FY20 SRC HCCBG funding plansoAAS-734
Julv 2019 th.ourh June 2020
Home strd Conmuolty Crre Block Grsnt for Older Adults
Communlty Servlce Provider
Strndsrd Aslurrnces
New Hmov€r County Senior Resoute C.at6 agrees to provide services through the Home aod
Community Care Block Grant, as specified on the Provider Services Summary (DAAS-732)
in ac.ordance with the following:
1. Services shall be prcvidod in accordance wilh rcquiremcnts s€t fonh in:
a) The County Funding Plan;
b) The Division of Aging and Adult Services Home and Community Care Block Grant Prccedu€s Manual for Comnunity
Sqvice Pmviders; and
c) The Division of Aging and Adult SeFic€s Standads Manual, Volumes I lhrcugh IV or at
htto://www-ncdhhs.govlarine/monitor/moolicy.htm .
Community service providers shall moritor any subcontsacts with pmvidrs of Block Grant services and tak€ appropriate
meariues to ensue that services are providod in accordance with lhe aforementioned documens.
2.
Prioaity shall be given to providing s€rvices to lhose older persons with the gr€atest economic or social needs. The service
needs of low-income minority elderly will b€ addrEssed in the manner specified on the Melhodolo5r !o Ad&€ss service
Needs of I-ow-lncome (tncluding Low Income Minodty Elderly), Rural Elderly and Eldedy with Limiled English
Proficiency forma! (DA,AS-733).
3 'Ihe following s€rvice authorization activities will b€ carried out in conjunction wilh all s€rices provided firough the Block
Crant:
a) Eligibility det€nnination;
b) Clieot intakdrEgistration;
c) Client ass€ssmen/rEass€ssmenls and quanerly visits, as appropriate;
d) Determidng tle arnount of s€rvices to be received by lhe clienq and
e) Rwiewing consrmer contributions policies with eligible clients.
4 AI licens€s, p6mits, bonds, ard in$rrance necessary for carrying out Block Crant Services will be maintained by the
community service providq and any contaacted pmvide6.
- As sp€cified in 45 CFR 75. Subpafl D-Post Federal Awad RoquirEineDts, Procur€rnetrt Standardq corpnunity service
providers shall have ptocedur€s for s€ttlinS all contractral and administ"ative issues arising out of!,mcur€rnent of savic€s
tluough the Block Grant. Community service proyiders shall have pmcedures governing the evaluation of bids for services
and procedurEs though which biddos aod confacted providers rnay app€al or dis?ute a docision made by fte community
service provider.
6. Applicany'Client 4p€als shall be addressed as specified in S€ction 7 of the Division of Aging ard Adult Sef,vic€s Home and
Community Carc Block Grant MaNal for C.mmuity Service Boviders, datod February I ?, I 997.
T Community service providers sre r€sponsible for pmvidilg or arranging for the provision of required local march, as
specified on the Provider Services Summary, (DAAS-732). t cal malch sh6ll be expeded simultanoously with Block
Grant funding.
E Community service prcviders agree to comply wilh audit and fiscal rcproning requirernents as specifi€d in the Agreement for
the Pmvision of County-Bas€d Aging Seflices (DAAS-?35).
9 Compliance with Equal Employment Opportunity and Americans with Disabilities Act ,lquirernents, as spocified in
pamgaph founeen (14) of the Agreemeni for the Provision of Couaty-Based Aging Services (DAAS-73S) shall be
maintain€d.
10.
Pmviders of In-Home Aide, Home Heallh, Housing and Home Imptovemen! and Adult Day Carc or Adult Day Health Care
shall sign and rEtum the attached assurance io the area agency on aging indicating !h8t rEcipients of these services have been
informed of their client rights, as rcquir€d in Section 3 I 4 of lhe 2006 Amerdments !o the Older Americans Act.
ll subcontracting - All HCCBG c.mmunity service providers must assue that subcontractors (fo.-profit and non-profit
entities oDly) meel lhe following rcquir€ments:
a. The subcontractor has not bee-n suspended or debarcd. (N.C.G.S. g l43C-6-23, 09 NCAC 03M)
b. The subcontractor has not becn barr€d fiom doing business al the fedoal level.
c. The subcontraclor is able to produce a notarized "State Grant Certification of No Overdue Tax Debts."
d. All licertses, permits, bonds and insrrance necessary for carrying out Home and Community Carc Block Crant s6vices
will be maintained by both the community s€rvice pmvider and any subcontracl,ors.
e. The subconFactor is registercd as a charitable, tax-exempt (501c3) organizalion with the Intemal Revenue Service (non-
profi I subcontracrors only).
12' Confidentiality and Security. Per the rcquiremenls in l0A NCAC 05J ard Section 6 ofthe Home and Community Carc
Block Grant Procedures Manual, clier infonnation in any fomat and whether recoded or not shall be kept confidential and
not disclosed in a form lhat identifies fte person without the irformed consent of the person or legal rcpreser ative.
Cornrnuniqt service providers, including subconEaclors and vendors, must adhere to all ap,plicable liieral, slate and
depanrnental rcquirernents for protecting lhe s€curity and confidentiality of client information including but not limited to
appmpriately rEstricting access, €stablishing ptoceduB io rEduce fi€ risk of accidental disclosues fiom data processing
systerns, and developing a process by which lhe Division of Adult Aging Services is notified of suspectod or confirmed
s€curity incidents and data br€aches.
13.
Record Rctention and Disposition. All community service providers are rcsponsible for maintaining custody of r€conds and
documenl.atio[ l,o suppon the allowable expenditurc of fundq servic€ provision, and the r€imbursemer of services. Service
providers must adhef,€ io the approved record rdention ard disposition schedule posted semiannually on the website offte
NC D€partnelt of Heallh and Human Sewice6 Conttoller at .
http://www.ncdhhs.qov/control/retention/retention.htm
Service providers arc not suthorized to destroy rccords r€lated to fte povision of services under ihis Agreement exc@t in
compliadce with the app.ovod DHHS retention and disposition schedulq which allows for the proper destuction of records
based on a schodule by funding source and fiscal year. The agency agrees to comply wilh O? NCAC 04M .0510 when
decidirg on a method of rccord desiuction. Confidential records will be destoyed in such a manner that the records cannot
be practically read or rEconstsucted.
(Authorized Signature) ,.\ - (Date)
6 o*t., *'t+"-qE;'1i's=t+o*-\ G*\ ult*. *-
fuNb'r
State Fiscal Year:
Provider Name:
Address Line 1:
Address Line 2:
County:
Area Agency on Aging:
sFY 2019-2020
New Hanover County Senior Resource Center
2222 S. Colleee Rd.
NC 28403
NEW HANOVER
Cape Fear Council of Governments
Federal/State Local Match
<<-Lcal Match will nr.d to br brokcn out by sou.cc (Cash/ln-Xind) on 732A Svc Cost Computation Form
<<-Lc!l Mltch will nlcd to bc broken out by sou.cc (Cash/ln-(ind) on 732A Src Cost ComputatDn Form
Match wlll nerd to bc brok.n out by sourcr lc.sh/tn-Kind) on 732A Sw Cost Compwatron Form
<-Le.l Mltch will nccd to b. brokrn out by source (C!sh/ln-Xind) on 732A Src Cort Computlton Form
<-L@al Match will nced to be brok.n out by sourcr (Cash/ln-Kind) on 732A Svc Cost Computation Form
.Ltr!l Mltch wlll nrcd to br brokcn out by sourcc (Cash/ln.Kind) on 732A Sw Cost Computation Form
<-L@.1 Match will na.d to bc brokrn out bV sourcc (Cash/ln-Xlnd) on 732A Svc Cost Computation Form
<<-L@al Match will ne.d to bc brokcn out by sourcc (Cash/ln-Kind) on 732A Svc Cost Computation Form
REQUIRES INPUT TO POPULATE WORXEOOX->
REQUIRES INPUT TO POPULATE WORI(8OOX->
REQUIRES INPUT TO POPUTATE WORKBOOI(->
REQUIRES INPUT TO POPULATE WOR(BOOX->
REQUIRES INPUT TO POPULATE WORXBOO(.:>
REOUIRES INPUT TO POPULATE WORKBOOK->
Please Select Services to 8e Dellvered
lnformation & Case Assistance
Contregate Nutrition
Home Delivered Meals
Senior Center Operation
f ransportation (General)
f ransportation (Medical)
Adult Day Care
ln-Home Aide-Level I - Home Management
Compoilson ol Fed/Stote Fundlng ond Rotes vs. Prlor yeor
Prior Year Rate Current YrService
nformation & Case Assistance
SonSregate Nutrition
lome Delivered Meals
;enior Center Operation
Transportation (General)
Transportation (Medical)
Adult Day Care
ln-Home Aide-Level l- Home Management
S L2,545
38,061S e,em
DAAS.73O
(Rev. 4/2019)
Home and Communify Care Block Grant for Older Adults
County Funding Plan
Identification ofAgency or Office with Lead Responsibility for County Funding Plan
County New II4IavaI July 1, 2019 through June 30,2020
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 Countv Senior Resource Center
(Name of agency/office with lead responsibility
Authorized signature
(Kathy Stoute, Assistant County Manager)
(date)
DAAS-731 (Rev. 2/16)
Homo and Communlty Caro Block Grant ror Oldgr Adults
County New Hanover
County Funding Plan July 1, 20'19 through June 30, 2020
County Ssrvlcss Summary
I c D E F G H
Services
Block Grant Fundinq Required
Local Match
Net
Service Cost
NSIP
Subsidy
Total
Fundinq
Projected
HCCBG
Units
Projected Projected
HCCBG
Clients
Projected
Total
UnitsAccessln-Home Other Total Rate
l&A Case Assist 186093 20677 206770 206770 2100
Conqreqate 112899 12544 125443 14254 139697 18641 6.7294 520 19005
Home Delivered Meals 342541 38060 380601 64470 445071 80662 4.7185 675 8s960
Senior Center Ops 80095 8899 88994 88994 6800
General Trans 31100 3456 34556 34556 3082 11.2127 160 10900
l,redical Trans 61347 6816 68163 68163 4711 14.4678 180 6450
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 278540 342541 192994 814075 90453 904527 74724 983251 107096 10435 122315
I
Home .nd Communlty Csre Block Grant for Older Adults
New Hanover County Senior Resource Center
2222 S. College Rd.
Wilmington, NC 28403
County Funding Plan
Provider SeMces Summary
DAAS-732
Couoty: NEW HANOVER
Budget Period: July 2019 through June 2020
Revlslon #: dt D!te: 7ll9l2\l9
Services
Serv. Delivery
B C D E F C H I
Block Crant Funding R€quired
Local
Match
Net Service
Cosl
NSIP
Subsidy
Total
Funding
Projected
HCCBC
Units
Projecled
Reimburse
Rate*
Projected
HCCBC Projected
Clients Total Units
(Chcck one)
Dir€ct In-Home Othcr Total
Information & Case Assistance $ 186,093 $$$ t86.093 $ 20.677 $ 206,710 s $ 206'770 s 2,100
Congregate Nutrition 5 $$ l12,899 $ r r2.E99 $ 12.544 $ 125,443 $ t4,2s4 $ t39,697 18,641 s 6.7294 s20 19,005
Home Delivered Meals $$ 142,541 $$ 342.541 $ 38,060 $ 380,601 $ 64,470 $ 445,07t 80,662 $ 4.7185 675 85,960
Senior Center Operation $$$ 80.095 $ 80,095 s 8,89 $ 88,994 $$ 88,994 $6.800
Transportation (Ceneral)$ lt,t00 $$$ 3 r,100 $ 3,456 $ 34,556 $$ 34,556 3,082 s I1.2127 t60 t0.900
Transponation (Medical)$ 61,347 $$$ 61,347 $ 6,816 s 68.163 $$ 68.163 4;tII $ 14.4678 Il30 6,450
Adult Day Care $$ 105,400 $$ t05.400 $ ,7l l $ llT,lll $$ llT,lll $45
In-Home Aide-tavel I - Home Management s $ 220,003 $$ 220.003 $ 24.445 $ 244.448 $$ 244.448 $38
0 s $$$$$$$$
0 s $$$$$$s s
0 s 5 $s $$$s $
0 $$$$$$$$$
0 $$$$$$$$$
0 $$$$$s $$$
Total s 278.540 $ 661,944 $ t92,994 $ t26,608 $ r,266,086 $ 78,724 $ I,344,810 107,096 10,518 t22,lt5rAdult Dry C.re & Adult Dry H€rlth Crre Proj. Scrvice
ADC
Daily Care
Administrative
Proj. Reimbursement Rate
Administralive o/o
s33.07
32.2a
$65.35
CosuR.tc
ADHC
s 40.00
S 31.1s
s 7t t5
n88%
t1t311*1$
Certification of requirod minimum local match availability.
Requircd local match will b€ expended simultaneously
with Block Grant Funding.
Signature, Title
Service Providr
Date
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NCDIVISIONOFAGINGANDADULTSERVICESCOSTOFSERVICES-LABORDISTRIBUTIONSCHEOULE DAAS.732A1
AGENCY NAME: N.w H.nowrCdnty S.nior R@ur@Clntar
Strte Fbsl Y6r: sFY 2ot9-2020
SATARY
TOTAL FTE FUtL TIME Assignable
PART TIME
SUBTOTALFTT S 632,800
rbol Hod:
SERVICE
ADMIN.
SATARY
166,123 ,aer 3 .8,i ,.ror ! :1,r, t : l-
PERCENT FT: 92.27 fDlv/o| 100.00p,6 60.91%88.98r'/6 100.00/6 100.00% 100.0096 {DlV/01 *DlV/Ot
s6
E
E
DAAS-733
(Rev. 2/19)
Ilome and Community Care Block Grant for Older Adults
Outreach Methodolory
Julv 2019 throush June 2020
Methodology to Address Service Needs of low Income (Including Low-Income Minority Eldedy), Rural
Elderly and Elderly with Limited English Proficiency (Older Americans Act, Section 305(a)(2)(E))
Community Service Provider: New Hanover Countv 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
(DMs-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 Count/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 15.7% over the age of 65 years. According to the 2016 census estimates 17,3% live
below the poverty level.
The Senior Resource's Center (SRC) is the focal point for aging services in New Hanover County. The SRC mission
to provide services which promote wellness, encourage independence and enhances the quality of life for all
older persons. The SRC is committed to providing quality community based services that addresses social
determinates of health. The SRc has 5 primary units of services: Recreation/Socialization, Nutrition,
Transportation, social Services, and Volunteerism. Within the 5 focus areas of service, there are a multitude of
programs and activities that are offered and provided to New Hanover County's older adults and caregivers.
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. lt is the Soal 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:
Home Based Services: Bringing resources to the home
Protection & Advocacy: Ensuring the ritht to rafety and dignity
Health lndependence Selvicei: Promoting wellness
Caregiver Support Programs: Providint respite and supportive seNices for caregivers.
Community Enrichment: Enhancint quality of life
Prescrlption Assistance Program: assistint seniors enroll in p.ogGmsto reduce prescription costs.
Social Workers arsess client needs and link individuals with the most appropriate services. The intake p.ocess
beSins with an inquiry from a prospedive client, family member, a member ofthe community, oran aSency.
Our socialworkers are very knowledteable aboutSRC seNices and comnunity resources. We act as a
community liaison between the client, family and multiple community o.tanizations. Our team responds to the
Srowin8 needs ofour Older Adult Community, and advocates on thei. behatf. We evaluate potential clients for
program elitibility and participate in the development ofcommunity resources and seNices. SocialWorke6
conduct home assessments, .eass€ssments, options counselin& facilitate support groups, provide information
and assistance, etc. Home visits are offered to engage and assisttamilies, who are in the process ofplanning
for loved ones.
The SRC has a Case Worker located at the buildi.g ent.ance who is dedicated to providing i€rvice ortriate to
the approp.iate individualto provide assistance. A kiosk for E-Pass has been installed in the SRC lobby for senior
access and handrrn assistance lif needed) from a case worker to make the use of the system less frustrdting
and still private,
The Center continues to maintain connedions with local community sites (churches, senior housing, etc.) in low
income and rural aommunities for presentations and educationa I events forall outreach protrams.
Transportation assistance is publicized forthese eventswhen fundin8 is available, The Center is also a site for
earlyvoting and primary elections with access to candidate forums and transportation as available for many on-
site events. Ourwebsite is r€niorfriendly and promotes the many se ices and specialprograms offered at the
SRC. The SRC also provides bi-monthly newsletters, bi-weekly Gov Oelivery announcementt and social media
out,eaah that promotes allservices and prog,ams.
The sRc has a robust nutrition program that includes Home oelivered Meals, conSregate Nutrition, rais€d bed
garden, on site nutritionlst, and a variety of heatthy cookint and wellness support troups. tn Fy19, the SRC
opened a nutrition satellite site in the ruralnorthern part ofthe county. wellness and socialservice activities
are also offered atthe satellite site.
The sRcaativities and recreation program consists ofapproximately so different exercise, education, and
socialization protrams for a divere troup oforder adurts to enjoy. The variety ofcrasses keeps seniors engaged
and promotes wellness, encourage independence, and enhance the quarity of life ofaI older persons. over 60%
ofthe activities offered are at no cost to the participant.
The SRC has an active Retired and S€niorVolunteer proSram (RWp) and Foster Grandparent proSram (FGpl
that engates approximately 6oof s€niors to volunteertheir time, skills, and talents in the community, The
majority ofvolunteer opportunities have a focus on healthyfutures and includes; Home oelivered Meals,
volunteer lncome Tax fusistance, senior Hearth rnsu.nce rnformation program, hospitar, food banks, curtuaar
arts, schools, etc.
The SRC Transportation Protram provides transportation services to seniors for nutrition, socialization, non-
emergency medical appointments, dialysis, employment seNices, and essential shopping. The SRC uses a
variety ofcontracted vendors who meet the federaland state contract standards. The SRC has one van that is
used for nutrjtion, essentialshopping trips, and day trips.
Standard Assurance To Comply with Older Americans Act
Requirements Regarding Clients Rights
For
Agencies Providing ln-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 ass;fl."";::r"
' Home Care (home health)
' Housing and Home lmprovement
' 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. ln 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.9. 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;
o 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;
o confidentiality of records relating to the individual;
o 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 priortothe onset ofservice. For allexisting clients, the above information will be provided no
later than the next regularly scheduled service reassessment.
Agency Name:
Name of Agency Administrator:Amber Smith
Signature:
(Please return this form to your Area Agency on Aging and retain a copy for your fires_)
NAMI AND ADDRESS
COMMT-INITY SERVICE PROVIDER
Interim Healthcare ofthe Eastem Carolinas. Inc
PO Box 2249
Whiteville, NC 28472
Home and Commtlnity Care Block Grant for Older Adnlts
County Funding Plan
Provider Services Summary
DAA3-732 (R€v. 2/16)
County NS!-lljllICI
July l,20!a ihrough June 30, gXlq
IRIVISIO\ i , DATF .
Services
B C D E I C H I
,at""r;;l Block Grant liunding Required
l-ocal Malch
Net+
Serv Cost
NSIP
Subsidy
Total
!unding
Proj€cted
HCCBG
Unils
Projected Projected
HCCBG
Cli€nts
Projected
Total
UnitsIn-Home Other Iixal l<ate
ln-Home Aide Lev I 3000 313 3331 3313 196 t6.9851
ln-llome Aide l,ev 2 2t000 2333 23133 23331 t352 t7.2575 20 t352
ln-Homc Aidc Lev l 36000 ,1000 10000 40000 2293 t 7 4496 20 2293
0 0 {)
0 0 0
l)0 o
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 (l
0 0 0
li)lal 0 60000 o 60000 6666 0 3 8,11 16 38.1r
*Adult Day Car€ & Adult Day Health Care Net Service Cost
ADC ADHC
Daily Care
Transportation
Adrninistrative
Net Ser. Cost Total
C-ertification ofrequlred minimum local m
Required local match will be expended sirr
with Block Grant Funding.
*:. \,r r,
Signature. County Finance Officer
t-L
atch availability.ka
Authorizcd Dale
>ralrq
I)ate (ol
D.
Interim Healthcare of the Eastern-.lQalqlin4s-lnc.
Name of Community Service Provider
Revision #
Supplement to Provider Services Summary
In-Home Services Detail
DAAS-732 Supplement (Effective: 7/08)
July l, 2019 through June 30, f!f,!
ln-Home Services
B C F G H
HCCBG
In-Home
Fundins
Required
Local
Match
Net
Service
Cost
Projected
HCCBG
Units
Projected
Reimbursement
Rate
Projected
HCCBG
Clients
Levelt-235Respite 0 0
Level I - 041 H Msmt 3000 333 3333 196 16.985 I 6
Subtotal LeYel I 3000 333 t96 6
Level lI - 236 Respite 0 0
Level Il - 042 PC 21000 2333 1352 17.25'75 20
Level tl - 043 H Mgmt 0 0
Subtotal Level II 2 1000 2333 23333 1352 20
Level Ill - 237 Respite 0 0
Level III - 044 H Msmt 0 0
Level III - 045 PC 36000 ,1000 40000 2293 t7 .4496 20
Subtotal Level llI 36000 4000 40000 2293 20
Level IV - 238 ResDite 0 0
Level IV - 046 H Mgmt 0 0
Subtotal Level lV 0 0 0 0 0
Total 60000 6666 66666 3841
Community Service Provider
North Carolina Division of Aging and Adult Services
Service Cost computation worksheet c:732A.xrs DAAS-732A
Provider: lnterim Healthcare ofthe Eastern Carolinas, lnc. 3/99
Counly: New Hanover
Budget Period: July 1, 2019 through June 30, 2020
Revision _yes, _X_no, revision date _
Service Service Service Service Service Service Service ServiceGrand IHA IHA IHA
l. Prorected Revenues Total Level 'l Level 2 Level 3
A. Fed/State Funding From the Division of Aging 60,000 3,000 21,000 36,000
Required Minimum l\ratch - Cash
1 0
2)0
3)0
total Required Minimum lvlatch - Cash 0 0 0 0 0 0 0 0 0
Required lvlinimum Match - ln-Kind
1 333 2.333 4,000
2)0
3)0
fotal Requrred Mrnrmum Match - ln-Kind 6,666 2.333 4,000 0 0 0 0 0
B Total Required Minimum Match (cash + in-kind)6,6 4,000 0 0 0 0 0
. Subtotal, Fed/State/Required Match Revenues 23,333 40,000 0 0 0 0 0
D. NSIP Cash Subsidy/Commodity Valuation
E. OAA Title V Worker Wages, Fringe Benefits and Costs
Local Cash, Non-Match
0
2 0
3 0
4 0
F Subtotal, Local Cash, Non-Match 0 0 0 0 0 U 0 0 0
Other Revenues, Non-Match
I 0
2 0
3 0
G. Subtotal, Other Revenues, Non-Match 0 0 0 0 0 0 0 0 0
Local ln-Kind Resources (lncludes Volunteer Resources)
0
2 0
3 0
H Subtotal, Local ln-kind Resources, Non-Match 0 0 0 0 0 0 0 U 0
I Client Cost Sherin.r 0
J. Total Projected Revenues (Sum lC,D,E,F,G,H, & l)66,666 3,333 23,333 40,000 0 0 0 0
ofAging
Cost Computation worksheet
Service Service Service
IHA IHA IHA
Level 1 Level 2 Level 3
Service Service Service Service Service
ll. Line ltem
Grand
Total
Admin.
Cost
2
of Aging and Adult Services
Cost Computation Worksheet
of Rates
The Division of Aging ARMS deducts reported program
income from reimbursement paid to providers. Line lll.D
indicates the number of units that will have to be produced
in addition to those stated on line lll.C in order to earn the
net revenues stated on line l.C.
lnformation on this form (DAAS-732A) corresponds with
information stated on the Provider Services Summary
(DMS-732) as follows:
DAAS-7324 DAAS-732
Block Grant Funding Lrne lA Col A
Required Local Match-Cash & ln-Kind Line LB Col. B
Net Service Cost Line l.C Col. C
NSIP Subsidy Line l.D Col. D
Total Funding L. l.C+l.D Col. E
Projected HCCBG Reimbursed Units Line lll.C Col. F
Total Reimbursement Rate Line Ill.B.5 Col. G
Projected Total Service Units Line lll.F Col. I
Service Service Service Service Service Service Service Service
Match ln-Kind (equals line I H and ll
3
NC DIVISION OF AGING AND ADULT SERVICES
COST OF SERVICES. ATTACHMENT A
LABORDISTRIBUTION SCHEDULE DAAS.732AI 2116
AGENCY NAME Interim Healthcare of the Eastern Carolinas, Inc FY:2020
SFY 2O2O
STAFF NAME POSITION
FULL TIME
PART TIME
TOTAL
SALARY
ADMIN.
SALARY
IHA Level
I
IHA Level
2
IHA Level
3 SERVICE SERVICE SERVICE SERVICE SERVICE
Reeistered Nurse ItN FULL TIME 5.079 $ I,399 $480 $ r,600 $ l,600
Scheduler Scheduler FULL TIME I,916 617 r55 572 572
Data Entry/Payroll DE/PR FULL TIME 876 722 r8 68 68
Billine Clerk Billine Clerk FULL TIME 753 s62 23 84 84
In-Home Aide HA PART TIME 49,931 1,789 t7,208 30,934
SUBTOTAL FT:$8,624 $3,300 $676 s2,324 $2,324 $0 $0 $0 $0 $0
SUBTOTAL PT:49,931 0 t,789 17,208 30,934 0 0 0 0 0
TOTAL $58,s55 $3,300 $2,465 $ 19,532 $33,2s8 $0 $0 $o $0 $0
PERCENT FT:14.73o/o r00.00%27.42o/o ll.90Yo 6.99o/o #DIV/O!#DIV/O!#DIV/O!#Drv/0!#Dwt0!
PERCENT PT:85.27o/o 0.00%72.s8%88.10%93.01o/o #DIV/O!#DIV/O!#DIV/OI #DIV/O!#DIV/OI
Page I
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DAAS-733
(Rev. 2/16)
Home and Community Care Block Grant for Older Adults
County Funding Plan
July l, 2019 through June 30,2020
Methodology to Address Service Needs of Low Income (lncluding Low-Income Minority
Elderly), Rural Elderly and Elderly with Limited English Proficiency
(Older Americans Act, Section 305(a)(2)(E))
Community Service Provider: Interim Healthcare of the Eastem Carolinas. Inc.
County: New Hanover
The Older Americans Act requires that the service provider attempt to provide services to low-
income minority individuals in accordance to their need for aging services. The community
service provider shall specifo 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 nanative shali
address outreach and service delivery methodologies that will ensure that this target population is
adequately served and conform with specific objectives established by the Area Agency on Aging, for
providing services to low income minority individuals. Additional pages may be used as necessary.
Interim HealthCare of the Eastern Carolinas, Inc. shall provide In Home Aide Level services
to qualified consumers in New Hanoyer County as outlined in the Home and Community Care Block
Grant for Older Adults. Those determined to be in need of In Home Aide services will be eligible for
services regardless of their income although some recipients will be asked to voluntarily participate
in the consumer contributions program.
lnterim will share information about the In Home Aide program with local doctors, hospital
discharge planners, hospice agencies, skilled agencies, senior advocacy groups, Adult Protective
Services and the Community Alternatives Program agency (CAP). The program information will be
disseminated via written and oral education as well as through weekly marketing visits and phone
calls made by Interim.
Interim will admit lo*'income, including low income minority elderly consumers, rural
elderly and rural elderly and elderly with limited English proliciency as well older adults (age 60 and
over) using the following priorities:
*Older adults for whom the need for Adult Protective Services has been substantiated by the
Department of Social Services and the service is needed as part of the adult protective services plan.
* Older adults who are at risk of abuse, neglect, and/or exploitation.
* Older adults with extensive impairments in actiyities ofdaily living (ADL's), or instrumental
activities of daily living (IADL's), who are at risk of placement or substitute care.
* Older adults with extensive ADL or IADL impairments.
* Older adults with less extensive (l-2) ADL or IADL impairments.
* Well older adults.
Interim HealthCare of the Eastern Carolinas, Inc. complies }tith Title vI ofthe Civil Rights
Act of 1964, the Rehabilitation Act of 1973. And the Americans with Disabilities Act of 1990.
DAAS-734
(revised 2/ l6)
July l, 2019 through June 30, 2020
Home and Community Care Block Grant for Older Adults
Community Service Provider
Standard Assurances
Interim Healthcare of the Eastem Carolinas. Inc., agrees to provide services through the
(Name of Provider)
Home and Community Care Block Grant, as specified on the Provider Services Summarv
(DAAS-732) in accordance with the following:
1. Services shall be provided in accordance with requirements set fo(h in:
a) The County Funding Plan;
b) The Division of Aging and Adult Services Home and Community Care Block
Grant Procedures Manual lor Community Service Providers; and
c) The Division of Aging and Adult Services Standards Manual, Volumes I
through IV or at http://ur'l"vl..ncdhhs.sov/aqins/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 Methodoloey to Address Service Needs ol
Low-lncome (Includine Low Income Minority Elderly). Rural Elderlv and Elderlv
with Limited Enelish Proficiency format, (DAAS-733).
3. The following service authorization activities will be canied out in conjunction with
all services provided through the Block Grant:
a) Eligibility determination:
b) Clientintake/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
5.
6.
7.
8.
DAAS-734
(revised 2/16)
Services will be maintained by the community service provider and any contracted
providers.
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
goveming the evaluation ofbids for services and procedures through which bidders
and contracted providers may appeal or dispute a decision made by the community
service provider.
Applicant/Client appeals shall be addressed as specified in Section 7 ofthe Division of
Aging and Adult Services Home and Community Care Block Grant Manual for
Community Service Providers, dated February 17 , 1997 .
Community service providers are responsible for providing or arranging for the
provision ofrequired local match, as specified on the Provider Services Summarv,
(DAAS-732). Local match shall be expended simultaneously with Block Grant
funding.
Community service providers agree to comply with audit and fiscal reporting
requirements as specified in the Aqreement for the Provision ofCounty-Based Asine
Services (DAAS-735).
Compliance with Equal Employment Opportunity and Americans with Disabilities Act
requirements, as specified in paragraph fourteen (14) ofthe Asreement for the
Provision ofCountv-Based Asins Services (DAAS-735) shall be maintained.
Providers of In-Home Aide, Home Health, Housing and Home Improvement, and
Adult Day Care or Adult Day Health Care shall sign and retum the attached assurance
to the area agency on aging indicating that recipients ofthese services have been
informed oftheir client rights, as required in Section 314 ofthe 2006 Amendments to
the Older Americans Act.
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. l 113 C -6-23, 09
NCAC O3M)
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 ofNo
Overdue Tax Debts."
9.
10.
ll.
12.
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 (501c3) organization
with the Internal Revenue Service (non-profit subcontractors only).
Confidentiality and Security. Per the requirements in 10A NCAC 05J and Section 6 of
the Home and Community Care Block Grant Procedures Manual, client information in
any format and whether recorded or not shall be kept confidential and not disclosed in
a form that identifies the person without the informed consent of the person or legal
representative. Community service providers, including subcontractors and vendors,
must adhere to all applicable federal, state and departmental requirements for
protecting the security and confidentiality of client information including but not
limited to appropriately restricting access, establishing procedures to reduce the risk of
accidental disclosures from data processing systems, and developing a process by
which the Division of Adult Aging Services is notified of suspected or confirmed
security incidents and data breaches.
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. qov/control/retentiorVretention. 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.
13.
Standard Assurance To Comply with Older Americans Act f'- -
Requirements Regarding Clients Rights
For
Agencies Providing ln-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:
o ln-Home Aide. Home Care (home health). Housing and Home lmprovement. 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. ln 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.9. 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:
o 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;o have property treated with respect; ando 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: lnterim Healthcare of the Eastern Carolinas. lnc.
Name of
Signature:o.t, Dtf olf -t 19
(Please return this form to your Area Agency on Aging and retain a copy for your files.)
CLIENT/PATIENT RIGHTS
L You have the right to be fully informed of all your rights and responsibilities as a
clienvpatient of the program.
2. You have the right to appropriate and professional care relating toyourneeds.
3. You have the right to be fully informed in advance about the care to be provided by the
pro9 ram.
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 determin ing 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. lf 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.
/3J-
llom€ rnd Commullity Csre Block Grsnt for Older Adults
DAAS-732
County: NEW IIANOVER
Budget Pcriodr July 2019 through June 2020
Rcvicion #: Dr&:
Elderhaus, lnc.
I 950 Amphitheater Dr.
Wilmington. NC 2840'1
County Funding Plan
Provider Services Summary
Services
Serv Delivery
B C D E F c H I
Block Clant Iunding Required
Local
Match
Net Service
qo6t
NSIP
Subsidy
Total
Funding
Projected
HCCBC
Units
Projected
Reimbune
,dut"'
PIojected
HCCBG Projected
Clients TotalUnits
(Check one)
Direct Access In-Home Other Total
Adult Day Care $$ 79,225 $ 79,225 s y' 8,803 s'/ 88,028 $$ 88,028 1,347 t 65.3541 1,350
Adult Day Carc-Transportation $$ 1,550 $$ 1,550 $ ./ 112 { ,/ 1.722 $$ t,722 1,t52 $,/t.4954 I, t85
Adult Day Health $s 24,475 $s 24,475 $ r' 2,it9 $ ./ 27.te4 $$ 27,194 382 A 1t.ts32 185
Adult Day Health-Transportation $xi 150 s $150 $,/17 $/t67 $$167 ll2 $/ 1.4966 145
0 $$s $$$$$$
0 $$$$s $$$
0 $s $$$$$$$
0 s $$$$$$$$
0 $$$$$$$$$
0 $$$$$$$s $
0 $$$$s $$$$
0 $$$$$$$$$
0 $$$$$$$$$
0 $$$$$$$$$
I olal $$ 105.400 $$ r05,400 s lr,7ll $ l r7,ll l $$ llT,lll 2,992 3,065
'Adult Dsy Crrc & Adull Dry H.alat C.r. proj. S.rvic.
Daily Care
Adminishative
Proj. Reimbursement Rate
Administrative 7o
Co(/Ratc
ADHC
S 4o.oo
s 31.1s
s 7t t5
77.55%
Ceaification ofrcquired minimum local match availability.
Required locsl match will be expended simultafleously
with Block Grant Funding.
ta-'
I)ate
r <.r i. 1,, ,-lz \nacL<r
s-
$-
ME AND ADDRESS
MMI]NITY SERVICE PROVIDER
YADA HOME IIEALTI] CARE, INC.
)5 Randall Parkway, Suite 205
mington, NC 28403
Home atrd Commutrity Care Block Gnnt for Older Adults
DAAS-?32 (Rea, 2/16)
County Fundlng Plan
Providsr Servic€s Summary
Courtv New llanover
October t. 2019 throush June30.2020IREvr$oill;iL--
Services
B C D E F G H I
A'""'*Jl Block Crant Fundins Required
Local Matcl
Net*
Serv Cost
NSIP
Subsidy
Total
Funding
Projected
HCCBG
Units
Projected Projected
HCCBG
Clients
Projected
Total
Unitsln-Home Other Tolal Rate
IHA LEVEL I x r6000 1118 17178 t'7't'78 l05l r6.9151 6 1051
IHA LE\EL II X 88002 9',118 91',780 97780 5570 t1.5541 20 5570
IIIA LEVEL III x s6001 6222 62223 62223 35?l t'7.4246 8 3571
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
0 0 0
Total 0 160003 0 160003 1',l1',l8 t'7't781 0 l'7'7',78t 10t 92 34 10192
*Adult Day Car€ & Adult Day Health Carc Net Service Cost.ADC ADHC
Daily Care
Transportation
Administrative
Net Ser. Cost Total
Certification of required minimum local match availability.
Reqlired local match will be expended simultaneously
with Block Grant Funding.
8-
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Date
Chaiman,Signalure, County Finarcc OfficerI r-\
(((
North Carolina Division of Aging and Adult Services
Service Cost Computation Worksheet c:732A.xr6 DAAS-732A
Provider: BAYADA HOME HEALTH CARE, lNC. 3/99
County: New Hanover
Budget Period; October 1,2019 through June 30,2020
Revision _yes, _X_no, revision date _
Service Servico Sgrvice Service Seryice Service Soryico Seryice
in-Home ln-Home ln-Home
Grand Aide Aide Aide
l. Projected Revenues Total Level I Level ll Level lll
Fed/State Funding From the Division ofAging 160.'16,1 88,002 56,00r
Reouired Minimum Match - Cash iiiiiiitl nt u n/t tl
0
3)0
Total Required Minimum Match - C 0 0 0 0 0 0
Required Minimum Match - ln-Kind
) Adminstrative Match ln-Kind 17,77 1,778 9,778 6,22:,
2\0
3)0
Total Required Minimum Match - ln-Kind 17.778 1,771 6,22:,0 0 0 0
B. Total Required Minimum Match (cash + in-kind 't7,778 1.778 9,778 0 0
C. Subtotal, Fed/Stat6lR6quired Match Revenues 177,7 17,778 97,780 62,223 0 0
D. NSIP Cash Subsidy/Commodity Vaiuation 0
E. OAA Title v Worker Waq€s, Fringo Bensfits and Costs 0
Local Cash, Non-Match
I
0
4)0
F. Subtotal. LocalCash. Non-Match 0 0 0 0
rer Revenues, Non-Match
2 0
3l 0
G. Subtotal, Other Reyenu6s, Non-Match 0 0 0 0 0 0 0
Local ln-Kind Resources (lncludes Volunteer Resources)
0
0
3)0
I tttutlttH. Subtotal, Local ln-kind Resources, Non.ilatch 0 0 0
l. Clieni Cosi Sharing
nmiiniiJ. Total Projected Revenues (Sum I C,D,E,F,G,H, & D 177,781 17,77A 97,7 62,0 0 0
((('
Servico Service
ln-Home ln-Home
Aide Aid6
Level I Level ll
Service Service Servics Service Sorvice Ssrvice
ln-Home
Aide
(
not include Title V workers
Division of Aging and Adult Services
Cost Computation Worksheet
' The Division ofAging ARMS deducts reported program
income from reimburs€ment paid to provid€6. Line lll.D
indicatEs the number of units that will have to be produced
in addition to those ststed on line lll.C in order to earn the
net revenues stated on line l.C.
lnformation on this form (DAAS-732A) corresponds with
stated on the Provider Services Summary
DMS-732A OMS-732
Block Grant Funding Line fi'----.o|. A
Required Local Match-Cash & ln-Kind Line LB Col. B
Net Service Cost Line l.C Col. C
NSIP Subsidy Line l.D Col. D
Total Funding L. l.C+l.D Col. E
Projected HCCBG Reimbursed l,Jnits Line lll.C Col. F
Total Reimbursement Rate Line lll.B.5 Col. G
Projected Total Service Units Line lll.F Col. I
Service Service
ln-Home ln-Home
Aide Aide
Level I Level ll
Servic€
ln-Home
Aide
Service Servicg Service Sorvice Service
(DAAS-732) as follows:
(('(
NC DIVISION OF AGING AND ADULT SERVICES
COSTOF SERVICES - ATTACHMENTA
LABOR DISTRIBUTION SCI{EDULE DAAS-732AI 2/16
AGENCY NAME:BAYADA HOME HEALTH CARE INC.FY:2020
SFY_October 1,20 9 - June 30, 2020
STAFF NAME POSITION
FULL TIME
PARTTIME
IOTAL
SALARY
ADMIN.
SALARY
IN HOME
AIDE
LEVEL I
IN HOME
AIDE
LEVELtr
TN HOME
AIDE
LEVELIII SERVICE SERVICE SERVICE SERVICE SERVICE
Terri Stallings
Director (salary
proportioned for Block
Grant Services)FullTime 3,000 3.000
Rebecca Seck, RN
Clinical Manager
(salary proportioned
for Block Grant
Services)FullTime 8,000 1.000 5,000 2,000
Samantha Rivenbark
Client Services
Manager (salary
proportioned for Block
Grant Services)Full Time 6,000 1,000 3,000 2,000
IHA LevelI In Home Aide Part Time 9.440 9,440
IHA Level ll In Home Aide Part Time 5t,921 51.921
IIIA Level III ln Home Aide Part Time 33,040 33,040
SUBTOTAL FT:$17,000 $3,000 $2,000 $8,000 $4,000 $0 $0 $0 $0 $0
SUBTOTAL PT:94,401 0 9.440 51,921 33,040 0 0 0 0 0
TOTAL $l11.401 $3,000 $11,440 $s9,921 $37,040 $0 $0 $0 $0 $0
(1
^'e" t
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I
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(
PERCENTFT:15.26%100.00%17.48o/o 13.35Yo 10.80%#DIV/OI #DIV/O!#Drv/0!#DIV/O!#DMo!
PERCENTPT:84.740 0.00v;o 82.52Yo 86.65yo 89.20o/c #DMO!#DIV/O!#DM0!#DMo!#DMol
((("eez
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YADA HOME HEALTH CARE, TNC.
ne of Commudty SerYice Provider
isiotr #
Supplement to Provider services Summary
In-Home Services Detail
DAA$732 Supplement (Effective: 7/08)
October I, 2019 through June 30' 2020
In-Home Services
B C I G H
HCCBG
In-Home
Funding
Required
Local
Match
Net
Service
Cosl
hojected
HCCBG
Units
Projected
Reimbursemen
Rate
Projected
HCCBG
Clients
Levell-235Respite 0 0
LevelI-04lHMgmt 16000 t'7'78 t'7't't8 l05l $ 16.9153 6
Subtotal Level I 16000 1',?78 t7'7'.18 l05l 6
Level II - 236 Respite 0 0
Level lI - 042 PC 88002 9778 97 780 5570 $ 17.5547 20
Level II - 043 H Mgmt 0 0
Subtotal Level II 88002 9',778 97780
0
5570 20
Level III - 237 Respite 0
Level III - 044 H Mpcnt 0 0
Level IU - 045 PC 56001 6222 62223 35',7 |s t7.4246 8
Subtotal Level lIl 56001 6222 62223 3571 8
Level IV - 238 Respite 0 0
Level IV - 046 H Mgml 0 0
Subtotal Level IV 0 0 0 0 0
Total 160003 1',t'778 177't8t 10192 tl L-
DAAS-733
(Rev.2/16)
Home and Community Care Block Grant for Older Adults
County Funding Plan
October l, 2019_ through June 30' 2020-
Methodology to Address Service Needs of Low Income (Including Low-lncome Minority
Elderty), Rural Elderly and Elderly with Limited English Proficiency
(Older Americans Act, Section 305(a)(2)(E)
Community Service Provider BAYADA HOME HEALTH C
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 speci$ how the service needs of low income, low-
income (including low income minority elderly), rural elderly and elderly with
Iimited English proficiency will be met through tlle services identified on the Provider
Services Summary @AAS-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.
BAYADA Home Health Care, lnc. shall provide In-Home Aide Level I, Level II,
and Level III services to qualified consumers in New Hanover County as outlined in the
Home and Community Care Block Grant for Older Adults. Those determined to be in
need of In-Home Aide services will be eligible for services regardless of their income,
although some recipients will be asked to voluntarily participate in the consumer
contributions program.
BAYADA will share information about the In-Home Aide program with local
doctors, hospital discharge planners, hospice agencies, skilled agencies, senior advocacy
groups, Adult Protective Services (APS) and Community Altematives Program (CAP).
Information regarding the In-Home Aide program will be disseminated via written and
oral education as well as through weekly marketing visits and phone calls made by
BAYADA.
BAYADA will admit low-income, including low-income minority elderly
consumers, rural elderly and rwal elderly with limited English proficiency, and well older
adults (age 60 and over) using the following priorities:
-Older adults for whom the need for Adult Protective Services has been substantiated
by the Department ofSocial Services and the service is needed as part ofthe Adult
Protective Services plan.
-Older adults who are at risk of abuse, neglect, and/or exploitation.
-Older adults with extensive impairments in activities of daily living (ADL's), or
instrumental activities of daily living (IADL's), who are at risk of placement or
substitute care.
-Older adults with extensive ADL or IADL impairments.
-Older adults with less extensive (1-2) ADL or IADL impairments.
-Well older adults
BAYADA Home Health complies with Title VI of the Civil Rights Act of 1964,
the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.
DAAS-734
(revised 2/16)
October 1, 2019 through June 30, 2020
Home and Community Care Block Grant for Older Adults
Community Service Provider
Standard Assurances
BAYADA HOME HEALTH CARE, INC. agrees to provide services through the Home and
(Name of Provider)
Community Care Block Grant, as specified on the Provider Services Summarv (DAAS-732)
in accordance with the following:
l. 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://www.ncdhhs.gov/asinq/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 Methodolosy to Address Service Needs of
Low-Income (Includinq Low Income Minori8 Elderlv). Rural Elderlv and Elderly
with Limited Enelish 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 ofbids for services and procedures through which bidders
and contracted providers may appeal or dispute a decision made by the community
service provider.
6. ApplicanVClient appeals shall be addressed as specified in Section 7 ofthe 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 Summarv,
(DAAS-732). Local match shall be expended simultaneously with Block Grant
firnding.
8. Community service providers agree to comply with audit and hscal reporting
requirements as specified in the Agreement for the Provision of Countv-Based Asine
Services (DAAS-735).
9. Compliance with Equal Employment Opporhmity and Americans with Disabilities Act
requirements, as specified in paragraph fourteen (14) of the Asreement for the
Provision of Countv-Based Asing 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 retum the attached assurance
to the area agency on aging indicating that recipients ofthese services have been
informed of their client rights, as required in Section 314 of the 2006 Amendments to
the Older Americans Act.
1 1. Subcontractins - 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-GS-$41ed23, 09
NCAC O3M)
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 Ce(iflcation of No
Overdue 'I'ax Debts."
12.
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 (501c3) organization
with the Intemal Revenue Service (non-profit subcontractors only).
Confidentialitv and Security. Per the requirements in 10A NCAC 05J and Section 6 of
the Home and Community Care Block Grant Procedures Manual, client information in
any format and whether recorded or not shall be kept confidential and not disclosed in
a form that identifies the person without the informed consent ofthe 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 confidentialiq/ 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 ofrecords 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. qov/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 ofrecords
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.
13.
Standard Assurance To Comply with Older Americans Act
RequiremenE Regarding Clients Rights
For
Agencies Providing ln-Home Services through the
Home and Community Care Block Grant for Older Adulis
As a provider of one or more of the services listed below, our agency agrees to notiry all Home and
Community Care Block Grant clients receiving any of the below listed services provided by this
agency oftheir rights as a service recipient. Services in this assurance include:
. ln-Home Aide. Home Care (home health). Housing and Home lmprovement. Adult Day Care orAdult 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. ln 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.9. copy of signed Client Bil! of Rights siatement).
Clients Rights information lo be communicated to service recipients will include, at a minimum, the
right to:
. be fully informed, in advance, abouteach 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 seNice that is or fails to be provided, without
discriminalion 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 ofthe
above listed services prior to lhe onset of service. For all existing clients, the above information will
be provided no later than the next regularly scheduled service reassessment.
Agency Name: BAYADA HOME HEALTH CARE. lNC.
Name ofAgency Administrator: Bobbv Shoemake. MA
Signature:oate: 7'?-t1
(Please return this form to your Area Agency on Aging and retain a copy for your files.)
CLIENT/PATIENT RIGHTS
. . You have the right to be fully informed of all your rights and responsibilities as a clienUpatient 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 ofthe 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 crnsent 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.
. 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. lf 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.