HomeMy WebLinkAbout2021-430-E-Aging-Home and Community Care Block Grant for adults-Triangle J Council of Government
DAAS -730
(Rev. 4/2019)
Home and Community Care Block Grant for Older Adults
County Funding Plan
Identification of Agency or Office with Lead Responsibility for County Funding Plan
County ORANGE__________________ July 1, _2021___ through June 30,
___2022__
The agency or office with lead responsibility for planning and coordinating the County
Funding Plan recommends this funding plan to the Board of Commissioners as a
coordinated means to utilize community-based resources in the delivery of
comprehensive aging services to older adults and their families.
ORANGE COUNTY DEPARTMENT ON AGING
(Name of agency/office with lead responsibility
Authorized signature (date)
JANICE TYLER, DIRECTOR
(Type name and title of signatory agent)
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
TJAAA Form, rev April 2017
CERTIFICATION OF REQUIRED MINIMUM LOCAL MATCH AVAILABILITY
Date: JULY 2021 Fiscal Year: FY 21-22
Agency: ORANGE COUNTY DEPARTMENT ON AGING
Service: SENIR CENTER OPERATION, CONGREGATE NUTRITION, INFORMATION AND CASE ASSISTANCE, IN
HOME ADIE LEVEL II- PERSONAL CARE, ADULT DAY CARE , ADULT DAY HEALTH
Itemization of Commitment:
Required Local Match (total must agree to amount in the Funding Plan)
1. Cash of: $11,277 provided by: ORANGE COUNTY
Cash of: $16,016 provided by: ORANGE COUNTY
Cash of: $29,744 provided by: ORANGE COUNTY
Cash of: $12,905 provided by: ORANGE COUNTY
Cash of: $1,112 provided by: ORANGE COUNTY
Cash of: $5,576 provided by: ORANGE COUNTY
2. Total Local Match: $76,628
It is understood that funds committed as required minimum local match will be used to match the Home and
Community Care Block Grant appropriation and will not be used to match any other federal or state funds during
the contractual period.
Print Name and Title: JANICE TYLER DIRECTOR, DEPARTMENT ON AGING
Signature: __________________________________________________________________________________
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
DAAS-731 (Rev. 2/16)
Home and Community Care Block Grant for Older Adults
County___________________ORANGE
County Funding Plan July 1, _2021______ through June 30, ___2022___
County Services Summary
A B C D E F G H I
Projected Projected Projected Projected
Block Grant Funding Required Net NSIP Total HCCBG Reimbursement HCCBG Total
Services Access In-Home Other Total Local Match Service Cost Subsidy Funding Units Rate Clients Units
Senior Center Operation -$ -$ 101,494$ 101,494$ 11,277$ 112,771$ -$ 112,771$ 205,000 0.5501$ 2,700 205,000
Congregate Nutrition -$ 144,142$ -$ 144,142$ 16,016$ 160,158$ -$ 160,158$ 21,000 7.6266$ 800 21,000
Information & Case Assistance 267,688$ -$ -$ 267,688$ 29,743$ 297,431$ -$ 297,431$ - -$ 1,000 -
In-Home Aide-Level II - Personal Care -$ 116,141$ -$ 116,141$ 12,905$ 129,046$ -$ 129,046$ 8,962 14.3992$ 10 8,962
Adult Day Care -$ 10,000$ -$ 10,000$ 1,111$ 11,111$ -$ 11,111$ 302 36.7914$ 302 302
Adult Day Health -$ 50,184$ -$ 50,184$ 5,576$ 55,760$ -$ 55,760$ 1,302 42.8264$ 1,302 1,302
0 0 0 0 -$ -$ -$ -$ - -$ -
Total 267688 320467 101494 689649 76628 766277 0 766277 236566 6114 236566
Signature, County Manager Date
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
8/4/2021
Home and Community Care Block Grant for Older Adults
DAAS-732
County Funding Plan County:
July 2021 through June 2022
Provider Services Summary Date:
B C D E F G H I
Block Grant Funding
Services Direct Purchase Access In-Home Other Total
Senior Center Operation -$ -$ 101,494$ 101,494$ 11,277$ 112,771$ -$ 112,771$ 205,000 0.5501$ 2,700 205,000
HDM to Congregate Clients/Delivery/Carry Out -$ 144,142$ -$ 144,142$ 16,016$ 160,158$ -$ 160,158$ 21,000 7.6266$ 800 21,000
Information & Case Assistance 267,688$ -$ -$ 267,688$ 29,743$ 297,431$ -$ 297,431$ - -$ 1,000 -
In-Home Aide-Level II - Personal Care -$ 116,141$ -$ 116,141$ 12,905$ 129,046$ -$ 129,046$ 8,962 14.3992$ 10 8,962
Adult Day Care -$ 10,000$ -$ 10,000$ 1,111$ 11,111$ -$ 11,111$ 302 36.7914$ 302 302
Adult Day Health -$ 50,184$ -$ 50,184$ 5,576$ 55,760$ -$ 55,760$ 1,302 42.8264$ 1,302 1,302
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
Total 267,688$ 320,467$ 101,494$ 689,649$ 76,628$ 766,277$ -$ 766,277$ 236,566 6,114 236,566
ADHC
Daily Care 40.00$ Certification of required minimum local match availability.
Administrative Required local match will be expended simultaneously Authorized Signature, Title Date
with Block Grant Funding.Community Service Provider
Proj. Reimbursement Rate 40.00$
Administrative %0.00%
Signature, County Finance Officer Date Signature, County Manager Date
0.00%
Projected
HCCBG
Units
Projected
Reimburse
Rate*
Projected
HCCBG
Clients
Projected
Total Units
Required
Local
Match
Net Service
Cost
NSIP
Subsidy
Total
Funding
$33.07
Orange County
PO Box 8181
Hillsborough NC 27278
Orange
Budget Period:
Revision #:
A
(Check One)
Serv. Delivery
ADC
$33.07
*Adult Day Care & Adult Day Health Care Proj. Service Cost/Rate
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
8/4/2021 8/4/2021
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
*The forms look the same, but the user experience is completely different
Quick Summary of Improvements
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Instructions for use
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Welcome to the New Improved HCCBG Provider Packet*
Increased number of service selections available on forms (increased from 8 to 14).
Electonic copy of workbook limits need to input all new data each year, just what changed.
Worbook is set up to be a 10 year workbook, just select the fiscal year from list on the "Input" worksheet and it populates all required dates for the new
year.
Dramatic reduction in keystrokes required! When you enter information now, it automatically forwards the value to the next sheet in the packet requiring
that information.
Calculation formulas are already included throughout, including match calculations.
Useful header information; click on a header row and it describes the field name and how to complete cell or column it labels.
732A instructions: Click on row desriptors to left and header cells, instruction on how to complete section or column will show. This is a complicated
sheet, it is recommended to review video link above prior to completion. Please check for red error messages that pop up below each section and at
bottom of page.
Detail service information by level eliminates requirement of In-home supplement form.
Salary calculation for fractional FTE reduces math errros on 732A1 Labor Distribution Schedule.
Color coding of input cells. If it is tan it is calculated and locked, if it is green it will accept your input.
Entry proof and error checking… if the system detects an error it will pop up a warning message. Need a second look? make sure no errors are on the new
"Proof" worksheet.
Read the "instructions" worksheet first. For a video walkthough of the HCCBG Provider Packet Please click on the link below. GoToMeeting will request
name/email information to register. When video launches please forward through the first 1:30 of the video as the screen is black prior to the video
starting, additionally, the webinar launches in "letterbox" format, to make larger click in the presentation and select the arrows in the lower right hand
corner.
Green cells on Input tab must be completed, they are necessary to populate entire workbook. Provider will not need to complete all cells for services, only
for the number of unique HCCBG services they provide. Tan cells are formulas, so let the program fill in the values there.
Navigation throgh worksheet is left to right, progress throught the workbook completing the green shaded cells
Click on the header cells, the specific instruction on what is necessary to complete the cell will pop up when clicked.
7321A new feature: Assignable salary is calcualated based on the FTE value multiplied by the staff salary. This assigned salary must also be categorized into
Admin or one of the services selected. The "assigned salary" must match the total keyed into green cells, or an error will pop up at the end of the row.
https://attendee.gotowebinar.com/recording/1667454861360868867
Save a copy of your file, and submit an electronic copy to the county and/or COG. A signed copy of the forms is also required, but please be aware that
some forms are not printer friendly as the forms are wider to incoporate a wider service selection.
In-Home Supplement is hidden as it is no longer required by most AAAs, if your AAA requires it, you will need to right click in the tab area of the workbook
and select unhide from the box that pops up. When clicking on unhide a few worksheet names are selected you will need to select the "In-Home Svc
Supplement Worksheet."
732 instructions: Much less to complete here as most cells are populated from the 732A form, must select drop down indicator for direct or purchased
service, and HCCBG clients anticipated to be served. If you are an adult day care or adult day health provider, please populate the administrative portion at
bottom of the page, those cells are not automatcially filled.
733 Instructions: Complete green shaded text box with narrative on outreach activites you have implemented or plan to pursue.
734 form Instructions (Standard Assurances and Client Rights Assurances): Read it, sign it and submit.
Proof Sheet: will display known calculation errors or questions. Please use this form to check for internal consistency and discuss issues with county or
COG staff. Errors are displayed with a specific message, and value of calculated variance is to the right of the message.
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
State Fiscal Year:SFY 2021-2022
Provider Name:Orange County
Address Line 1:PO Box 8181
Address Line 2:Hillsborough NC 27278
County:Orange
Area Agency on Aging:Triangle J Council of Governments
Please Select Services to Be Delivered Federal/State Local Match
Senior Center Operation 170 101,494$ 11,278$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
HDM to Congregate Clients/Delivery/Carry Out 185 144,142$ 16,016$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Information & Case Assistance 040 267,688$ 29,744$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
In-Home Aide-Level II - Personal Care 042 116,141$ 12,905$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Adult Day Care 030 10,000$ 1,112$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Adult Day Health 155 50,184$ 5,576$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
Service Prior Yr. Funding Prior Year Rate Current Yr Funding Current Year Rate Funding Diff.Rate Diff.
Senior Center Operation 170 76,494$ 101,494$ 0.5501 25,000$ 0.5501$
HDM to Congregate Clients/Delivery/Carry Out 185 149,284$ 7.9000$ 144,142$ 7.6266 (5,142)$ (0.2734)$
Information & Case Assistance 040 259,514$ 267,688$ 0.0000 8,174$ -$
In-Home Aide-Level II - Personal Care 042 113,725$ 36.0400$ 116,141$ 14.3992 2,416$ (21.6408)$
Adult Day Care 030 10,000$ 33.0700$ 10,000$ 36.7914 -$ 3.7214$
Adult Day Health 155 52,108$ 40.0000$ 50,184$ 42.8264 (1,924)$ 2.8264$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
0.0000 -$ -$
Comparison of Fed/State Funding and Rates vs. Prior Year
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
<<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
AGENCY NAME:Fiscal Period: July 2021 through June 2022
State Fiscal Year:SFY 2021-2022
SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE
STAFF NAME POSITION
TOTAL
SALARY
FTE
Equivalent
FULL TIME
PART TIME
Assignable
Salary
ADMIN.
SALARY Senior Center Operation
HDM to Congregate
Clients/Delivery/Carry Out Information & Case Assistance
In-Home Aide-Level II -
Personal Care Adult Day Care Adult Day Health 0 0
Myra Austin Senior Centers Administrator 70,129$ 0.5 PART TIME 35,065$ 35,065$
Robin Bailin Program Assistant 48,404$ 0.5 PART TIME 24,202$ 24,202$
Deborah Lemmerman Office Assistant II 25,697$ 0.5 PART TIME 12,849$ 12,849$
Dawn Smith Program Assistant 43,152$ 0.5 PART TIME 21,576$ 21,576$
Latonya Brown Wellness Coordinator 53,991$ 0.5 PART TIME 26,996$ 26,996$
William Crist Passmore Site Manager 11,210$ 0.9 PART TIME 10,089$ 10,089$
Isabel Jackson Food Services Coordinator 48,714$ 1 FULL TIME 48,714$ 48,714$
James Burnett Seymour Site Manager 11,212$ 0.9 PART TIME 10,091$ 10,091$
-$
Marie Dagger Occupational Therapist 63,244$ 0.85 PART TIME 53,757$ 53,757$
Kim Lamon-Loperfido Eldercare Serv Administrator 57,000$ 0.85 PART TIME 48,450$ 48,450$
Kendall Kopchick Eldercare Manager 45,000$ 0.85 PART TIME 38,250$ 38,250$
OPEN Social Worker II 50,218$ 0.85 PART TIME 42,685$ 42,685$
Lisa Meinert Human Services Coordinator 33,957$ 0.85 PART TIME 28,863$ 28,863$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
SUBTOTAL FT:48,714$ -$ -$ 48,714$ -$ -$ -$ -$ -$ -$
SUBTOTAL PT:352,873$ -$ 120,688$ 20,180$ 212,005$ -$ -$ -$ -$ -$
TOTAL 401,587$ -$ 120,688$ 68,894$ 212,005$ -$ -$ -$ -$ -$
PERCENT FT:12.13%#DIV/0!0.00%70.71%0.00%#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
PERCENT PT:87.87%#DIV/0!100.00%29.29%100.00%#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - LABOR DISTRIBUTION SCHEDULE DAAS-732A1
Orange County
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
SERVICE SERVICE SERVICE SERVICE SERVICE SERVICE
0 0 0 0 0 0
-$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$
#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!#DIV/0!
NC DIVISION OF AGING AND ADULT SERVICES COST OF SERVICES - LABOR DISTRIBUTION SCHEDULE DAAS-732A1
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DAAS-732A
Provider:
County:
Budget Period:July 2021 through June 2022
Other In-Home
Service Service
Senior Center Operation
HDM to Congregate
Clients/Delivery/Carry Out
Grand Total 170 185
689,649$ 101,494$ 144,142$
1) 76,630$ 11,278$ 16,016$
2) -$
3) -$
76,630$ 11,278$ 16,016$
1) -$
2) -$
3) -$
Total Required Minimum Match - In-Kind -$ -$ -$
76,630$ 11,277$ 16,016$
766,279$ 112,771$ 160,158$
-$ -$ -$
-$
1) -$
2) -$
3) -$
4) -$
-$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$
-$
766,279$ 112,771$ 160,158$
Orange County
Orange
North Carolina Division of Aging and Adult Services`
Service Cost Computation Worksheet
Required Minimum Match - In-Kind
B. Total Required Minimum Match (cash + in-kind)
I. Projected Revenues
A. Fed/State Funding From the Div. of Aging & Adult Svcs.
Required Minimum Match - Cash
Total Required Minimum Match - Cash
G. Subtotal, Other Revenues, Non-Match
Local In-Kind Resources (Includes Volunteer Resources)
H. Subtotal, Local In-kind Resources, Non-Match
I. Client Cost Sharing
J. Total Projected Revenues (Sum I.C,D,E,F,G,H, & I)
C. Subtotal, Fed/State/Required Match Revenues
F. Subtotal, Local Cash, Non-Match
Other Revenues, Non-Match
D. NSIP Cash Subsidy/Commodity Valuation
E. OAA Title V Worker Wages, Fringe Benefits and Costs
Local Cash, Non-Match
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Service Service
Grand Admin.Senior Center Operation HDM to Congregate Clients/Delivery/Carry Out
Total Cost 170 185
48,714$ -$ -$ 48,714$
352,873$ -$ 120,688$ 20,180$
401,587$ -$ 120,688$ 68,894$
1) FICA @ 7.65 30,721$ -$ 9,233$ 5,270$
-$
-$
-$
-$
-$
30,721$ -$ 9,233$ 5,270$
1) -$
2) -$
3) -$
-$ -$ -$ -$
-$
-$
-$
-$
-$ -$ -$ -$
1) -$
2) -$
3) -$
4) -$
5) -$
6) -$
7) -$
8) -$
-$ -$ -$ -$
-$
Division of Aging and Adult Services
Service Cost Computation Worksheet
II. Line Item Expenses
6) Other
B. Subtotal, Fringe Benefits
Staff Salary From Labor Distribution Schedule
1) Full-time Staff (do not include Title V workers)
2) Part-time staff (do not include Title V workers)
A. Subtotal, Staff Salary
Fringe Benefits
%
Travel
2) Health Insurance
3) Retirement
4) Unemployment Insurance
5) Worker's Compensation
1) Per Diem
2) Mileage Reimbursement
3) Other Travel Cost
E. Subtotal, Travel
General Operating Expenses
Local In-Kind Resources Non-Match
C. Subtotal, Local In-Kind Resources Non-Match
D. OAA Title V Worker Wages, Fringe Benefits and Costs
F. Subtotal, General Operating Expenses
G. Subtotal, Other Administrative Cost Not Allocated in
Lines II.A through E
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
432,308$ -$ 129,921$ 74,164$
(333,969)$ 17,150$ (85,994)$
766,277$ 112,771$ 160,158$
ERROR, Sum of Services Must Equal Projected Revenues
Service Service
Grand Senior Center Operation HDM to Congregate Clients/Delivery/Carry Out
Total 170 185
766,277$ 112,771$ 160,158$
205,000 21,000
0.5501$ 7.6266$
766,279$ 112,771$ 160,158$
-$ -$ -$
-$ -$ -$
-$ -$ -$
766,279$ 112,771$ 160,158$
205,000 21,000
0.5501$ 7.6266$
205,000 21,000
- -
- -
205,000 21,000
Certification:
Authorized Signature
DAAS-732A DAAS-732
Line I.A Col. A
Line I.B Col. B
Line I.C Col. C
Line I.D Col. D
L. I.C+I.D Col. E
Line III.C Col. F
III. Computation of Rates
A. Computation of Unit Cost Rate:
1. Total Expenses (equals line II.J)
2. Total Projected Units
H. Total Proj. Expenses Prior to Admin. Distribution
I. Distribution of Admininistrative Cost
J. Total Proj. Expenses After Admin. Distribution
3. Revenues Subject to Unit Reimbursement
4. Total Projected Units (equals line III.A.2)
5. Total Reimbursement Rate
C. Units Reimbursed Through HCCBG
D. Units Reimbursed Through Program Income*
E. Units Reimbursed Through Remaining Revenues
3. Total Unit Cost Rate
B. Computation of Reimbursement Rate:
1. Total Revenues (equals line I.J)
2. Less: NSIP (equals line I.D)
Title V (equals line I.E less II.D)
Non Match In-Kind (equals line I.H less II.C)
F. Total Units Reimbursed/Total Projected Units
* The Division of Aging ARMS deducts reported program income from reimbursement paid to providers. Line III.D indicates the number of units that will have to be produced in addition to those stated on line III.C in order to earn the net revenues stated on
line I.C.
I certify to the best of my knowledge and belief that the information included in the cost computation above is accurate and complies with all laws and regulations. I also understand that material
deviations in reported cost information could limit funding, and also result in return of funds if the error or omission results in a higher than actual reported cost.
NSIP Subsidy
Total Funding
Projected HCCBG Reimbursed Units
Information on this form (DAAS-732A) corresponds with
information stated on the Provider Services Summary
(DAAS-732) as follows:
Block Grant Funding
Required Local Match-Cash & In-Kind
Net Service Cost
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Line III.B.5 Col. G
Line III.F Col. I
Total Reimbursement Rate
Projected Total Service Units
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Access In-Home In-Home In-Home 0 0 0
Service Service Service Service Service Service Service
Information & Case Assistance
In-Home Aide-Level II - Personal
Care Adult Day Care Adult Day Health 0 0 0
040 042 030 155 #N/A #N/A #N/A
267,688$ 116,141$ 10,000$ 50,184$ -$ -$ -$
29,744$ 12,905$ 1,111$ 5,576$
29,744$ 12,905$ 1,111$ 5,576$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
29,743$ 12,905$ 1,111$ 5,576$ -$ -$ -$
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Service Service Service Service Service Service Service
Information & Case Assistance In-Home Aide-Level II - Personal Care Adult Day Care Adult Day Health 0 0 0
040 042 030 155 #N/A #N/A #N/A
-$ -$ -$ -$ -$ -$ -$
212,005$ -$ -$ -$ -$ -$ -$
212,005$ -$ -$ -$ -$ -$ -$
16,218$ -$ -$ -$ -$ -$ -$
16,218$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
228,223$ -$ -$ -$ -$ -$ -$
(69,208)$ (129,046)$ (11,111)$ (55,760)$ -$ -$ -$
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
Service Service Service Service Service Service Service
Information & Case AssistanceIn-Home Aide-Level II - Personal Care Adult Day Care Adult Day Health 0 0 0
040 042 030 155 #N/A #N/A #N/A
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
8,962 302 1,302
-$ 14.3992$ 36.7914$ 42.8264$ -$ -$ -$
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$
297,431$ 129,046$ 11,111$ 55,760$ -$ -$ -$
- 8,962 302 1,302 - - -
-$ 14.3992$ 36.7914$ 42.8264$ -$ -$ -$
- 8,962 302 1,302 - - -
- - - - - - -
- - - - - - -
- 8,962 302 1,302 - - -
Director, Department on Aging
Title Date
* The Division of Aging ARMS deducts reported program income from reimbursement paid to providers. Line III.D indicates the number of units that will have to be produced in addition to those stated on line III.C in order to earn the net revenues stated on
line I.C.
I certify to the best of my knowledge and belief that the information included in the cost computation above is accurate and complies with all laws and regulations. I also understand that material
deviations in reported cost information could limit funding, and also result in return of funds if the error or omission results in a higher than actual reported cost.
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
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0 0 0 0 0
Service Service Service Service Service
0 0 0 0 0
#N/A #N/A #N/A #N/A #N/A
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
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Service Service Service Service Service
0 0 0 0 0
#N/A #N/A #N/A #N/A #N/A
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
Service Service Service Service Service
0 0 0 0 0
#N/A #N/A #N/A #N/A #N/A
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
-$ -$ -$ -$ -$
- - - - -
-$ -$ -$ -$ -$
- - - - -
- - - - -
- - - - -
- - - - -
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DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Home and Community Care Block Grant for Older Adults
DAAS-732
County Funding Plan County:
July 2021 through June 2022
Provider Services Summary Date:
B C D E F G H I
Block Grant Funding
Services Direct Purchase Access In-Home Other Total
Senior Center Operation -$ -$ 101,494$ 101,494$ 11,277$ 112,771$ -$ 112,771$ 205,000 0.5501$ 2,700 205,000
HDM to Congregate Clients/Delivery/Carry Out -$ 144,142$ -$ 144,142$ 16,016$ 160,158$ -$ 160,158$ 21,000 7.6266$ 800 21,000
Information & Case Assistance 267,688$ -$ -$ 267,688$ 29,743$ 297,431$ -$ 297,431$ - -$ 1,000 -
In-Home Aide-Level II - Personal Care -$ 116,141$ -$ 116,141$ 12,905$ 129,046$ -$ 129,046$ 8,962 14.3992$ 10 8,962
Adult Day Care -$ 10,000$ -$ 10,000$ 1,111$ 11,111$ -$ 11,111$ 302 36.7914$ 302 302
Adult Day Health -$ 50,184$ -$ 50,184$ 5,576$ 55,760$ -$ 55,760$ 1,302 42.8264$ 1,302 1,302
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
0 -$ -$ -$ -$ -$ -$ -$ -$ - -$ -
Total 267,688$ 320,467$ 101,494$ 689,649$ 76,628$ 766,277$ -$ 766,277$ 236,566 6,114 236,566
ADHC
Daily Care 40.00$ Certification of required minimum local match availability.
Administrative Required local match will be expended simultaneously Authorized Signature, Title Date
with Block Grant Funding.Community Service Provider
Proj. Reimbursement Rate 40.00$
Administrative %0.00%
Signature, County Finance Officer Date Signature, Chairman, Board of Commissioners Date
A
(Check One)
Serv. Delivery
ADC
$33.07
*Adult Day Care & Adult Day Health Care Proj. Service Cost/Rate
Orange County
PO Box 8181
Hillsborough NC 27278
Orange
Budget Period:
Revision #:
0.00%
Projected
HCCBG
Units
Projected
Reimburse
Rate*
Projected
HCCBG
Clients
Projected
Total Units
Required
Local
Match
Net Service
Cost
NSIP
Subsidy
Total
Funding
$33.07
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DAAS-733
(Rev. 2/19)
Home and Community Care Block Grant for Older Adults
Outreach Methodology
July 2021 through June 2022
Community Service Provider:
County:
Outreach Methodology to Address the Service Needs of Target Population
Orange County
Orange
While all older adults age 60 and over are eligible for services, sec. 305(a)(2)(E) of the Older Americans Act
requires programs to target services to older individuals with the greatest economic and social need, (with
particular attention to low-income older adults, including low-income minority older adults, older adults
with limited English proficiency, and older adults residing in rural areas). The community service provider
shall specify how these service needs will be met through the services identified on the Provider Services
Summary (DAAS-732). This narrative shall address outreach and service delivery methodologies that will
ensure that this target population is adequately served and conform with specific objectives established by
the Area Agency on Aging, for providing services to low income minority individuals. Additional pages may
be used as necessary.
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DAAS-734
July 2021 through June 2022
Orange County
Community Care Block Grant, as specified on the Provider Services Summary (DAAS-732)
in accordance with the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.Providers of In-Home Aide, Home Health, Housing and Home Improvement, and Adult Day Care or Adult Day Health Care
shall sign and return the attached assurance to the area agency on aging indicating that recipients of these services have
been informed of their client rights, as required in Section 314 of the 2006 Amendments to the Older Americans Act (DAAS-
734 Standard Assurances Regarding In-Home Client Rights).
Community service providers are responsible for providing or arranging for the provision of required local match, as
specified on the Provider Services Summary, (DAAS-732). Local match shall be expended simultaneously with Block
Grant funding.
Community service providers agree to comply with audit and fiscal reporting requirements as specified in the Agreement for
the Provision of County-Based Aging Services (DAAS-735).
Compliance with Equal Employment Opportunity and Americans with Disabilities Act requirements, as specified in
paragraph fourteen (14) of the Agreement for the Provision of County-Based Aging Services (DAAS-735) shall be
maintained.
As specified in 45 CFR 75, Subpart D-Post Federal Award Requirements, Procurement Standards, community service
providers shall have procedures for settling all contractual and administrative issues arising out of procurement of services
through the Block Grant. Community service providers shall have procedures governing the evaluation of bids for services
and procedures through which bidders and contracted providers may appeal or dispute a decision made by the community
service provider.
Applicant/Client appeals shall be addressed as specified in Section 7 of the Division of Aging and Adult Services Home and
Community Care Block Grant Manual for Community Service Providers.
c) Client assessment/reassessments and quarterly visits, as appropriate;
d) Determining the amount of services to be received by the client; and
e) Reviewing consumer contributions policies with eligible clients.
All licenses, permits, bonds, and insurance necessary for carrying out Block Grant Services will be maintained by the
community service provider and any subcontracted providers.
Community service providers shall monitor any subcontracts with providers of Block Grant services and take appropriate
measures to ensure that services are provided in accordance with the aforementioned documents.
Priority shall be given to providing services to those older persons with the greatest economic or social needs. The service
needs of low-income minority elderly will be addressed in the manner specified on the Outreach Methodology to Address
Service Needs of Target Population (DAAS-733).
The following service authorization activities will be carried out in conjunction with all services provided through the Block
Grant:
a) Eligibility determination;
Home and Community Care Block Grant for Older Adults
Community Service Provider
Standard Assurances
Services shall be provided in accordance with requirements set forth in:
a) The County Funding Plan;
b) The Division of Aging and Adult Services Home and Community Care Block Grant Procedures Manual for Community
Service Providers; and
b) Client intake/registration;
c) The Division of Aging and Adult Services Standards at
agrees to provide services through the Home and
https://www.ncdhhs.gov/divisions/daas/monitoring
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
11.
b. The subcontractor has not been barred from doing business at the federal level.
c. The subcontractor is able to produce a notarized
12.
13.
https://archives.ncdcr.gov/government/local
(Authorized Signature)(Date)
Record Retention and Disposition. All community service providers are responsible for maintaining custody of records and
documentation to support the allowable expenditure of funds, service provision, and the reimbursement of services. Service
providers must adhere to the approved record retention and disposition schedule posted at
Service providers are not authorized to destroy records related to the provision of services under this Agreement except in
compliance with the approved DHHS retention and disposition schedule, which allows for the proper destruction of records
based on a schedule by funding source and fiscal year. The agency agrees to comply with 07 NCAC 04M .0510 when
deciding on a method of record destruction. Confidential records will be destroyed in such a manner that the records cannot
be practically read or reconstructed.
________________________________________________________________________
https://www.ncdhhs.gov/about/administrative-offices/office-controller/records-retention
Subcontracting – All HCCBG community service providers must assure that subcontractors (for-profit and non-profit
entities only) meet the following requirements:
Confidentiality and Security. Per the requirements in 10A NCAC 05J and Section 6 of the Home and Community Care
Block Grant Procedures Manual, client information in any format and whether recorded or not shall be kept confidential
and not disclosed in a form that identifies the person without the informed consent of the person or legal representative.
Community service providers, including subcontractors and vendors, must adhere to all applicable federal, state and
departmental requirements for protecting the security and confidentiality of client information including but not limited to
appropriately restricting access, establishing procedures to reduce the risk of accidental disclosures from data processing
systems, and developing a process by which the Division of Adult Aging Services is notified of suspected or confirmed
security incidents and data breaches.
a. The subcontractor has not been suspended or debarred. (N.C.G.S. §143C-6-23, 09 NCAC 03M)
d. All licenses, permits, bonds and insurance necessary for carrying out Home and Community Care Block Grant services
will be maintained by both the community service provider and any subcontractors.
e. The subcontractor is registered as a charitable, tax-exempt (501c3) organization with the Internal Revenue Service (non-
profit subcontractors only).
“State Grant Certification of No Overdue Tax Debts.”
by the NC Department of Health and Human Services Controller's Office, as well as the local government schedules posted
by the NC Department of Natural and Culltural Resources at
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
.In-Home Aide.Home Care (home health).Housing and Home Improvement.Adult Day Care or Adult Day Health Care
•
•
•
•
•
•
Agency Name:
Name of Agency Administrator:
Signature:
Client Rights will be distributed to, and discussed with, each new client receiving one or more of the above
listed services prior to the onset of service. For all existing clients, the above information will be provided
no later than the next regularly scheduled service reassessment.
Orange County
JANICE TYLER
(Please return this form to your Area Agency on Aging and retain a copy for your files.)
Standard Assurance To Comply with Older Americans Act
Requirements Regarding Clients Rights
For
Agencies Providing In-Home Services through the
Home and Community Care Block Grant for Older Adults
be fully informed both orally and in writing, in advance of receiving an in-home service, of
the individual’s rights and obligations.
As a provider of one or more of the services listed below, our agency agrees to notify all Home and
Community Care Block Grant clients receiving any of the below listed services provided by this agency of
their rights as a service recipient. Services in this assurance include:
Notification will include, at a minimum, an oral review of the information outlined below as well as
providing each service recipient with a copy of the information in written form. In addition, providers of in-
home services will establish a procedure to document that client rights information has been discussed with
in-home services clients (e.g. copy of signed Client Bill of Rights statement).
Clients Rights information to be communicated to service recipients will include, at a minimum, the right to:
be fully informed, in advance, about each in-home service to be provided and any change
in service(s) that may affect the wellbeing of the participant;
participate in planning and changing any in-home service provided unless the client is
adjudicated incompetent;
voice a grievance with respect to service that is or fails to be provided, without
discrimination or reprisal as a result of voicing a grievance;
confidentiality of records relating to the individual;
have property treated with respect; and
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
7/28/2021
CLIENT/PATIENT RIGHTS
1. You have the right to be fully informed of all your rights and responsibilities as a client/patient of
the program.
2. You have the right to appropriate and professional care relating to your needs.
3. You have the right to be fully informed in advance about the care to be provided by the program.
4. You have the right to be fully informed in advance of any changes in the care that you may be
receiving and to give informed consent to the provision of the amended care.
5. You have the right to participate in determining the care that you will receive and in altering the
nature of the care as your needs change.
6. You have the right to voice your grievances with respect to care that is provided and to expect that
there will be no reprisal for the grievance expressed.
7. You have the right to expect that the information you share with the agency will be respected and
held in strict confidence, to be shared only with your written consent and as it relates to the
obtaining of other needed community services.
8. You have the right to expect the preservation of your privacy and respect for your property.
9. You have the right to receive a timely response to your request for service.
10. You shall be admitted for service only if the agency has the ability to provide safe and
professional care at the level of intensity needed.
11. You have the right to be informed of agency policies, changes, and costs for services.
12. If you are denied service solely on you inability to pay, you have the right to be referre d
elsewhere.
13. You have the right to honest, accurate information regarding the industry, agency and of the
program in particular.
14. You have the right to be fully informed about other services provided by this agency.
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
CLIENT/PATIENT RIGHTS
1. You have the right to be fully informed of all your rights and responsibilities as a client/patient of
the program.
2. You have the right to appropriate and professional care relating to your needs.
3. You have the right to be fully informed in advance about the care to be provided by the program.
4. You have the right to be fully informed in advance of any changes in the care that you may be
receiving and to give informed consent to the provision of the amended care.
5. You have the right to participate in determining the care that you will receive and in altering the
nature of the care as your needs change.
6. You have the right to voice your grievances with respect to care that is provided and to expect that
there will be no reprisal for the grievance expressed.
7. You have the right to expect that the information you share with the agency will be respected and
held in strict confidence, to be shared only with your written consent and as it relates to the
obtaining of other needed community services.
8. You have the right to expect the preservation of your privacy and respect for your property.
9. You have the right to receive a timely response to your request for service.
10. You shall be admitted for service only if the agency has the ability to provide safe and
professional care at the level of intensity needed.
11. You have the right to be informed of agency policies, changes, and costs for services.
12. If you are denied service solely on you inability to pay, you have the right to be referre d
elsewhere.
13. You have the right to honest, accurate information regarding the industry, agency and of the
program in particular.
14. You have the right to be fully informed about other services provided by this agency.
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Review of Local Match Comparison Input Sheet vs. 732A Cash and In-Kind Totals
Senior Center Operation Match Totals Do Not Match Difference Is--->
HDM to Congregate Clients/Delivery/Carry Out OK
Information & Case Assistance Match Totals Do Not Match Difference Is--->
In-Home Aide-Level II - Personal Care OK
Adult Day Care OK
Adult Day Health OK
0 OK
0 OK
0 OK
0 OK
0 OK
0 OK
0 OK
0 OK
732A1 Labor Distribution Schedule Comparison of Assignable Salary To Overall Salary Entered
Total Assignable Salary and Cumulative Salary total for Service/Admin 0
Internal Consistency Checks
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54
Difference
(1)
-
(1)
-
-
-
-
-
-
-
-
-
-
-
-$
Internal Consistency Checks
DocuSign Envelope ID: 16A1D963-40F9-46F1-A38B-8B0D62C87C54