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Home My WebLink About2018-025-E Finance - Club Nova Performance AgreementDocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ( "Effective Date ") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ( "County ") and Club Nova Community, Inc., a not - for - profit corporation, located at 103 D. West Main Street, Carrboro, NC 27510 ( "Provider "). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Club Nova Community, Inc. agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 12500 b. All funds appropriated shall be used for purposes described in Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. The Provider shall be paid in four equal installments in the amount of 3125. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Club Nova Community, Inc.) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 — December 31; January 1 — March 31 and April 1 - June 30. Reports are due on January 12, April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default "), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: Il�f.` IiI7_\ �[ ��7�f. Y�1: 7it7111[ �)► i�ihil ul�l� ■:75L�1�Iii�l�7K�1` /�17_�ii�! • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non - Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non - Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that Club Nova Community, Inc. provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the parry addressed as follows: (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Club Nova Community, Inc. 103 D. West Main Street Carrboro, NC 27510 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti - discrimination laws, policies, rules, and regulations and the Orange County Non - Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http: / /www.orangecountync.gov/ departments / purchasing _division /contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147 - 86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For DocuSigned by: SE005F7�F1771411C... Karen Dunn e Provider Executive Director Date 1/26/2018 (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Page S of 10 Rev. 7117 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 For ant' -- o-cu-S'-ig-ne nd --' --,nty Government 66WA L, C�K416� O6379949755E477.. Bonnie Hammerstey, tounty manager (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Rev. 7117 2/2/2018 Date Page 6 of 10 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Club Nova Community, Inc. Program(s) Club Nova FOR OFFICE USE ONLY Received By Date /Time / Section Subsection 1. Cover Page a. ® Applicant Contact Information b. ® Funding Requests C. ® Signed Application Cover Page d. ®Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ® Agency's Years in operation b. ® Agency's Purpose /Mission c. ® Agency's Types of Services Provided d. ® Agency's Experience with Programs e. ® Other Pertinent Agency Information f. ® Schedule of Positions g. ® Living Wage h. ® Agency Budget 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is c. ® Agency Collaboration required for each program. d. ® Summary of Program e. ® Description of Identified Need f. ® Description of Population to be Served g. ® Program Staffing, Capacity, & Expertise h. ® Program Implementation Timeline L ® Value of Investment j. ® Impact of Reduced /No Allocation k. ® Other Pertinent Information I. ® Target Population /Beneficiary Chart M. ® Work Statement n. ® Program Budget, Detail, & Cost per Individual 4. Attachments a. ® Audit: Organizations receiving $300,000 or more in Federal financial assistance, and /or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ® IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax - Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors g. ® Solid Waste Program Fee (SWPF) Verification Application Submittal Checklist 2/9/2017 1:51:06 PM Page 1 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Club Nova Community, Inc. Applicant Organization's Physical Address: 103 -D W Main St, Carrboro, NC 27510 Applicant Organization's Mailing Address: 103 -D W Main St, Carrboro, NC 27510 Applicant Organization's Web Address: www.clubnova.org Executive Director: Karen Kincaid Dunn Telephone Number: 919- 968 -6682 E -Mail: kdunn @clubnova.org Tax ID Number: 27- 0103430 b) Funding Request List all FY17 -18 Human Services (HS) Funding Being Requested - For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Cha elel Orange Total ='HS Hill - HS County -HS Ex 'YouthAfterschool Program $10 000 $15:080 $5,000 $30,000 Afterschool Program Coordinator salary and materials for':. outh activities and projects . ` Critical Safety Net, Health and Wellness $20,000 $20,000 Critical Safety Net - Operating $20,000 $20,000 Employment/Education, Transportation: expenses and $120,000 $120,000 salary- Increase to Living Wage to become Orange County Living Wage Certified, Critical Safety Net Totals $20.,000 ;':. $20,000 $120,000 $160,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature. n_�� r viv � � - j -Le S61 A ' 112 v� F Ex cutive Director Dat Signature: K041-41 I - Board Chairperson Date AGENCY INFORMATION 1/31/2017 1:58:44 PM Page 2 of 23 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ® ❑ c) Current beneficiaries of the program for which funds are being requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. As part of our inclusive governance, Club Nova has two members of Club Nova on the Club Nova Community, Inc. Board of Directors. NON - DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identitylexpression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signatu Signature: cutive Dire Chairperson M AGENCY INFORMATION 1/31/2017 1:47:53 PM Page 3 of 23 I -rl- DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): August /2004 Club Nova was founded July 1, 1987. Our founding members were at the core of our inception. Club Nova has been in operation for almost 30 years, operating for 19 years under the auspices of OPC Area Authority. Club Nova Community, Inc. incorporated on August 23, 2004. On May 21, 2006, Club Nova was divested and came under the governance of Club Nova Community, Inc. We have operated as a private non - profit for over 10 years. b) Agency's Purpose /Mission (no more than a few sentences): Club Nova provides opportunities for individuals living with sever and persistent mental illness to lead meaningful and productive lives of their choice in the community. Club Nova focusses on members' strengths and potential rather than their illness. c) Types of Services the Agency Provides (bullet format): * * ** The Basic Components of Clubhouse: Community Support • Members get help with acquiring and keeping affordable and dignified homes. • Members get help with government disability and pension benefits. The Basic Components of Clubhouse: Supported Housing • Club Nova is committed to securing a range of choices of safe, decent and affordable housing including independent living opportunities for all members. • Members choose the location of their housing and their roommates. • The level of support increases or decreases in response to the changing needs of the members. The Basic Components of Clubhouse: Health and Wellness • Club Nova provides 13 affordable, nutritious meals each week. • Members are given help accessing and navigating the social and healthcare services they require. • Members get help with averting crisis and crisis intervention. • Members have opportunities to participate in smoking cessation other wellness programming. The Basic Components of Clubhouse: Outreach • When a member does not attend or is hospitalized, a reach -out call or visit is made. • Outreach provides an early warning system for members who are experiencing difficulties. • Through routine contact, a crisis, hospitalization or worse is often prevented. • The Basic Components of Clubhouse: The Work Ordered Day o Members and staff work together as colleagues to carry out all the critical work necessary to sustain Clubhouse functions. Agency Information 2/9/2017 1:51:06 PM Page 4 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION o Through participating and contributing, members regain skills, a sense of purpose, self - worth, and confidence working in the Clubhouse • The Basic Components of Clubhouse: The Employment Programs • People with SMI have the lowest employment rates of any disability. • Returning to paid employment is a right of membership and a priority at the Clubhouse • We provide members opportunities to return to paid employment in integrated work settings. • Three types of employment programs: Transitional, Supported, and Independent • Employment is at the employer's place of business and pays the prevailing wage for the required work. • The Basic Components of Clubhouse: Education • Often education has been interrupted by SMI. Our Supported Education assists with admissions, financial aid, and utilization of disability offices. • The Clubhouse provides opportunities and assistance helping members complete or start their certificate or degree programs at colleges and universities. • The Basic Components of Clubhouse: Evening, Weekend, Holiday Program • Many people with SMI live in isolation. • Our Evening, Weekend, Holiday Program reduces isolation and gives members a sense of social connectedness and belonging. • The Basic Components of Clubhouse: Transportation • Access to Club Nova is essential for our members to participate in our full range of opportunities. • Transportation operates a morning and an evening route throughout Orange County. d) Agency's History with Providing These Services: Club Nova offers solutions to the challenges our members and our community face on a daily basis. For almost 30 years, Club Nova has been saving and changing lives and making a positive impact on the health of our community. We have over 29 years of experience in providing the full range of supports and opportunities that define the Model and are in our funding request. The Model operates on proven standards and has been replicated effectively with over 300 Clubhouses worldwide. A rigorous accreditation process assures fidelity to the standards of the Model. Club Nova holds a 3 Year Accreditation and is one of six accredited Clubhouses in North Carolina. The Clubhouse Model is included in the Substance Abuse and Mental Health Services Administration (SAMHSA) registry for Evidence -Based Practices. In 2017 the Conrad N. Hilton Foundation, of the world's most prestigious humanitarian prizes, chose the Clubhouse International /Fountain House Clubhouse Model as the answer to alleviating worldwide human suffering for individuals living with mental illness. Our dedication to our members and this community have earned Club Nova the 2016 GlaxoSmithKline Impact Award and Employee Choice Award, 2016 Chamber of Commerce Business Excellence Award for Community Impact, 2016 Faith Connections Community Servant Award and recognition by Towns of Carrboro and Chapel Hill for being a Model of Excellence in mental Health. With Club Nova's current plans for expansion, we look forward to the next 30 years. Agency Information 2/9/2017 1:51:06 PM Page 5 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) While Club Nova has not experienced any major changes in the past year, we have continued to provide employment services despite elimination of state funds - as well as retaining members who receive other services which Club Nova cannot be reimbursed for (ACTT services) despite the two services' being complementary of each other. While no major changes have occurred, we are always aware the Medicaid state funds could shift without much notice. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE-Full-Time Paid Positions: 10 # of FTE - Paid Part -Time Positions: 4 (these are quarter time positions) # of Volunteers: 127 # of FTE - Volunteers:0 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes /No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. Club Nova Community has strived to give our employees living wages, but still fall short with four of our quarter time employees for transportation. With the low Medicaid reimbursement rates and exclusions of services we cannot be reimbursed for, our budget cannot currently handle the increase to Living Wage for all employees. We are working on a gradual, yearly, increase and hope to be in line with Living Wage in Orange County and be an Orange County Living Wage Certified Employer in the upcoming year. Agency Information 2/9/2017 1:51:06 PM Page 6 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget Is your agency currently receiving and /or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes /No) Yes. Club Nova is currently working with Orange County, Town of Carrboro, Town of Chapel Hill regarding financial support for Club Nova expansion. If yes, please list below: Include all programs that have funding requests /awards /totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 6-17 Award FYI 7-18 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other Agency Information 2/9/2017 1:51:06 PM Page 7 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Yes, actual numbers show a minimal surplus. Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. As seen in the budget worksheet, the surplus for actual, current and projected are minimal. Last year's actuals had a surplus of $5,115. iv. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/9/2017 1:51:06 PM Page 8 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Club Nova Program Primary Contact and Title: Sadie Brooks, Associate Director Telephone Number: 919 - 968 -6682 E -Mail: s brooks(a-)cl u b nova. org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing X Affordable Healthcare X Education X Family Resources Jobs /Jobs Training X Food X Transportation X Other: Please specify Crisis Prevention and Intervention - Outreach - Benefits and Entitlements - Supported Housing X * *Club Nova works with adults 18+ who live with serious mental illness. c) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. • Mental Health Care Services- Club Nova Community, Inc. coordinates its' services with other agencies involved with our members. For example, some of our members receive outpatient services from the UNC Center for Excellence in Mental Health. When members and staff create their person centered plan, we include the psychiatrist and therapist's input and they are involved in the plan. The psychiatrist will sign the Person Centered Plan for our service order, meaning the psychiatrist agrees that our services are needed. We maintain periodic contact to review progress and to exchange any needed information. Some of our partners include: PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 9 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • UNC Center for Excellence in Mental Health, Including ACTT, STEP, and Oasis • UNC Department of Psychiatry and Walk Clinic • Lutheran Family Services — Assertive Community Treatment Team (ACTT) • Referring Organizations and Agencies • Private Psychiatrists • Community Resource Court • Crisis Prevention and Intervention Work - CNCI staff maintain contact with the following agencies when a member is in crisis and needs to be evaluated for harm to self or others and /or checked on if the member has not been seen or heard from in a couple of days. Some of these partners include: • UNC Emergency Department • Freedom House • UNC On -Call Psychiatry • Carrboro and Chapel Hill Police Departments — Wellness Checks are highly effective • Chapel Hill Police Department Crisis Unit • Lutheran Family Services, XDS and other ACT Teams — intense collaboration especially during crisis. • Primary and Other Health Care - CNCI staff assist members in obtaining quality health care. With the life expectancy of people living with serious mental illness being 25 years shorter than the general population, it is critical that our members receive quality health care. We may help coordinate the care needed and accompany members to medical appointments to provide a support person to help listen, help provide information and ask questions, process the information for decision making, and provide support during the decision making process. Numerous members have faced life threatening diseases and have had to make difficult decisions. Providing emotional support is imperative. Staff will attend appointments and communicate with the providers as needed. Some of these partners include: • Physicians (Primary Care, Specialists) • EI Futuro • Piedmont Health Services • UNC Family Medicine • UNC Cancer Hospital • Other Private Providers • Food Access and Healthy Living - The partnerships held by Culinary Program at CNCI highlight the power of community partners: we are able to offer our members nearly 1000 affordable, nutritious, and tasty plates each month through relationships with local food organizations. Some of these partners include: • Farmer Foodshare Donations Station and POP Market • Chapel Hill Farmers' Market • Carrboro Farmers' Market • Orange County Solid Waste - Composting • Sysco and Ecolab PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 10 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • Housing - CNCI assists members in locating, securing, and maintaining safe, dignified, affordable housing. We collaborate with group homes and CASA to support our members and advocate as needed if a member's residency is in jeopardy. Some of these partners include: • CASA (Manages Club Nova apartments) • Interfaith Council • Alberta Services — Homestead Place and Booth Road (Group Homes) • Overlook Apartments • Orange County Housing Authority • Empowerment • Landlords • Securing Other Benefits and Entitlements - CNCI assists members with securing benefits and entitlements such as applying for Medicaid, Medicare, & Social Security. All of these applications and re- certifications can be overwhelming. Some of these partners include: • Orange County Department of Social Services — Medicaid and SNAP • Social Security Administration • Partnerships with Local Business Community — CNCI has an employment program that helps members return to paid work at local businesses in the community. Our employment program helps members move toward economic stability and independence. Our local business partners in our Transitional Employment Program include: • Town of Carrboro • Cafe Driade • Open Eye Cafe • National Mail Service • Supported Education — We assist members in their educational pursuits through our Supported Employment. As examples, we offer assistance with application process and getting connected with the Disabilities Office. Some of these partners include: • Durham Tech • Central Carolina Community College • University of North Carolina • Job Link • Orange County Literacy Council • Community Empowerment Fund • Academic and Community Education Partnerships - We partner with students and community members to educate the public and future mental health providers about living with mental illness, the mental health system, the Clubhouse Model and dismantling stigma. We have an ongoing relationship with the University of North Carolina and are part of the academic curriculum for numerous departments, hosting many interns throughout the year at the Clubhouse. This relationship is beneficial to the students who gain relevant and meaningful experiences to facilitate their classroom learning as well as to our members who PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 11 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION are social practitioners imparting knowledge to students and develop positive relationships. We also speak to civic and community organizations. Some of these partners include: ■ University of North Carolina • Occupational Therapy • School of Nursing • Medical School • Psychology • Dental School • School of Social Work • School of Public health o School of Journalism • Allied health — Rehabilitation Counseling • UNC Student Affairs ■ North Carolina State University o School of Social Work (Masters and Bachelors Programs) ■ Community Education Partnerships / Collaborations • Crisis Intervention Training — CIT • Police Academy • The Johnson Service Corps o Churches • Civic Groups • Local Business Community — Over 50 Contacts for Job Development ■ Research • University of Massachusetts School of Medicine • University of North Carolina • Veterans Administration (VA) • Clubhouse International • Advocacy Partnerships - CNCI works to raise awareness about the needs of individuals navigating the mental health system on a local, state, and national policy level. By partnering with others we create a unified voice for change. Some of these partners include: • North Carolina Clubhouse Coalition (NCCC) • United States Clubhouse Coalition • Caramore Community, Inc. • Josh's Hope Foundation • Alberta Services • Threshold • NAMI -NC • Annual Legislative Breakfast • NC Council of Community Programs • State Consumer Family Advisory Council (CFAC) PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 12 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • Local, State, and Federal Government — CNCI works with various local, state and Federal entities to advocate for positive changes in the rules, regulations and treatment of persons living with mental illness. Some of these partners include: ■ Orange County, Town of Chapel Hill, and Town of Carrboro • Managed Care Organizations (MCOs) — Cardinal and Alliance • Centers for Medicare and Medicaid (CMS) • NC Department of Health and Human Services including Division of Mental Health and Division of Medical Assistance Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? Priorities Addressed by Club Nova: Critical Safety Net, Health and Nutrition, and Quality of Life The Clubhouse Model is one of the most comprehensive, integrated programs in the United States offering persons with mental illness access to the supports and opportunities needed to rebuild their lives. Club Nova addresses the risks of mental illness while providing supports and opportunities to live meaningful lives of one's choice in the community. Specifically, we provide the following: • Community Support Assistance in accessing and navigating quality healthcare. Addresses shorter life expectancy and serious health problems. Housing supports to secure and maintain safe, affordable, dignified housing. Averts homelessness. 100 % of Club Nova members maintained housing in 2016. Crisis prevention and intervention. Saves lives and avoids costly ER and hospitalization costs. • Assistance in securing and maintaining benefits and entitlements. Provides more economic security. • Health and wellness with nutritious, affordable meals that are prepared by members and staff. Addresses hunger and helps mitigate health problems. • Outreach. Combats isolation and reduces risk of crisis, ER visits, and hospitalization. • Transportation. Essential in members accessing Club Nova and the full range of opportunities and supports. • Employment. Addresses high unemployment for our members and increases economic security. • Supported Education. Addresses education that has been interrupted by mental illness. • Work Ordered Day. Provides a sense of community, common purpose, and opportunities to contribute. Builds confidence, self- worth, and skills. • Evening /Weekend /Holiday Program. Addresses isolation and social connectedness. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. GOALS AND PRIORITIES CLUB NOVA ADDRESSES Orange County Board of County Commissioners: Supporting affordable housing; providing affordable and healthy meals; providing transportation to low income residents living with mental illness especially those unable to access PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 13 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION public transportation; bridging the gaps in quality of aging and mental health; connecting students to community colleges; meeting a living wage for all staff Town of Chapel Hill Town Council: Supporting affordable housing and healthcare; Jobs and jobs training, and education supports; Affordable and healthy food options; Increased access to services through coordination and communication; Increased community engagement. Town of Carrboro Board of Aldermen: Enhance and sustain quality of life /place for everyone. Maintain Carrboro's unique identity. The following match the Direction of County Commissioners, Carrboro Board of Aldermen, and Chapel Hill Town Council: The mission of Club Nova is unique and serves a vulnerable population. We provide a critical social safety net and address the needs of persons living with severe and persistent mental illness. Geographically, we ensure Club Nova is available and accessible to residents throughout Orange County, including Carrboro, Chapel Hill, Hillsborough, Cedar Grove, Efland, Hurdle Mills, and Mebane. Local government funds are essential to fulfilling our mission. Club Nova is effective in helping a vulnerable population access county and other services. Risks of Serious Mental Illness According to the National Alliance on Mental Illness, 1 in 4 adults experience a mental health disorder in a given year and one in 17 live with a serious mental illness. With a population of approximately 139,694, the target population of people with serious mental illness in Orange County is 8,217. Mental Illness threatens lives everywhere: suicide claims a life every 30 seconds. Every day, nearly 3,000 people in the world — almost 1 million each year — commit suicide. For every person who succeeds in committing suicide, there are at least 20 more who try. Worldwide, suicide causes more deaths each year than homicide or war.' People living with mental illness are at risk for crisis, repeated hospitalization, ER visits, homelessness, and involvement in the legal system. The life expectancy of people living with serious mental illness is 25 years shorter than the general population. Newer data suggests a 30 -40% reduction in potential life- years. A high prevalence of co- occurring medical conditions exists. While mitigating the symptoms of mental illness, psychiatric medications along with other factors, often result in serious health conditions including weight gain, diabetes, and cardiovascular and respiratory disease. Access to quality health care and navigating the health care system is critical. According to the Orange County Homeless Count January 27, 2016, the total homeless count was 70 for those 18 and over. Out of that total, 14 had serious mental illness. In the prison system, 24% of those incarcerated in state prisons and 21% incarcerated in local jails have a recent history of a mental health disorder. The onset of mental illness is often early adulthood. Mental illness interrupts relationships, education, employment, and economic stability. The majority of Club Nova members live well below the poverty threshold with a monthly income of —$733 per month. Preliminary research indicates 44% of individuals with SMI are food insecure while the national rate for the general population is just over 14 %. Over the past decade, national unemployment rates for adults living with SMI have increased to as high as 90 %. This scenario exists despite studies showing that adults living with mental illness want to work, and that 60% can succeed with appropriate support. Inadequate funding and resources present significant barriers to receiving treatment that is proven to help PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 14 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION ameliorate symptoms, lower dependence on tax dollars and improve quality of life for the person and the family. Its chronic nature means life -long treatment and vigilance. People living with serious mental illness need trusting relationships, social connections, supports, and opportunities to avert isolation, unnecessary hospitalizations, homelessness, and involvement with the legal system. Assistance in navigating the complex healthcare and benefits systems is essential. People living with serious mental illness need opportunities for education and employment to mitigate the social and economic impact of mental illness. In order to have quality staff, Club Nova is seeking to ensure even our part -time transportation staff have a living wage. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Club Nova works with Orange County adults living with serious mental illness (SMI), primarily schizophrenia and bipolar disorder. All members are beneficiaries. Beneficiaries are identified through outreach, community education, other providers and organizations, families, and members of the community. Our referral process ensures that Club Nova is preserved for the intended beneficiaries — adults living with serious mental illness. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) All staff must have the following trainings in order to maintain our Mental Health License, be accredited by CARF, and in order to bill for Medicaid services: • CPR and First Aid —Annually • Client Rights • Confidentiality • HIPAA • Infectious Diseases and Bloodborne Pathogens • Alternatives to Restrictive Intervention and Crisis Management The following are our key staff related to the program and their credentials: • Karen Kincaid Dunn, Executive Director, BA, QP, 32 years of direct mental health experience • Steven Warnock, Associate Director of Program, MDiv, QP, 10 years of direct mental health experience Volunteers go through a Club Nova orientation, and are trained directly by an Associate Director and members. They are required to have confidentiality and Clubhouse Model trainings. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Implementation Timeline: Club Nova has been fully operational for 29 years. • We are open six days per week and all major holidays on the holiday. We are open 54 + hours per week. • Community Supports are provided on a daily, ongoing, and as needed basis. PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 15 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • Nutritious, Affordable Meals: 5 Breakfasts (Mon -Fri), 6 Lunches (Mon -Sat), 2 Dinners (Mon & Thurs), Holiday Meals. Serve 12,000 + meals annually. Members are involved in planning and preparation. • Employment, Supported Education, and Outreach are provided on a daily, ongoing basis. • Transportation: Operates two routes a day (morning and evening) Mon -Sat and major holidays. • Work Ordered Day operates Mon -Fri 8 AM -6 PM and Sats 10 AM -4 PM. • Evening, Weekend, Holiday Program is provided on Thurs 4 PM -8 PM and Sat typically from 11AM- 4 PM. Holiday hours vary depending on the holiday. We are typically open 5 hours on holidays. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) The lesson that is repeatedly reaffirmed is that relationships, inclusion, and opportunities are interwoven with and at the heart of a healthy community. Club Nova can serve a member for an entire year, for what it cost for less than a week in the hospital. There is a positive impact on alleviating human suffering that people with mental illness are at risk for such as suicide, homelessness, incarceration hospitalization and isolation Evidence substantiates the fact that clubhouses provide communities with a cost effective solution for dealing with the devastating impact that mental illness has on society, and for helping people living with serious mental illness achieve their full potential in their communities. "As we attempt to affirm what we know from our moral princples – that we are all in this together and if anybody is diminished, if anybody is left behind, if anybody is marginalized, then we are all diminished —I hope we can commit to making that something we live by. It is something Club Nova embodies every day." -- NC Congressman David Price j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. We are filling a critical need in our community that would otherwise go unmet. Club Nova requires a healthy blend of public and private dollars. We are in need of more robust local funding given the challenges in the NC Mental Health System. Without county and municipal funds, Club Nova would have to lay off staff and reduce the number of members accepted and served which would cause our program and members to suffer. North Carolina has one of the lowest reimbursement rates for Clubhouses of any other state in the nation. In a national survey conducted by the University of Massachusetts School of Medicine, representing 30 states, the average hourly reimbursement rate is $23.96 per hour. The hourly reimbursement rate in NC is $10.76. With the continuing changes in mental health, Club Nova has stepped up to meet more of the critical needs of members that historically other services were available to help support. Additionally, services we used to be reimbursed for have been eliminated or now have exclusions that result in Club Nova providing in excess of $100,000 in services that are not reimbursed. This amount does not include the elimination of state funding for our Employment Program. Our Employment Program with job development, job training, and ongoing support is an essential facet of Club Nova. k) Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 16 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information 1) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Gender Male Female Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify _Hispanic Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51+ years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Actual Estimated Projected 2015 -16 2016 -17 2017 -18 78 82 86 31 34 37 109 116 123 18 20 22 0 0 0 1 2 2 86 88 92 0 0 0 5 6 7 109 116 123 5 6 7 104 110 116 109 116 123 0 0 0 4 4 4 55 59 63 54 57 60 109 116 F 123 0 0 0 4 4 4 2 2 2 0 0 0 14 14 16 37 41 44 41 44 46 10 10 10 1 1 1 0 0 0 Total I 109 116 123 PROGRAM INFORMATION 2/9/2017 1:51:06 PM P a g e 1 7 o f 2 6 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (�jpecific, Measurable, Achievable, Relevant, and Time - bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly /disabled residents.) • Program Goal should explain what the program is trying to achieve /accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday- Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Club Nova Community, Inc 1. Program Activity Name Club Nova offers a round trip ride for members throughout Orange County six days a week, and on holidays. Transportation is offered with no out -of- pocket charge to members. Club Nova's transportation service ensures each member has equal access to all of our opportunities. Club Nova transportation serves members who live in areas not accessible to public transportation or are unable to utilize the bus system for various reasons (including symptoms related to diagnoses like paranoia) and need viable transportation to Club Nova. Club Nova transportation staff receives necessary training and certification. Staff maintains vehicles. Program Goal Club Nova will maintain a full transportation program that employs and trains 100% of a team of drivers, maintains its vehicles, and provides our membership with approximately 60,000 miles of transportation to and from Club Nova (plus socials and occasional medical appointments) throughout Orange County six days a week and on all major holidays. Performance Measures Club Nova will: • Maintain logs in each vehicle to track ridership and mileage for all trips • Maintain vehicle logs, tracking overall mileage and gas expenditures • Document of certification of all trainings received by drivers (in CPR, AED, 1st Aid, Blood Borne Pathogens, etc.) • Maintain log of social and community events attended by Club Nova members through Club Nova transportation Previous Year Program Results Club Nova provided 61,560 miles of unreimbursed transportation services to members. • 100% of members had access to our transportation services and therefore had access to the rest of our services. (0% were unable to participate due to lack of transportation.) • 80% of Club Nova members utilized transportation opportunities. PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 18 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 19 of 26 • 100% of drivers attended all needed trainings. • Transportation continued to facilitate enhanced engagement by members in the larger community. Current Year Estimated Results Club Nova will provide approximately 60,000 miles of unreimbursed transportation services to members. • 100% of members will have access to our transportation services and therefore have access to the rest of our services. (0% will be unable to participate due to lack of transportation.) • 80% of Club Nova members will utilize transportation opportunities. • 100% of drivers will attend all needed trainings. • Transportation will continue to facilitate enhanced engagement by members in the larger community. Next Year Projected Results Club Nova will provide approximately 60,000 miles of unreimbursed transportation services to members. • 100% of members will have access to our transportation services and therefore have access to the rest of our services. (0% will be unable to participate due to lack of transportation.) • 80% of Club Nova members will utilize transportation opportunities. • 100% of drivers will attend all needed trainings. • All drivers will receive a "living wage" of at least $13.15 per hour • Transportation will continue to facilitate enhanced engagement by members in the larger community. 2. Program Activity Name Club Nova offers the spectrum of services to ACTT members regardless of our ability to receive payment for these services, due to ACTT /PSR exclusion, which amounts to roughly $110,000 annually. Club Nova actively collaborates with the ACTT providers to coordinate care and ensure the health and safety support of these members. Program Goal 20 current members who receive Assertive Community Treatment Team (ACTT) non - billable services (typically those members that experience the most disabling effects of mental illness) will continue to receive full access to the supports and opportunities provided by Club Nova. Performance Measures Club Nova will: • Monitor our provision of services to ACTT members through calculating monthly participation and attendance hours. • Write monthly service notes on each member receiving ACTT services. Previous Year Program Results 100% of Club Nova members who received ACTT services, maintained their Club Nova membership, and received supports and services provided through Club Nova. Current Year Estimated Results 100% of Club Nova members who receive ACTT services will maintain their Club Nova membership, and receive supports and services provided through Club Nova. Next Year Projected Results 100% of Club Nova members who receive ACTT services will maintain their Club Nova membership, and receive supports and services provided through Club Nova. 3. Program Activity Name Club Nova builds relationships with businesses throughout the county, resulting in structured Transitional Employment (TE) sites. We provide on -site training and support, absence coverage, job skill development, transportation to and from, and ongoing communication with the employers. Club Nova also assists with skill - building and educational opportunities, PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 19 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 20 of 26 resume writing, benefit counseling and goal - planning. We hold a weekly employment support meeting with employment staff to go over goals, progress and skills. Program Goal 40 Club Nova members will return to paid employment in the community through our Transitional and Supported Employment (SE) program. Performance Measures Club Nova will: • Maintain logs of member participation in employment programs • Maintain logs of members attending weekly Employment meetings •Maintain logs of the number of TE & SE sites available through Club Nova Previous Year Program Results 100% of Club Nova members had access to our TE and SE services, as well as, educational and /or job skills opportunities. 45 members returned to paid employment through these supports. These services led to the following outcomes: • Increased financial stability & independence • Increased self- esteem • Reduced community stigma • Increased member civic engagement Current Year Estimated Results 100% of Club Nova members will have access to our TE and SE services, as well as, educational and /or job skills opportunities. An estimated 45 members will return to paid employment through these supports. These services will lead to the following outcomes: • Increased financial stability & independence • Increased self- esteem • Reduced community stigma • Increased member civic engagement Next Year Projected Results 100% of Club Nova members will have access to our TE and SE services, as well as, educational and /or job skills opportunities. At least 48 members will return to paid employment through these supports. These services will lead to the following outcomes: • Increased financial stability & independence • Increased self- esteem • Reduced community stigma • Increased member civic engagement 4. Program Activity Name Club Nova provides high - quality programming related to housing, employment, wellness and social engagement to members living in Orange County and the townships within. Club Nova maintains necessary staff to execute programming. Program Goal Club Nova will operate six days a week, 54 -60 hours per week and on all major holidays, to provide our members the full range of programming and safety -net services, such as housing support, crisis prevention and intervention, and access to healthcare, inherent in a Clubhouse Model. Club Nova will: *Ensure housing supports to secure and maintain safe, affordable, dignified housing for members, and to avert homelessness. • Provide crisis prevention and intervention to save lives and avoid costly ER and hospitalization costs. • Assist in accessing and navigating quality healthcare, including access to primary care. Performance Measures Data on our general operating costs are maintained in our financial books. We will track costs of utilities, payroll, and other daily supplies via receipts and Quickbooks to reflect the basic expenses of Clubhouse programming. We will keep record of all paper invoices /receipts. PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 20 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 21 of 26 Club Nova will keep records and statistics via our member database and progress notes. Club Nova will: • Track the housing security of membership • Track hospitalization and re- hospitalization of members • Survey members, yearly, on housing security, hospitalization, access to healthcare including primary care, dentistry, and supportive care. Previous Year Program Results Club Nova was open 6 days a week, 54 -60 hours per week, and had the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance), and necessary programming supplies and training. Current Year Estimated Results Club Nova will remain open 6 days a week, 54 -60 hours per week, and will have the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance), and necessary programming supplies and training. The following are estimated for the year: 90% of Club Nova members will report having safe, secure, and affordable housing, with 0% homelessness. 80% of Club Nova members will report no re- hospitalization due to psychiatric concerns. 100% of Club Nova members will report access to healthcare with 50% reporting access to primary care. Next Year Projected Results Club Nova will remain open 6 days a week, 54 -60 hours per week, and will have the necessary assistance to pay the cost of utility bills, staff compensation and benefits (including payroll taxes and insurance), and necessary programming supplies and training. 90% of Club Nova members will report having safe, secure, and affordable housing, with 1% homelessness. 80% of Club Nova members will report no re- hospitalization due to psychiatric concerns. 100% of Club Nova members will report access to healthcare with 50% reporting access to primary care. 5. Program Activity Name Club Nova partners with local food organizations to secure approximately 750 pounds of fresh, local produce and meat monthly. Members and staff cook from scratch and address individual dietary needs in our meals. Club Nova members and staff prepare and serve 13 meals per week. Members are be given opportunities to engage in every step of the process, including menu planning, grocery shopping, cooking and cleaning. Club Nova uses its garden as an educational and wellness activity and engages community experts for workshops and trainings related to wellness. Staff work closely with members who have individual goals specifically related to healthy eating and increased wellness to ensure they have the supports needed. Program Goal Club Nova will address food insecurity and diet related disease by providing at least 12,000 healthy, affordable meals, engaging at least 80% of membership in Clubhouse meals, and providing education and training related to cooking, nutrition, obtaining and growing food. Performance Measures Club Nova will: • Maintain records of the number of meals served daily. • Maintain daily records of individuals eating at the Clubhouse. • Survey its membership yearly to evaluate the achieved health and food PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 21 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 22 of 26 security benefits of our healthy, affordable meal program and nutrition education. • Staff will closely monitor specific individuals' wellness goals through progress notes. Previous Year Program Results 100% of Club Nova members had access to an average of 13 healthy, well - balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with 11,100 meals served for the year. 80% of Club Nova members participated in meals. This service led to: • Decreased food insecurity for members • Increased knowledge of culinary skills, nutrition, and gardening • Increased knowledge in the health benefits related to a healthy diet • Decreased incidence of nutrition - related diseases Current Year Estimated Results 100% of Club Nova members will have access to an average of 13 healthy, well - balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with an estimated 12,000 meals served for the year. An estimated 87% of Club Nova members will participate in meals. This service will lead to: • Decrease in food insecurity for members • Increase in knowledge of culinary skills, nutrition, and gardening • Increase in knowledge in the health benefits related to a healthy diet • Decrease in incidence of nutrition - related diseases Next Year Projected Results 100% of Club Nova members will have access to an average of 13 healthy, well - balanced meals each week (5 breakfasts, 6 lunches and 2 dinners), with 12,500 meals served for the year. At least 85% of Club Nova members will participate in meals. This service will lead to: • Decrease in food insecurity for members • Increase in knowledge of culinary skills, nutrition, and gardening • Increase in knowledge in the health benefits related to a healthy diet • Decrease in incidence of nutrition - related diseases PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 22 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants o Other Revenue Expenditures o Compensation o Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 100% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 23 of 26 Actual 2015 -16 Estimated 2016 -17 Projected 2017 -18 Total Cost of Program 777,352 839,792 881,000 Total # of Individuals 109 116 123 Cost Per Individual 7132 7240 7163 PROGRAM INFORMATION 2/9/2017 1:51:06 PM Page 23 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'SeO T- S�IDEez4GENCY APPLICATION Operating Budget for Entire Agency AGENCY NAME: Club Nova Community, Inc. AGENCY REVENUE Private Donations Agency Generated Revenue (fees) Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Agency Revenue AGENCY EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Include the following: Payroll taxes, Benefits, Consulting /professional services, Legal counsil, IT, accreditation and certification, dues and memberhsip Total Agency Expenses SURPLUS/(DEFICIT) FOR PERIOD: 1 $ 5,1151$ 3,698 1 $ 7,990 1 116% FY 2015 -16 Comparative Agency Budget Revised 9/29/2014 Actual 2015 -16 Estimated 2016 -17 Projected .2017-18: Percent Change $ 93,088 $ 100,000 $ 100,000 0% $ 440,452 $ 467,000 $ 477,000 2% $ 10,500 $ 13,500 $ 20,000 48% $ - $ - $ _ 0 $ 9,500 $ 16,000 $ 20,000 25% $ - $ - $ - 0 $ 75,000 $ 95,000 $ 120,000 26% $ - $ - $ - 0 $ - $ _ $ - 0 $ 56,676.91 $ 44,990.00 $ 44,990.00 $ - $ _ $ _ $ - 0 $ - $ _ $ _ 0 $ 29,251.24 $ 15,500.00 $ 15,500.00 $ _ $ 68,000 $ 91,500 $ 91,500 $ - $ $ 782,468 412,949 $ $ 843,490 468,792 $ $ 888,990 500,000 5% 7% $ 34,008 $ 36,000 $ 37,000 3% $ 62,091 $ 65,000 $ 67,000 3% $ 49,576 $ 50,000 $ 52,000 4% $ $ 218,728 777,352 $ $ 220,000 839,792 $ $ 225,000 881,000 2% 5% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ 5,1151$ 3,698 1 $ 7,990 1 116% FY 2015 -16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - O.C. Funding for Transportation PROGRAM REVENUE Private Donations Program Generated Revenue Local Governmont Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBG /HOME /etc.) Private Foundation Grants $ 29,053 $ $ $ $ $ $ $ $ $ $ $ $ $ Other Revenue Total Program Revenue 5 201.6 -17 2017 =98 Change $ - $ - 0 $ - $ - 0 $ - $ - 0 $ - $ - 0 $ - $ - 0 $ - $ - 0 50,000 $ 50,000 $ 65,000 30% $ - $ - 0 $ - $ - 0 $ 50,000 1 $ 50,000.1 $ 65,000 I 30 PROGRAM EXPENSES Compensation: Drivers, living wage increase, transportation coordinator Rent & Utilities Supplies & Equipment: Vehicle expenses /maintanance Travel & Training Other Expenses: Total Program Expenses $ 29,053 $ 42,000 $ 58,038 38% $ - $ - $ - 0 $ 30,163 $ 32,000 $ 35,000 9% $ - $ - $ - 0 $ - $ - $ - 0 $ 59,216 $ 74,000 $ 93,038 26% SURPLUSI(DEFICIT) FOR PERIOD: 1 $ (9,216) $ (24,000) $ (28,038) -17% We hired another staff for transortation coordinator and want to be Orance County Living Wage Certified which entales an increase for drivers DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - Oange County Funding -PSR Services -ACTT Members Actual I Estimated ' I Projected Prrrcent PROGRAM REVENUE mis-16 2016:17 2017 18 Ch'anaw Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants $ $ $ $ $ $ $ $ $ $ $ $ $ - $ - $ - $ - $ - 0 „ � 0 � llf a Other Revenue : MCO County Allocations for ACTT j $ 68,000 1 $ 68,000 1 $ 68,000 1 $ - Total Program Revenue I $ 83,000 I $ 83,000 I $ 83,000 ! 0% PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: # of hours at PSR Reim. Rate Total Program Expenses 1 $ - $ - 0 - $ - $ - 0 - $ - $ - 0 - $ - $ - 0 Other Revenue : MCO County Allocations for ACTT j $ 68,000 1 $ 68,000 1 $ 68,000 1 $ - Total Program Revenue I $ 83,000 I $ 83,000 I $ 83,000 ! 0% PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: # of hours at PSR Reim. Rate Total Program Expenses 1 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ 93,270 $ 108,000 $ 125,000 16% $ 93,270 $ 108,000. $ 125,000 16% SURPLUSI(DEFICIT) FOR PERIOD: $ (10,270) $ (25,000) $ (42,000) -68% DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program AGENCY NAME: Club Nova Community, Inc. - Orange County Funding for Employment AGENCY REVENUE Private Donations Agency Generated Revenue (fees) I Local Government Grants: Human Services - Town of Carrboro I Other - Town of Carrboro $ Human Services - Town of Chapel Hill $ Other - Town of Chapel Hill $ Human Services - Orange County $ Other - Orange County $ Other - Town of Hillsborough $ Other Government Grants Triangle United Way $ State Government $ Federal Government (CDBG/HOMEIetc.) $ Private Foundation Grants $ Other Revenue Total Agency Revenue 1 $ 10,000 $ 159000 1 $ 20,000 1 33% AGENCY EXPENSES Compensation - Salaries, FICA, Fringe Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Agency Expenses $ 35,145 $ 41,000 $ 54,342 33% $ - $ - $ - 0 0 $ - $ - 0 $ - $ - � ��f •, Mfr $ - $ - $ - 0 $ 3.5,145 $ 41,000 1 $ 54,342 Total Agency Revenue 1 $ 10,000 $ 159000 1 $ 20,000 1 33% AGENCY EXPENSES Compensation - Salaries, FICA, Fringe Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Agency Expenses $ 35,145 $ 41,000 $ 54,342 33% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ 3.5,145 $ 41,000 1 $ 54,342 33 %0 SURPLUS /(DEFICIT) FOR PERIOD: FY 2015 -16 Comparative Agency Budget Revised 9/29/2014 $ (25,145) $ (26,000) $ (34,342) -32% DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - Orange County Funding for Critical Safety Net PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM E=XPENSES $ - $ - $ - 0 Is - $ - $ - 0 $ 10,000 $ 13,500 $ 20,000 48% $ - $ - $ - 0 $ 9,500 $ 16,000 $ 20,000 25% $ - $ - $ - 0 $ - $ 10,000 $ 20,000 100% $ - $ - $ - 0 _ d. _ It _ n $ 19,500 I `$ 39,500 I $ 60,000 52 Compensation: include Living Wage Increase Rent & Utilities Supplies & Equipment: Food and Provisions Travel & Training Other Expenses: Total Program. Expenses $ 412,949 $ 468,792 $ 500,000 7% $ - $ - $ - 0 $ 30,207 $ 32,000 $ 35,000 9% $ - $ - $ - 0 $ - $ - $ - 0 $ 443,156 $ .500,792 $ 535,000- 7% SURPI_USI(DEFICIT) FOR PERIOD; 1 $ (423,656) $ (461,292) $ (475,000) -3% DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Infc. - Carrboro Funding for Critical safety net, Health and Wellness PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation: Only includes Culinary Unit Leader Salary, but all staff privide this servise Rent & Utilities Supplies & Equipment: Food and Provisions Travel & Training Other Expenses: Total Program Expenses SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (53,361) $ (52,154) $ (50,000) 4750 Actual 2015 =16 Estimated.': 201647 Projected 2017 718 :Percent..... Change $ - $ - $ - 0 $ - $ - $ - 0 $ 10,500 $ 13,500 $ 20,000 48% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ $ 10,500 33,654 $ $ 13,500 33,654 $ $ 20,000 35,000 48% 4% $ - $ - $ - 0 $ 30,207 $ 32,000 $ 35,000 9% $ - $ - $ - 0 $ - $ - $ - 0 $ 63,86'1 $ 65,654 $ 70,000 7% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (53,361) $ (52,154) $ (50,000) 4750 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME Club Nova Community, Inc. - Chapel Hill Funding for CNCI Critical Safety Net PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (397,852) $ (823,792) $ (411,000) 50% Actual:' 2015-16 Estimated 2016 -17 Projected 2017 -18 Percent Change $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ 0 $ - $ - $ 0 $ 9,500 $ 16,000 $ 20,000 25% $ - $ - $ 0 $ - $ - $ 0 $ - $ - $ 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 Is - I $ - $ - 0 $ $ 9,500 42,949 $ $ 16,000 468,792 $ $ 20,000 50,000 25% -89% $ 34,008 $ 36,000 $ 37,000 3% $ 62,091 $ 65,000 $ 67,000 3% $ 49,576 $ 50,000 $ 52,000 4% $ 218,728 $ 220,000 $ 225,000 2 % $ 407,352 $ 839,792 $ 431,000 -49% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (397,852) $ (823,792) $ (411,000) 50% DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015 -16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit /report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990 -N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F -3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax - Exemption Letter A copy of the agency's IRS tax - exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 2/9/2017 1:51:06 PM Page 24 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Occurrence $1 million Each Liability $1,000,000 Bodily $2 million Aggregate Occurrence Injury ry and Property $2 million Aggregate Damage Limit Automobile Liability Not Applicable $1 million Each Occurrence $500,000 Each Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016 -17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 2/9/2017 1:51:06 PM Page 25 of 26 DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 EXHIBIT `B" Scope of Services FY 2017 -18 Outside Agency Performance Agreement Agency Name: Club Nova Community, Inc Program Name: Club Nova Community, lnc Funding Award: $107,500 Outline how the agency will spend Orange County's funding award, Expense Description Amount Transportation (fuel, travel, etc) $67,500 Critical Safety Net $20,000 Employment (training and providing support for members to gain employment) $20,000 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2018. • Transportation: Maintain a high - quality transportation program so our members have the opportunity to attend and engage in our program and continue in the recovery process. • Members Receiving ACTT Services: Provide opportunities and support to our members who are also receiving Assertive Community Treatment Team services. • Employment: Continue to support and assist members who desire to return to paid employment in the community, The Transitional and Supported Employment Programs will maintain and strive to increase the number of placements available to members and the number of members who work in the community. Anticipated Outcomes The Anticipated Results column trust include quantifiable results in the form of number of persons /units served within Orange County, on] x (all Towns and municipalities). if you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Number of drivers certified in CPR, AED, Ist Aid, Blood borne Pathogens, Seizure Management 4 Number of members who receive ACTT services 21 Number of members supported in their effort to return to paid employment in the community 30 Oocusigned by: Exec tive Director 17 z 677U18-- 8E005F7DFD714DC... Certified by: Title: D l Date: (Provr er's ignature) DocuSign Envelope ID: 134C4810- 3CA5- 4008- 9E74- 2A07D3AECED8 ATTACHMENT "A" Orange County Certifications — FY 2017 -18 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: Docu5igned by: '^ tYU\,1' Executive Director 1/26/2018 sE005F7oFD714DC... Title: Date: (Provider's Signature) (Club Nova Community, Inc) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID: 134C4810- 3CA5- 4OC8- 9E74- 2AO7D3AECED8 OP ID: KR '4k� ° CERTIFICATE OF LIABILITY INSURANCE 0501 � DATE 0710512017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERIS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 15 WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endarsemen s . PRaaucER CITIZENS INSURANCE AGENCY P 0 BOX 109 HENDERSON, NC 27536 House AccountlJoel T. Cheatham MP Kim Rhodes FAX .2524$2.4061 (AIC. Hal* „ ss, kim nca ent.com aR cusTOMEgIppoCLUBN-2 INSUR a AFFORDING COVERAGE KAIC a INSURSO Club Nova Community, Inc. INSUFMA:PHILADELPHIA INSURANCE CO EACH OCCURRENCE P.O. Box 1346 Carrboro, NC 275104346 INSURERB, X COMMERCIAL GENERAL LIABILITY X CLAIMS#LAOE U OCCUR INSURER(: INSUIUM D 0710112017 07/0112018 IROURO E: s 300,00 LIED EXP lAny an INSURER F! X Retro 5113106 COVERAGES CERTIFICATE NUMBER! RFVLRInN 14"URFR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. M�Se TYPEOFINSURANCi Hausa Accou Joel T. Cheatham POLICY NUMUR LIMITS QUIRAL LIABRrrY EACH OCCURRENCE s 11000,0 A X COMMERCIAL GENERAL LIABILITY X CLAIMS#LAOE U OCCUR PHPKI679290 0710112017 07/0112018 PR s 300,00 LIED EXP lAny an 3 6,00 X Retro 5113106 PERSOWL3ADVINJURY s 11000100 GENERALAGGREGATE s 3.000,0 GENL AGGREGATE LIMIT APPLIES PER: X POLICY PRO- I 1 LOC PRODUCTS - COMPIOP AGG S 3,000,00 S B AUTOMOBILE LIABILITY X ANY AUTO HPKI672290 0710112017 0710112018 COMBINED SINGLE LOAT IEa I` 1 f 1,000,04 BOOILYINJURY(Perpamm) s ALL OWNED AUTOS BODILY INJURY (Par Kddord) f B SCHEDULED AUTOS X HIRED AUTOS PHPK1679290 0710112017 07/01/2018 PROPERTY DAMAGE (PER ACCIDENT} s B X NON*WNEDAUTOS PHPKIS79290 0710112017 0710112018 IMedPay s 5,00 UMIUIM s 500,00 UMBRELLA UAB OCCUR EACH OCCURRENCE 9 AGGREGATE S EXCESS LIAM CLVMS4AAOE DEDUCTIBLE S i RETENTION 3 WORKERS COMPENSATION V,ICSTATU OTH• AND EMPLOYERS' LUIBLM YON AMY PROPRIETORJPARTNEMWECUTNE OFFKMWEMBER EXCLUDED? � N J A E L EACH ACCIDENT f E.L DISEASE .EA EMPLOYEE f (Msndatory InNH) sa to utder er PTION E Ti E.L DISEASE - POLICY LWMT S A Llab. i PHPKIS79290 07101/2017 0710112018 EachClalm 1,000,00 rrof*33ional laims Made I O 6113106 Aggregate 3100010 DESCFJPMN Of OPERATIONS J LOCATIONS I VENICLSS (AMeeA ACORD 10I. AdNtlatsl ponds SshaWk, B mom apses Is mgmindl CERTIFICATE HOLDER CANCFI I ATInm D 1988 -2004 ACORD CORPORATION. All rights reserved. ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE QESCPMW POLICIES BE CANCELLED BEFORE Orange County 200 S Cameron St THE WITHTH POLICYPROVISIWNS. BE QELNEREQ IN Hillsborough, NC 27278 AUTOO REP ATNE Hausa Accou Joel T. Cheatham D 1988 -2004 ACORD CORPORATION. All rights reserved. ACORD 26 (2009109) The ACORD name and logo are registered marks of ACORD