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Home My WebLink AboutFY19 SRC HCCBG Funding PlanDAAS -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, 2018 through June 30, 2019 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 Aut iorized signature (date) Avril M. Pinder, Deputy County Manager (Type name and title of signatory agent) New Hanover County Home & Community Care Block Grant Allocation SFY 2018/2019 August 6, 2018 Minimum Minimum Minimum Budget Budget Budget Total Requirement Requirement Requirement Allocation Access In -Home Congregate SFY 2019 Local Plus Local 30% 25% 33% COUNTY /REGION HCCBG Match Match New Hanover $1,133,082 $125,898 $1,258,980 $53,079 $44,233 $61,727 August 6, 2018 DAAS -731 (Rev. 2/16) Home and Community Care Block Grant for Older Adults County New Hanover_ County Funding Plan July 1, 2018 through June 30, 2019 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 Fundino Projected HCCBG Units Projected Reimbursemen Rate Projected HCCBG Clients Projected Total Units Access In -Home Other Total I &A Case Assist 185093 \ \ \ \ \ \ \ \ \ \ \\ 20566 205659 205659 2200 2450 Congregate 106899 \A \ \ \ \ \ \% 11878 118777 118777 14483 8.2 515 19880 HDM Nutrition 340541 \\\ \ \\ \ % \\ 37838 378379 378379 66382 5.57 682 89716 Sr. Center O s 86095 \ \ \ \ \ \ \ \ \ \ \\ 9566 95661 95661 330 Trans.- General 29800 \ \ \ \ \ \ \ \ \ \ \\ 3311 33111 33111 2838 11.66 134 7940 Trans: Medical 60251 \ \ \ \ \ \ \ \ \ \ \\ 6695 66946 66946 5287 14.24 235 7335 Adult Day Care 1 69195 \ \ \ \ \ \ \ \ \ \ \\ 7688 76883 76883 1199 64.12 32 1202 Adult Day Health 34081 \ \ \ \ \ \ \ \ \ \ \\ 3787 37868 37868 542 69.85 8 545 Trans. - ADC 944 \ \ \ \ \ \ \ \ \ \ \\ 105 1049 1049 700 1.5 11 733 Trans. -ADH 180 \ \ \ \ \ \ \ \ \ \ \\ 20 200 200 133 1.5 3 166 In Home Aide 1 18000 \ \ \ \ \ \ \ \ \ \ \\ 2000 20000 20000 1178 16.9851 15 1178 In Home Aide II 82000 \ \ \ \\\ \\ \ \ \\ 9111 91111 91111 5280 17.2575 25 5280 In Home Aide III 120003 \ \ \\U\\\\\\ 13334 133337 133337 7641 17.4496 30 7641 \ \ \ \ \ % \ \ \\ 0 0 0 Total 275144 323279 534659 1133082 1 125898 1258981 0 1258981 105663 \ \ \ \ \ \ \ \ \ \ \ \ \\ 4220 1 144066 Woody White, hai an, Board of Commissione Date F NAME AND ADDRESS Home and Community Care Block Grant for Older Adults COMMUNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16) NHC Senior Resouce Center County Funding Plan County_New Hanover 2222 S. College Rd. July 11 2018 through June 30, 2019 Wilmington, NC 28409 Provider Services Summary REVISION # 1 , DATE: 10/19/2018 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 HCCSG Units Projected Reimburse Rate Projected HCCBG Clients Projected Total Units Daed Porch. Access In -Home Other Total I &A Case Assistance x 185093 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 20566 205659 205659 2200 Congregate Nutrition x 106899 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 11878 118777 118777 14483 8.2 515 19880 HDM Nutrition x 340541 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 37838 378379 378379 66382 5.57 682 89716 Sr. Center Ops x 86095 VAAAAAAAAAAAAAAAAA 9566 95661 95661 330 Transportation General x 29800 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 3311 33111 33111 2838 11.66 134 7940 Trans rtation Medical 60251 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 6695 66946 66946 5287 14.24 235 7335 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 1 01 1 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total AAAAAAA AAAAAAA 275144 0 533535 808679 89854 898533 0 898533 88990 AAAAAAAAAAAAAA 4096 124871 *Adult Day Care & Adult Day Health Care Net Service Cost ADC ADHC Daily Care Certification of required minimum kcal match availability. 1 Z$ Transportation Required local match will he expended simultaneously Avril M. Pinder, Deputy County Manager Date Administrative with Block Grant Funding. Co uni S ice Provider Net Ser. Cost Total n�t7'(-, M It kilt � Lisa Wurtzbacheq County Finance O Acer Date Wendy %K, Chairman, Board of Co issio n Date North Carolina Division of Aging and Adult Services Service Cost Computation Worksheet C:732A.xls DAAS -732A Provider: Senior Resource Center 3/99 County: New Hanover Budget Period: July 1, 2018 through June 30, 2019 Revision _yes, _X_no, revision date Service Service Service Service Service Service Service Service Grand Case Asst Cong HDM Senior Transport Transport Adult Day IHA I. Projected Revenues Total I&A Nutrition Nutrition Center General Medical Care /Home A. Fed /State Funding From the Division of Aging 1,133,0821/////////////// 185,093 106,899 340,541 86,095 29,800 60,251 104,400 220,003 Required Minimum Match - Cash llllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll llllllllllllll lllllllllllllll llllllllllllll! !1!!1!11111111/ T111!!!1l11111l llllllllllllll 1 0 2 0 3 0 Total Required Minimum Match - Cash 125,899 / / / / / / / / / / / / /// 20,566 11,878 37,838 9,566 3,311 6,695 11,600 24,445 Required Minimum Match - In -Kind llllllllllllllll lllllllllllllll 1/111111111111/ lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll 1111/11/11/1117 lllllllllllllll lllllllllllllll 1 0 2 0 3 0 Total Required Minimum Match - In -Kind 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 01 0 B. Total Required Minimum Match cash + in -kind 125,899 / / / / / / / / / / / / /// 20,566 11,878 37,838 9,566 3,311 6,695 11,600 24,445 C. Subtotal, Fed/State/Required Match Revenues 1,258,981 / / / / / / / / / / / / /// 205,659 118,777 378,379 95,661 33,111 66,946 116,000 244,4411 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 County Contribution 457,039 / / / / / / / / / / / / /// 1 119,498 56,217 175,428 13,854 57,040 35,002 0 0 2 o uuulail!!1/ 3 0 4 0 F. Subtotal, Local Cash, Non -Match 457,039 / / / / / / / / / / / / /// 119,498 56,217 175,428 13,854 57,040 35,002 0 0 Other Revenues. Non -Match lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll llllllllllllll/ 111111111111111 1 0 2 0 /llllllllllllll 3 0 G. Subtotal, Other Revenues, Non -Match 0 / / / /I / / / / /1 / //I 01 0 01 0 01 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 0 0 jJ0 I. Client Cost Sharin 30,200 / / / / / / / / / / / / /// 3,200 22,000 2,500 2,500 J. Total Projected Revenues Sum I C,D,E,F,G,H, & I 1,746,220 / / / / /! / / / / / / /// 325,157 178,194 575,807 109,515 92,651 104,448 116,000 244,448 Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. I&A Cong HDM Sr. Center Trans Trans ADC IHA II. Line Item Expense Total Cost General Medical ADH Staff Salary From Labor Distribution Schedule 1 Full -time Staff 730,366 317,647 64,729 204,508 81,405 31,038 31,039 2 Part-time staff do not include Title V workers 108,382 35,755 31,647 30,276 10,704 A. Subtotal, Staff Salary 838,748 0 317,647 100,484 236,155 81,405 61,314 41,743 0 0 Fringe Benefits included in salary) 1 FICA @ % 0 2 Health Ins. 0 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 / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / /I / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// / / / / / / / / / / / / /// !!/1/1/1!!1/!/! 1 0 2 0 3 0 C. Subtotal, Local in -Kind Resources Non -Match 0 01 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 O erating Expenses 1 Contract Service - MIS fee 1,797 150 525 7221 0 200 200 2 Contract Services - vendors 461,327 0 68,800 299,650 2,600 28,877 61,400 3 Postage 1,250 150 50 50 400 1501 450 4 Printing Off Site 2,075 200 400 150 1,250 01 75 5 Printing - in house copies 5,895 780 980 915 2,900 100 220 6 Supplies 25,515 600 5,795 3,000 15,800 100 220 7 Dues and Subscriptions 1,030 0 180 225 625 0 0 8 M & R 5,050 0 150 2,500 2,350 25 25 9 Cell Phone Expense 2,480 1,080 180 540 360 320 0 10 Gas 3,550 0 01 2,100 0 1,450 0 11 Volunteer Mileage Reimbursement 28,850 0 0 28,850 0 0 0 12 Training and Travel 4,345 1,550 560 6351 1,450 75 75 13 Employee Reimursement (mileage) 3,860 3,000 90 315 375 40 40 F. Subtotal, General Operating Expenses 547,024 0 7,510 77,710 339,6521 28,110 31,337 62,705 0 0 G. Subtotal, Other Administrative Cost Not Allocated /ll /111///1 /ll/ I//I/I / /1//1111 llllllll /1111// ll/I/ /ll /ll /ll/ ll /ll /ll /11/11/ 111 /ll /1111111/ 111 /1/11111 /ll/ /ll /ll /ll /II /ll I/lll /1/111 / /I/ /I/I/llllll/ll/ in Lines ILA Service Cost Computation Worksheet 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 1.13 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. I NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - ATTACHMENT A LABOR DISTRIBUTION SCHEDULE DAAS -732A1 2/16 AGENCY NAME:j New Hanover County Senior Resource Center - FY: 2018 -2019 SFY 18 -19 -- - . -- 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 $50,730 $50,730 BRYANT, M Cong, Mgr. PART TIME 29,005 29,005 CANNY, B Social Worker FULL TIME 71,619 60,876 10,743 CONNER, E Nutrition Mgr. FULL TIME 78,616 39,308 39,308 DAVIS, S Activities Asst FULL TIME 52,905 52,905 DODSON, C Trans Coord FULL TIME 62,077 _ 31,038 31,039 GILL, K Vol Coordinatc FULL TRgE 57,185 57,185 HATTEN, V Case Worker FULL THAE 54,199 54,199 HAYES, R Social Worker FULL TIME 71,297 60,602 10,695 HEALTH, T Admin FULL TIME 50,842 25,421 25,421 LEE, J Social Worker FULL TIME 69,510 59,083 10,426 _ NORRIS, H Trans Asst. PART TIME 40,970 40,970 TERRY, J HDM Driver PART TIME 31,647 31,647 ZELDIN, A SW Supervisor FULL TIME 82,887 82,887 TBA (1/2 year) Wellness Coor FULL TIME 28,500 28,500 TBA (1/2 year) Nutrition Mgr. PART TU%4E 6,750 6,750 SUBTOTAL FT: $730,367 $0 $317,647---- $64,729 $204,508 31,647 $81,405 0 $31,038 40,970 $31,039 0 $0 0 $0 0 SUBTOTAL PT: 108,372 0 0 35,755 TOTAL $838,739 $0 $317,647 $100,484 $236,155 $81,405 $72,008 $31,039 $0 $0 PERCENT FT: 87.08% #DIV /0! 100.00% 64.42% 86.60% 100.00% 43.10% 100.00% #DIV /0! #DIV /0! PERCENT PT: 12.92% #DIV /0! 0.00% 35.58% 13.40% 0.00% 56.90% 0.00% #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, 2018 through June 30, 2019 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 Senior Resource Center 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. 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 i 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 social workers are very knowledgeable about SRC services and community resources. 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. Social Workers conduct home assessments, reassessments, options counseling, facilitate support groups, provide information and assistance, etc. 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 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 is 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. DAAS -734 (revised 2/16) July 1, 2018 through June 30, 2019 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 Community Care Block Grant, as specified on the Provider Services Summary (DAAS -732) in accordance with the following: 1. 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 /myoligy.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 intakelregistration; c) Client assessment/reassessments and quarterly visits, as appropriate; d) Determining the amount of services to be received by the client; and e) Reviewing consumer contributions policies with eligible clients. 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant DAAS -734 (revised 2/16) Services will be maintained by the community service provider and any contracted providers. 5. As specified in 45 CFR 75, Subpart D -Post Federal Award Requirements, Procurement Standards, community service providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community service provider. 6. Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and Community Care Block Grant Manual for Community Service Providers, dated February 17, 1997. 7. Community service providers are responsible for providing or arranging for the provision of required local match, as specified on the Provider Services Summary, (DAAS -732). Local match shall be expended simultaneously with Block Grant funding. 8. Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for the Provision of County -Based Aging Services (DAAS -735). 9. Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in paragraph fourteen (14) of the Agreement for the Provision of County -Based Aging Services (DAAS -735) shall be maintained. 10. Providers of In -Home Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act. 11. Subcontracting — All HCCBG community service providers must assure that subcontractors (for -profit and non -profit entities only) meet the following requirements: a. The subcontractor has not been suspended or debarred. (N.C.G.S. & 143C -6 -23, 09 NCAC 03M) b. The subcontractor has not been barred from doing business at the federal level. c. The subcontractor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts." DAAS -734 (revised 2/16) d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services will be maintained by both the community service provider and any subcontractors. e. The subcontractor is registered as a charitable, tax - exempt (5016) organization with the Internal Revenue Service (non -profit subcontractors only). 12. Confidentiality and 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.,ov/ 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. Pinder, Deputy County Manager Date) _ %l NAME AND ADDRESS I tome and Community Care Illoek (:rant for Older Adults COMMUNITY SERVICE PROVIDER DAAS -732 (Rev. 2/16) Interim Healthcare ofthe Eastern Carolinas, Inc. County Funding Plan County New Hanover PO Box 2249 July 1, 2018 through June 30, 2019 Whiteville, NC 28472 Provider Services Summary IREVISION# , DATE: A B C D E F G H 1 Ser, Deevev Projected Projected Projected Projected (Check one) Block Grant Funding Required Net- NSIP Total HCCBG eimburse HCCBG Total Di—I Porch. I Access In -Home Other Total Services Local Match Sery Cost Subsidy Funding Units Rate Clients Units In -Home Aide Lev 1 18000 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 2000 20000 20000 1178 16.9851 15 1178 In -Home Aide Lev 2 82000 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 9111 91111 91111 5280 17.2575 25 5280 In -Home Aide Lev 3 120003 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 13334 133337 133337 7641 17.4496 1 30 7641 \ \ \\ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \1 \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 1 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 0 0 0 Total \ \ \ \ \ \\ \ \ \ \ \ \\ 0 220003 0 220003 24445 244448 0 244448 14099 \ \ \ \ \ \ \ \ \ \ \ \ \\ 70 14099 *Adult Day Care & Adult Day Health Care Net Service Cost h ADC ADHC y 1 Daily Care Certification of required minimum local match availability. 1 1ty1 Transporm[ion Required local match will be expended simultaneously A homed Si atme, Title I /� `t Ij3te Administrative with Block Grant Funding. Community ervi eider Net Ser. Cos[ Total �J •2 /plod ) k_ 1l)a -'Ilk 11 t4 Signature, County Finance Officer Date Signs e, Ch rman, Board of Commissioners D to L 2r Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. IHA IHA IHA II. Line Item Exoense Total Cost Level 1 Level 2 Level 3 Staff Sala From Labor Distribution Schedule 1 Full -time Staff 81,998 50,466 3,871 12,001 15,660 2) Part-time staff do not include Title V workers 122,225 10,000 45,556 66,669 A. Subtotal, Staff Sala 204,223 60,466 13,871 57,557 82,329 0 0 0 0 0 Frin a Benefits 1 FICA 7.65 % 6,273 3,861 296 918 1,198 2 Health Ins. U 0 31 Retirement a 0 4 Unemployment Insurance SUTA .720% 590 3631 28 861 113 5 Worker's Com ensation @ 7% 5,740 3,533 271 840 1,096 6 Other FUTA CC 0.8% 656 404 31 96 125 B. Subtotal, Fringe Benefits 13,269 8,160 626 1,941 2,632 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 Ol 0 01 0 0 0 0 0 D. OAA Title V Worker Wages, Fringe Benefits and Costs 0 Travel ! / / / / /I / / / / /// /! /I /I / /ll /! /// / / / /! / / / / / / / //! / / /! / / /! / / / / //! / // /!N / /N/ /// 1 Per Diem 0 2 Miles a Reimbursement 0 3 Other Travel Cost: 0 E. Subtotal, Travel 0 0 0 0 0 0 0 0 0 0 General 5-p-erating Expenses 1 Mana ementInformation Systems 168 36 60 72 2 e ui mentde reciation /de reciation 1,741 157 3481 1,236 3 rent/lease 4,304 387 8611 3,056 4 insurances 9,148 397 1,0451 7,706 5 consumable supplies 3,556 812 1,0731 1,671 6 RN supervision 5,500 1,000 2,0001 2,500 7) utilities - computers, phones 2,549 300 667 1,582 8 0 F. Subtotal, General Operating Expenses 26,966 0 3,089 6,054 17,823 0 0 0 0 0 G. Subtotal, Other Administrative Cost Not Allocated In Lines ILA through F lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll l /lllllllllllll 11 /ill /Ill /llll lllllllllllllll lllllllllllllll lllllllllllllll lllll /lllllllll lllllllllllllll lllllllllllllll H. Total Proj. Expenses Prior to Admin. Distribution 244,448 58,626 17,586 66,552 102,684 0 0 0 0 0 I. Distribution of Admininistrative Cost /////////////// - 58,626 2,414 25,559 30,553 0 0 01 01 0 J. Total Proj. Expenses After Admin. Distribution 2",4481/////////////// 1 20,0001 91,111 133,337 0 0 or 01 0 of Aging and Adult Services Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Total 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 forth (DAAS -732A) corresponds with information stated on the Provider Services Summary (DAAS -732) as follows: DAAS -732A DAAS -732 Block Grant Funding Line LA Col. A Required Local Match -Cash & In -Kind Line LB Col. B Net Service Cost Line LC Col. C 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 III.B.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 DAAS -732A 1 2/16 AGENCY ME NA: Interim Healthcare of the Eastern Carolinas, Inc I FY: 2019 SFY 2019 - -_ - FULL TIME TOTAL ADMIN. IHA Level IHA Level IHA Level STAFF NAME POSITION PART TIME SALARY SALARY 1 2 3 SERVICE SERVICE - SERVICE SERVICE SERVICE Registered Nurse 'RN Scheduler Scheduler Data Entry/Payroll DE/PR Billing Clerk Billing Clerk FULL TIME 38,592 $14,873 $3,091 $9,111 $11,517 - 618 2,288 3,280 - -- 72 268 384 90 334 - 479 t 10,000 45,556 66,669 - FULL TIME 16,279 10,093 FULL TIME 12,077 11,353 FULL TIME 15,050 122,225 14,147 In -Home Aide IHA PART TIME -- 1 SUBTOTALFT: $81,998 $50,466 $3,871 $12,001 $15,660 $0 $0 $0 66,669 0 0 0 $0 $0 0 0 SUBTOTAL PT: 122,225 0 10,000 45,556 TOTAL $204,223 $50,466 $13,871 $57,557 $82,329 $0 $0 19.02% #DIV /0! #DIV /0! $0 $0 $0 PERCENT FT: 40.15% 100.00% 27.91% 20.85% #DIV /0! #DIV /01 #DIV /0! PERCENT PT: 59.85% 0.00% 72.09% 79.15% 80.98% #DIV /0! #DIV /0! #DIV /0! #DIV /0! #DIV /0! Page 1 DAAS -734 (revised 2/16) July 1, 2018 through June 30, 2019 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 (Name of Provider) Home and Community Care Block Grant, as specified on the Provider Services Summ (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 http: / /w�,w, ncdhhs gov /ggina/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 Methodolo to Address Service Needs of Low- Income (Including-Low Income Minority Elderly), Rural Elder] and Elder] with Limited English Pro ficient 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. 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant 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. 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. (Date) NAME AND ADDRESS', Home and Community Care Block Grant for Older Adults COMMUNITY SERVICE PROVIDER DOA -732 (Rev. 4/14) County Funding Plan County_ New Hanover Elderhaus, Ina July 1, 2018 through June 30, 2019 1950 Amphiteater Dr. Provider Services Summary IREVISION# , DATE : 7/18 Wilmington, NC 28401 A B C D E F G H I Ser. Delivery Projected Projected Projected Projected (Check One) Block Grant Funding Required Net* NSIP Total HCCBG eimburse HCCBG Total Direct Punch I Access In -Home Other Total Services Local Mate Sery Cost Subsidy Funding Units Rate Clients Units Adult Day Care 69195 \ \ \ \ \ \ \ \ \ \ \ \ \\ 7688 76883 76883 1199 64.12 32 1202 Adult Day Health 34081 \ \ \ \ \ \ \ %A \\ \ \\ 3787 37868 37868 542 69.85 8 545 Transportation - ADC 944 % \ \ \ \ \ \ \ \ \ %A\ 105 1049 1049 700 1.50 11 733 Transportation - ADH 180 \ \ \ \ \ \ \ \ \ \ \\ \ \ \ \ \\ 20 200 200 133 1.50 3 166 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \\ 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 103276 1 1124 104400 11600 116000 0 116000 2574 \ \\\ \ \ \ \ \ \ \ \\ 1 54 1 2646 *Adult Day Care & Adult Day Health Care Net Service Cost 10 1D /l ADC ADHC ( f Daily Care 33.07 40.00 Certification of required minimum local match availability. Transportation Required local match will be expended simultaneously Authorized Si e, Title Date Administrative 31.21 30.24 with Block Grant Funding. o ity Servicqftvider Net Ser. Cost Total 64.28 70.24y('�� OCL�O �t �� t/ ( } Signature, County Finance Officer Date Signature, Ch irman, Board of Comm ssioners Date U5q Wuc\z e�— West .►, North Carolina Division of Aging and Adult Services Service Cost Computation Worksheet C:732A.xls DAAS -732A Provider: Elderhaus,Inc. 3/99 County: New Hanover Budget Period: June 2018 through July 2019 Revision _yes, _X_no, revision date Service Service Service Service Service Service Service Service Grand I. Projected Revenues Total ADC ADH ADC Trans ADH Trans A. Fed /State Funding From the Division of Aging 104,4001/////////////// 69,195 34,081 944 180 Required Minimum Match - Cash / / / / /lllllllllll lllllllllllllll lllllllllllllll l/1 /lllllllllll lllllllllllllll lllllllllllllll lllllllllllllll ll1 /lllllllllll lllllllllllllll lllllllllllllll 1 Elderhaus, Inc. 11,600 / / / / / / / / / / / / /// 7,688 3,787 105 20 2 0 3 0 Total Required Minimum Match - Cash 11,600 / / / / / / / / / / / / /// 7,688 3,787 105 20 0 0 0 0 Required Minimum Match - In -Kind llllllllllllllll ( llllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll 1ll!!11l11!ll!l lllllllllllllll lllllllllllllll lllllllllllllll lllllll /lllllll 1 0 2 0 3 0 Total Required Minimum Match - In -Kind 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 01 0 B. Total Required Minimum Match cash + in -kind 11,600 / / / / / / / / / / / /I // 7,688 3,787 105 20 0 0 0 0 C. Subtotal, Fed /State /Required Match Revenues 116,000 / / / /I / / / / / / / /// 76,883 37,868 1,049 200 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 3 4 0 F. Subtotal, Local Cash, Non -Match 0 /(1//(1/////11/ 0 0 0 0 0 0 0 0 Other Revenues, Non -Match lllllllllllllll lllllllllllllll lllllllllllllll //lllllll /Ill // lllllllllllllll lllllllllllllll lllllllllllllll lllll /lllllll// lllllllllllllll llll /!//lllllll 1 0 2 0 3 0 G. Subtotal, Other Revenues, Non -Match 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 0 0 Local In -Kind Resources Includes Volunteer Resources) 1 0 2 0 0 ESubtotal, Local In -kind Resources, Non -Match 0 / / / / / / / / / / / / /// 0 0 0 0 0 0 0 0 st Sharin 500 / / / / / / / / / /I //// 200 200 50 50 ected Revenues Sum I C,D,E,F,G,H, & I 116,500 / / / / / / / / / / / / /// 77,083 38,068 1,099 250 0 0 0 0 Division of Aging Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Admin. II. Line Item Expense Total Cost Staff Salary From Labor Distribution Schedule 1 Full -time Staff 202,180 29,393 96,509 64,339 7,163 4,776 2 Part-time staff do not include Title V workers 37,128 13,260 7,956 5,304 6,365 4,243 A. Subtotal, Staff Salary 239,308 42,653 104,465 69,643 13,528 9,019 0 0 0 0 Fringe Benefits lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllll!llll/ll/1 lllllllllllllll 1 FICA @ % 18,307 3,263 7,992 5,328 1,035 690 2 Health Ins. @ 46,227 1,485 26,845 14,765 1,790 1,342 3 Retirement @ 0 4 Unem to mentInsurance 0 5 Worker's Compensation 0 6 Other 0 B. Subtotal, Fringe Benefits 64,534 4,748 34,837 20,093 2,825 2,032 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 01 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 Gas & Van Maint 11,951 8,007 1,578 2,366 2 Nursing Supplies 300 201 39 60 3 Meals, Snacks and Supplies 41,679 27,925 5,502 8,252 4 Activity Supplies 2,473 1,657 326 490 5 Admin Expenses, Supplies Commercial Ins. 63,601 16,790 17,045 25,568 4,198 6 Facility & Utilities 56,522 37,870 7,461 11,191 7 Marketing & Information Systems 5,408 3,623 714 1,071 8 Depreciation and Interest 39,059 26,170 5,156 7,733 F. Subtotal, General Operating Expenses 220,994 122,243 37,821 56,732 4,198 0 0 0 0 0 G. Subtotal, Other Administrative Cost Not Allocated // // /I /// / / / /// // / / / / // / / / / /// / / / / / / / / / / / /I// // ////II / / // /I/ / / //I//ll ////// T11111111111111 in Lines ILA through F lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll ll1llll /Illllll lllllllllllllll 111I111I1111111 ll1 1l11lllllll1 lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll lllllllllllllll llllllllll/ll/I /ll/lllllllllll H. Total Pro'. Expenses Prior to Admin. Distribution 524,836 169,644 177,123 146,468 20,550 11,051 0 0 0 0 I. Distribution of Admininistrative Cost lllllllllllllll 227,891 - 100,040 - 108,400 - 19,451 - 10,801 0 0 0 1 0 J. Total Pro. Expenses After Admin. Distribution 116,5001/////////////// 1 77,083 38,0681 1,0991 2501 01 01 01 0 Division of Aging and Adult Services Service Cost Computation Worksheet Service Service Service Service Service Service Service Service Grand Rates 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 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 III.6.5 Col. G Projected Total Service Units Line III.F Col. I Page 1 NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - ATTACHMENT A LABOR DISTRIBUTION SCHEDULE DAAS -732A1 2/16 AGENCY NAME Elderhaus, Inc. FY:18 /19 SFY 18/19 STAFF NAME POSITION FULL TIME PART TIME TOTAL SALARY ADMIN. SALARY ADC ADH ADC Trasport ADH Transport SERVICE SERVICE SERVICE SERVICE Fox Program Direci FULL TIME $39,520 $19,760 $11,856 $7,904 Whitley RN PART TIME $26,520 $13,260 $7,956 $5,304 James Receptionist FULL TIME $19,266 $9,633 $5,780 $3,853 Cook C N A FULL TIME $23,878 $14,327 $9,551 Smith . use Driver C N A PART TIME FULL TlME $10,608 $20,800 $12,480 $8,320 $6,365 $4,243 Hankins C N A FULL TIME $23,878 $14,327 $9,551 Moss Tyler C N A / driver C N A FULL TIME FULL TIME $23,878 $21,840 ! $7,163 $13,104 $4,776 $8,736 7,163 4,776 Stevens C N A FULL TIME $29,120 $17,472 $11,648 - I - t i SUBTOTAL FT: $202,180 1 $29,393 1 $96,509 $64,339 $7,163 $4,776 4,243 $0 0 $0 0 $0 0 $0 0 SUBTOTAL PT: 37,128 13,260 7,956 5,304 6,365 TOTAL $239,308 $42,653 $104,465 $69,643 $13,528 $9,019 52.95% $0 #DIV 10! $0 #DIV /0! $0 #DIV /0! $0 #DIV /0! PERCENT FT: 84.49% 68.91% 92.38% 92.38% 52.95% PERCENT PT: 15.51% 31.09% 7.62% 7.62% 47.05% 47.05% #DIV /01 #DIV /0! #DIV /0! #DIV /0! Page 1 DAAS -734 (revised 2/16) July 1, 2018 through June 30, 2019 Home and Community Care Block Grant for Older Adults Community Service Provider Standard Assurances 15it7r121 -V" S 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 htti)://www.nedhhs.POv/apinWmonitor/mt)olicv.ht . 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. 4. All licenses, permits, bonds, and insurance necessary for carrying out Block Grant DAAS -734 (revised 2/16) Services will be maintained by the community service provider and any contracted providers. 5. As specified in 45 CFR 75, Subpart D -Post Federal Award Requirements, Procurement Standards, community service providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community service provider. 6. Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and Community Care Block Grant Manual for Community Service Providers, dated February 17, 1997. 7. Community service providers are responsible for providing or arranging for the provision of required local match, as specified on the Provider Services Summary, (DAAS -732). Local match shall be expended simultaneously with Block Grant funding. 8. Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for the Provision of County -Based Aging Services (DAAS -735). 9. Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in paragraph fourteen (14) of the Agreement for the Provision of County -Based Aging Services (DAAS -735) shall be maintained. 10. Providers of In -Home Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act. 11. Subcontracting — All HCCBG community service providers must assure that subcontractors (for - profit and non - profit entities only) meet the following requirements: a. The subcontractor has not been suspended or debarred. (N.C.G.S. §143C -6 -23, 09 NCAC 03M) b. The subcontractor has not been barred from doing business at the federal level. c. The subcontractor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts." DAAS -734 (revised 2/16) d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services will be maintained by both the community service provider and any subcontractors. e. The subcontractor is registered as a charitable, tax- exempt (501 c3) 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.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. �Iu1211I4e S 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:i� Name of Agenc Administrator: A�(7) N-M J- A-rTT Signature: ) Date: 212312-0t5 (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. Grant Document Routing Start date: 11/27/18 From: Teresa Hewett, Finance Department (7408) Signatures required: V/ Lisa Wurtzbacher, Chief Financial Officer Z_ Avril Pinder, Deputy County Manager 1/ Chairman Woody White Return to Teresa Hewett, Finance Department (7408) Type(s) of document(s) attached: 1 original — SRC HCCBG (Home and Community Care Block Grant) FYI Funding Plans Explanation of document(s): The HCCBG is a recurring grant that supports several Senior Resource Center programs, such as home delivered meals, in -home aid and case management /referral services. The FYI 9 adopted budget included this funding, therefore no budget amendment is necessary. Please let me know if you have any questions. Thank you. --------------------------- - - - - -- for finance department use--------------------------------------------- DATE ADDED TO LASERFICHE PICKED UP BY: Print Name & Date Signature Org Object Project 11068733 302250 G0001 11068733 302250 G0002 11068733 302250 G0003 11068733 302250 G0005 11068733 302250 G0006 11068723 300930 G0011 11068733 302250 G0016 Description GRANT - FEDERAL -STATE REV GRANT GRANT - FEDERAL -STATE REV GRANT GRANT - FEDERAL -STATE REV GRANT GRANT - FEDERAL -STATE REV GRANT GRANT - FEDERAL -STATE REV GRANT GRANT - FEDERAL GRANT - FEDERAL -STATE REV GRANT 2019 Revised Budget - 104,400.00 - 185,093.00 - 106,899.00 - 340,541.00 - 220,003.00 - 86,095.00 - 90,051.00 - 1,133,082.00