II. A. Program Module - General Requirements ______ · Web viewProvide services, education, and referrals to meet specific needs of individuals with dementia EXPLANATION : This objective

ElderSourceState General Revenue Programs

Service Provider Application Update 7/1/2016 – 6/30/2017 Contract Period

This packet contains the formats to be used by Lead Agencies receiving funding under the following Department of Elder Affairs State General Revenue funded programs:

Community Care for the Elderly

Home Care for the Elderly

Alzheimer’s Disease Initiative

Local Services Program

April 2016 Page 1 of 50

Service Provider Application Update

Table of Contents

PAGE I. A. Service Provider Summary Information ______

II. A. Program Module - General Requirements ______1. Demographics and Community Care Service System ______2. Consumer Identification ______3. Case Management Functions ______4. Services ______4a. Subcontract Monitoring Schedule ______

5. Quality Assurance ______6. Process for Reporting Adverse Incidents, Consumer

Complaints and Reducing or Terminating Services ______7. Reporting ______8. Client Confidentiality & Security ______9. Disaster Preparedness ______10. Volunteer Plan ______11. Organizational Chart ______12. Description of Service Delivery (by Service) ______13. Objectives and Performance Measures ______14. SPA Appendix ______15. Program Module Review Checklist ______

II. B. Contract Module – General Requirements ______1. Personnel Allocations Worksheet ______

2. Unit Cost Worksheet ______

3. Supporting Budget Schedule by Program Activity ______

4. Commitment of Cash Donation ______

5. Commitment for Donation of Building Space ______

6. Commitment of In-Kind Contribution of Supplies ______

7. Commitment of In-Kind Contribution of Equipment ______

8. Commitment of In-Kind Contribution of Services ______

9. Commitment of in-Kind Volunteer Personnel and Travel ______10.Availability of Documents ______


11.Contract Module Review Checklist ______


I.A. SERVICE PROVIDER SUMMARY INFORMATION PAGE

PSA: 4 ORIGINAL [ ] REVISION [ ]1. PROVIDER INFORMATION: Executive Director: [Name/Address/Phone]

Legal Name of Agency:

Mailing Address:

Telephone Number:

2. GOVERNING BOARD CHAIR: [Name/Address/Phone]

Name of Grantee Agency:

3. ADVISORY COUNCIL CHAIR: (if applicable) [Name/Address/Phone]

4. TYPE OF AGENCY/ORGANIZATION:

NOT FOR PROFIT: ___ PRIVATE ___ PUBLIC PRIVATE FOR PROFIT: ___

5. PROPOSED FUNDING PERIOD: 07/01/2016 – 06/30/2017 A. New Applicant ___ B. Continuation ___

6. FUNDS REQUESTED:

[ ] OAA Title IIIB [ ] CCE[ ] OAA Title III-C1 [ ] HCE [ ] OTHER (SPECIFY)[ ] OAA Title III-C2 [ ] ADI [ ] OAA Title IIID [ ] LSP[ ] OAA Title IIIE [ ] EHEAP [ ] OAA Title VII [ ] NSIP

7. SERVICE AREA: [ ] Single County

[ ] Selected Communities of a County: Specify [ ] Multiple Counties: List

8. ADDRESS FOR PAYMENT OF CHECKS ITEM #: [ ] #1 [ ] #2

9. CERTIFICATION BY AUTHORIZED AGENCY OFFICER:

I hereby certify that the contents of this document are true, accurate and complete statements. I acknowledge that intentional misrepresentation or falsification may result in the termination of financial assistance.

Name: Signature: ______________________________Title: _________________________________ Date:___________________



Service Provider Application Update7/1/2016 – 6/30/2017 Contract Period

Section II. A.

Program Module – General Requirements


II.A.1. DEMOGRAPHICS AND COMMUNITY CARE SERVICE SYSTEM

a. Provide an overview of the social, economic and demographic characteristics of your county. Focus should be given to geographic areas and population groups within the county that have special needs.

b. Describe your agency’s ability to accept referrals and provide services on a countywide basis. This must include administering and managing the Community Care for the Elderly program (CCE), the Home Care for the Elderly program (HCE), the Alzheimer’s Disease Initiative program (ADI) and the Local Service Program (LSP).

c. Describe your agency’s efforts to participate in local networks and consortiums where hospitals, home health, social and medical providers are represented in order to target high-risk individuals in need of services.

It is important to include strategies for gaining input from the public in your agency’s planning process. This should address how your agency will reach out to the community for feedback when significant program service changes are being considered (i.e. discontinuation of service or change in model being utilized to provide services).

II.A.2. Consumer Identificationa. Describe the anticipated activities your agency will conduct for the 2016-2017 fiscal year to

identify and inform frail elders and their caregivers of the range and availability of services.

b. Describe your agency’s outreach efforts and the process of coordinating all formal and informal resources to meet client need (ADRC, EHEAP, Food stamps, etc.).

c. Describe your agency’s process for referral to the Aging and Disability Resource Center (ADRC) for the intake and screening, assessment, and eligibility determination of consumers.

d. Describe what procedures are in place to request enrollment of wait listed clients through communication with the ADRC following wait list enrollment protocols.

e. Describe how your Agency will staff referrals from the Department of Children and Families for Aging Out and Adult Protective Services (APS) moderate and low risk clients and other assessed priority ranked community referred clients utilizing the required priority ranking guidelines.

f. Provide current copies of the internal procedures that will ensure first priority service delivery to APS High Risk clients.

g. Provide copies of the current procedures your agency uses to ensure client data entry into APS Referral Tracking Tool (ARTT) and Client Information and Registration Tracking System (CIRTS) occurs as required. Include the agency’s internal tracking log and provide assurance that all required case managers have received the necessary ARTT Training


Tutorial and certifications. The training log and case manager certification(s) assuring compliance must be included in the agency’s Appendix to the Service Provider Application.

h. Provide current copies of the internal procedures which ensure prioritization as well as appropriate and timely follow through on referrals through the ADRC. The procedure should include each step from the initial receipt of the referral through all required and documented actions.

i. What plans and procedures are in place to interface with the ADRC’s Information and Referral function? Describe the steps and criteria your agency will use to determine if a caller should be referred to the ADRC’s Helpline. Provide current copies of your agency’s ADRC interface and determination policies and procedures in the Service Provider Application (SPA) Appendix.

II.A.3. Case Management Functions

a. Describe the action steps, number of staff involved, consumer to case manager ratio and average timelines for consumer assessments, care plan development, and service initiation. Specifically address the timeline procedures from the ADRC wait list enrollment authorization date through service initiation. The timeline should correlate with the current applicable wait list enrollment guidelines and with processes that are streamlined to ensure consumers are promptly assessed and enrolled.

b. Explain how overall coordination will be provided to inform consumers of all programs and services accessible through the lead agency.

c. Explain your agency’s process for reviewing general revenue funded clients for potential services in other DOEA funded and non-funded programs, including steps staff will utilize when wait listing clients.

Please note – The Lead Agency’s process should include a mechanism for notifying the ADRC when an individual appears to be eligible for State Medicaid Managed Care Long Term Care (SMMC LTC) services; however, it is the ADRC’s responsibility to enroll the individual on the Assessed Prioritized Client List (i.e. APCL for LTCC) for Medicaid Waiver services (preferred method is a fax referral).

d. Describe how all other available alternative resources for consumer services will be explored, utilized, and documented prior to using general revenue funded services. Explain any changes in the amount of other resources your agency plans to commit in the support of these services for the coming year compared to the amount of the current contract period.

e. Explain your agency’s internal procedure for assessing, billing, and collecting co-payments in a timely manner. Identify any changes your agency plans to make to the internal procedures to improve the assessing, billing or collection of co-payments.


II.A.4. ServicesIt is important that lead agencies ensure a variety of home-delivered, day care services, and other basic services needed to prevent institutionalization are available within your service area. When planning your agency’s service array, please take into account the recent ElderSource Area Plan indicating priority service needs include access to chore, homemaking, personal care, nutrition and transportation.

a. List the services your agency will offer other than Case Management. Note: A detailed explanation of each service must be provided in section “II.A.12. “Description of Service Delivery”.

b. List the services your agency plans to offer directly.

c. List the services your agency intends to outsource.

d. Describe the vendor agreement and selection process (include timeframes).

e. Outline the process for ensuring all required subcontractor employees/volunteers have successfully completed a level 2 background screening.

f. Provide an action plan for the programmatic and fiscal monitoring of subcontractors. Include copy of the subcontract monitoring tool(s) utilized by your agency in the SPA Appendix.

g. Complete the attached “Subcontract Monitoring Schedule” on the following page. Include information on all subcontractors who will provide services with State General Revenue funding.

h. Provide a list of all CCE vendor agreements/subcontracts in the SPA Appendix. NEW BIDDERS ONLY: ElderSource will require any newly appointed Lead Agency to provide a list of all CCE vendor agreements/subcontracts by August 1, 2016.


County: Date:


II.A.4.a SUBCONTRACT MONITORING SCHEDULE

Include all AAA Funded

Subcontractors and Vendors

Subcontractor or Vendor

Date of Visit Program Service

[F]iscal/Admin. [P]rogrammatic

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.


II.A.5. Quality Assurance

a. Describe your agency’s methods (i.e. process/frequency) to assure the delivery of quality services by staff. Provide current copies of your Quality Assurance/Quality Initiative procedures in the SPA Appendix.

b. Describe your agency’s methods (i.e. process/frequency) to assure the delivery of quality services by subcontractors (if applicable).

c. Explain how the results of your quality assurance process will be used to improve services. Provide a narrative of quality improvement initiatives undertaken by your agency during the 2015 calendar year as appropriate.

d. In-Service Case Management Staff Training1. Describe your plan to provide required six (6) hours of in-service training to case

management staff. Your plan should include the minimum standards as outlined in the DOEA Programs and Services Handbook.

2. List and describe all Case Management Staff Training Lesson Topics and your anticipated schedule for training dates (see Chapter 2, In-Service Training Program for required standards):

3. For current Lead Agencies: Include a copy of the agency’s current Case Management Training Log in the SPA Appendix in order to provide assurance that all case managers are current and have received the required training for their positions. Include certification documents for all currently employed case managers to ensure they have received the required training on the new DOEA Comprehensive Assessment (DOEA 701B) screening form.

e. Provide a current copy of the policies and procedures your agency uses to evaluate consumer satisfaction in the SPA Appendix. The policies should include: 1) the proposed survey schedule, 2) proposed sample size, 3) tabulation information, 4) analysis and follow up process, 5) information on how the results are utilized to make improvements to services, and 6) timeframe for forwarding the results of the survey to the Area Agency on Aging.

Please provide a sample survey, copy of the agency’s 2015 consumer satisfaction survey results, including the analysis and any necessary follow-up in the SPA Appendix.


II.A.6. Process for Handling and Reporting Adverse Incidents, Consumer Complaints and Grievances

a. Explain your agency’s policies and procedures for ensuring compliance with the required reporting of adverse incidents consistent with Chapter 415, F.S., DOEA Programs and Services Handbook (See Appendix D, Minimum Guidelines for Recipient Grievance Procedures) and all related ElderSource notices, policies and procedures. Include a copy of your agency’s Adverse Incident Procedure and blank log in the SPA Appendix.

b. Provide a summary of the process your agency follows for receiving, reporting and remediating consumer complaints. Include a copy of the agency’s Complaint Procedures and blank log in the SPA Appendix. Please be sure that the complaint log allows for detailed information to be maintained, including the nature of the complaint, outcome and resolution.

c. Explain your agency’s process for handling consumer grievances; along with the process for appeals regarding denial, reduction, or termination of services. The grievance procedures must provide for informing all consumers of the grievance/appeal process and providing assistance to consumers desiring to file a grievance/appeal.

Include a copy of your agency’s Grievance Procedures and blank log in the SPA Appendix. The applicant’s Grievance Procedure must comply with the Master Contract.

II.A.7. Reporting

a. Describe the steps your agency will follow in order to provide for accurate and timely entry of all service and consumer specific information in the Client Information, and Registration, Tracking System (CIRTS) database.

b. Explain your agency’s policies and procedures for utilizing available CIRTS reports. Include how your agency uses these reports to improve data integrity in the CIRTS database.

c. Include a listing of all reports run, the schedule for running these CIRTS reports and required follow-up due dates for staff addressing any exceptions noted as part of this process.

d. Provide current copies of your agency’s internal policies and procedures utilized to ensure timely and accurate CIRTS reporting in the SPA Appendix.


II.A.8 Client Confidentiality and Security

a. The Lead Agency must ensure the confidentiality of consumer information by all employees, service providers and volunteers as required by state and federal laws. Describe what security measures are in place to address confidentiality and consumer-specific information as it relates to state and federal (HIPAA) requirements.

Submit a copy of your Privacy Notice. The applicant’s Privacy Notice must be HIPPA compliant and included in the SPA Appendix.

b. The Lead Agency must ensure consumers are notified of the purpose for collecting an individual’s social security number in compliance with section 119.071(5), F.S. Whenever possible, when a CIRTS identification number is available, it is to be used for reporting purposes in lieu of a social security number. For example, when communicating information for billing or client concerns to ElderSource the provider should use the CIRTS identification number provided by DOEA.

Include a copy of your agency’s current consumer notification which discloses the purpose for which the client’s social security number is being collected in the SPA Appendix.

c. The Lead Agency is responsible for complying with Executive Order Number 11-116 and all applicable ElderSource Notices of Instruction related to the requirements to utilize the U.S. Department of Homeland Security’s E-verify system to verify the employment of all new employees hired by the agency.

Include a brief summary of the procedures implemented by your agency to be certain that all required employees are properly verified and determined eligible for hire through the U.S. Department of Homeland Security’s E-verify system. Provider is required to maintain documentation to assure new employees hired by the agency within the contract period are eligible for employment. Verification of eligibility must be maintained for monitoring purposes by the ElderSource.

d. The Lead Agency must ensure that all employees, volunteers and contractors have successfully completed the background screening process pursuant to Chapter 2010-114, Laws of Florida (L.O.F.) and Sections 430.0402 and 435.01(2) Florida Statutes and all applicable ElderSource Notices of Instruction.

Include a brief summary of the procedures implemented by your agency to be certain that all applicable parties are properly screened and determined to have no disqualifying offenses prior to employment. Be sure to include your agency’s process for notifying the Department of Elder Affairs when staff/volunteers are no longer employed by your organization. Provider is required to maintain documentation to assure required direct service providers utilized by the agency have successfully completed the level 2 background screen through the Department of Elder Affairs. Verification assuring compliance must be maintained for monitoring purposes by ElderSource.


II.A.9. Disaster Preparedness

The information provided in response to this section will serve as a quick reference for the key elements outlined in your agency’s full disaster plan. The response should be written from the viewpoint of disaster preparedness in general, not just hurricane preparedness.

Listed below are key elements to include in your service provider application.

Included a full copy of the disaster plan with the proposal.a. Identification of all key personnel

b. Identification of all vendor agreements

c. Alternate office site in time of disaster

d. Emergency Coordinating Officer and alternate contact information

e. Description of how the Applicant’s services are integrated with the local County Emergency Plan

f. Detail coordination efforts for special needs clients


II.A.10. Volunteer Plan

The information provided in response to this section should provide a written plan of action to assure that your agency maintains procedures on recruitment, training, utilization, and retention of volunteers to assist with your agency’s functions.

II.A.11. Organizational Chart

Submit a current organizational chart which illustrates the structure and relationship of positions, units, supervision, and functions of your agency in the SPA Appendix.


II.A.12. Description of Service Delivery (by Service)(This page must be completed for each service including case management)

Service: ___ Program(s): ______________ a. Subcontractor:

Will your Agency provide this service directly? ____ Yes ____ No

If your Agency will subcontract this service then list all subcontractors below:

Subcontractor(s)Business Name:Address:Phone Number:License Number (if applicable):Contract Start/End Date:Anticipated Monitoring Date:

b. Site Location: (Bidder may attach a list of site locations.)

c. Days And Hours Of Operation:

d. Activities: Describe the specific activities your agency will provide under this service.

e. Training Requirements: Describe the orientation and annual in-service training required of direct service staff providing this service.

f. Unit Tracking Methodology: Describe the method for validating service units from referral, to service delivery, to billing ElderSource.


II.A.13. 2016-2017 OBJECTIVES AND PERFORMANCE MEASURES

GOAL 1: Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers

OBJECTIVE 1.1 : Identify and serve target populations in need of home and community-based services (HCBS)

EXPLANATION: The primary intent of this objective is twofold: 1) to address how the Provider will identify the target populations in their county, and 2) to address how the Provider will provide services to the targeted populations who may be in hard-to-reach areas.

STRATEGIES/ACTION STEPS:

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OUTCOMES:<Enter Text Here>

Note: The Provider must include strategies to address the following measures in this section.

Percent of most frail elders who remain at home or in the community instead of going into a nursing home

Average monthly savings per consumer for home and community-based care versus nursing home care for comparable client groups

Percent of new service recipients whose Activities of Daily Living (ADL) assessment score has been maintained or improved

Percent of new service recipients whose Instrumental Activities of Daily Living (IADL) assessment score has been maintained or improved

Percent of customers who are at imminent risk of nursing home placement who are served with community-based services

Percent of elders assessed with high or moderate risk environments who improved their environment score

Percent of new service recipients with high-risk nutrition scores whose nutritional status improved


DOEA Internal Performance Measures:

Percent of high-risk consumers (Adult Protective Services (APS), Imminent Risk, and/or priority levels 4 and 5) out of all referrals who are served

OUTPUTS:

<Enter Text Here>

OBJECTIVE 1.2 : Ensure efforts are in place to fulfill unmet needs and serve as many clients as possible

EXPLANATION: The primary intent of this objective is to address how the Provider plays an active role in the service delivery system in their Community Care Service Area..

STRATEGIES/ACTION STEPS:<Enter Text Here>







Percent of customers who are at imminent risk of nursing home placement who are served with community based services


Percent of new service recipients with high-risk nutrition scores whose nutritional status improved


OUTPUTS:

<Enter Text Here> Number of people served with registered long-term care services

OBJECTIVE 1.3 : Provide high quality services

EXPLANATION: The primary intent of this objective is for the Provider to detail quality assurance efforts in their agency.


<Enter Text Here>







Percent of customers who are at imminent risk of nursing home placement who are served with community-based services


Percent of new service recipients with high-risk nutrition scores whose nutritional status improved.

OUTPUTS:<Enter Text Here>


OBJECTIVE 1.4 : Provide services, education, and referrals to meet specific needs of individuals with dementia

EXPLANATION: This objective focuses on individuals with dementia to ensure that the specific needs of these individuals are not overshadowed by serving populations without dementia.


OUTCOMES:

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Percent of customers who are at imminent risk of nursing home placement who are served with community based services


Percent of new service recipients with high-risk nutrition scores whose nutritional status improved.

OUTPUTS: <Enter Text Here>

OBJECTIVE 1.5 : Improve caregiver supports

EXPLANATION: The primary intent of this objective is to strengthen caregiver services to


meet individual needs as much as possible. For example, existing caregiver support groups may not sufficiently address the differing challenges of spouse caregivers compared to adult child caregivers.


<Enter Text Here>

OUTCOMES:

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Note: The Provider must include strategies to address the following measures in this section.:

Percent of customers who are at imminent risk of nursing home placement who are served with community-based services (Standard: 90%)

Percent of family and family-assisted caregivers who self-report they are very likely to provide care (Standard: 89%)

OUTPUTS:

<Enter Text Here>

GOAL 2: Empower seniors and their caregivers to live active, healthy lives to improve their mental and physical health status

OBJECTIVE 2.1 : Promote good nutrition and physical activity to maintain healthy lifestyles

EXPLANATION: The primary intent of this objective is to focus specifically on nutrition and physical activity, since they are two key components to maintaining health. Many elders are not aware of the long-term implications of a less-than-adequate diet and how it may exacerbate chronic health conditions. Likewise, they may be unaware of the positive effect physical activity might have on their overall health and/or chronic conditions.


<Enter Text Here>


OUTCOMES:

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OBJECTIVE 2.2 : Promote the adoption of healthy behaviors

EXPLANATION: The primary intent of this objective is to focus on lifestyle choices beyond nutrition and physical activity as in objective 2.1. Lifestyle choices include such activities as smoking, alcohol, and/or drug consumption, average nightly hours of sleep, amount of stress, amount of socialization, engaging in enjoyable pursuits, etc.


<Enter Text Here>

OUTCOMES:

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OBJECTIVE 2.3 : Promote social connectivity, community service, and lifelong learning to maintain positive mental health

EXPLANATION: The primary intent of this objective is to address the benefits to the individual and the community when elders are active and engaged in the community.




OUTPUTS:

<Enter Text Here>

OBJECTIVE 2.4 : Advocate for prevention and early intervention of mental health and substance abuse services for elders

EXPLANATION: The primary intent of this objective is to enable the Provider to focus on advocacy specific to the need for mental health and substance abuse services.



OUTPUTS:


<Enter Text Here>


GOAL 3: Ensure the legal rights of seniors are protected and prevent their abuse, neglect, and exploitation

OBJECTIVE 3.1 : ▲ Facilitate the integration of Older Americans Act elder rights programs into Community Care Service Area.

EXPLANATION: The primary intent of this objective is to make legal services a more visible and mainstream part of their Community Care Service Area.


<Enter Text Here>

OUTCOMES:

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OBJECTIVE 3.2 : Promote primary prevention of elder abuse, neglect, and exploitation

EXPLANATION: The primary intent of this objective is for the Provider to expand existing education/outreach/awareness efforts such as websites, newsletters, presentations, etc., to include prevention of abuse, neglect, and exploitation.



OUTCOMES:

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OBJECTIVE 3.3 : Reduce the rate of abuse, neglect, and exploitation (ANE) recidivism through education and the provision of services

EXPLANATION: The intent of this objective is to expand existing efforts supporting ANE interventions.


<Enter Text Here>

OUTCOMES:

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Percent of Adult Protective Services (APS) referrals who are in need of immediate services to prevent further harm who are served within 72 hours

OUTPUTS:

<Enter Text Here>


OBJECTIVE 3.4 : Increase the awareness of health care fraud and other elder rights issues

EXPLANATION: The intent of this objective is for the Provider to use existing mechanisms to increase public awareness.



OUTPUTS:

<Enter Text Here>


GOAL 4: Promote planning and collaboration at the community level that recognize the benefits and needs of its aging population.

OBJECTIVE 4.1 : Foster opportunities for elders to be an active part of the community

EXPLANATION: The intent of this objective is to collaborate with communities to identify opportunities for elders that benefit them and their community.


<Enter Text Here>

OUTCOMES:

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OBJECTIVE 4.2 : Promote safe and affordable communities for elders that will benefit people of all ages

EXPLANATION: The intent of this objective is to encourage communities to incorporate elements of universal design into new construction and renovations of streets, sidewalks, and other common areas that will support an elder’s ability to age in place.



OUTCOMES:

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OBJECTIVE 4.3 : Promote cultural competency and awareness of a diverse population

EXPLANATION: The intent of this objective is for the Provider to recognize and address the unique benefits, needs, and challenges of its diverse and aging population.


<Enter Text Here>

OUTCOMES:

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GOAL 5: Maintain effective and responsive management

OBJECTIVE 5.1 : Promote and incorporate management practices that encourage greater efficiency

EXPLANATION: Best practice strategies may include internal monitoring, quality assurance, and performance-based standards and outcomes.



OUTPUTS:

<Enter Text Here>

OBJECTIVE 5.2 : Effectively manage state and federal funds to ensure consumers’ needs are met and funds are appropriately spent

EXPLANATION: The intent of this objective is for all state and federal funds to be appropriately spent, as well as to identify alternate resources for funding. In addition, the intent is for the funds to be spent on those populations for which the funds were intended.


<Enter Text Here>

OUTCOMES:

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Percent of co-pay goal achieved

Percent of increase in providers participating in the Adult Care Food Program

Percent of state and federal funds expended for consumer services (Standard: 100%)

OUTPUTS:

<Enter Text Here>


OBJECTIVE 5.3 : Ensure that providers continue to strengthen the disaster preparedness plans to address specific needs of elders

EXPLANATION: Strategies may include the development of formal agreements with local, state, and federal entities that provide disaster relief and recovery. Consideration should also be given to the planning and identification of consumer needs and the availability of special needs shelters in times of disaster.



OUTPUTS:

<Enter Text Here>

OBJECTIVE 5.4 : Accurately maintain the Client Information and Registration Tracking System (CIRTS) data

EXPLANATION: The intent of this objective is to ensure that data is entered accurately in CIRTS and that data is updated in a timely manner as to reflect changes.




OUTPUTS:

<Enter Text Here>

OBJECTIVE 5.5 : Promote volunteerism by and for seniors when possible

EXPLANATION: The intent of this objective is twofold: 1) detail how incorporating volunteers might extend the Provider’s capacity to provide services and 2) promote the benefit of utilizing elder volunteers.


OUTCOMES: <Enter Text Here>


Develop strategies for the recruitment and retention of volunteers



Essential Elements

The following table provides a detail of the Essential Elements that should be included in the development of your responses to each Goal at the Objective level.

GOAL

Objective Essential Elements

Goal 1 Enable individuals to maintain a high quality of life for as long as possible through the provision of home and community-based services, including supports for family caregivers

Objective 1.1. Identify and serve target populations in need of home and community-based services

↑

Strategies must include but not be limited to: Identifying and serving individuals who are in need of

HCBS with limited English proficiency; low-literacy, low-income individuals in rural populations; and grandparents caring for grandchildren.

Identifying and using best practices in the prioritization and services for clients according the to the Department’s prioritization criteria.

Developing and leveraging new partnerships, processes, and technologies in order to reach rural clients with services to address hunger, memory disorders, and caregiver supports.

Objective 1.2. Ensure that efforts are in place to fulfill unmet needs and serve as many clients as possible↑

Strategies must include but not be limited to: Identifying unmet needs and/or gaps through strategic

partnerships and collaborations with other entities which have expertise in meeting the identified needs and/or gaps.

Developing specialized support services for aging caregivers.

Objective 1.3. Provide high quality services↑

Strategies must include but not be limited to: Establishing procedures to assure client satisfaction and

the delivery of quality services.


GOAL


Objective 1.4. Provide services, education, and referrals to meet specific needs of individuals with dementia

↑

Strategies must include but not be limited to: Implementing caregiver programs that adopt or expand

state and federal volunteer respite program models and innovative projects that address caregiver needs and reduce their stress.

Developing and maintaining effective partnerships with organizations and providers who have dementia expertise, training staff to recognize possible cognitive impairment, and person-centered services planning.

Providing services for rural aging caregivers of individuals with dementia.

Objective 1.5. Improve caregiver supports

↑

Strategies must include but not be limited to: Providing education, training, and options to help

caregivers make better decisions and deal with current and prepare for possible future needs.

Home-delivered meals, older adult companionship, socialization, transportation, homemaking, home maintenance and repair, in-home care training, and daily calls to check on an isolated older adult.

Volunteer companions (retired seniors helping seniors) and older caregivers providing care for spouse, grandchildren, or other relatives.

Goal 2: Empower older seniors and their caregivers to live active, healthy lives to improve their mental and physical health status

Objective 2.1. Promote good nutrition and physical activity to maintain healthy lifestyles

↑

Strategies must include but not be limited to: Engaging stakeholders and community partners in

coordinated comprehensive nutrition and physical activity programs and community programs that help build social supports (e.g. increasing the use of congregate meal sites).

Developing social support for programs that promote active lifestyles and use of public facilities (e.g. walking or bike trails, classes at gyms or senior centers, athletic fields, etc.).


GOAL


Objective 2.2. Promote the adoption of healthy behaviors

↑

Strategies must include but not be limited to: Conducting community-wide campaigns that combine

highly visible messages to the public, community events, and support groups that encourage seniors to become or remain active.

Recruiting older adults to participate in the promotion of healthy behaviors through advertising and marketing to community partners.

Promoting the adoption of a healthy lifestyle by reducing smoking, alcohol, and/or drug consumption, and by encouraging sleep and stress management, socialization, and engaging in enjoyable pursuits, etc..

Objective 2.3. Promote social connectivity, community service, and lifelong learning to maintain positive mental health

↑

Strategies must include but not be limited to: Increasing the use of congregate meal sites. Developing comprehensive programs that include an

intergenerational component. Providing volunteer opportunities within aging network

and external partners. Providing community service training opportunities that

could lead to sustainable employment.

Objective 2.4. Advocate for prevention and early intervention of mental health and substance abuse services for elders

↑

Strategies must include but not be limited to: Public awareness activities to increase the

understanding of mental and substance-use disorders. Improving or developing partnerships with mental health

and recovery advocates in the community. Encouraging group-based activities composed of older

adults, like those at a senior center. Consideration of physical health issues such as nutrition,

sleep habits, medication, and pain management.


GOAL


Goal 3: Ensure the legal rights of seniors are protected and prevent their abuse, neglect, and exploitation

Objective 3.1. ▲ Facilitate the integration of Older Americans Act elder rights programs into aging services

↑

Strategies must include but not be limited to: Promoting an understanding of individual rights;

developing personal empowerment to exercise choices; and providing information regarding the benefits of services and opportunities authorized by law among vulnerable and at-risk seniors.

Objective 3.2. Promote primary prevention of elder abuse, neglect, and exploitation

↑

Strategies must include but not be limited to: Public education of the special needs of elders and the

risk factors for abuse in vulnerable adults. Primary prevention activities focused on preventing elder

abuse, neglect, and exploitation.

Objective 3.3. Reduce the rate of abuse, neglect, and exploitation recidivism through education, outreach, and the provision of services

↑

Strategies must include but not be limited to: Reducing the rate of recidivism through education and

outreach for caregivers and clients to help them with coping skills and services to alleviate caregiver stress and possible family strife.

Establishing and maintaining collaborative relationships with other entities that endeavor to prevent elder abuse, neglect, and exploitation.

Objective 3.4. Increase the awareness of health care fraud and other elder rights issues

↑

Strategies must include but not be limited to:

Use of websites, social media, newspapers, and direct mail.

Goal 4: Promote planning and collaboration at the community level that recognize the benefits and needs of its aging population

Objective 4.1. Foster opportunities for elders to be an active part of the community

↑

Strategies must include but not be limited to: Promoting volunteer services by and for older persons

including the use of intergenerational activities that allow elders to “give back” while educating younger generations about the value elders bring.


GOAL


Objective 4.2. Promote safe and affordable communities for elders that will benefit people of all ages

↑

Strategies must include but not be limited to: Developing and maintaining comprehensive health and

support service systems; providing input regarding land use and transportation planning; the expansion of educational, employment, cultural, and recreational resources; and the promotion of active, caring, and inclusive communities that respect autonomy, informed decision-making, and empowerment of older adults.

Objective 4.3. Promote cultural competency and awareness of a diverse population

↑

Strategies must include but not be limited to: Facilitating opportunities for cross-cultural interactions

among clients, caregivers, and program staff; promoting a diverse governance and workforce that are representative of the population being served; offering language assistance to individuals with limited English proficiency; and increasing awareness and access to programs and supports across literacy, ethnicity, race, gender, religion, sexual orientation, gender identity, and socioeconomic status.

Increasing accessibility to services, expanding program delivery, and enhancing retention, as well as maximizing the health and well-being outcomes of diverse populations within the aging and disability communities.


GOAL


Goal 5: Maintain effective and responsive management

Objective 5.1. Promote and incorporate management practices that encourage greater efficiency

↑

Strategies must include but not be limited to: The development and monitoring of standards, criteria, or

specific procedures to be used by the service providers in evaluating the quality of services provided.

Management analysis of performance and performance gaps based on internal monitoring, quality assurance, and performance-based standards and outcomes.

Management analysis of improvement objectives based on internal monitoring, quality assurance, and performance-based standards and outcomes.

Objective 5.2. Ensure federal and state funds are used to effectively and efficiently serve elders’ needs

↑

Strategies must include but not be limited to: Effectively reporting budgetary surplus/deficit projections. Analyzing management policies to reduce and eliminate

unspent contracted program funds.

Objective 5.3. Ensure that providers continue to strengthen the disaster preparedness plans to address specific needs of elders

↑

Strategies must include but not be limited to: Developing and maintaining formal agreements with

local, state, and federal entities that provide disaster relief and recovery.

Identifying and planning for consumer needs and the availability of special needs shelters in times of disaster.

Objective 5.4. Accurately maintain the Client Information and Registration Tracking System (CIRTS) data

↑

Strategies must include but not be limited to: Actively comparing CIRTS data to information in client

files to verify the accuracy of CIRTS data. Providing training and ongoing technical assistance to

ensure that employees understand how appropriately use CIRTS.


GOAL


Objective 5.5. Promote volunteerism by and for seniors whenever possible

↑

Strategies must include but not be limited to: Identifying, evaluating, and implementing “best practices”

that enhance the recruitment and use of trained volunteers in providing direct services to older individuals and individuals with disabilities.


II.A.14. SPA Appendix

Submit requested documentation (i.e. recently updated copies of Policies and Procedures, Consumer Complaint and Client Confidentiality documents, Subcontracts, and Sample Survey).

As noted in sections above, the Appendix, at a minimum, should include the following: Adult Protective Service and ARTT Procedures, including training tutorial log Prioritization Policies Aging and Disability Resource Center, Helpline Interface Procedures Program and Fiscal Subcontractor Monitoring Tool Samples CCE Subcontracts Current Case Manager Training Log, ensuring all employed staff have received required

training Quality Assurance and Quality Improvement Initiative Procedures 2015 Customer Satisfaction Survey Report, including results, analysis and necessary

follow-up Customer Satisfaction Sample Survey Adverse Incident Procedure and Log Consumer Complaint Procedure and Log Grievance Procedure CIRTS Reporting Procedures Sample of Privacy Notice Issued to Clients Sample of Notification to Clients Regarding Collection of Social Security Number Current Organizational Chart CIRTS Error Exception Achievement Level Report

II.A.15. SPA Program Module Checklist

Submit a completed Program Module Checklist indicating each item has been addressed and the page location for each item.



Service Provider Application7/1/2016 – 6/30/2017 Contract Period

Section II. B.

Contract Module – General Requirements


II. B. 1. Personnel Allocations Worksheet Included with the “2016-2017 SGR Contract Module Worksheets.xls”

II. B. 2. Unit Cost Worksheet Included with the “2016-2017 SGR Contract Module Worksheets.xls”

II. B. 3. Supporting Budget Schedule by Program Activity Included with the “2016-2017 SGR Contract Module Worksheets.xls”

II. B. 4. Commitment of Cash Donation (form attached)

II. B. 5. Commitment for Donation of Building Space (form attached)

II. B. 6. Commitment of In-Kind Contribution of Supplies (form attached)

II. B. 7. Commitment of In-Kind Contribution of Equipment (form attached)

II. B. 8. Commitment of In-Kind Contribution of Services (form attached)

II. B. 9. Commitment of In-Kind Volunteer Personnel and Travel (form attached)

II. B. 10. Availability of Documents (form attached)

II.B.11. SPA Contract Module ChecklistSubmit a completed Contract Module Checklist indicating each item has been addressed and the page location for each item.


II. B. 4. Match Commitment of Cash Donation

Agency Name:

Donor Identification:

Name:Street:

City:State:Zip:Phone:

Authorized Representative:

Total Amount $

# Payments

Amount/Payment $

Contribution Period

Special Conditions:

Donor Certification:

I hereby certify intent to make the cash donation set forth above for use in the specified program during the program's upcoming funding period. This cash is not included as match for any other State or Federally assisted program or contract and is not borne by the federal government directly under any federal grant or contract.

Signature of Donor or Representative: Date:_______


II. B. 5. Match Commitment for Donation of Building Space

Agency Name: Donor Identification:

Name:Street:


Authorized Representative: Description of Space: [ ] Office [ ] Site [ ] Other Provider Owned Space:

1. Number of square footage used by project: sq/ft

2. Appraised rental value per square foot: $

3. Total value of space used by project (1x2): $

Donor Owned Space:

1. Established monthly rental value:$

2. Number of months rent to be paid by donor: mos.

3. Value of donated space (1x2):$

Special Conditions: Donor Certification:

I hereby certify intent to donate use of the space set forth above for the program specified above during the program's upcoming funding period. This space is not being used as match for any other State or Federal program or contract.


Signature of Donor or Representative: Date:__ II. B. 6. Match Commitment of Supplies

Agency Name:


Name:Street:


Authorized Representative:

The below described supplies are committed for use by the project for the period of:

Description of Supplies:

Computation of value method:

Value to be claimed by project: $ Donor Certification:

These supplies are not included as contributions for any other State or Federally assisted program or contract and are not borne by the Federal Government directly or indirectly under any Federal grant or contract except as provided for under (cite the authorizing Federal regulation or law if applicable).



II. B. 7. Match Commitment of Equipment

Agency Name:


Name:Street:


Authorized Representative: The below described equipment is committed for use by the project for the period of:

Item Description Number Acquisition Cost Value to Project*1.

2.

3.

4.

TOTAL VALUE CLAIMED: $

* Items that are currently owned by the Grantee or are loaned or donated to the project are valued at an annual rate of 6-2/3 percent of the acquisition value.

Donor Certification:This equipment is not included as match for any other State or Federally assisted program or contract and are not borne by the Federal Government directly or indirectly under any Federal grant or contract except as provided for under (cite the authorizing Federal regulation or law if applicable).



II. B. 8. Match Commitment of In-Kind Contribution of Services by Staff of Service Provider or Staff of Other Organizations

Agency Name: Donor Identification:

Name:Street:City:State:Zip:Phone:

Authorized Representative: The personal services described below are committed for use by the project for the period of: Description of Positions:

Position/Title Service Hourly Rate or #Hours Value Annual Salary Worked to Project

1.

2.

3.

4.

TOTAL - $ * Value to project = (# of hours provided) x (hourly rate of annual salary). Donor Certification: It is certified that the time devoted to the project will be performed during normal working hours.

These services are not included as match for any other State or Federally assisted program or contract and are not borne by the Federal Government directly or indirectly under any Federal grant or contract except as provided for under (cite the authorizing Federal regulation or law if applicable).



II. B. 9. Match Commitment of In-Kind Volunteer Personnel And Travel

Agency Name:

Donor Identification: The volunteer staff positions identified below will be filled by local volunteers who will be recruited, trained and supervised as an ongoing activity of our agency. We will maintain volunteer records to document individual volunteer activity.

Describe Volunteer Effort:

Position Title Equivalent # of Value to Hourly Rate Hours

Project 1.

$ 2.

$ 3.

$ 4.

$ 5.

$ TOTAL VALUE TO AGENCY $

Equivalent Hourly Rates were determined by:

[ ] Rates for comparable positions within own agency.[ ] State Employment Service estimate of rates for type of work.[ ] Rates for comparable positions within other local agencies.

Estimated Mileage X Rate per mile = Value

Donor Certification:

I certify that commitments have been received from individual volunteers or groups sufficient to provide the volunteer hours and travel as identified above.


Signature of Agency Official: Date:_______

II. B. 10. AVAILABILITY OF DOCUMENTS

The undersigned hereby gives assurance that the following documents are maintained in the administrative office of the provider and are accessible for review by the AAA.

a. Current Board Rosterb. Articles of Incorporation and Corporate By-Lawsc. Advisory Council By-Laws and Membershipd. Corporate fee documentatione. Insurance and Bonding Verificationf. Staffing Plan (i.e. Position Descriptions, Pay Plan, Organizational Chart with staff names)g. Personnel Policies Manualh. Financial and Purchasing Procedures Manuali. Operational Procedures Manualj. Affirmative Action Plank. Targeting Plan and documentation of activities l. Americans With Disabilities Act Assurances and Policiesm. Staff Development and Training Plan (i.e. schedule, agendas, handouts, sign in sheets)n. Unusual Incident Fileo. Service subcontracts and subcontractor monitoring reportsp. Co Payment System (i.e. Policies and Procedures for CCE and ADI)q. Civil Rights Compliance documentationr. Confirmation of successful completion of the Level II background checks of required staffs. E-Verify Resolution t. Volunteer documentation (i.e. hours, assignments, training)u. Quality Assurance documentation (client satisfaction surveys and compiled results)v. Safety/Licensure compliance (annual fire inspection reports of administrative offices and

agency buildings with SGR funded services and licensure documentation if applicable.)w. Interagency agreementsx. Conflict of Interest Policyy. Current equipment inventoryz. Documentation of match commitmentsaa. Detailed documentation supporting contract expenditures and units of servicebb. Client filescc. Subcontractor Affidavit of Compliance

CERTIFICATION BY AUTHORIZED AGENCY OFFICIAL:

I hereby certify that the documents identified above currently exist and are available for review upon request.

_______________________ _______ _______________________________________Signature Date Name and Title of Authorized Individual
