U111
0
0
0
N1 \1111111\1\1111
0
0
0
111111\\ \ \ \\1 \\111
0
0
0
\ %AAI\\1\\ \111
0
0
0
11111111 \\1111111\
0
0
0
T
\\I \ \I\
262145 1
0
442375
704520
78280 1
782800 1
76499
859299
77658
\I\NUI\\N\
3560
115950
*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 wilibe expended simultaneously Avr-fFM. Finder, Deputy County Manager Date
Administrative with Block Grant Funding. Community Service Provider
Net Ser. Cost Total
moo, �� cola���� 6.11.18
Lisa Wurtzbacher, County Finance Officer Date Chmrman, Woody-White Date
AND ADDRESS Home and Community Care Block Grant for Older Adults
UNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16)
Healtheareofthe Eastern Carolinas, Inc. County Funding Plan County New Hanover
.2249 July 1, 2017 through June 30, 2018
ills, NC 28472 Provider Services Summary JREVISION#2 , DATE: 06/152018
A
ser
[)truer Pmrfi. Access In -Home
Aide Lev 1 15764
Aide Lev 2 78003
Aide Lev 3 113769
total
1�'ai�,P,luyN.l� I (
'Adult Day Care & Adult Day Health Care Net Service Cost
H
Projected
HCCBG
ADC ADHC
Daily Care
Units
1031
Transportation
Clients
10
Administrative
86670
Net Ser. Cost Total
17.2575
Certification of required minimum local match availability .
Required local match will be expended simultaneously
with Block Grant Funding.
Je. �6 -- �0b-,I�'�
Signature, County Finance ORcepr Date
4�� 1�u6 }Zl'Z "sr
E
Total
F
Projected
HCCBG
G
Projected
Remburse
H
Projected
HCCBG
Projected
Total
undin8
17516
Units
1031
Rate
16.9851
Clients
10
Units
1031
86670
5022
17.2575
20
5022
126410
7244
17.4496
25
7244
0
0
0
0
0
0
0
0
0
0
0 230596 13297 T7",d�t``. 55 13297
Authorized Signature. Tit,) � „ . " Date
Communiq Service Provider
Signature. Chairman, Board \\of Comj�m.,is umcrs Date
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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
/ / / / / / / / / / / / ///
I / / /1 / / / / / / / ///
/ / / / / / / / / / / / ///
/ / / / / / / / / / / / ///
/ / / / / / / / // / / ///
/ / / / / / / / / / / / ///
/ / /1 / / / / / / / / ///
/ / / / / / / / / / / / ///
/ / // / / / / / / / / ///
1 Full -time Staff
666,828
288,276
67,634
198,246
50,332
19,670
42,670
2) Part-time staff (do not include Title V workers )
93,979
28,366
31,477
34,136
A. Subtotal, Staff Salary
760,807
0
288,276
96,000
229,723
50,332
53,806
42,670
0
0
Fringe Benefits (included in salary)
1) FICA @ %
0
2 Health Ins. @
0
3) Retirement @
0
4 Unemployment Insurance
01
1
5 Workers 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
/ / / / / / / / / / / / ///
!!/!/11//! / / ///
/ / / / / / / / / / / / ///
/ / / / / / / / / / / / ///
/ / / / / / / / / / / / ///
/ / / / / / / / / / / / ///
/ // / / / / / / / / / ///
1/1/1/!!1/!1 ///
1 Contract Services -ARMS MIS fee
2,009
0
350
639
0
350
670
2) Contract Services (vendors)
421,202
0
56,252
288,450
0
25,500
51,000
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) Su lies -Gas
5,820
0
0
3,900
0 1
11 HDM Volunteer Mileage Reimbusment
27,260
0
0
27,260
01
0
0
12) Training and Travel
$,950
1,400
100
500
1,650
150
150
13 Employee Mileage Reimbursment
3,785
3,000
25
430
250
40
40
F. Subtotal, General Operating Expenses 1
500,4341
0
5,966
61,027
327,753
24,920
28,536
52,232
0
0
G. Subtotal, Other Administrative Cost Not Allocated
/ / / / / / // / / / / ///
/I /! / / /I / /I /!I/
/ /! / / / / / / / / / ///
/ / / / / / / / / /I / ///
/ / / / / / / / / / / / ///
I /! / / / / // / / / ///
/ / / / / / / /I / / / ///
I / / / / / / / / / / / ///
/ / / / /I /I / / / /I /I
/1 /! //// / / / /! //
Cost Computation Worksheet
Service Service Service Service Service Service Service Service
Grand Casr Asst Cong HDM Senior
of Rates Total I &R Nutrition Center
" 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 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 1.6
Col. B
Net Service Cost
Line LC
Col. C
NSIP Subsidy
Line I.D
Col. D
Total Funding
L. I.0 +I.D
Col. E
Projected HCCBG Reimbursed Units
Line III.0
Col. F
Total Reimbursement Rate
Line 111.6.5
Col. G
Projected Total Service Units
Line III.F
Col. 1
3