reporting requirements for social and nutrition services ...€¦ · amended, and section 504 of...

Reporting Requirements

For Social and Nutrition Services

Fiscal Years 2017-2019 (October 1, 2016 - September 30, 2019)

Our Mission: The Area Agency on Aging 1-B (AAA 1-B) enhances the lives of older adults and adults with disabilities in the communities we serve. The Area Agency on Aging 1-B is funded in part by the federal Older Americans Act and the Michigan Department of Health & Human Services (MDHHS)/Aging and Adult Services Agency (AASA) and complies with the terms and regulations of the Title V of the Civil Rights Act of 1964 as amended, and Section 504 of the Social Rehabilitation Act of 1973 and is an Equal Opportunity Employer program. Reasonable accommodations will be provided upon notification or request.

Tina Abbate Marzolf Ann H. Langford Chief Executive Officer Director, Community & Business Advancement

29100 Northwestern Highway Suite 400, Southfield, Michigan 48034 Toll Free 800-852-7795 website: aaa1b.com

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PROGRAMMATIC REPORTING REQUIREMENTS Contractors are required to submit a number of reports on a periodic basis to AAA 1-B, the National Aging Program Information System (NAPIS), OmbudsManager and/or the Legal Services Information System (LSI). All reports are to be submitted electronically, unless otherwise directed by AAA 1-B. These reports are used by AAA 1-B and NAPIS to monitor contract performance and participant and unit serving levels. Programmatic reports must reconcile and be consistent with fiscal and NAPIS reports submitted. AAA 1-B has implemented a process to ensure that units reported to NAPIS form the basis for reimbursement to contracts. All quarterly programmatic reports are due to NAPIS, LSI, or to AAA 1-B at [email protected], by the 10th of the month following the end of each fiscal quarter, January, April, July and October. Additional information that cannot be emailed, such as brochures or newsletters, may be mailed or faxed to: AAA 1-B, 29100 Northwestern Highway, Suite 400, Southfield, MI 48034, fax (248) 948-0096. Please direct it to the attention of the appropriate program manager. Contractor Plan of Work AAA 1-B Social Service and Nutrition programs will report their programmatic activity to AAA 1-B electronically in an Excel file, called the Contractor Plan of Work Tool. Each awarded contractor will receive a customized Tool, which includes 2 or more worksheet templates. Worksheets can be accessed by clicking on a colored tab at the bottom of the Excel screen. The first tab on the file contains instructions for completing the worksheets. Please review these instructions before and during your work with the file. Also, create and save a backup copy of the file in case of loss. To submit reports, simply email the entire Excel file to [email protected]. Questions about how to complete these should be directed to the appropriate program manager. Contact the program manager if, for any reason, the reports will be submitted late. Late reports can affect the status of the contract, and are a compliance issue. Nutrition Education Assessment Report For nutrition services only, this worksheet is submitted annually with renewal of the contract. Legal Services Information System (LSI) Legal Assistance contractors will complete and submit quarterly activity reports using the electronic Legal Services Information System (LSI). Contractors will work with their AAA 1-B program manager to access LSI.

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mailto:[email protected],

mailto:[email protected]

OmbudsManger Long-Term Care Ombudsman contractors will complete and submit activity reports using the electronic OmbudsManger program. Contractors will work with their AAA 1-B program manager to access OmbudsManager. NAPIS Electronic Submission Process Contractors of the following services are required to submit electronic data to NAPIS each quarter. Electronic submissions are due the 10th of the month following the end of each quarter. The due dates are: January 10, April 10, July 10 and October 10.

• Adult Day Health Service • Chore • Congregate Meals • Grandparents Raising Grandchildren • Home Delivered Meals • Volunteer Caregiver

NAPIS reporting procedures for Holiday Meals on Wheels (HMOW) service AAA 1-B will reimburse for HMOWs after the data has been imported into NAPIS and reconciled with the nutrition program provider. As such, providers who submit HMOW data electronically can expect their reimbursement sooner. AAA 1-B requires providers to submit HMOW data electronically. FISCAL REPORTING REQUIREMENTS The Monthly Financial Report #008 is due on the 10th of each month for the preceding month of service. Late reports will not be processed and monthly payment will be withheld. If a contractor is late any two months in a three consecutive month period, the contractor will be placed on probation. Reporting forms may be obtained from AAA 1-B website at www.aaa1b.com. Social Service Program Monthly Financial Report #008 All funds received from AAA 1-B under this contract and all match and program income/voluntary cost share related to the contract must be accounted for in a manner that is distinct and separate from all other funds received by the contractor and separate from any other contracts and agreements with AAA 1-B. Fill in all requested information. All dollar amounts are to be rounded to the nearest dollar. Revenue: Record all income received to date pertaining to this contract as indicated on each line. For federal/state funds (not yet received but owed for this period) enter earned funds from the bottom section.

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http://www.aaa1b.com/

Expenditures: Report line item expenditures per the approved contract budget. Expenses should be broken out by direct costs vs. indirect costs. The sum of the direct and indirect expenses will automatically total. Do not include additional resources. Fill in the “Completed by” section. Reports may be emailed except for the final report, which should b e signed by an authorized official and mailed to AAA 1-B. Monthly Financial Report #009 All funds earned from the AAA 1-B under this contract and all match and program income/voluntary cost share related to the contract must be accounted for in a manner that is distinct and separate from all other funds received by the contractor and separate from any other contracts and agreements with the AAA 1-B. Fill in all requested information. All dollar amounts are to be rounded to the nearest dollar. Revenue: Record all income earned to date pertaining to this contract as indicated on each line. For federal/state funds (not yet received but owed for this period) enter earned funds from the bottom section. Expenditures: Report line item expenditures per the approved contract budget. Expenses should be broken out by direct costs vs. indirect costs. The sum of the direct and indirect expenses will automatically total. Do not include additional resources. Cash On Hand Balance: Total YTD revenues less total YTD Direct and Indirect Expenditures. This represents you cash standing AFTER this report is processed. If estimated expected funds are not received in 5-7 days, contact AAA 1-B immediately. Manually input the additional resources applied to this contract. The AAA 1-B website report form will automatically carry forward all other figures to this section.

Fill in the “Completed by” section. Reports may be e-mailed to the AAA 1-B except for the final report, which should be signed by an authorized official and mailed to the AAA 1-B. Social Services Under/Overspending Reconciliation Report #006 Explanation of Differences: Please explain differences of 10% or more that occur between the planned and the actual expenditures, for the expense line items that have been allowed under your contract. State what corrective action will be taken to bring under/over spending in line with budgeted levels. If under spending occurs in a Direct Cost Line Item, explain why it is necessary to continue to receive payment. If under spending occurs in an Indirect Cost Line Item explain why the contract amount shouldn’t be reduced to reflect efficiencies.

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Annual Equipment Inventory #0015 Complete a #0015 form for each program contract annually and submit with year-end fiscal reports. Only equipment purchased with AAA 1-B federal/state contract dollars is to be included on this report. Do not include all equipment associated with the contracted program. Equipment must be reported while the program is in existence even if records indicate the equipment is fully depreciated. Enter the quantity and the item description where indicated. Only include items that are defined as non-consumable goods that have an expected service life of at least one-year and with a total acquisition value of $5,000 or greater. Indicate the acquisition date and the cost of the equipment. Equipment cost is defined as the net invoice price including any modifications, attachments, accessories or auxiliary apparatus that make the equipment useful. Taxes, freight, duty and installation may or may not be included in accordance with contractor’s regular accounting practices. Indicate the portion of the total cost charged to the AAA 1-B program contract. Only include the amount purchased with grant funds. Do not include the amount, if any, purchased with additional resources. Indicate the disposal date and disposal method if applicable. Disposal options include:

• Selling the equipment that is no longer used at fair market value and using the proceeds to assist in the purchase of replacement equipment.

• Using the equipment for other AAA 1-B contracted programs when it is no longer needed for the original program.

• Throwing away the equipment when it no longer functions. Contact AAA 1-B prior to disposal if the fair market value of the equipment is greater than $5,000.

Sign and date the form for return to AAA 1-B.

Nutrition Services Monthly Financial Report #1020M This report is to be used by contracted and NSIP-only nutrition providers for monthly reporting of units served and as the basis for NSIP monthly reimbursement. For NSIP-only providers this will also serve as the final fiscal report at year-end and must be submitted to AAA 1-B with an original signature. Enter name and contract number, if a c ontractor, appropriate fiscal year and month that the report covers. Enter the current NSIP rate. For Contractors Only: Enter applicable contract information for Congregate and Home Delivered Meals as indicated in the General Information section.

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Monthly Program Summary: All providers must enter the number of congregate and/or home delivered meals served monthly and year to date. For contractors, the federal/state earned funds sections will automatically calculate. For NSIP- only providers, this line will be zero. Enter the amount of grant funds, NSIP payments and program income received where indicated. The over/under serving level percentage will automatically calculate. NSIP only providers will only provide the amount of NSIP reimbursement that has been received. For Contractors Only: If the percentage of over/under serving is 10% or greater, an explanation must be provided on this report. For over serving, indicate the plan for continuing service levels through the end of the fiscal year. Expenditures: Report line item expenditures per the approved contract budget. Expenses should be broken out by direct costs vs. indirect costs. The sum of the direct and indirect expenses will automatically total. Do not include additional resources. The "Title III C/State Funds Earned" line item in this section should match the "Title III C/State Funds Earned" line item in the Monthly Program Summary section of this form. The Contractor/NSIP-only provider section is to be completed by any Contractor that purchases units with contract funding from a NSIP-only provider and any NSIP-only provider that sells units to a Contractor. The individual responsible for completing this report must enter their name, title and the date that the report is completed prior to emailing. Annual Financial Report #1020Y

The #1020Y report must be submitted annually by all contractors and requires an original signature. This report will not be accepted by email. A preliminary #1020Y report is due by October 10th following the close of the fiscal year. The final report is due to AAA 1-B no later than November 10th following the close of the fiscal year. Units reported on the #1020Y form must match the units reported in NAPIS for the contract year to close. Final reports not matching NAPIS will not be accepted. Final payments will be based off units reported in NAPIS. This form is to be completed with actual expenditure information in the same manner as the nutrition budget. Attach form #0015 Annual Inventory Schedule if applicable.

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Attach a written explanation if either service has under-serving of 10% or more. Annual Equipment Inventory #0015 Complete a #0015 form for each program contract annually and submit with year- end fiscal reports. Only equipment purchased with AAA 1-B federal/state contract dollars is to be included on this report. Do not include all equipment associated with the contracted program. Equipment must be reported while the program is in existence even if records indicate the equipment is fully depreciated. Enter the quantity and the item description where indicated. Only include items that are defined as non-consumable goods that have an expected service life of at least one-year and with a total acquisition value of $5,000 or greater. Indicate the acquisition date and the cost of the equipment. Equipment cost is defined as the net invoice price including any modifications, attachments, accessories or auxiliary apparatus that make the equipment useful. Taxes, freight, duty and installation may or may not be included in accordance with contractor’s regular accounting practices. Indicate the portion of the total cost charged to the AAA 1-B program contract. Only include the amount purchased with grant funds. Do not include the share (if any) purchased with additional resources. Indicate the disposal date and disposal method if applicable. Disposal options include: o Selling the equipment that is no longer used at fair market value and using the proceeds

to assist in the purchase of replacement equipment. o Using the equipment for other AAA 1-B contracted programs when it is no longer

needed for the original program. o Throwing away the equipment when it no longer functions. Contact AAA 1-B prior to

disposal if the fair market value of the equipment is greater than $5,000. Sign and date the form for return to AAA 1-B.

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CONTRACTOR ASSESSMENT INFORMATION The operating standards of the Michigan Department of Health and Human Services (MDHHS/Aging and Adult Services Agency (AASA), for Area Agencies on Aging calls for a formal programmatic and fiscal assessment of each contractor, every fiscal year. The intent is to insure that service programs for older persons are being operated in accordance with service contracts, in compliance with AASA Operating Standards, and that the intended benefits are being realized by older persons. A second assessment during the fiscal year will be required for any contractor that is found to be out of compliance with the AASA Operating Standards for Service Programs, and/or AAA 1-B policies. Contractor Assessment Procedure Each winter, the AAA 1-B program and fiscal managers will notify service providers by email that a formal program assessment is being planned. This email will contain the general scope of the assessment and the scheduled assessment site visit date. Certain service providers may be eligible to have a desk assessment completed, which will be administered in lieu of an on-site visit. Service providers will be required to complete a written assessment tool, with specific questions that confirm compliance with requirements discussed in this Manual. The service-specific assessment tool will be available on the AAA 1-B website at www.aaa1b.com for review prior to the assessment. Following the assessment, the contractor will receive a written report of the findings of the assessment, including any follow-up action required, when necessary.

PROBATION, SUSPENSION, AND TERMINATION PROCEDURES Probation, Suspension and Termination are independent actions that may be taken by AAA 1-B and are not part of a successive disciplinary progression. Probation Probation is defined as a specified period of time within which the contractor must comply with specified terms of the contract and/or corrective actions identified by AAA 1-B. When the contractor has failed to comply with the terms of the contract, AAA1-B may place the contractor’s program operations on probation in whole or in part. AAA 1-B will send to the contractor, via US Mail with confirmed receipt, notification of probation. This notice shall contain reason(s) for probation, any corrective action required of the contractor, the effective date, and the right of the contractor to appeal. Probation may commence upon the contractor’s receipt of the notifications.

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http://www.aaa1b.com/

During the probationary period, the contractor will continue to receive reimbursement for expenses incurred as part of the contract. If, during the probationary period, the c ontractor does not comply with or implement the required corrective actions, suspension or termination processes may be initiated. Suspension Suspension is defined as the cessation of payment of funds to the contractor for a specific period of time. When the Contractor has failed to comply with the terms of the contract, AAA1-B may suspend financial support for program operations in whole or in part. Financial support for any part shall automatically be terminated when the contract has been suspended for more than ninety (90) days. Before suspending support for program operations, AAA 1-B will notify the contractor in writing, by confirmed receipt US mail, of the action being taken, the reason(s) for such action including specific violations, the effective date, and the conditions of the suspension. This notice will be given at least ten (10) calendar days prior to the effective date of the suspension and will note the right of the contractor to appeal. Under extreme conditions, such as danger to older persons or improper use of funds, AAA 1-B may give immediate notice of suspension. New obligations incurred by the contractor during the suspension period will not be allowed unless AAA 1-B expressly authorizes them in the written notice of suspension or written amendment to it. Necessary and otherwise allowable costs which the contractor could not reasonably avoid during the suspension period will be allowed, if they result from obligations properly incurred by the contractor before the effective date of the suspension and not in anticipation of suspension or termination. Should contract operations be suspended AAA 1-B shall determine: the amount of unearned funds the contractor has on hand; anticipated length of suspension; extent of operations suspended; and the amount of the fund balance on hand to determine whether AAA 1-B should require the balance to be returned. AAA 1-B may reinstate the suspended contract operations if it determines conditions warrant such action. Such reinstatement shall be made by issuance of a written statement of reinstatement. Financial participation by AAA 1-B in reinstated contract operations may resume immediately upon reinstatement, but not for any costs incurred for those contract operations while they were suspended. The obligational authority unearned at the time of suspension may again become available for earning at the previously established matching ratio, unless AAA 1-B reduces the amount of the contract.

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Contract Termination Contract termination is defined as the complete cessation of contracted services and contract funding. For adequate cause, AAA 1-B may terminate support for the contract prior to the end of the approved budget year. Examples of adequate cause include:

• Funds are unavailable, • Contractor violates conditions under which the contract was approved, • Contractor fails or inadequately complies with reporting requirements, • Program performance is inadequate as documented through assessment visits, • Assessment findings are inadequate, • Other resources are unavailable, • The contractor has been suspended for more than ninety (90) days.

To terminate the Contract, AAA 1-B will notify the Contractor in writing by confirm receipt US mail at least thirty (30) days prior to the effective date of termination and give the reasons for such action. The notice will specify any reports to be completed, the right of the Contractor to appeal, and the procedures to be followed for appeal. Under extreme conditions, such as gross negligence, misappropriation of funds, or lapse in liability insurance, immediate contract termination may be initiated. When financial support of the contract terminates on or before the end of the approved contract period, the contractor shall compete and submit a final program and financial report to AAA 1-B by the date established by AAA 1-B. When the contract is terminated or completed, equipment and supplies purchased with budgeted funds must be disposed of in accordance with procedures prescribed by 45 CFR Part 74, Subpart O Property. Any funds realized from the sale of such equipment or supplies are an adjustment to the program cost. The contractor may terminate the contract upon thirty (30) days written notice to AAA 1-B at any time prior to the completion of the Contract. GRIEVANCE PROCEDURES Right to Grieve Any older adult or his/her representative who has been: denied service; has had service terminated; or perceives unfair treatment by an AAA 1-B funded contract service provider may file a complaint or grievance with the organization in question. The contracted provider is to their established procedures. At this time the provider must also provide a copy of the “AAA 1-B Service Recipients Grievance Procedure” to any older adult or his/her representative who files a complaint with the organization.

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Should the matter be unresolved through the provider’s grievance procedure, a grievance may be filed with AAA 1-B. The complainant must submit a written statement of the grievance within ten (10) calendar days of the final step of the contractor's grievance procedure. A grievance filed against a Contract Service Provider of legal services while the complainant legal case is still open, will be held until the legal case is closed by entry of a final judgment or dismissal with prejudice and the expiration of all appeal periods. In this case, the Contract Service Provider will be instructed to inform AAA 1-B immediately upon the closure of the case. Step one of the grievance process will commence within ten (10) calendar days of the case closure. GRIEVANCE PROCESS Step One: Informal Inquiry:

• AAA 1-B staff will meet with the older adult or his/her representative, and a representative of the Contract Service Provider organization involved, within ten (10) calendar days of receipt of the written grievance statement, to discuss the issues involved in the complaint. Information and/or criteria on which the grieved action was based will be reviewed at this time, in an effort to resolve the complaint.

• Should the complaint be unresolved through the informal inquiry, within five (5)

calendar days of the inquiry, the complainant must submit to AAA 1-B a written request for a grievance hearing before the AAA 1-B Board of Directors. The reasons for the grievance must be included in this request.

Step Two: Hearing before the AAA 1-B Board of Directors:

• Within five (5) calendar days of receipt of the written request for a grievance hearing, AAA 1-B will schedule a hearing before the Board of Directors or a sub-group of the Board to take place at the end of the next regularly scheduled meeting of the AAA 1-B Board of Directors. If the next regularly scheduled Board meeting is scheduled to occur within three (3) weeks of receipt of the written request, the hearing will be scheduled for the next subsequent Board meeting, and the complainant and service provider will be so informed.

• A complainant shall be given a maximum of fifteen (15) minutes to present his/her

complaint, and the Contract Service Provider organization shall be given a maximum of fifteen (15) minutes to present its explanation of the grieved action. This will be followed by a fifteen (15) minute question and answer period.

• The Board of Directors or sub-group of the Board shall reach a final

determination by majority vote of the Directors present, and shall render this determination to the complainant when the vote is taken. The complainant and

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Contract Service Provider will also be sent the determination in writing within five (5) calendar days of the grievance hearing.

Board Approved 3/31/06

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Planned Action Steps Expected Outputs Performance Outcomes

Measurable activities that result in outcomes. Be

specific: who, where, when, how many

Measurable results of

action stepsMeasurable change over 1 year

1. Number and names of

subcontractors.

2. Data from surveys of

stakeholders.


referral sources and their social

program.


organizations that can also

provide chore services.

5. Number of new participants

added during current year.

1. 80% of participants report being satisfied with service.

2. Number of participants in targeted underserved/priority

population group is at least double their proportion in the

community.

3. 80% of participants report knowing how to access relevant

supportive services.

4. 80% of participants report their homes are safer as a result

of chore services.

First Quarter Action Steps Taken First Quarter Outputs First Quarter Outcomes

Second Quarter Action Steps Taken Second Quarter Outputs Second Quarter Outcomes

Third Quarter Action Steps Taken Third Quarter Outputs Third Quarter Outcomes

Fourth Quarter Action Steps Taken Fourth Quarter Outputs Fourth Quarter Outcomes

THE PROGRESS

Plan and Progress Worksheet

FISCAL YEAR: FY 2017SERVICE: ChoreORGANIZATION NAME:

THE PLAN

SAMPLE

Area Agency on Aging 1-B (800)852-7795 www.aaa1b.com Rev. 2/2016

SERVICE:

FISCAL YEAR:

ORGANIZATION NAME:

Person Preparing Report: Email:

Telephone: Fax:

NARRATIVE REPORT Attach separate sheet(s) if needed.

Describe: a) significant service developments, b) staffing changes/updates, c) recommendations implemented,

d) service needs, service gaps, and e) other significant activities experienced in your funded service to date.

Discuss contract status items: a) current contract stipulations, b) compliance issues, c) over/under serving,

d) number of participants and units served in the quarter.

WAITING LIST INFORMATION (Non-Medicaid Participants)

Enter the number of individuals on the waiting list:

Describe the length of stay for individuals on the waiting list: (these should total the number above)

Less than 30 days

30-60 days

Greater than 60 days

Greater than 180 days

Other: (please describe below)

Quarterly Programmatic Narrative & Waiting List Report

Access, In-Home, and Priority Services

FIRST QUARTER: Due January 10, for the period Oct, Nov, Dec

Service delays and/or disruptions

Shortages of in-home service staff/direct care workers

Enter the number of individuals that currently receive services that are "underserved" (i.e. services

are being provided at less than assessed level, etc.)

Loss of caregivers or informal support that supplemented AASA/AAA services or programs

Prioritization of participants leads to "underservice" for some participants based on priority level

Describe the resons that participants are "underserved" (check all that apply):

Reduced or closed services or programs

Participant served fewer hours of service than assessed or requested service hours

Area Agency on Aging 1-B 4/22/2016

Describe any assistance/referrals provided to individuals that are placed on waiting lists:

Referred to a local non-AAA-funded food assistance program (e.g. MiCAFE, Project FRESH)

that is currently accepting participants.

Referred to a local food bank/pantry shelf Referred to local DHS office

Referred to HCBS/ED Waiver Program Referred to AAA's CLP for service options

Referred to private pay program

Other assistance (please describe below)

Additional comments on the waiting list: (e.g. changes, events, issues impacting list, etc.)

Limited funding for services

Limited service area/service delivery availability

Driver/worker shortage

Participant choice

In order to address service demand that exceeds service availability, are services provided:

At levels less than identified need (underserved)? (yes, no, unknown)

Serving all participants at identified need level, and individuals who cannot be served at identified

need level are placed on a waiting list. (yes, no, unknown)

Additional comments on "underservice":

If a "0" count of individuals is reported on the waiting list, please describe:

Service capacity/funding is sufficient to serve all individuals who are eligible.

Other (describe)

E-mail reports to [email protected] by reporting due date. Late reports may result in loss of funding. Please contact

the service-specific program manager with questions.

Does the demand for in-home, access and priority services exceed service availability? (yes, no, unknown) If yes,

describe below and check all that apply.

Area Agency on Aging 1-B 4/22/2016

Fiscal Year: 2014

Service:

Agency Name:

Person Preparing Report: Name: Phone:

E-mail: Fax:

Percent of

Projection

Achieved

Number of Unduplicated Participants Served 0 #VALUE! 4 1 1 1 1

Number of Units Served 0 #DIV/0!

Service Coordination Units

Grandparents Raising Grandchildren 0

Volunteer Caregiver Program 0

Title II Unduplicated Participant Count by Characteristic

Participant Race/Ethnicity

a. Black or African American 0 #VALUE!

b. American Indian, Eskimo, Aleutian 0 #VALUE!

c. Asian* 0

d. Native Hawaiian/Pacific Islander* 0

e. Multi-racial 0 #VALUE!

Total Minority (sum of a-e) 0 0 #DIV/0! 0 0 0 0

f. White/Non-Hispanic or Latino 0 #VALUE!

g. Hispanic or Latino 0 #VALUE!

Total Non-Minority (sum of f, g) 0 0 #DIV/0! 0 0 0 0

FALSE 0

Participants in Poverty (100% of federal level) 0 #VALUE!

Total Participants in Poverty and Minority Group 0 #VALUE!

*The US Census and your Targeting Plan combine Asian and Native Hawaiian/Pacific Islander categories, but they must be reported separately on this form and to NAPIS.

Quarterly Programmatic Participant Unit Report Cumulative year-to-date participants served under OAA Title III and state funds

Due 10th of the month - January, April, July, October

For services: Adult Day Health Service, Evidence-based Programs, Grandparents Raising Grandchildren,

Hearing Impaired, Home Injury Control, Prevention of Elder Abuse, Resource Advocacy, Vol. Caregiver

Cumulative Total

Year-to-Date

Total

projected on

Targeting Plan

Number in yellow must equal total participants on contract

Fill in white boxes only

#VALUE!

1st Quarter

2nd Quarter 3rd Quarter Cumulative Total

Year-to-Date

Total

projected on

Contract

4th Quarter

Percent of

Projection

Achieved

Area Agency on Aging 1-B (800) 852-7795 www.aaa1b.com 4/22/2016

FISCAL YEAR:

NAME OF PERSON PREPARING REPORT:

Email:

NUMBER OF RESOURCE ADVOCATES REPRESENTED:

Ship

Line

Code

Enrollment

Ship

Line

Code

Pract.

Assist.

Savings

per part.

Total

Projected

Savings per

Prog.

Inform. &

ReferralFollow-Up

$2,370 $ -

Total MMAP Participants

v $7,000 $0

ia i $2,500 $0

ix-a ix $8,000 $0

Medicaid Application * (iii) iii-a iii $12,183 $0

Medicaid MSP App. Assistance * (iv) iv-a iv $1,259 $0

Low Income Subsidy * (ii) ii-a iii $4,000 $0

vi $5,000 $0

MMAP & Prescription (Not D) Sub-Total $0

$1,266 $0.00

0 0 -$ 0 0

Follow-Up: Provision of continued support/assistance to a participant on a previously identified need.

Prescription Assistance (NOT Part D) (vi)

Home Delivered Meals $

Focus Hope/Food Pantry

Veterans Benefits/Administration (vii)

Total Quarter Savings - All Programs

Food Assistance/Bridge Card

Ship Line Code: Ship Line Code aligns the service line on this tool with the service line on the Ship Talk form.

Medicaid Waiver

Medicare Advantage * (ix)

Transportation

Medicare Part D* (i)Medicare Part A & B*

Other (Please Specify):

Information & Referral: Provision of verbal or written information only (no extensive assistance with comparing plans/completing forms) to clients/caregivers in need of service(s). I &

R may or may not be documented in the participant file.

AAA 1-B Programs

MMAP

Other:

Emergency Needs

Tax Assistance

Practical Assistance: Assistance with reviewing available program options, determining participant eligibility, and/or completing applications or required forms/paperwork for the participant who

does not enroll at that time. Practical assistance is always documented in the participant file.

RESOURCE ADVOCATES OUTCOMES REPORT Due 10th of the month - January, April, July, October

PHONE:

Adult Home Help Grant $

Housing Assistance

Enrollment: Assistance with completion and submission of forms to enroll in a MMAP/Other program. Enrollment is always documented in the participant file.

ORGANIZATION:

Community Living Program

Gatekeeper Referral

Activity

FAX:

Housing

Adult Protective Services

G:\All Staff\CPS\Contracts\RFP\FY 2017-2019 RFP\FY 2017-19 RFP Process\Forms for RFP\Reporting Forms\4 Copy of Resource Advocates Outcomes Report Draft 3-13

FISCAL YEAR:

Organization:

1. Agency/person(s) conducting for congregate nutrition education:

2. Resource person/agencies/handouts/programs (summary)

October

November

December

January

Nutrition Service Chart 3 - Operational Resources

Annual Congregate Meals Report

3. Materials used and any information provided in other languages (list).

CONGREGATE NUTRITION EDUCATION ACTIVITIES PLAN AND OUTCOMES

February

March

April

May

June

July

August

September

4. List of congregate sites:

5. Number of Home Delivered Meal (HDM) recipients who also attended a congregate site:

7. Average Volunteer FTE's at meal time:

8. Average Paid Staff FTE's at meal time:

Submitted by: Date:

AAA 1-B Comments

Congregate Site Information

6. Describe vehicles and equipment used for delivering/holding hot, cold and ambient foods.

NUTRITION PROVIDER SUPPLEMENT FOR ELDERCARE FUNDING

HOLIDAY MEALS-ON-WHEELS PLAN

Provider Name:

Contact Person:

Phone #: Fiscal Year:

1. Indicate the geographic area(s) targeted to receive holiday meals on wheels. 2. What food preparation source(s) will you use for holiday meals? 3. Indicate how potential recipients will be assessed to determine their need for holiday meals. (Attach sample) 4. Identify if/how volunteers will be used. 5. Identify equipment used to maintain hot/cold temperatures during delivery. 6. Indicate the three (3) holidays you plan to serve, the projected number of meals, and menu for each holiday:

Holiday # Requested Menu

Thanksgiving (required)

Christmas or

Chanukah (required)

and New Year’s Day

or

Easter or

Passover

Other Holiday (requires approval)

Provider Name: Fiscal Year:

AAA 1-B Approval Date:

Contractor Name: Contracted Units:

Contract Number: Contracted Participants:

Service:

Cumulative No. of Month 1

Monthly

Expenditures

Year to Date

Expenditures

Year to

Date

Budget

Year to Date

Variance

Annual

Budget

Direct Cost: - - - Indirect Cost: - - -

* Total Cost: - - - - - -

Less Program Income/Voluntary Cost Share: - - -

Net Cost: - - - - -

-

Federal/State Share: - - - - - -

Local Match Share: - - - - -

Year to Date Units - - -

Year to Date Participants - - -

Completed by: Title: Phone:

I certify that the information provided in this statement is accurate, that all resources received have

been accounted for and that all costs reported herein have been incurred in accordance with the

conditions of the contract.

Signature (Required for Final Report) : Title: Date:

E-mail this report to [email protected] on or before the 10th of: Nov,Dec,Feb,Mar,May,June,

Aug, Sept. Final Report must be signed by an Authorized Official and mailed to the Area

Agency on Aging 1-B at 29100 Northwestern Hwy., Suite 400, Southfield, MI 48034.

AREA AGENCY ON AGING 1-B

MONTHLY FINANCIAL REPORT #009

SOCIAL SERVICES

G:\DEPT\FA\WIP\009NUR07.xls


QUARTERLY FINANCIAL REPORT #008

SOCIAL SERVICES

Contractor Name:

Contracted Service: Financial Year: to

Contract Number: Quarter Ending:

Contract Amount: Final Report: Yes ( ) No ( )

REVENUE YTD YTD Contract

Actual Planned Budget

Federal/State Funding

Cash Match

In-Kind Match

Prog. Inc./Vol. Cost Share

Total: $0 $0 $0

EXPENDITURES YTD YTD Contract

Actual Planned Budget

Direct

Salaries and Wages

Fringe Benefits

Travel

Supplies

Equipment

Rent and Utilities

Communications

Service Contracts

Other

Total: $0 $0 $0

Indirect

Salaries and Wages

Fringe Benefits

Travel

Supplies

Equipment

Rent and Utilities

Communications

Service Contracts

Other

Total: $0 $0 $0

Total Direct and Indirect

Expenditures $0 $0 $0

CASH BALANCE ON HAND: $0

$0 Completed by:

$0

$0 Title:

$0 Date: Phone #:

$0

$0

$0

Signature:

$0 (Required for the Final Report)

Title:

E-mail this report to [email protected] on or before: January 10, April 10, July 10 and October 10.

Final Report must be signed by an Authorized Official and mailed to the AAA 1-B.

I. GENERAL INFORMATION

II. CONTRACT REVENUE AND EXPENDITURES

Total Service Cost

Total Contract Cost

Additional Resources

Net Program Cost

Total Cost Charged to Contract

Less:Program Income Received

Net Program Cost

III. PROGRAM SUMMARY

I certify that the information provided in this statement is accurate,

that all resources received have been accounted for and that all

costs reported herein have been incurred in accordance with the

conditions of the contract.

Federal/State Share (80%)

Cash/In-Kind Match (20%)

Revised 01/06

Contractor Name: Contract Number:

Service:

Quarter Ending: Date Submitted:

Value of Value Allocated

Contribution to AAA 1-B Program Donor

Total Value this Quarter:

Value Reported Previous Quarters:

Combined Value (Cumulative Year to Date) :

Budgeted In-Kind Match for Current Fiscal Year:


Signature (Required for Final (fourth quarter) Report) : Title:


IN-KIND CONTRIBUTIONS DETAIL

QUARTERLY FINANCIAL REPORT #0010

have been accounted for and that all costs reported herein have been incurred in accordance

with the conditions of the contract.

E-mail this report to [email protected] on or before: January 10, April 10, July 10, and

October 10. Final Report must be signed by an Authorized Official and mailed to the Area Agency

on Aging 1-B at 29100 Northwestern Hwy., Suite 400, Southfield, MI 48034.

Date Contributed/Description

I certify that the information provided in this statement is accurate, that all resources received

G:\DEPT\FA\WIP\0010InkindReport07.xls

AREA AGENCY ON AGING 1-B QUARTERLY FINANCIAL REPORT #006

UNDER/OVER SPENDING RECONCILIATION SOCIAL SERVICES

Contractor Name:

Contract Number:

Service:

EXPLANATION OF DIFFERENCES

1. Please explain differences of 10 percent or more that occur between the planned and the actual expenditures, for the expense line items that have been allowed under your contract. State what corrective action will be taken to bring under/over spending in line with budgeted levels.

If under spending occurs in an indirect cost line item, explain why it is necessary to continue to receive payment. If under spending occurs in a direct cost line item, explain why the contract amount shouldn’t be reduced to reflect efficiencies.

Direct Cost Line Item: Explanation:

Indirect Cost Line Item: Explanation:

2. Do you presently have any unpaid obligations? Yes No

Please explain:

If yes, are these costs included in this month’s report? * Yes No

* You must include these costs in your Year End 008 Form. If you were formerly reporting on a cash basis, you may want to identify these included accrued costs with an asterisk.


I certify that the information provided in this statement is accurate, that all resources received have been accounted for and that all costs reported herein have been incurred in accordance with the conditions of the contract.

Signature (Required for Final Report): Title:

E-mail this report to [email protected] on or before: January 10, April 10, July 10, and October 10. Final Report must be signed by an Authorized Official and mailed to the Area Agency on Aging 1-B at 29100 Northwestern Hwy., Suite 400, Southfield, MI 48034.

mailto:[email protected]

PROGRAM

FISCAL YEAR

Cost $ AmountDate (Dollars Federal/State Disposal Disposal

Qty. Acquired Only) Share Date Method

The above equipment has been purchased per contract restrictions and requirements.

Authorized Signature Date

Item Description andIdentification Number

CONTRACT NO.

CONTRACTOR


ANNUAL EQUIPMENT INVENTORY #0015

ALL SERVICES

8/5/2016; 11:57 AM CPS\CONTRAC\FY2001RFP\RFP EXCEL DOCS\11 Equipment Inventory #0015\0015 Equipment


MONTHLY FINANCIAL REPORT #1020M

NUTRITION SERVICES

Provider Name: Contract Amount

Contract Number:

Participants Contracted

Fiscal Year to Unit Rate

Month Ending NSIP Rate

Meals Served

Participants Served

Title III C/State Funds Earned:

Title III C/State Revenue Received:

NSIP Revenue Received:

Program Income Received:

Over/Under Serving Level*:

* If over/under serving level is 10% or greater provide explanation of variance(s):* Participants and units reported must match the data reported and reconciled in NAPIS.

Provider Name: Provider Name:

Congregate Meals: Congregate Meals:

Home Delivered: Home Delivered:

Completed by:

Title: Date:

E-mail this report to [email protected] on or before the 10th of the month subsequent to the report period.

Direct Costs

$0

GENERAL INFORMATION

Home Delivered

$0

MONTHLY PROGRAM SUMMARY

Indicate meals (not reported above) that have been purchased by

Nutrition Contractor:

Indicate number of meals reported above that were

purchased from a NSIP only provider:

CONTRACTOR

Indirect Costs

Units Contracted

NSIP ONLY PROVIDER

Congregate Home DeliveredHome DeliveredCongregate

$0

Year to Date

$0

Current Month Year to DateCurrent Month

Congregate

Revised 01/06

Area Agency on Aging 1-B

Year End Financial Form #1020Y

Contractor: Contract Period:

Required

Grant Funding Match Units Unit Rate Clients

Congregate Meals $0 $0 -

Home Delivered Meals $0 $0 -

Grant Total $0 $0 -

NSIP Rate $0.56

Home Total Total

Congregate Unit Delivered Unit Contract Additional Program

Meals Ratio Meals Ratio Expenditures Resources Expenditures

Direct Costs

1. Raw Food $0 $0 $0

2. Purchased Meals $0 $0 $0

3. Nutrition Supplements $0 $0 $0

4. Direct Labor Salary $0 $0 $0

5. Direct Labor Fringe $0 $0 $0

6. Direct Kitchen Expenses $0 $0 $0

7. Transportation $0 $0 $0

Total Direct Costs $0 0.00 $0 0.00 $0 $0

Indirect Costs

8. Other $0 $0 $0

9. Indirect Labor Salary $0 $0 $0

10. Indirect Labor Fringe $0 $0 $0

11. Facilities (Rent / Utilities) $0 $0 $0

12. Equipment $0 $0 $0

13. Consultants $0 $0 $0

Total Indirect Costs $0 0.00 $0 0.00 $0 $0

Total Program Budget $0 0.00 $0 0.00 $0 $0

III. BUDGET SUMMARY

$0 Total Program Cost $0

$0 Total Program Unit Cost

$0

$0

$0

$0

$0

Signature: Title:

Budget Approval: CPS Date FA Date

AAA 1-B Use Only

$0

II. YEAR ONE BUDGET EXPENDITURES

$0

$0

$0

$0

$0

$0

$0

$0

Less: HDM Program Inc./Vol.Cost Share

$0

$0

$0

$0

I. GENERAL INFORMATION

$0

$0

$0

2014

Total Contract Budget

Federal/State Grant

CERTIFICATION: I certify that I am authorized to sign as a representative, officer or agent of the above mentioned entity. The budget amounts represent necessary costs for

implementing the Congregate and Home Delivered Meal Programs as described in the AAA 1-B Contract. Documentation required under the contract will be maintained and

accessible for the entire period of the contract and until an audit of the records has been completed after the end of the three year contract.

Less: NSIP Reimbursement

Less: Required Match

Less: CM Program Inc./Vol.Cost Share

Sub Total

CONGREGATE AND HOME DELIVERED MEALS PROGRAM BUDGET DETAIL

Contractor

Meal Type Units Cost Total Units Cost Total

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

Meal Type Units Cost Total Units Cost Total

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

Case Cost Units Cost Total Units Cost Total

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ -$ - -$ -$

- -$ - -$

1. RAW FOOD

Production Facility

HOME DELIVERED MEALS

Enter Type and # of Cases

CONGREGATE MEALS

CONGREGATE MEALS

2. PURCHASED MEALS

CONGREGATE MEALS

TOTAL RAW FOOD

TOTAL FOOD UNITS / COST

TOTAL PURCHASED MEALS

3. NUTRITION SUPPLEMENT

Provider


TOTAL NUTRITION SUPPLEMENTS


CONGREGATE MEALS HOME DELIVERED MEALS

CONGREGATE EXPENDITURE DETAIL

9. INDIRECT LABOR SALARY

Position/Title: Work Week Hours: FTE Total Position/Title: Work Week Hours: FTE Total

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$ -$ -$

FTE Total FTE Total

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$ -$ -$

-$

-$

-$ Rent Rate: Sq. Ft. -$

-$ Utilities: Months: -$

-$ Utilities: Months: -$ -$ -$

-$

-$

-$ -$

-$ -$

-$ -$

-$ -$

Miles: Rate Per Mile: -$

Other: -$

-$ -$

-$

-$

-$ -$ -$

-$

-$

-$

-$

TOTAL DIRECT KITCHEN EXPENSES

7. TRANSPORTATION

6. DIRECT KITCHEN EXPENSES

TOTAL DIRECT LABOR FRINGE

TOTAL DIRECT LABOR SALARIES

Contractor:

5. DIRECT LABOR FRINGE

Position/Title

0

10. INDIRECT LABOR FRINGE

4. DIRECT LABOR SALARY

TOTAL INDIRECT LABOR SALARIES

Position/Title:

TOTAL INDIRECT LABOR FRINGE

11. CONGREGATE FACILITIES (RENT/UTILITIES)

TOTAL FACILITIES

12. EQUIPMENT

13. CONSULTANTS

TOTAL EQUIPMENT

TOTAL CONSULTANTS

TOTAL TRANSPORTATION

TOTAL OTHER

8. OTHER

HOME DELIVERED MEALS EXPENDITURE DETAIL

9. INDIRECT LABOR SALARY

Position/Title: Work Week Hours: FTE Total Position/Title: Work Week Hours: FTE Total

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$ -$ -$

FTE Total FTE Total

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$ -$ -$

-$

-$

-$ Rent Rate: Sq. Ft. -$

-$ Utilities: Months: -$

-$ Utilities: Months: -$ -$ -$

-$

-$

-$ -$

-$ -$

-$ -$

-$ -$

Miles: Rate Per Mile: -$

Other: -$ -$

-$ -$

-$

-$ -$

-$

-$

-$

-$

-$

0Contractor:

4. DIRECT LABOR SALARY

TOTAL DIRECT LABOR SALARIES TOTAL INDIRECT LABOR SALARIES

5. DIRECT LABOR FRINGE 10. INDIRECT LABOR FRINGE

Position/Title Position/Title:

TOTAL DIRECT LABOR FRINGE

TOTAL INDIRECT LABOR FRINGE

12. EQUIPMENT

6. DIRECT KITCHEN EXPENSES

11. HDM FACILITIES (RENT/UTILITIES)

TOTAL FACILITIES

TOTAL DIRECT KITCHEN EXPENSES

7. TRANSPORTATION

TOTAL EQUIPMENT

13. CONSULTANTS

TOTAL TRANSPORTATION

TOTAL OTHER

TOTAL CONSULTANTS8. OTHER

Name of Agency:

BUDGET LINE CURRENT PROPOSED Service:

ITEM CHANGES BUDGET BUDGET

Direct Cost Items Contract No:

Salaries and Wages

Fringe Benefits Fiscal Year:

Travel - Staff

Supplies Effective Date:

Equipment

Rent/Utilities/Space

Communications

Service Contracts

Other:_______________

Indirect Cost Items

Salaries and Wages

Fringe Benefits

Travel - Staff

Supplies

Equipment

Rent/Utilities/Space

Communications

Service Contracts

Other:_______________

Total Budget -$

Less: Prog. Inc./Vol. Cost Share*

Net Cost -$

Additional Resources

* See Program Income/Voluntary Cost Share policy in the RFP.1)

Requested Change:

Requests for Budget line item changes (exceeding 20% or $200 of a line item) may only be made on or

before July 10. Budget line changes not exceeding 20% or $200 of a line item do not need approval.

Requests for Budget changes due to Program Income adjustments may be submitted until September 10.

2)

Rationale for Change:

All proposed contract budget changes must include an explanation of why the change is necessary. (Be specific, you may attach a separate page if more space is needed. If change is a result of increased program income, explain how the program will be enhanced.)

Authorized Signature Date

Mail original to: AAA 1-B Program Manager, 29100 Northwestern Hwy., Ste. 400, Southfield, MI 48034

For AAA 1-B Use Only

CBA Department Signature & Date CBA Director Approval Date

Finance and Administration Signature & Date Chief Fiscal Officer Approval Date

Addendum: Yes ( ) No ( )

SOCIAL SERVICES


BUDGET CHANGE REQUEST

-$

-$

reporting requirements for social and nutrition services ...€¦ · amended, and section 504 of...

Documents