HomeMy WebLinkAbout2022-243-E-Aging-Area agency on aging-provider checklist for HCCBG findingDocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
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, _2022 through June 30, ___2023
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
6/28/2022
State Fiscal Year:SFY 2022-2023
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 170 102,580$ 11,398$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Congregate Nutrition 180 214,168$ 23,797$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Information & Case Assistance 040 263,713$ 29,302$ <<--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 20,184$ 2,243$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
Adult Day Health 155 40,000$ 4,445$ <<--Local Match will need to be broken out by source (Cash/In-Kind) on 732A Svc Cost Computation Form
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
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REQUIRES INPUT TO POPULATE WORKBOOK-->-$
REQUIRES INPUT TO POPULATE WORKBOOK-->-$
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Service Prior Yr. Funding Prior Year Rate Current Yr Funding Current Year Rate Funding Diff. Rate Diff.
Senior Center Operation 170 101,494$ 0.5501$ 102,580$ 0.0000 1,086$ (0.5501)$
Congregate Nutrition 180 190,488$ 7.6271$ 214,168$ 10.3463 23,680$ 2.7191$
Information & Case Assistance 040 267,688$ 10.9049$ 263,713$ 0.0000 (3,975)$ (10.9049)$
In-Home Aide-Level II - Personal Care 042 116,141$ 14.3992$ 116,141$ 14.3992 -$ -$
Adult Day Care 030 10,000$ 36.7914$ 20,184$ 59.9652 10,184$ 23.1738$
Adult Day Health 155 50,184$ 42.8264$ 40,000$ 64.9766 (10,184)$ 22.1502$
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
AGENCY NAME:Fiscal Period: July 2022 through June 2023
State Fiscal Year:SFY 2022-2023
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 Congregate Nutrition Information & Case Assistance
In-Home Aide-Level II -
Personal Care Adult Day Care Adult Day Health 0 0
Myra Austin Senior Centers Administrator 79,250$ 0.4 PART TIME 31,700$ 31,700$
Alexander Burress Program Assistant 43,230$ 0.4 PART TIME 17,292$ 17,292$
Jan Olderburg Office Assistant II 25,367$ 0.4 PART TIME 10,147$ 10,147$
vacant Program Assistant 45,197$ 0.4 PART TIME 18,079$ 18,079$
Latonya Brown Wellness Coordinator 56,361$ 0.45 PART TIME 25,362$ 25,362$
-$
William Crist Food Services Coordinator 12,000$ 1 FULL TIME 12,000$ 12,000$
James Burnett Seymour Site Manager 12,000$ 1 FULL TIME 12,000$ 12,000$
-$
Marie Dagger Occupational Therapist 66,142$ 1 FULL TIME 66,142$ 66,142$
Kim Lamon-Loperfido Eldercare Serv Administrator 61,435$ 1 FULL TIME 61,435$ 61,435$
Kendall Kopchick Eldercare Manager 49,410$ 1 FULL TIME 49,410$ 49,410$
Lydia Arnold Social Worker II 51,000$ 1 FULL TIME 51,000$ 51,000$
Lisa Meinert Human Services Coordinator 35,726$ 1 FULL TIME 35,726$ 35,726$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
-$
SUBTOTAL FT:287,713$ -$ -$ 24,000$ 263,713$ -$ -$ -$ -$ -$
SUBTOTAL PT:102,580$ -$ 102,580$ -$ -$ -$ -$ -$ -$ -$
TOTAL 390,293$ -$ 102,580$ 24,000$ 263,713$ -$ -$ -$ -$ -$
PERCENT FT:73.72%#DIV/0!0.00%100.00%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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Home and Community Care Block Grant for Older Adults
ORANGE COUNTY DAAS-732
County Funding Plan County: ORANGE
PO Box 8181
Provider Services Summary
Budget Period:
Revision #:
July 2022 throu
gh
June 2023
Hillsborough NC 27278 Dat
e:
Services
Serv. Delivery
A B C D E F G H I
Block Grant Funding
Required
Local
Match
Net Service
Cost
NSIP
Subsidy
Total
Funding
Projected
HCCBG
Units
Projected
Reimburse
Rate
Proje
cted
HC
Projected
Total Units
(Check One)
Direct
Purchase
Access
In-Home
Other
Total
Senior Center Operation $ - $ - $ 102,580 $ 102,580 $ 11,398 $ 113,978 $ - $ 113,978 2,700
Congregate Nutrition $ - $ - $ 214,168 $ 214,168 $ 23,796 $ 237,964 $ 18,400 $ 256,364 23,000 $ 10.3463 800 23,000
Information & Case Assistance $ 263,713 $ - $ - $ 263,713 $ 29,301 $ 293,014 $ - $ 293,014 200
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 $ - $ 20,184 $ - $ 20,184 $ 2,243 $ 22,427 $ - $ 22,427 374 $ 59.9652 2 374
Adult Day Health $ - $ 40,000 $ - $ 40,000 $ 4,444 $ 44,444 $ - $ 44,444 684 $ 64.9766 4
684
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
0 $ - $ - $ - $ - $ - $ - $ - $ - - $ - -
Total $ 263,713 $ 176,325 $ 316,748 $ 756,786 $ 84,087 $ 840,873 $ 18,400 $ 859,273 266,020 3,710 266,020
Certification of required minimum local match availability.
Required local match will be expended simultaneously
with Block Grant Funding.
Authorized Signature, Title Community
Service Provider
Date
Signature, County Finance Officer Date Signature, County Manager Date
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
6/28/2022
6/29/2022 6/29/2022
DAAS-732A
Provider:
County:
Budget Period:July 2022 through June 2023
Other Other Access In-Home In-Home In-Home 0 0 0 0 0 0 0 0
Service Service Service Service Service Service Service Service Service Service Service Service Service Service
Senior Center Operation Congregate Nutrition Information & Case Assistance
In-Home Aide-Level II - Personal
Care Adult Day Care Adult Day Health 0 0 0 0 0 0 0 0
Grand Total 170 180 040 042 030 155 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A
756,786$ 102,580$ 214,168$ 263,713$ 116,141$ 20,184$ 40,000$ -$ -$ -$ -$ -$ -$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) 84,088$ 11,398$ 23,796$ 29,301$ 12,905$ 2,243$ 4,445$
2) -$
3) -$
Total Required Minimum Match - In-Kind 84,088$ 11,398$ 23,796$ 29,301$ 12,905$ 2,243$ 4,445$ -$ -$ -$ -$ -$ -$ -$ -$
84,088$ 11,398$ 23,796$ 29,301$ 12,905$ 2,243$ 4,444$ -$ -$ -$ -$ -$ -$ -$ -$
840,874$ 113,978$ 237,964$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
18,400$ -$ 18,400$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$
1) -$
2) -$
3) -$
4) -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$
859,274$ 113,978$ 256,364$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
Service Service Service Service Service Service Service Service Service Service Service Service Service Service
Grand Admin.Senior Center Operation Congregate Nutrition Information & Case Assistance In-Home Aide-Level II - Personal Care Adult Day Care Adult Day Health 0 0 0 0 0 0 0 0
Total Cost 170 180 040 042 030 155 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A
287,713$ -$ -$ 24,000$ 263,713$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
102,580$ -$ 102,580$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
390,293$ -$ 102,580$ 24,000$ 263,713$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) FICA @ 7.65 29,857$ -$ 7,847$ 1,836$ 20,174$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$
-$
-$
-$
-$
29,857$ -$ 7,847$ 1,836$ 20,174$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) -$
2) -$
3) -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$
-$
-$
-$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
1) 129,046$ 129,046$
2) 66,871$ 22,427$ 44,444$
3) -$
4) -$
5) -$
6) -$
7) -$
8) -$
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
Division of Aging and Adult Services
Service Cost Computation Worksheet
II. Line Item Expenses
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)
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
contractual
support to clients
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
195,917$ -$ -$ -$ -$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
-$
616,067$ -$ 110,427$ 25,836$ 283,887$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
(243,206)$ (3,551)$ (230,528)$ (9,127)$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
859,273$ 113,978$ 256,364$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
ERROR, Sum of Services Must Equal Projected Revenues
Service Service Service Service Service Service Service Service Service Service Service Service Service Service
Grand Senior Center Operation Congregate Nutrition Information & Case AssistanceIn-Home Aide-Level II - Personal Care Adult Day Care Adult Day Health 0 0 0 0 0 0 0 0
Total 170 180 040 042 030 155 #N/A #N/A #N/A #N/A #N/A #N/A #N/A #N/A
859,273$ 113,978$ 256,364$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
23,000 8,962 374 684
-$ 11.1463$ -$ 14.3992$ 59.9652$ 64.9766$ -$ -$ -$ -$ -$ -$ -$ -$
859,274$ 113,978$ 256,364$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
18,400$ -$ 18,400$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
-$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$
840,874$ 113,978$ 237,964$ 293,014$ 129,046$ 22,427$ 44,444$ -$ -$ -$ -$ -$ -$ -$ -$
- 23,000 - 8,962 374 684 - - - - - - - -
-$ 10.3463$ -$ 14.3992$ 59.9652$ 64.9766$ -$ -$ -$ -$ -$ -$ -$ -$
- 23,000 - 8,962 374 684 - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- 23,000 - 8,962 374 684 - - - - - - - -
Certification:
Authorized Signature Title Date
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
Line III.B.5 Col. G
Line III.F Col. I
F. Subtotal, General Operating Expenses
G. Subtotal, Other Administrative Cost Not Allocated in
Lines II.A through E
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
Total Reimbursement Rate
Projected Total Service 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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
6/28/2022Director
DAAS-733
(Rev. 2/19)
Home and Community Care Block Grant for Older Adults
Outreach Methodology
July 2022 through June 2023
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.
Continue the USDA Food Box program targeting low-income residents in senior housing and in the Cedar
Grove and Efland Community Center service areas. Provide services through the Seymour and Passmore
centers with scholarships available when applicable. Use Department on Aging website and Endless
Possibilities print edition to advertise these options. Promote free transportation services provided by
Chapel Hill Transit and Orange County Public Transportation. Provide office space for DSS adult services
social workers at each Senior Center. Continue Project Engage initiatives utilizing volunteers to promote
service availability in rural Orange County. Continue contract for Mandarin-speaking social worker. Continue
outreach to Spanish-speaking seniors through the weekly Spanish Social Club.
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
.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
(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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Janice Tyler
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 referred
elsewhere.
13. You have the right to honest, accurate information regarding the industry, agency and of the
program in particular.
14. You have the right to be fully informed about other services provided by this agency.
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
DAAS-734
July 2022 through June 2023
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.
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
10.
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
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).
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
6/28/2022
TJAAA Form, rev April 2017
CERTIFICATION OF REQUIRED MINIMUM LOCAL MATCH AVAILABILITY
Date: July 2022 Fiscal Year: FY 22-23
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)
Please Select Services to Be Delivered Local Match
Senior Center Operation 170
$
11,398
Congregate Nutrition 180
$
23,797
Information & Case Assistance 040
$
29,302
In-Home Aide-Level II - Personal Care 042
$
12,905
Adult Day Care 030
$
-
Adult Day Health 155
$
6,688
Total Local Match: $84090
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: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Exhibit 14A: List of Subcontractors – Instructions
Version 2016
List each subcontractor in the chart below. For the purpose of Subcontractor Monitoring, a subcontractor is defined as an entity that has
been contracted to do a job within the scope of the service provider’s HCCBG grant award. The subcontractor is accountable f or the same
requirements as the service provider, depending on the terms of the sub contract. Subcontractors must adhere to service standard
requirements by the Division of Aging and Adult Services.
Do not list vendors that provide services through a “purchase of service.” These are services which do not follow prescribed service
standards and are goods or services sold equally to all consumers.
Here are some service-specific examples to illustrate whether or not a subcontractor should be listed on Exhibit 14A.
Service SUBCONTRACT OR PURCHASE OF SERVICE?
In-Home Aide If a human service agency (provider) receives the IHA allocation and contracts with a home health or home care
agency, it is a subcontract and not a purchase of service. Even if the subcontract only delegates just the tasks
on a plan of care for clients, the agency is still a subcontractor because grant requirements (service standards)
related to service delivery must be met as part of the scope of work. An example would be the aide
competency and supervision requirements in the standards that are often o utsourced to the home health or
home care agency that employs the aides.
Nutrition Subcontracts with commercial kitchens or restaurants to prepare meals are never just “purchase of service”
arrangements because there are grant requirements that must be met as part of the caterer’s scope of work
(e.g., approved menus, protocols for menu substitutions, documentation requirements for end of preparation
time, documentation of each food item delivered, daily sanitizing of food delivery carriers by the food ser vice
provider, etc.).
A contract between the HCCBG nutrition provider and a local dairy to deliver pints of milk once a week is just a
purchase of goods and services and would not need to be listed because those pints of milk could be bought at
any store. A purchase of service is when goods and/or services are sold to all purchasers without special
conditions or requirements related to the grant.
Adult Day Services
(Adult Day Care, Adult
Day Health or
ADC/ADH Combination
Programs)
A human service agency that receives the allocation and contracts with an ADC/ADH center to provide services
has a subcontract, not a purchase of service, because there are grant requirements that must be met as part of
the center’s scope of work.
An ADC/ADH center that provides services directly, but also contracts with another ADC/ADH center to provide
adult day services has a subcontract with that center.
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Exhibit 14A: List of Subcontractors – Instructions
Version 2016
Health Promotion If an agency funded for health promotion hires an exercise instructor, that person is a vendor, not a
subcontractor.
Transportation If a county human service agency receives the grant allocation and contracts with the county transportation
system to provide rides, it should be treated as a subcontract* and not a purchase of service because there are
grant requirements that the transportation system is responsible for assuring. For example, the HCCBG vehicle
and driver documentation requirements should be specified in the written contract/agreement and should
match the requirements in the transportation service standard.
Family Caregiver
Support Program
If the provider with the FCSP allocation outsources any service requirements, including eligibility determination,
then it is a subcontract relationship that should be reported on Ex. 14A. For example, a county department of
aging has a contract with the AAA to provide respite services. The county department takes all calls from
caregivers regarding respite and routes the callers to the respite providers to determine if they are eligible for
the service based on FCSP eligibility. In this case the respite providers would be subcontractors because they are
not merely providing the service, but have a role in determining who receives the service. On the other hand, if
the FCSP service provider (the one receiving the allocation) determines eligibility, then the respite provider is
just a vendor because currently there are no service standard requirements that have to be met for FCSP and no
service requirements would be outsourced to the vendor.
* When a county agency with a HCCBG allocation for any service uses another county agency to carry out the grant’s requiremen ts, the
arrangement should be treated like a subcontract. There should be a written agreement that details what grant requirements have been
outsourced to the second county agency and other pertinent details. Written agreements/contracts make it clear to the HCCBG provider,
its subcontractor, and the AAA who is responsible for what requirements. The stipulations provide a framework for the monitoring of
grant requirements and identify which entity is responsible for the documentation of grant activities.
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Exhibit 14A: List of Subcontractors Region _J_FY22-23
Provider: Orange County Department on Aging Provider Code: 047 County : Orange
Version 2016 Page _______ of _______
Subcontractor
Name
Type Agency Subcontracted
Service
Subcontractor
Contact
Name, Address
& Phone Number
Scope of the Subcontract
Briefly describe any service requirements that will be delegated to the
subcontractor, e.g. eligibility determination, service authorization, client
assessments/reassessments, preparation and delivery of meals, provision of a
ride and driver/vehicle requirements, tasks on an In-Home Aide plan of care, aide
competency testing, aide supervision, etc.
Rymackees Café
and Caterer, LLC
Non-Profit
For-Profit
Government
Congregate Meals Keshia Criss
912 S. Cliffs Circle
Spring Lake, NC
28390shia
Prepare and deliver noon meals in bulk to the Passmore and
Seymour Senior Centers each weekday
Non-Profit
For-Profit
Government
Non-Profit
For-Profit
Government
Non-Profit
For-Profit
Government
Non-Profit
For-Profit
Government
Non-Profit
For-Profit
Government
Attest Statement: Providers utilizing subcontractors must provide assurance that both for-profit and non-profit subcontractors are compliant
with state and federal regulations. These assurances are that the subcontractor: (A) has not been suspended or debarred (G.S. §143C-6-23;
09 NCAC 03M), (B) has not been barred from doing business at the federal level, (C) is able to produce a notarized “State Gra nt Certification
of No Overdue Tax Debts”, and (D) has obtained all licenses, permits, bonds and insurance necessary for carr ying out HCCBG Services. In
addition, non-profit subcontractors are registered as a charitable (501c3) organization with the federal government.
Provider Signature __________________________________________ Title: DIRECTOR, DEPARTMENT ON AGING
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
Exhibit 14A: List of Subcontractors Region _J_FY22-23
Provider: Orange County Department on Aging Provider Code: 047 County : Orange
Version 2016 Page _______ of _______
Date ______________
DocuSign Envelope ID: 77B99AE1-C8D6-40A2-BBF0-532F9F8FCC22
6/28/2022