FY19 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