Fourth Amendment - Proposed — City Council and Authorities Concurrent, June 6, 2023

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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FOURTH AMENDMENT TO THE CONTRACT BETWEEN THE COUNTY OF SANTA CLARA AND CITY OF SANTA CLARA – CONGREGATE MEALS
T
his is the Fourth Amendment to the Contract between the County of Santa Clara (COUNTY) and City of Santa Clara (CONTRACTOR) entered into on July 1, 201 9, for the provision of Congregate Meal Services. The original contract was approved by the Board on June 18, 2019.

T
his Contract is amended as follows:

Effective upon execution, the parties agree to comply with the provisions contained in the following exhibits, which are either attached hereto or stated below, and incorporated herein by this reference and made a part of the Contract.

1. Add Attachment A: List of Programs which is attached hereto and incorporated by this reference.

2. Replace Exhibit A-3: Program Provisions with Exhibit A-4: Program Provisions, which is attached hereto and incorporated by this reference.

3. Add Exhibit A-4.1: Program Provisions, which is attached hereto and incorporated by this reference.

4. Replace Exhibit B-3: Program Plan & Requirements with Exhibit B-4: Program Plan & Requirements, which is attached hereto and incorporated by this reference.

5. A
dd Exhibit B-4.1: Program Plan & Requirements, which is attached hereto and incorporated by this reference.

6. Re
place Exhibit C-4: Budget Plan with Exhibit C-5: Budget Plan, which is attached hereto and incorporated by this reference.

7. A
dd Exhibit C-5.1: Budget, which is attached hereto and incorporated by this reference.

8. Re
place Exhibit D-3: Logic Model with Exhibit D-4: Logic Model, which is attached hereto and incorporated by this reference.

9. A
dd Exhibit D-4.1: Logic Model/Purchase report, which is attached hereto and incorporated by this reference.

All other terms and conditions of the Contract remain in full force and effect. In the event of a conflict between the original Contract and this Amendment, this Amendment controls.

IN WITNESS WHEREOF, COUNTY and CONTRACTOR hereby agree to the terms of this Amendment to the Contract.

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Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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UNTY OF SANTA CLARA CONTRACTOR
Jeffrey Smith M.D., J.D., County Executive Office of City Manager Date: __________ Date: __________
ATTEST
__________________________ ___________________________ John P. Mills, Deputy County Executive Assistant City Clerk Date: Date: __________
A

PPROVED AS TO FORM AND LEGALITY APPROVED AS TO FORM
De
puty County Counsel Office of the City Attorney
Date: __________ Date: __________
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Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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Attachment A

List of Programs
Each program listed on this Attachment will have a corresponding set of Exhibits to specify the program terms and conditions. All Exhibits are attached hereto and incorporated herein by this reference.

1. Congregate Meals
Exhibit A-4: Program Provisions
Exhibit B-4: Program Plan Requirements
Exhibit C-5: Budget Plan
Exhibit D-4: Logic Model

2. Home and Community Based Services (HCBS) Senior Nutrition Infrastructure Funding Exhibit A-4.1: Program Provisions
Exhibit B-4.1: Program Plan Requirements
Exhibit C-5.1: Budget
Exhibit D-4.1: Logic Model/Purchase Report

DRAFT

Exhibit A-4 Program Provisions

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CONTRACTOR: City of Santa Clara

PROGRAM/PROJECT NAME: Senior Nutrition Program – Congregate Meals

This is a contract between the County of Santa Clara (COUNTY) and the (CONTRACTOR) for the purpose of providing meals for persons 60 years of age and older, which is funded, authorized by, and to be performed in accordance with the Older Americans Act of 1 965, as amended, P.L. 89- 73, U.S.C. Section 3000 et seq., and all amendments, rules, and regulations pertaining thereto.

1. CO

NDITIONAL AMENDMENTS
The County Executive, or designee, received delegation of authority from the Board of Supervisors on December 6, 2022, to negotiate, execute, amend, and terminate the scope of services, the term, new or revised contracting requirements, maximum financial obligation and budget of this Contract through June 30, 2023 based upon the following conditions:

a. COUNTY has appropriated sufficient funds for the modification of this Contract, b. CONTRACTOR is meeting the performance requirements for this contract, c. County Counsel has reviewed and approved the amendment as to form and legality, and
d. County Executive has approved the amendment.

2. T

ERM OF CONTRACT
The term begins on July 1, 2019, and expires on June 30, 2023, unless terminated earlier or otherwise amended.

3. MAXIMUM FINANCIAL OBLIGATION
COUNTY will reimburse CONTRACTOR actual allowable expenditures subject to the provisions of this Contract, for a total not to exceed $ 129,631.65 in FY2019-2020, $110,774.16 in FY2020-2021, $121,324.08 in FY2021-2022, and $135,780.00 in FY2022- 2023 for a total not to exceed $497,509.89.

4. BUDG

ET CONTINGENCY
This Contract is contingent upon the appropriation of sufficient funding by the County for the services covered by this Contract . Notwithstanding the termination provisions set forth herein, if funding is reduced or depleted by the County for services covered by this Contract, the County has the option to either terminate this Contract without notice (except that necessary to transition clients in the discretion of the County) and with no liability occurring to the County, or to offer an amendment to this Contract indicating the reduced amount.

5. CO

MPENSATION TO CONTRACTOR
a. FEE FOR SERVICE CONTRACT
i. CONTRACTOR will be paid by COUNTY in accordance with Exhibit A-4 Program Provisions, Exhibit B-4: Program Plan & Requirements, Exhibit C-5: Budget, and Exhibit D-4 : Logic Model, for the performance of services as outlined in this Contract up to the maximum compensation. These costs will also be in DRAFT

Exhibit A-4 Program Provisions

_________________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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accordance with current cost principles and with all other requirements of this contract:

1. For Non-Profit Agencies, OMB Circular A-122.

2. For Local Governments, OMB Circular A-87.

3. For Public and Nonprofit Institutions of Higher Education, OMB Circular A- 121.

4. For Profit Making Organization, 41 CFR Part 1.

i. If CONTRACTOR provides any tasks, deliverables, goods, services, or other work, other than as specified in this Contract, the same will be deemed to be a gratuitous effort on the part of the C ONTRACTOR, and the CONTRACTOR will have no claim whatsoever against COUNTY.

ii. CONTRACTOR must participate in a quarterly reconciliation process. During the reconciliation process all funds awarded to CONTRACTOR must be reconciled to the costs incurred and to the remaining cash, if any. Quarterly reconciliations must be submitted with the corresponding monthly invoice. During each reconciliation, all funds paid to CONTRACTOR under its fee for service claims must be reconciled to the actual costs incurred by the contractor and the remaining cash, if any. This provision survives the termination of this Contract.

iii. CONTRACTOR must participate in a closeout period at the end of the COUNTY funding period. During the closeout period all funds awarded to CONTRACTO R must be reconciled to the costs incurred and to the remaining cash, if any. A closeout packet will be provided to CONTRACTOR by COUNTY at the end of the funding period and is due within forty -five (45) days thereafter. If actual cost of providing services base on Unit Cost per meal is less than the amount reimbursed by COUNTY, CONTRACTOR’S final reimbursement will be reduced by the overpayment received from COUNTY. This provision survives the termination of this Contract.

COMPENSATION
CONTRACTOR must submit to COUNTY an invoice in a form approved by COUNTY, by the tenth (10th) calendar day of each month for the month just preceding in which services were performed. The CONTRACTOR will get paid on a monthly basis upon receiving an accurate account and invoice for services rendered, as well as payment for participant and guest contributions as outlined in Exhibit B -4: Program Plan & Requirements.

(i) Prior to submittal, invoices must be certified and signed by a responsible officer of CONTRACTOR with authority to certify that the information submitted by CONTRACTOR is accurate and CONTRACTOR is entitled to payment under the terms of the Contract. COUNTY may rely on said certification in making payment, but this payment will not constitute a waiver of any of COUNTY's legal rights or objections.

DRAFT

Exhibit A-4 Program Provisions

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(ii) In order to ensure continuation of service, CONTRACTOR will not be paid for meals in excess of the number of year-to-date meals listed in the Service Delivery Plan in Exhibit C-5 : Budget. Meals that are provided but not reimbursed in a particular month may be reimbursed if claimed on later invoice so long as CONTRACTOR has offered the agreed upon services continuously.

(iii) If the invoice is in proper form and the items billed are payable under this Contract, COUNTY will make payment to CONTRACTOR.

(iv) COUNTY will not be required to make payment if the amount claimed is not in accordance with the provisions of this Contract. All payments under this Contract will be made directly to CONTRACTOR as a corporate entity. Under no circumstances will COUNTY be required to make payments in any amount pursuant to this Contract to any other parties, including individual employees or creditors of CONTRACTOR.

(v) COUNTY is not obligated to reimburse CONTRACTOR for any expenditure not reported to COUNTY within sixty (60) calendar days after the end of the last month of the Contract term.

6. P

ARTICIPANT CONTRIBUTIONS
a. CONTRACTOR will submit participant contributions on a monthly basis with the monthly expense claims.

b. CONTRACTOR will deposit all participant contributions in a bank account maintained for the Senior Nutrition Program (SNP). All deposits, withdrawals, and balances for the Senior Nutrition Program must be separately identified. COUNTY has the right to review all financial records and bank accounts for audit purposes. Participants’ contributions will be collected, counted, and recorded daily by CONTRACTOR. Two persons designated by CONTRACTOR will co -verify the collection and count of participant contributions daily by their signature and date on a participant contribution accounting record. Participant contributions are to be deposited daily when possible, but no less frequently than on a weekly basis. Participant contributions are to be kept in a secure locked location and at night locking in a safe, pending deposit into the Senior Nutrition Program bank account.

7. ADV ANCE PAYMENTS
a. COUNTY, at its discretion may make advance payments under this contract to CONTRACTOR up to a maximum of 25% of the total contract amount and under conditions as the COUNTY may specify. Such advance payments will in no way increase the total maximum financial obligation specified under this contract.

b. CONTRACTOR must meet fidelity bond requirements as specified in Article V F. of this contract prior to receiving advance payment.

c. All advance payments require full repayment prior to the expiration of the contract.

COUNTY will specify repayment method of the advance payment amount by deducting an agreed upon monthly amount from the outstanding balance of the DRAFT
Ex
hibit A-4 Program Provisions
________
_________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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contract until the repayment obligation is fulfilled, or; deducting the advance payment amount in a lump sum from the remaining contract balance.

8. ADJUST MENT TO EXHIBIT B-4: PROGRAM PLAN & REQUIREMENTS A written adjustment to the Scope of Service/Staffing Plan may be approved by the COUNTY Representative, or designee, identified in this Exhibit, without a contract amendment as long as the adjustment reflects approved original program provisions and both parties are notified at least 10 days before the adjusted Scope of Service/Staffing Plan begins.

9. ADJUST MENT TO EXHIBIT C-5: BUDGET
A budget adjustment can be made without a contract amendment if Contractor submits a written budget adjustment request to the COUNTY Contract Representative, or designee, and the request is approved by the COUNTY in writing. A budget adjustment must not increase the maximum financial obligation of this Contract.

CO
NTRACTOR may request a budget revision by submitting the COUNTY’s Budget Revision Request form to the COUNTY’s designated contract/program monitor. The Budget Revision Request must include a statement explaining the impact that the budget revision, if approved, would have on the program/service delivery. Upon approval of the CONTRACTOR’s Budget Revision Request, COUNTY will forward an approved copy of the Budget Revision Request form to the CONTRACTOR.

10. ADJUST MENT TO EXHIBIT D-4: LOGIC MODEL
A written adjustment to the Logic Model may be approved by the COUNTY Representative, or designee, identified in this Exhibit, without a contract amendment as long as the adjustment reflects approved original program provisions and both parties are notified at least 10 days before the adjusted Logic Model begins.

11. SERVICE PROVIDED
a. CONTRACTOR must inform COUNTY of services and activities performed under this Contract and accept appropriately referred clients from the COUNTY for contract services as part of CONTRACTOR’s client base.
b. CONTRACTOR must coordinate services with other organizations providing similar services in order to foster community cooperation and avoid unnecessary duplication of services.
c. CONTRACTOR mus t assist in the coordination of and v erification of eligibility for mobility management serv ices for participants who use CONTRACTOR’S site as a home meal site.

12. CONTRACT REPRESENTATIVES
a. CONTRACTOR designates Jōvan Grogan, City Manager as CONTRACTOR’s representative for the purpose of performing the services as required by this Contract.

Unless otherwise indicated in writing, the above named person has the primary authority and responsibility to carry out this Contract.

DRAFT
Ex
hibit A-4 Program Provisions
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_________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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b. COUNTY designates the Director of Social Services Agency, or designee, as it s representative for the purpose of managing the services performed pursuant to this Contract.

13. NOTICES
All notices prescribed by this Contract will be in writing and deemed effective if sent by certified mail or registered mail and properly deposited with the United States Postal Service, postage prepaid with return receipt requested and addressed as follows:
a. To
COUNTY: Social Services Agency
Office of Contracts Management
333 West Julian Street
San Jose, California 95110-2335
b. To CO
NTRACTOR: City of Santa Clara
Jōvan Grogan, City Manager
1500 Warburton Avenue
Santa Clara, CA 95050

14. COUNTY’S CONTRACT TRANSITION PROCESS
CONTRACTOR agrees to provide all information deemed necessary by the County for us
e in subsequent procurement cycles.

DRAFT
Exhibit A-4.1: Program Provisions
_____________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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AGENCY: City of Santa Clara

PROGRAM NAME: Senior Nutrition Program – Congregate Meals – Home and Community Based Services Infrastructure Funding (HCBS Infrastructure Funding)

1. SER VICE DESCRIPTION
This is a contract between the County of Santa Clara (COUNTY) and City of Santa Clara (CONTRACTOR) for the purpose of purchasing, upgrading, or refurbishing infrastructure for the production and distribution of congregate or home-delivered meals provided through the regular Congregate Meals program, which is funded, authorized by, and to be performed in accordance with the Older Americans Act of 1965, as amended, P.L. 89-73, U.S.C. Section 3000 et seq., and all amendments, rules, and regulations pertaining thereto.

2. CO

3. T

ERM OF CONTRACT
The term begins on July 1, 2019, and expires on June 30, 2023, unless terminated earlier or otherwise amended.

4. M AXIMUM FINANCIAL OBLIGATION
COUNTY will reimburse CONTRACTOR actual allowable expenditures subject to the provisions of this Contract, for a total not to exceed $27,022.00 in FY2022-2023.

5. BUDG ET CONTINGENCY
This Contract is contingent upon the appropriation of sufficient funding by the County for the services covered by this Contract. Notwithstanding the termination provisions set forth herein, if funding is reduced or depleted by the County for services cov ered by this Contract, the County has the option to either terminate this Contract without notice (except that necessary to transition clients in the discretion of the County) and with no liability occurring to the County, or to offer an amendment to this Contract indicating the reduced amount.

6. CO

MPENSATION TO CONTRACTOR
a. COST REIMBURSEMENT CONTRACT
DRAFT
Exhibit A-4.1: Program Provisions
_____________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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i. CONTRACTOR will be reimbursed by COUNTY for its actual, reasonable, necessary, and allowed costs incurred up to the maximum compensation, for the performance of services as specified in this contract. These costs will also be in accordance with current cost principles and with all other requirements of this contract:

1. For Non-Profit Agencies, OMB Circular A-122.

2. For Local Governments, OMB Circular A-87.

3. For Public and Nonprofit Institutions of Higher Education, OMB Circular A-121.

4. For Profit Making Organization, 41 CFR Part 1.

ii. If CONTRACTOR provides any tasks, deliverables, goods, services, or other work, other than as specified in this Contract, the same will be deemed to be a gratuitous effort on the part of the CONTRACTOR, and the CONTRACTOR will have no claim whatsoever against COUNTY.

b. C

OST REIMBURSEMENT CLAIM
CONTRACTOR must submit to COUNTY a cost reimbursement claim in a form approved by COUNTY, by the tenth (10th) working day of each month for services performed during the preceding month.

i. Prior to submittal, cost reimbursement claims must be certified and signed by a responsible officer of CONTRACTOR with authority to certify that the information submitted by CONTRACTOR is accurate and CONTRACTOR is entitled to payment under the terms of the Contract.

COUNTY may rely on said certification in making payment, but this payment will not constitute a waiver of any of COUNTY's legal rights or objections.

ii. If the cost reimbursement claim is in proper form and the items billed are payable under this contract, COUNTY will make payment to CONTRACTOR within twenty-one (21) working days after receipt of the cost reimbursement claim.

iii. COUNTY will not be required to make payment if the amount claimed is not in accordance with the provisions of this Contract. All payments under this Contract will be made directly to CONTRACTOR as a corporate entity. Under no circumstances will COUNTY be required to make payments in any amount pursuant to this Contract to any other parties, including individual employees or creditors of CONTRACTOR.

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iv. COUNTY is not obligated to reimburse CONTRACTOR for any expenditure not reported to COUNTY within sixty (60) calendar days after the end of the last month of the Contract term.

7. P URCHASE REPORTING
This contract requires SSA’s purchase reporting. CONTRACTOR shall monitor and report the purchases outlined in Exhibit D: Logic Model/Purchase Report.

CONTRACTOR must submit to COUNTY a report in a form approved by COUNTY, by the tenth (10th) working day of each month, accompanied with the monthly cost reimbursement claim.

8. ADJ
USTMENT TO EXHIBIT B-4.1: PROGRAM PLAN & REQUIREMENTS
A written adjustment to the Program Plan & Requirements may be approved by the COUNTY Representative, or designee, identified in this Exhibit, without a contract amendment as long as the adjustment reflects approved original program provisions and both parties are notified at least 10 days before the adjusted Program Plan & Requirements begins.

9. ADJ
USTMENT TO EXHIBIT C-5.1: BUDGET
A budget adjustment can be made without a contract amendment if Contractor submits a written budget adjustment request to the COUNTY Contract Representative, or designee, and the request is approved by the COUNTY in writing. A budget adjustment must not increase the maximum financial obligation of this Contract.

CONTRACTOR may request a budget revision by submitting the COUNTY’s Budget Revision Request form to the COUNTY’s designated contract/program monitor. The Budget Revision Request must include a statement explaining the impact that the budget revision, if approved, would have on the program/service delivery. Upon approval of the CONTRACTOR’s Budget Revision Request, COUNTY will forward an approved copy of the Budget Revision Request form to the CONTRACTOR.

10. ADJ
USTMENT TO EXHIBIT D-4.1: LOGIC MODEL/PURCHASE REPORT
A written adjustment to the Logic Model/Purchase Report may be approved by the COUNTY Representative, or designee, identified in this Exhibit, without a contract amendment as long as the adjustment reflects approved original program provisions and both parties are notified at least 10 days before the adjusted Logic Model begins.

11. SER

VICE PROVIDED
a. CONTRACTOR must inform COUNTY of services and activities performed under this Contract and accept appropriately referred clients from the COUNTY for contract services as part of CONTRACTOR’s client base.

b. CONTRACTOR must coordinate services with other organizations providing similar services in order to foster community cooperation and avoid unnecessary duplication of services.

12. CO

NTRACT REPRESENTATIVES
DRAFT
Exhibit A-4.1: Program Provisions
_____________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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a. CONTRACTOR designates Jōvan Grogan, City Manager as CONTRACTOR’s representative for the purpose of performing the services as required by this Contract. Unless otherwise indicated in writing, the above named person has the primary authority and responsibility to carry out this Contract. b. COUNTY designates the Director of Social Services Agency, or designee, as its representative for the purpose of managing the services performed pursuant to this Contract.

13. NOTICES
All notices prescribed by this Contract will be in writing and deemed effective if sent by certified mail or registered mail and properly deposited with the United States Postal Service, postage prepaid with return receipt requested and addressed as follows:
a. T
o COUNTY: Social Services Agency
Office of Contracts Management
333 West Julian Street
San Jose, California 95110-2335
b. T
o CONTRACTOR: City of Santa Clara
Jōvan Grogan, City Manager
1500 Warburton Avenue
Santa Clara, CA 95050

14. COUNTY’S CONTRACT TRANSITION PROCESS
CONTRACTOR agrees to provide all information deemed necessary by the County for use in subsequent procurement cycles.

DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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CONTRACTOR: City of Santa Clara

PROGRAM NAME: Senior Nutrition Program – Home and Community Based Services (HCBS) Senior Nutrition Infrastructure Funding

1. SER VICE DESCRIPTION & EXPECTED OUTCOME
CONTRACTOR will work with the Social Services Agency – Senior Nutrition Program (COUNTY) and other community partners to ensure that the seniors receive nutritious and healthy meals at CONTRACTOR’s nutrition site(s). The PROGRAM provides seniors and older adults of Santa Clara County access to healthy, nutritious meals and the opportunity to socialize, take classes, and access other services. CONTRACTOR will perform services in compliance with the Senior Nutrition Program, Congregate Policy & Procedures Manual, and any updates thereto.

2. PER

MITS AND LICENSES
CONTRACTOR will obtain all permits and licenses necessary to the performance of this contract will assure that its subcontractors obtain the same. The CONTRACTOR will pay all normal fees for permits, licenses, inspections or any other certification or service required in the performance of this contract.

3. E

LIGIBLE INDIVIDUALS
Persons who are eligible for meals and services under this contract are those persons who are 60 years of age or older or who are spouses of persons who are 60 years of age or older. Meals may be made available to handicapped or disabled individuals who have not attained 60 years of age but who reside in housing facilities occupied primarily by the elderly at which congregate nutrition services are provided, or individuals with disabilities who reside at home with and accompany older individuals who are eligible for services. Priority will be given to those older persons in greatest social and economic need with particular attention to seniors who are age 75 or older, low-income, living alone, and/or minorities as defined by the Older Americans Act of 1965.

4. MEALS
a. Meals served by CONTRACTOR must provide at least one-third (1/3rd) of the current recommended dietary allowance specified by the Food and Nutrition Board of the National Academy of Sciences – National Research Council.

b. Menus will be planned by CONTRACTOR in cycles, the minimum period being five (5) weeks. Such menus must be planned in accordance with COUNTY requirements. Such menus will be submitted to COUNTY three (3) weeks prior to initial use. Menus will be posted in a conspicuous location at the meal site at least one (1) week in advance of use.

c. Table settings will be of reasonable quality. If disposable dinnerware is used, it will be of sturdy quality.

5. C

ONGREGATE MEAL SITES
DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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a. CONTRACTOR will provide congregate meals at the meal site(s), days, and times indicated in Exhibit C-5: Budget. Notwithstanding, CONTRACTOR may make minor changes to the service days and times listed in Exhibit C-5 with prior written approval of COUNTY.

b. CONTRACTOR may not relocate the meal site or add a meal site without prior notification, inspection, and approval by COUNTY. Relocation or addition of a meal site without the prior approval of the COUNTY may be considered a breach of the provisions of this contract. COUNTY may suspend or withhold payments, or terminate the contract if the relocation affects any of t he provisions of the contract including, but not limited to the following:

i. The relocation or addition reduces or terminates the provision of services to seniors in the geographic area served by this contract. ii. The relocation or addition changes the service area served by this contract. iii. The relocation or addition does not serve or give priority to older persons in the greatest social or economic need as defined by the Older Americans Act of 1965 as amended.

c. The site must have adequate lighting and ventilation and must meet all applicable health, fire, safety and sanitation regulations. CONTRACTOR must obtain current certificates from appropriate public officials indicating the site is in compliance with health and fire regulations.

d. CONTRACTOR ensures that a pleasant dining atmosphere is maintained and that there is adequate space for the equipment of participants, such as canes, crutches and wheelchairs.

e. There will be no architectural barriers which would prevent an eligible individual from having access to the meal site facility.

f. Innovative services may added to the PROGRAM during the term of this contract, or upon an extension of this contract, upon written approval of the COUNTY.

g. If a site is designated as a catered site in Exhibit C -5: Budget, upon written approval from COUNTY and upon obtaining all required governmental approvals, CONTRACTOR may switch to being a cook on site location. In the event of this switch, CONTRACTOR’s per -meal rate will be changed to the standard cook on site per-meal rate if different than the catered meal rate.

6. NUM

BER OF MEALS, SERVING DAYS, AND HOLIDAYS
a. CONTRACTOR will provide the number of hot meals as specified in Exhibit C- 5: Budget. If demand by eligible individuals in the first six (6) months of this Contract does not result in CONTRACTOR providing the average number of meals per day specified in Exhibit C-5: Budget, COUNTY may terminate this Contract. Prior to termination, COUNTY and CONTRACTOR may attempt to renegotiate this Contract to allow CONTRACTOR to reduce the average number of meals to be provided per day. If CONTRACTOR provides additional DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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meals and such additional meals will cause CONTRACTOR to exceed the Maximum Financial Obligation of this Contract, such additional costs will be the sole expense of CONTRACTOR, unless the parties agree and execute a Contract Amendment.

b. CONTRACTOR will be paid for the number of meals served at a meal site, not the number of meals prepared. COUNTY will not reimburse meals served that do not meet the dietary requirements in Section 4(a).

c. CONTRACTOR must open its Nutrition Site(s) for the number of service days specified in Exhibit C-5: Budget. CONTRACTOR must open its Nutrition Site(s) at minimum the number of serving days indicated each week except for holidays. Should CONTRACTOR close its Nutrition Site(s) due to unforeseen circumstances, CONTRACTOR will notify COUNTY immediately and work collaboratively to reschedule the day(s) that the Nutrition Site(s) was closed.

Should CONTRACTOR close their Nutrition Site(s) due to foreseen circumstances and not be able to reschedule the day(s) of services, CONTRACTOR will not be reimbursed for the number of meals allocated to the serving day(s) that the Nutrition Site(s) was closed.

7. ADV

ISORY COUNCIL
CONTRACTOR will ensure that an election is held to elect a participant to represent the nutrition site on the countywide program Advisory Council. It will be the responsibility of the program Advisory Council to advise the COUNTY on policy matters relating to the delivery of the congregate nutrition services throughout the COUNTY program area.

8. SU PPORTIVE SERVICES
a. CONTRACTOR will provide supportive services, to the extent that such services are needed and are not already available from third parties and accessible to individuals participating in the Congregate Meals Program.

Supportive services may include:

i. Transportation of eligible individuals to and from congregate meal sites so that nutrition and other services will be accessible to those eligible individuals living within the program area who, because of lack of mobility or physical or mental handicap, would otherwise be unable to participate in the program;

ii. Information and referral services designed to provide eligible individuals with current information of, and referral to, all appropriate services to meet their needs;

iii. Health and welfare counseling services designed to assist eligible individuals in dealing with the problems and stresses that interfere with normal health and social functioning. CONTRACTOR may provide such services through person-to-person assistance from trained counselors or referrals to other resources;

DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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iv. Nutrition education through a formal program of regularly scheduled meetings to make available pertinent facts related to nutritional need;

v. Recreation activities designed to foster the health and social well-being of program participants through social interaction and satisfying use of free time;
vi. Outreach activities to assure maximum particip ation of hard to reach and other eligible individuals.

b. CONTRACTOR will report the supportive services provided at its meal site(s) to the COUNTY in the format requested by the COUNTY and whether the service is provided by CONTRACTOR or another entity at least annually, or more often, as requested by the COUNTY. COUNTY may request this information from CONTRACTOR up to once per quarter.

9. F

OOD INVENTORY
CONTRACTOR will develop a written plan for conducting food inventories. The plan will include the procedures for conducting food inventories, identify persons responsible for conducting the inventory, and set the schedule for completing the inventories. The plan will also include a description of the "First -in-First Out" food rotation system that will be used to ensure stored goods are rotated to prevent deterioration. CONTRACTOR will provide COUNTY with a copy of its food inventory plan and completed food inventories, upon request.

10. PEST

CONTROL
CONTRACTOR is required to follow the pest control requirements in the current Senior Nutrition Program, Congregate Policy & Procedures Manual. In addition, if a pest issue is identified. COUNTY reserves the right to require CONTRACTOR to take corrective action to remedy the issue or require any other action from CONTRACTOR necessary to protect the health and welfare of participants.

11. DAT

A COLLECTION AND PRIVACY
a. At intervals prescribed by the COUNTY and, on forms provided by COUNTY, CONTRACTOR will collect program data and information relating to nutrition risk assessments, registered site participants, meals, use of services and program contributions. CONTRACTOR will also be required to collect program data through the use of electronic collection methods. Such methods may include the use of computers, scanners, or other means. CONTRACTOR must comply with collection requirements as directed by COUNTY. Unless otherwise specified, COUNTY will provide CONTRACTOR with the equipment needed to collect data by electronic means. COUNTY will be considered legal owner of all equipment provided to CONTRACTOR for this purpose. Such equipment is considered Non- Expendable property as described in Section 16 of this Exhibit.

b. CONTRACTOR must submit a completed and signed Santa Clara Senior Nutrition Program – Monthly Report for the prior month by the fourth (4 th) working
day of the current month to their assigned registered dietitian.

DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

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c. No later than the second time an eligible participant attends a congregate meal site operated by CONTRACTOR, CONTRACTOR must have the participant complete a registration form with participant’s information. Registration forms must be submitted to the designated COUNTY staff person at least monthly for registrants from the prior month along with the Monthly Report. CONTRACTOR must submit any new monthly registrations prior to the f ifth (5 th) working day of
every month.

d. CONTRACTOR must complete their monthly scanning for the prior month by the first (1st) working day of the month immediately following.

e. Quarterly Report. Quarterly Reports with output and outcome data must be turned in with September, December, March, and July invoices. Quarterly Reports must be prepared on the form provided by the COUNTY. Submission of the Quarterly Report is required before the corresponding monthly invoice can be paid.

f. Within 30 days of executing this agreement, and annually thereafter if the term of this agreement is extended, all employees, volunteers, subcontractors, or agents of CONTRACTOR who handle confidential client information, including but not limited to registration forms, must complete the information security and privacy presentation online training provided by the California Department of Aging (currently available at:
https://www.aging.ca.gov/ProgramsProviders/Information_Security_and_Privac y/Presentation/index.html). Upon completi on, evidence must be submitted to COUNTY to provide to Sourcewise.

12. P ARTICIPANT CONTRIBUTION PRINCIPLES
a. CONTRACTOR will provide meals to eligible individuals regardless of their ability to pay for all or part of their meals. Recipients are requested to make a financial contribution to offset the cost of the meals. Suggested contribution for congregate meals is $3.00 per meal. If CONTRACTOR also provides home delivered meals, the suggested contribution is $3.00 per day. Contributions are confidential. CONTRACTOR will not disclose records of the amount of contribution received or the name of contributor to third parties without written permission of the contributor. COUNTY has the right to review CONTRACTOR'S contribution records for audit purposes. Payment of the suggested contribution is not a condition for the receipt of meals.

b. CONTRACTOR will submit part icipant contributions on a monthly basis to be included with the monthly reimbursement claims. One hundred percent of these contributions must be submitted to COUNTY.

13. V

OLUNTEER, GUEST, AND STAFF MEALS
a. Volunteer Meals: A volunteer under the age of 60 who provides services during meal hours may be offered a meal, if doing so will not deprive an older individual of a meal. Volunteers under age 60 who receive a full meal that meets the requirements in Section 4 must pay a $3.00 fee and the fee must be included with the participant contributions and returned to the COUNTY. CONTRACTOR DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 6 of 9 ends

must record the number of volunteer meals served. CONTRACTOR will be reimbursed for volunteer meals provided.

c. Guest Meals: A guest under the age of 60 may be offered a meal during meal hours if doing so will not deprive an older individual of a meal or add to the cost of meals prepared. A guest must pay a fee of a t least $8.00 or up to the actual cost of the meal served, as specified in Exhibit C-5: Budget. CONTRACTOR must record the number of guest meals served and keep guest fees separate from participant contributions. CONTRACTOR may keep guest fees received.

The cost of providing guest meals may not be included in the quarterly reconciliation.

d. Staff Meals: Nutrition services staff under the age of 60 may receive a meal if doing so will not deprive an older individual of a meal or add to the cost of meals prepared. CONTRACTOR must record the number of nutrition services staff meals served. The cost of providing staff meals may not be included in the quarterly reconciliation.

14. M

ANDATORY ATTENDANCE
CONTRACTOR must have a representative attend every required training and meeting offered by the COUNTY that is specific to the Senior Nutrition, Congregate Meals Program.

15. P

URCHASES
COUNTY may require CONTRACTOR, by written notice, to obtain approval of COUNTY for all purchases of food and materials. Approval will not be withheld by COUNTY except for good cause.

16. NO

N-EXPENDABLE PROPERTY
Any acquisition by CONTRACTOR of non-expendable property with a retail purchase price in excess of five- hundred dollars ($500.00), that is required by CONTRACTOR for performance of this Contract, must require prior written approval of COUNTY.

COUNTY will be the legal owner of all equipment that is purchased with COUNTY funds. COUNTY may take possession of its equipment if it is not being used primarily for program purposes and will determine disposition of that equipment upon expiration or termination of this contract.

17. CO

MPETITIVE BID REQUIREMENTS
a. All equipment purchases by the CONTRACTOR exceeding five-hundred dollars ($500.00) must be procured through a competitive process in compliance with Sourcewise’s bidding procedures unless services or materials can be obtained only from a single source. Any procurement exceeding ten-thousand dollars ($10,000.00) must also comply with the requirements of Office of Management and Budget Circular Uniform Guidance.

b. Unless CONTRACTOR uses the COUNTY’s designated vendor, prior to making any equipment purchase that has a value of five-hundred dollars ($500) or more, CONTRACTOR will submit to COUNTY evidence that it has received a minimum of three (3) bids for such subcontract and justification for selection of the DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 7 of 9 ends

successful bidder or submit documentation to support the use of the sole supplier. Record shall be maintained by CONTRACTOR showing the parties solicited and the bids submitted.

18. O VERTIME WORK
Overtime work expenditures that are incurred by the CONTRACTOR will not be paid by reducing services or meals under this contract.

19. RE

STRICTION OF DISCLOSURES
Any reports, analysis, studies, drawings, information or data generated as a result of this contract are to be provided to COUNTY prior to public dissemination.

20. CARE

ACCESS ERROR RATE REQUIREMENT
Federal regulations pursuant to Title III of the Older Americans Act of 1965 (OAA) establish procedures for allocating money to states for various senior services. States have established allocation mechanisms to award monies to their Area Agencies on Aging (AAA). These AAAs in turn, award monies via contracts or grants to carry out the mission of the OAA.

Sourcewise, the County of Santa Clara’s designated AAA, allocates money for the provision of the Congregate Meals Program by reimbursing the County based on the number of meals served to seniors each month. This data is tracked through Sourcewise’s Care Access Database. When there is a discrepancy between the paper total (signatures of SNP participants) and scanner total (scanned barcodes of SNP participants), an error rate arises. Currently, if the total combined error rate of all Senior Nutrition Meal Sites exceeds five percent (5%), the County will not be reimbursed by Sourcewise. Therefore, CONTRACTOR’s data that is imported into Sourcewise’s Care Access Database must not exceed an error rate of 5%.

If CONTRACTOR’s imported data exceeds an error rate of 5%, COUNTY will withhold a percentage of CONTRACTOR’s invoice equivalent to the percentage of the error rate exceeding the 5% threshold. For example, if CONTRACTOR has an error rate of 23%, COUNTY will withhold 18% (23% - 5%) of CONTRACTOR’s invoice for that month.

Should Sourcewise decide to reimburse the County regardless of the combined error rate of all Senior Nutrition Meal Sites, then the County will not withhold any percentage of CONTRACTOR’s invoice regardless of CONTRACTOR’s error rate for that month.

21. G

RIEVANCE POLICY
a. CONTRACTOR must establish a written grievance process for reviewing and attempting to resolve complaints of older individuals receiving services funded by this Contract which complies with Sourcewise’s requirements and the Older Americans Act, Section 315(b)(4). At a minimum, the process shall include all of the following:

i. Time frames within which a complaint will be acted upon.

DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 8 of 9 ends

ii. Written notification to the complainant of the results of the review, including a statement that the complainant may appeal to Sourcewise if dissatisfied with the results of CONTRACTOR’s review.

iii. Confidentiality provisions to protect the complainant’s rights to privacy. Only information relevant to the complaint may be released to the respo nding party without the older individual’s consent.

b. CONTRACTOR shall notify older individuals of the grievance process available to them by:

i. Posting notification of the process in visible and accessible areas, such as the bulletin boards in multipurpose senior centers or areas in which there are a substantial number of older adults. For individuals are non-English speaking, the notification shall also be posted in the primary language of a significant number of older individuals.

ii. Advising homebound older individuals of the process either orally or in writing upon CONTRACTOR’s contact with the individuals.

c. Complaints may involve, but not be limited to, any or all of the following:

i. Amount or duration of a service.

ii. Denial or discontinuance of a service.

iii. Dissatisfaction with the service being provided or with the service provider.

If the complaint involves an issue of professional conduct that is under the jurisdiction of another entity, such as the California Medical Board or the State Bar Association, the complainant shall be referred to the proper entity.

iv. Failure of the service provider to comply with any of the requirements set forth in California Department of Aging regulations or in your contract with Sourcewise.

d. Nothing in this Grievance policy shall be construed as prohibiting older individuals from seeking other available remedies, such as presenting their complaints at an open meeting of CONTRACTOR’s governing board.

e. Notify Sourcewise in writing within ten working days after statement has been issues to complainant detailing the complaint, resolution and a copy of the statement sent to complainant. The address for mailing is 3100 De La Cruz Blvd., Suite 310, Santa Clara, CA, 95054.

22. F

ISCAL YEAR CLOSEOUT SUBMISSION
DRAFT
Exhibit B-4: Program Plan & Requirements
_____________________________________________________________________________________________

Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 9 of 9 ends

Due to fiscal reporting deadlines imposed by the California Department of Aging and Sourcewise, CONTRACTOR must submit requested fiscal year -end closeout documents to COUNTY accounting staff by July 5, 2023.

DRAFT
Exhibit B-4.1: Program Plan & Requirements
_____________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 1 of 3 ends

CONTRACTOR: City of Santa Clara

PROGRAM NAME: Senior Nutrition Program – Home and Community Based Services (HCBS) Senior Nutrition Infrastructure Funding

1. SER VICE DESCRIPTION & EXPECTED OUTCOME
The Social Services Agency – Senior Nutrition Program (COUNTY) is contracted to receive Home and Community Based Services (HCBS) Senior Nutrition Infrastructure grant revenue from Sourcewise, the local Area Agency on Aging, to pass through to designated subcontractors (including CONTRACTOR) that provide Title III congregate meals or home-delivered meals services. The pass -through funding will reimburse only for Sourcewise-approved infrastructure items and items on the California Department of Aging’s Title IIIC Capital Expenditure Approved List, CDA 7038 (REV 03/2022), attached as Exhibit E.

CONTRACTOR will work with the Social Services Agency – Senior Nutrition Program (COUNTY) to purchase, upgrade, or refurbish infrastructure to enhance production and distribution of congregate or home-delivered meals in compliance with HCBS funding rules.

2. PO

LICIES & PROCEDURES
CONTRACTOR will perform services in compliance with the Senior Nutrition Program, Congregate Policy & Procedures Manual, and any updates thereto as well as the Sourcewise Provider Manual equipment disposal procedures, attached as Exhibit F.

3. I NTENT
During Spring 2021, Meals on Wheels submitted an Advocacy Proposal to the Legislature, requesting $40 million to support the capacity and infrastructure improvement grants for senior nutrition programs. The HCBS Senior Nutrition Infrastructure Funding resulted from that proposal. Statewide, this funding will provide $38 million to enhance, expand, and increase senior nutrition infrastructure. The intent of this funding opportunity is to add capacity and make infrastructure improvement grants to senior nutrition programs under the Mello-Granlund Older Californians Act.

4. BACKG
ROUND
The specific items and prices listed in Exhibit C-5.1: Budget have been pre-approved for purchase with the funds in the agreement by Sourcewise and the California Department of Aging.

5. PER MITS AND LICENSES
CONTRACTOR will obtain all permits and licenses necessary to the performance of this contract will assure that its subcontractors obtain the same. The CONTRACTOR will pay all normal fees for permits, licenses, inspections or any other certification or service required in the performance of this contract.

6. P

URCHASES
CONTRACTOR must complete purchases in their entirety prior to June 30, 2023. Any change to the items in Exhibit C-5.1: Budget, including increased price or specification change, must be pre-approved in writing by the COUNTY Senior Nutrition Program DRAFT
Exhibit B-4.1: Program Plan & Requirements
_____________________________________________________________________________________________ Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 2 of 3 ends

Manager and Sourcewise (who will also get approval from the California Department of Aging) prior to purchase. CONTRACTOR may not be reimbursed without written preapproval.

7. PURCHASES
CONTRACTOR must complete purchases in their entirety prior to June 30, 2023.

8. P URCHASING RESTRICTIONS
This funding shall not be used to make additions, improvements, modifications, replacements, rearrangements, reinstallations, renovations, or alterations to capital assets that materially increase their value or useful life. This includes any equipment that is permanently affixed to a building such as non-portable generators, walk -in refrigerators, and walk-in freezers.

9. NO

N-EXPENDABLE PROPERTY
Any acquisition by CONTRACTOR of non-expendable property with a retail purchase price in excess of five-thousand dollars ($5,000.00), requires prior written approval of COUNTY.

10. CO

MPETITIVE BID REQUIREMENTS
a. All equipment purchases by the CONTRACTOR exceeding five-thousand dollars ($5,0 00.00) must be procured through a competitive process in compliance with Sourcewise’s bidding procedures unless services or materials can be obtained only from a single source. Any procurement exceeding ten- thousand dollars ($10,000.00) must also comply with the requirements of Office of Management and Budget Circular Uniform Guidance.
b. Unless CONTRACTOR uses the COUNTY’s designated vendor, prior to making any equipment purchase that has a value of five-thousand dollars ($5,000) or more, CONTRACTOR will submit to COUNTY evidence that it has received a minimum of three (3) bids for such subcontract and justification for selection of the successful bidder or submit documentation to support the use of the sole supplier. Record shal l be maintained by CONTRACTOR showing the parties solicited and the bids submitted.

11. E

QUIPMENT TRACKING
Property acquired under this agreement that has a normal useful life of at least one year and has a unit acquisition cost of at least $5,000 (a desktop or laptop setup, is considered a unit, if purchased as a unit), all computing devices, regardless of cost (including, but not limited to: workstations, servers, laptops, personal digital assistants, notebook computers, tablets, smartphones, and cellphones) and all portable electronic storage media, regardless of cost (including, but not limited to: thumb/flash drives and portable hard drives) must be reported to COUNTY , which will be reported to Sourcewise and the California Department of Aging, on the Equipment Request Justification Form (CDA 7037), attached as Exhibit G, for approval and tracked on an annual basis. In addition, the equipment purchased with this funding may be monitored by Sourcewise, the state government, and federal government based on equipment purchasing requirements.

Page 3 of 3 ends

All prior equipment/property purchased by CONTRACTOR will remain on the Sourcewise Program Property Inventory List. CONTRACTOR will submit the following to COUNTY in the month of June:

a. List of equipment and the condition of the item;

b. Location of the equipment;

c. Picture of the equipment including Sourcewise tag number.

12. EQ

UIPMENT DISPOSAL
CONTRACTOR may only dispose of equipment purchased under this agreement in compliance with the Senior Nutrition Program, Congregate Policy & Procedures Manual, and any updates thereto, as well as the Sourcewise Provider Manual equipment disposal procedures, attached as Exhibit F.

CONTRACTOR will submit an Equipment/Property Disposal Form to COUNTY for submittal to Sourcewise prior to disposal of the equipment/property that is no longer needed, defective, and/or stolen.

Equipment/property remaining on the Program Property Inventory List that is less than five-thousand dollars ($5,000.00) and does not meet the criteria for a computing device or portable electronic storage, will still require approval for disposal prior to removal from the inventory.

13. AUDI
T
This funding could be subject to audits by the COUNTY, Sourcewise, the state government, and federal government.

14. RE STRICTION OF DISCLOSURES
Any reports, analysis, studies, drawings, information, or data generated as a result of this contract are to be provided to COUNTY prior to public dissemination.

15. F ISCAL YEAR CLOSEOUT SUBMISSION
Due to fiscal reporting deadlines, CONTRACTOR must submit requested fiscal year- end closeout documents to COUNTY accounting staff by July 5, 2023.

DRAFT
County of Santa Clara
Social Services Agency
FY 2022-2023 Exhibit C-5
Master Budget
Agency Name:

Program:

A
Budget
Per Meal Reimbursement Rate
Contract Total $135,780.00
18,600 $7.30 $135,780.00
Annual Units Rate Total
City of Santa Clara
SNP Congregate Meals
B C D
Fourth Amendment to the Contract between the County of Santa Clara Social Services Agency and City of Santa Clara Page 1 of 4 DRAFT
County of Santa Clara
Social Services Agency
FY 2022-2023 Exhibit C-5
Site 1 - Service Plan & Budget
Agency Name:

Site:

A
Budget
Per Meal Reimbursement Rate*
Grand Total
Weekly Service Plan Mon Tues Weds Thurs Fri Sat Sun
Service
Days
Service Start 11:30 AM 11:30 AM 11:30 AM 11:30 AM 11:30 AM N/A N/A Service End 12:30 PM 12:30 PM 12:30 PM 12:30 PM 12:30 PM N/A N/A Total Hours 1.00 1.00 1.00 1.00 1.00 N/A N/A 5
Monthly Service Delivery Plan Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total Possible Serving Days 21 23 22 21 22 22 22 20 23 20 23 22 261 Unpaid Days Off 0 0 0 0 0 0 0 0 0 0 0 0 0
Holidays 1 0 2 1 3 1 2 1 0 1 1 0 13
Actual Serving Days 20 23 20 20 19 21 20 19 23 19 22 22 248 Budgeted Monthly Meals
(Serving Days x # of Daily Meals) 1500 1725 1500 1500 1425 1575 1500 1425 1725 1425 1650 1650 18600 YTD Budgeted Meals** 1500 3225 4725 6225 7650 9225 10725 12150 13875 15300 16950 18600 Santa Clara Senior Center

E FB C D
# of
Daily Meals
# of
Serving Days Annual Units
Site Preparation Type
Catered
*Only meals provided to eligible participants which meet dietary requirements will be reimbursed. The maximum number of meals reimbursed by the County will not exceed the YTD number of budgeted meals based on County-approved holiday schedule. Meals provided in a previous month but not reimbursed may be billed in a subsequent month. **Food costs must equal at least 25% less $.25 of the Total Contract Amount. Meals that are unserved will not be reimbursed.

Rate
$7.30
Total Contract
Amount**
$135,780.00
$135,780.00
75 248 18,600
City of Santa Clara
Fourth Amendment to the Contract between the County of Santa Clara Social Services Agency and City of Santa Clara Page 2 of 4 DRAFT
County of Santa Clara
Social Services Agency
FY 2022-2023 Exhibit C-5
Site 1 - Staffing Plan
Agency Name: City of Santa Clara
Site: Santa Clara Senior Center
75 248 18,600 13 1.45%
# of Daily
Meals
Serving Days Annual Meals Paid Holidays Payroll
Tax Rate
Paid Hours*

A B C D E F G H I
Job Title
Daily
Hours Hourly Rate
Paid Time
Off
(Days)
Do not include
Holidays Salaries
Payroll
Taxes
Retirement
Contribution
Health
Insurance
Other
Fringe
Benefits
Site Manager 5.00 $19.93 33.40 $ 26,009 $ 377 $ 659 Kitchen Aide 4.00 $20.79 33.40 $ 21,705 $ 315 $ 503 $ - $ -
$ - $ -
$ - $ -
$ - $ -
Total 9.00 $ 47,714 $ 692 $ - $ - $ 1,162

A B C D
Volunteer Hours
Daily
Hours
Valuation
Hourly Rate

Valuation
(In-Kind
Server 1 2.00 $25.31 $ 12,554
Server 2 2.00 $25.31 $ 12,554
Check-in 1 2.00 $25.31 $ 12,554
Check-in 2 2.00 $25.31 $ 12,554
Total 8.00 $ 50,216
Unpaid Volunteer Hours
*All personnel costs in the Staffing Plan are built into the per meal rate listed in Exhibit C-5: Budget, Service Plan & Budget.

Fourth Amendment to the Contract between the County of Santa Clara Social Services Agency and City of Santa Clara Page 3 of 4 DRAFT
County of Santa Clara
Social Services Agency
FY 2022-2023 Exhibit C-5
Resource Table
Agency Name: City of Santa Clara
Program: SNP Congregate Meals

A B C D
Source of Funds FY23 Amount % of Total Commitment Code
Santa Clara County Senior Nutrition
Program (This Contract) 135,780.00$ 64% 1 Volunteer Hours* $50,216.00 24% 3
Agency General Fund $3,445.00 2% 1
CDBG $24,000.00 11% 1
Non-senior contributions $0.00 0% 3
Total Program Cost 213,441.00$ 100% Total Per Meal Match
Actual Meal Cost
(Match + SCC Rate)
$4.18 $11.48
Commitment Code
1 2
3 4
5 Firm Commitment-Already have an agreement or letter confirming funding Anticipated Renewal of Existing Funding-Continuation of current year funding Anticipated Resource-Projection of previous fees or donations Application Pending-Application has been submitted, no confirmation at this time Pre-Application-Not yet submitted
Resources Provided by County
Resources Provided by Agency (Match)
In-Kind Resources
Cash Resources
* Volunteer Hours are valued by the County as: Living Wage * Hours Per Day * Serving Days SCC Rate
$7.30
Fourth Amendment to the Contract between the County of Santa Clara Social Services Agency and City of Santa Clara Page 4 of 4 DRAFT
Santa Clara County
Social Services Agency
FY 2022 - 2023 Exhibit C-5.1: BUDGET
Resource Table
1 of 3
Agency Name: City of Santa Clara
Contract Period: December 6, 2022 - June 30, 2023
Project Name: Senior Nutrition Program - Congregate Meals - Home and Community Based Services Infrastructure Funding (HCBS Infrastructure Funding)

A B C D
Source of Funds FY22-23 Amount
% of Total
Funding Commitment Code
Social Services Agency (SSA)* 27,022.00$ 100% 1 Other Funding Sources:
0%
0%
0%
0%
0%
0%
Total Funding Resources** 27,022.00$ 100% Commitment Code
1 2
3 4
5 * The SSA line in FY 22-23 Amount, Column "B" should equal the Grand Total of Column "B" in the Budget Detail.
** The Total Funding Resources in Column "B" should equal the Grand Total of Column "D" in the Budget Detail.

Firm Commitment-Already have an agreement or letter confirming funding
Anticipated Renewal of Existing Funding-Continuation of current year funding
Anticipated Resource-Projection of previous fees or donations Application Pending-Application has been submitted, no
confirmation at this time
Pre-Application-Not yet submitted and expect funding
Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 1 of 3 ends

DRAFT
Santa Clara County
Social Services Agency
FY 2022 - 2023 Exhibit C-5.1: BUDGET
Resource Table
2 of 3
Agency Name: City of Santa Clara
Contract Period: December 6, 2022 - June 30, 2023
Project Name: Senior Nutrition Program - Congregate Meals - Home and Community Based Services Infrastructure Funding (HCBS Infrastructure Funding)

A B C D
Operating Expenses** Contract Amount Other Funding Total 2 Door Reach-In Refrigerator 5,815.00 5,815.00 Cold Food Drop In Unit 3,838.00 3,838.00 Hot Food Drop In Well Unit 3,287.00 3,287.00 Milk Cooler 3,800.00 3,800.00 Roll-In Refrigerator 6,758.00 6,758.00 Inflation 3,524.00 3,524.00 Subtotal Operating Expenses 27,022.00 - 27,022.00 Grand Total*** 27,022.00 - 27,022.00 *Direct Costs are those costs for activities or services that benefit “specific projects” and are usually charged directly to projects on an item-by item basis.
**These expense accounts are examples only. Vendors are not required to use these. ***The Grand Total for Column "D" should equal Total Funding Resources of Column "B" in the Resource Table.

If there are any budget changes in certain line item expenses during the course of FY23, contractor must submit to the County a budget revision request form.

Direct Costs *
Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 2 of 3 ends

DRAFT
Santa Clara County
Social Services Agency
FY 2022 - 2023 Exhibit C-5.1: BUDGET
Resource Table
3 of 3
Agency Name: City of Santa Clara
Contract Period: December 6, 2022 - June 30, 2023
Project Name: Senior Nutrition Program - Congregate Meals - Home and Community Based Services Infrastructure Funding (HCBS Infrastructure Funding) Please provide an explanation for each line item. Narrative should be consistent with budget. 2 Door Reach-In Refrigerator
True TS-35-HC 39 1/2" Two Section Reach In Refrigerator, (2) Left/Right Hinge Solid Doors, 115v
Cold Food Drop In Unit
Cold Food Drop-In Unit, refrigerated, 2-pan size, self- contained refrigeration, insu Code: ATL-WCM-2
Hot Food Drop In Well Unit
Hot Food Drop-In Well Unit, electric, 3-well, individual pan design, wet or dry oper Code: ATL-WIH-3
Milk Cooler
True TMC-34-S-HC Milk Cooler w/ Top & Side Access - (512) Half Pint Carton Capacity, 115v
Roll-In Refrigerator
Turbo Air PRO-26R-RI-N 34" One Section Roll In Refrigerator, (1) Right Hinge Solid Door, 115v
Inflation
This item is included to capture cost increases that occur after the execution of the agreement.

Operating Expenses
Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara

Page 3 of 3 ends

DRAFT
Santa Clara County
Social Services Agency
FY 2022-2023 Exhibit D-4: Logic Model
Logic Model - Agency Name: City of Santa Clara
A. Contract Goal:

B. Situation C. Activities/Services
D1. # of
unduplicated
clients/families
served per FY
D2. # of
Outputs
per FY
D3. Output E. Short/Long Term
Outcome Measures
By June 30, 2023, City of Santa
Clara will have provided 18,600
meals over 248 lunch meal service
days to at least (# of unduplicated
seniors) unduplicated seniors.
275 18,600 Meals
Provide training to meal site
volunteers on food safety topics.
12 6 Volunteer Trainings
Provide training to meal site
participants on food safety topics.
200 4 Informational
Handouts
SNP - Congregate Meals
Provide nutritious meals, opportunities to socialize, transportation, and resources to older adults across Santa Clara County.

Lack of food access,
financial instability, and
social isolation are
pervasive issues among the
older adult community. In
order to meet the needs of
this community services
need to include ethnically
diverse cuisine served in
locations in proximity to low-
income neighborhoods,
innovative service models
that bring the food to the
people, transportation
options, and additional
safety net resources. These
services are a vital
component to keeping
people healthy and living
independently.

By June 30, 2023, at least 75% of eligible older adult
congregate meal participants will have participated in at least one other service offered at the meal site.

Fourth Amendment to the Contract between the County of Santa Clara Social Services Agency and City of Santa Clara Page 3 of 3 DRAFT
Santa Clara County
Social Services Agency
FY 2022 - 2023 Exhibit D-4.1: LOGIC MODEL/PURCHASE REPORT 1 of 1
Agency Name: City of Santa Clara
Contract Period: October 20, 2022 - June 30, 2023
Project Name: Senior Nutrition Program - Congregate Meals - Home and Community Based Services Infrastructure Funding (HCBS Infrastructure Funding) Item* Narrative Date of Purchase Total
Item Narrative mm/dd/yyyyy $0.00
*Provide invoice and proof of payment
Fourth Amendment to the Contract Between the County of Santa Clara and City of Santa Clara C1 HCBS

Page 1 of 1 ends

DRAFT
Title IIIC Capital Expenditure Approved List
Instructions: The list of equipment below are approved to be purchased using the Home and Community Based Services (HCBS) Senior Nutrition Infrastructure
Grant for the Title IIIC Older Californians Nutrition
Program (OCNP) only. No written justification or CDA approval is required. *If the equipment requested is not listed below the AAA will need to submit a completed
Equipment Justification Form CDA 7037 with their proposal to the CDA for review and approval.

Please note walk-in refrigerators
and freezers are not allowable.

Type of Equipment: Oven/Range/Stove,
Steamer, Gas or Electric
Categories: Combi
Convection
Conventional
Conveyor
Countertop
Double Stack
Griddle
Heat-n-Hold
Holding Unit
Induction Cooktop
Range Top
Reel
Rotating Rack
Type of Equipment: Cart/Cabinet, Hot or Cold
Categories: Beverage Service
Buffet
Holding
Mobile
Proofing Retherm
Rolling
Self-Serve
Serving
Warming
Type of Equipment: Hood
Categories: Exhaust
Condensate
Type of Equipment: Mixe
r
Categories: Countertop
Floor
Type of Equipment: Kit
chen Sink
Categories: Compartment
Hand
Utility
Type of Equipment: Refrigerator and Freezer
Categories: Blast Chiller
Cam chiller
Side by Side
Glass Door
Ice Chest
Milk Cooler
Mobile
Reach-In
Roll-In
Undercounter
Work-top
(Walk-in refrigerator
s and walk-in freezers are
excluded.)
Exhibit E: Title IIIC Capital Expenditure Approved List DRAFT
Individual Equipment Items
Barbecue (allowable when serving meals
to older adults in OCNP)
Bagging Machine
Braising Pan
Broiler
Cold
Pan Serving Counter
Cook/Chill System
Depositor and Filling Machine
Dishwasher
Dough Divider
Drawer Warmer
Food Display (Hot or Cold)
Food Processor
Food Slicer,
Chopper, Dicer, etc.

Fryer
Griddle
Menu Boards (Kitchen/Serving Area)
Microwave
Plate/Tray Dispenser
Produce Washers
Salad Bar
Serving Equipment
Serving Line System (Hot or Cold)
Shrink Wrapper Machine
Tray Sealer
Machine
Speed Line (Hot or C
old) Stainless
Steel Work Tables Steam Table
Styrofoam Recycling Machine Tilt
Skillet
* Per Program Memo No: 20-05 Equipment/Property Justification and Reporting Threshold.

CDA has adjusted the requirement f
or reporting equipment/property purchased as a part of
one of the above referenced contracts to $5,000 per
unit cost. All computing devices,
regardless of cost (including, but not limited to: workstations, servers, laptops, personal digital assistants, notebook computers,
tablets, smartphones, and cellphones) and all
portable electronic storage media, regardless of cost (including, but not limited to: thumb/ flash drives and portable hard drives) m
ust still be reported.
* Per Title 2, Code of Federal Regulations, Section 200.439: "Capital expenditures for special purpose equipment are allowable as direct costs, pr
ovided that items with a unit cost of
$5,000 or more have the prior w
ritten approval of the Federal awarding agency or pass- through entity."
* Require CDA approval
Exhibit E: Title IIIC Capital Expenditure Approved List DRAFT

SOURCEW

ISE PROVIDER MANUAL,
PLANNING SERVICE AREA, 10

SANTA CLARA COUNTY
Last updated: 08/2022
FY 2022-2023
Exhibit F: Sourcewise Provider Manual
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PROVIDER MANUAL TABLE OF CONTENTS

SECTION 1: INTRODUCTION ......................................................................................................................................... 5 Overview .......................................................................................................................................................................... 5 Who should read the Provider Manual?................................................................................................................ 5 SECTION 2: GENERAL INFORMATION, REQUIREMENTS, & DUE DATES .................................................. 6 Funding Sources .......................................................................................................................................................... 6 Service Type and Program Definition ................................................................................................................... 7 Timeline and Due Dates throughout the fiscal year ....................................................................................... 10 SECTION 3: SERVICE & CONTRACT COMPLIANCE REQUIREMENTS ....................................................... 12 Contract Requirements & Certifications ............................................................................................................. 12 California Civil Rights Law Certification ............................................................................................................. 12 Certification regarding Lobbying.......................................................................................................................... 12 Information Integrity & Security ............................................................................................................................ 13 Data Security Policy & Procedure ......................................................................................................................... 13 Security Awareness Training .................................................................................................................................. 13 Transition Plan ............................................................................................................................................................. 13 Grievance Procedure ................................................................................................................................................. 14 Insurance ....................................................................................................................................................................... 15 120 Day Contract Compliance Requirement and Guidance ........................................................................ 15 SECTION 4: GENERAL OLDER AMERICAN ACT PROGRAM REQUIREMENTS & LOCAL REQUIREMENTS ............................................................................................................................................................. 17 Goals & Objectives ..................................................................................................................................................... 17 Target Population - -- Title III B, C, D, and Title VII services ........................................................................... 17 Target Population - -- Title III E services ................................................................................................................ 18 Staffing and Volunteers - -- Title III B, C, D, E, and Title VII services ........................................................... 18 Coordination ................................................................................................................................................................. 18 Public Information ...................................................................................................................................................... 18 Client Input ................................................................................................................................................................... 18 Client Contribution ..................................................................................................................................................... 18 SECTION 5: SERVICE PERFORMANCE ................................................................................................................... 19 Service Performance Requirements .................................................................................................................... 19 R
equesting Technical Assistance .......................................................................................................................... 19 SECTION 6: DATA & PROGRAM REPORTING ..................................................................................................... 20 Data Management Overview ................................................................................................................................. 20 Data Collection - -- Service Units ............................................................................................................................ 20 Data Collection - -- Assessments.............................................................................................................................. 21 Exhibit F: Sourcewise Provider Manual
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Data Verification and Monitoring of Service Units .......................................................................................... 21 Data Performance Management Process ........................................................................................................... 21 Registered Service Required Client Fields and Data Elements: Title III B & C ..................................... 22 Registered Service Required Client Fields and Data Elements: Title III E ............................................. 23 Non-Registered Service Requirements: Title III B & C .................................................................................. 25 Non-Registered Service Requirements: Title III E .......................................................................................... 25 Restrictive Service Requirements: Title III B .................................................................................................... 25 Database Requirements for Registered, Non-Registered, and Restrictive Services: ........................ 26 SECTION 7: FISCAL, ACCOUNTING, RECORDKEEPING & AUDITS ............................................................ 27 Monthly Expenditure Request for Funds: ......................................................................................................... 27 Quarterly Expenditure Request for Funds: ....................................................................................................... 27 Sourcewise Internal Review and Corrective Action for Request for Funds .......................................... 27 Matching requirements: ........................................................................................................................................... 28 In-Kind Revenues and Expenses: ......................................................................................................................... 28 Indirect Costs .............................................................................................................................................................. 29 Qualifications and exceptions: .............................................................................................................................. 30 Non-Utilization of Federal Funds for Local Match: ........................................................................................ 30 Accounting Records, Recordkeeping & Retention: ....................................................................................... 30 Audits and Financial Closeouts ............................................................................................................................. 31 Funding Sources ......................................................................................................................................................... 31 Audited Financials and Single Audit Requirement ........................................................................................ 33 Closeout Report ......................................................................................................................................................... 33 Contract Resolution .................................................................................................................................................. 34 SECTION 8: PROGRAM MONITORING ................................................................................................................... 34 Monitoring Schedule Requirements .................................................................................................................... 34 Notification of In-Person Monitoring .................................................................................................................. 34 Pre-Program and Pre-Fiscal Monitoring ............................................................................................................ 35 Program Monitoring Only ....................................................................................................................................... 35 Program & Fiscal Monitoring ................................................................................................................................. 35 Site Visit and Accommodations ........................................................................................................................... 35 Post-Prog
ram and Post-Fiscal Monitoring ........................................................................................................ 35 Corrective Action Plan ............................................................................................................................................. 35 SECTION 9: GRANT MODIFICATIONS ................................................................................................................... 36 Contract Modifications ............................................................................................................................................ 36 Requested by Contractor ....................................................................................................................................... 36 Amendments to Service Agreement .................................................................................................................. 36 Budget Modifications and Revisions ................................................................................................................... 36 SECTION 10: EQUIPMENT ........................................................................................................................................... 37 Exhibit F: Sourcewise Provider Manual
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Equipment/Property is defined by CDA as: ..................................................................................................... 37 Equipment/Property Approval Process ............................................................................................................ 37 Equipment Disposal Process ................................................................................................................................. 37 Equipment/Property Maintenance ...................................................................................................................... 38 SECTION 11: CO-BRANDING AND MEDIA ............................................................................................................. 39 SECTION 12: CONTRACTED SERVICES GRIEVANCE PROCEDURE & POLICY ....................................... 39 SECTION 13: GLOSSARY OF TERMS ......................................................................................................................40 OAA Title III & Title VII Program Eligible Population and Program Definitions ...................................40 Supplement Glossary of Terms ............................................................................................................................. 42 SECTION 14: DATA & FISCAL TEMPLATES ......................................................................................................... 45

Exhibit F: Sourcewise Provider Manual
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SECTION 1: INTRODUCTION
Overview
Sourcewise has prepared this Provider Manual to assist the contracted organization’s (aka service provider) administrative, fiscal and program staff to successfully manage their grant funded programs. The manual contains the most frequently utilized procedures required to maintain contractor compliance with federal, state, and Sourcewise regulations and policies that govern the grant funded programs and services.

We look forward to working with you to deliver quality services for older adults in Santa Clara County.

Who should read the Provider Manual?
Within each contracted organization, the below individuals should read, in detail, this PROVIDER MANUAL and the fully executed service agreement for the applicable fiscal year.

Position/Title Responsibil ities
Program Manager Person(s) is responsible for administering/managing the Sourcewise/OAA grant funded program
Data Manager Person(s) responsible for collecting client level data and entering into the respective program (Q Database System or other database)
Fiscal Manager Person(s) responsible for the fiscal aspect (budgets, reporting expenditures, etc.) of the Sourcewise/OAA grant-funded program.

Operations Manager/Site
Coordinators
Person(s) responsible for day-to-day operations of the program if different from the program manager.

*This manual replaces all previous Sourcewise provider manuals. However, it is not a replacement for program-specific manuals and regulations issued by the State of California such as the Long- Term Care Ombudsman Program manual or California Statewide Guidelines for Legal Assistance manuals, etc.

**NOTE: Contractor, contractor, subcontractor, service provider, and grantee may be used interchangeably throughout the manual. The terms have the same meaning regardless of how the term is used.

Exhibit F: Sourcewise Provider Manual
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SECTION 2: GENERAL INFORMATION, REQUIREMENTS, & DUE DATES Funding Sources
It is important for all contractors and their team to understand the dollar amount, source of funds and the match requirement for your grant. Older American Act program funding is federal funding unless otherwise identified by the AAA to the contracted service provider. Additional funding may include State General Fund or one-time only initiatives.

Older American Act (OAA) Federal Funding S ources with Descriptions and Minimum Required In-Kind or Cash -Match
OAA Funding
Source Description Minimum Match
In-Kind or Cash
Title III B Adult Day Care/Health Center; Legal Services; LTC-OMB; Case Management; Transportation; Senior Center Activities; Ombudsman Program

11.11%
Title III C Nutrition Services; Congregate Meal (C-1); Home Delivered Meals (C-2)

11.11%
Title III D Health Promotion - -- Evidence-Based 0%
Title III E Family Caregiver Support Programs (Caregivers of Older Adults & Older Adult Relative Caregivers)
35%
Title VII A Prevention of Elder Abuse - -- Ombudsman Program 0% Title VII B Prevention of Elder Abuse, Neglect and Exploitation 0% State LTCOMB Ombudsman Program 0%
NSIP Nutrition Services Incentive Program (NSIP); United States Department of Agriculture (ASDA)
0%

The funding source for Families First Coronavirus Response Act (FFCRA) & Coronavirus Aid, Relief and Economic Security (CARES) Act, Consolidated Appropriation Act (CAA), and American Rescue Plan Act (ARPA) program funding and CDFA number is listed below for you to reference.

Emergency funding awarded to Title III and Title VII services started in March 2020 in response to the Coronavirus Disease (COVID19).

Families First Coronavirus Response Act (FFCRA) & Coronavirus Aid, Relief and Economic Security (CARES) Act , Consolidated Appropriation Act (CAA), and American Rescue Plan Act (ARPA) Federal Funding Sources with Description and Minimum Required In -Kind or Cash -Match

FFCRA/ CARES
Act
Funding
Source Description
Minimum
Match In -
Kind or
Cash
CARES Title III B Special Programs for the Aging, Title III, Part B, Grants for Supportive Services 0%
FFCRA Title III C,
Part 1
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 0%
FFCRA Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 0%
CARES Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 0%
CARES Title III E Family Caregiver Support Programs 0% CARES Title VII Prevention of Elder Abuse - --
Ombudsman Program 0%
Exhibit F: Sourcewise Provider Manual
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CAA Title III C,
Part 1
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 0%
CAA Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 0%
ARPA Title III B Special Programs for the Aging, Title III, Part B, Grants for Supportive Services 15%
ARPA Title III C,
Part 1
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 15%
ARPA Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 15%
ARPA Title III D Health Promotion - -- Evidence-Based 0% ARPA Title III E Family Caregiver Support Programs 35% ARPA Title VII Prevention of Elder Abuse - --
Ombudsman Program 0%

Service Type and Program Definition
To help each contractor and their teams successfully administer their Title III or Title VII program, it is important to understand the unique program or service definition of the Older American Act (OAA) Title III or Title VII Program, the type of unit for measurement and the type of funding (registered v. non-registered).

Outlined in Appendix B is the California Department of Aging (CDA) Service Categories and Data Dictionary. You can also find the below list of the Service Categories and Data Dictionary compon
ents for contracted services funded by Sourcewise.

CDA Data Service Cateories & Definitions
Service
Category Definition Unit of
Measure
Registered
v Non-
registered
Funding
Type
Adult Day
Care/Health
Personal care for dependent elders in a
supervised, protective, and congregate
setting during some portion of a day.

Services offered in conjunction with adult
day care/adult day health typically include
social and recreational activities, training,
counseling, and services such as
rehabilitation, medications assistance and
home health aide services for adult day
health.
1 hour Registered Title III B
Case
Management
Assistance either in the form of access
coordination in circumstances where the
older person is experiencing diminished
functioning capacities, personal conditions
or other characteristics which require the
provision of services by formal service
providers or family caregivers. Activities of
case management include such practices
as assessing needs, developing care plans,
authorizing and coordinating services
1 hour Registered Title III B
Exhibit F: Sourcewise Provider Manual
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among providers, and providing follow-up
and reassessment, as required.

Transportation Transportation from one location to
another. Does not include any other
activity. May include travel vouchers and
transit passes.
1 way
trip
Non-
registered
Title III B
Legal
Assistance
Legal advice, counseling and/or
representation by an attorney or other
person acting under the supervision of an
attorney.
1 hour Non-
registered
Title III B
Senior Center
Activities
Services designed to enable older
individuals to attain and/or maintain
physical and mental well-being such as
recreation, music, creative arts, physical
activity, education, leadership
development and other supportive
services not covered under other service
categories. Development and provision of
new volunteer opportunities and services,
and creation of additional services and
programs to remedy gaps and deficiencies
in existing services. Entertainment costs
such as tickets to shows or sporting
events, meals, lodging, rentals,
transportation and gratuities, are not
allowable.
1 hour Non-
registered
Title III B
Telephone
Reassurance
Telephone a client to provide contact and
safety checks to reassure and support
older individuals.
1 contact Non-
registered
Title III B
Congregate
Meals
A meal provided to an eligible individual in
a congregate group setting, that meets all
of the requirements of the Older
Americans Act and State/Local laws, and
assures a minimum one-third of the Dietary
Reference Intake, and shall comply with
Dietary Guidelines for Americans.
1 meal Registered Title III
C-1
Home
Delivered
Meals
A meal provided to an eligible individual in
his or her place of residence, that meets all
of the requirements of the Older
Americans Act and State/Local laws,
assures a minimum one-third of the current
Dietary Reference Intake, and shall comply
with Dietary Guidelines for Americans.
1 meal Registered Title III
C-2
Health
Promotion
Evidence-
Based
An evidence-based health promotion
program, including programs related to the
prevention and mitigation of the effects of
chronic disease (including, but not limited
to, osteoporosis, obesity, diabetes, and
cardiovascular disease), alcohol and
substance abuse reduction, smoking
cessation, weight loss and control, stress
management, falls prevention, physical
1 contact Non-
registered
Title III D
Exhibit F: Sourcewise Provider Manual
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activity, and improved nutrition. For a list
of ACL approved Evidence-Based
programs, please visit the National Council
on Aging website at
https://www.ncoa.org/resources/ebpchart.

Caregiver
Training
(Caregiver of
an Older
Adult)
An FCSP Support Service consisting of
workshops or one-on-one individually
tailored sessions, conducted either in
person or electronically by a skilled and
knowledgeable individual, to assist
caregivers in developing the skills and
gaining the knowledge necessary to fulfill
their caregiving responsibilities; and
address the areas of health, nutrition, and
financial literacy.
1 hour Registered Title III E
Caregiver
Case
Management
(Caregiver of
an Older
Adult)
An FCSP Support Service provided by a
person who is trained and experienced in
the skills that are required to coordinate
and monitor the provision of formal
caregiver-related services in circumstances
where caregivers are experiencing
diminished capacities due to mental
impairment or temporary severe stress
and/or depression.
1 hour Registered Title III E
Caregiver
Respite In-
Home
(Caregiver of
an Older
Adult)
An FCSP Respite Care service that includes
the provision of care receiver day and/or
overnight supervision and friendly visiting
by an appropriately skilled provider or
volunteer in order to prevent wandering
and health or safety incidents.
1 hour Registered Title III E
Caregiver
Respite Out-
of-Home Day
Care
(Caregiver of
an Older
Adult)
An FCSP Respite Care service where the
care receiver attends a
supervised/protective, congregate setting
during some portion of a day, and includes
assess to social and recreational activities.
1 hour Registered Title III E
Community
Education on
Caregiving
(Caregiver of
an Older
Adult)
An FCSP Information Service designed to
educate groups of current or potential
caregivers and those who may provide
them with assistance about available FCSP
and other caregiver support resources and
services (e.g., booth at a health fair).
1 Activity Non-
registered
Title III E
Caregiver
Case
Management
(Older Adult
Relative
Caregiver)
An FCSP Support Service provided by a
person who is trained and experienced in
the skills that are required to coordinate
and monitor the provision of formal
caregiver-related services in circumstances
where caregivers are experiencing
diminished capacities due to mental
impairment or temporary severe stress
and/or depression.
1 hour Registered Title III E
Exhibit F: Sourcewise Provider Manual
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Elder Abuse
Prevention,
Education &
Training
Public education and training of
professionals to develop, strengthen, and
carry out programs for the prevention,
detection, assessment, and treatment of,
intervention in, investigation of, and
response to elder abuse, neglect, and
exploitation (including financial
exploitation). This includes training for Title
III E caregivers.
1 Session Non-
registered
Title VII-
B
Elder Abuse
Prevention
Education
Materials
Educational materials and guidance kits
distributed for the prevention, detection,
assessment, and treatment of, intervention
in, investigation of, and response to elder
abuse, neglect, and exploitation (including
financial exploitation).
1 Product
Non-
registered
Title VII-
B
Timel
ine and Due Dates throughout the fiscal year
Set forth below are due dates which do not change throughout the year, and it is expected that the contracted service provider submits the required information by the due dates outlined below.

Dates are subject to change depending on unique requests received from the State. These updates will be communicated by email to the contracted service contact person and provide as much time available to complete the request.

GENERAL DUE DATES /TIMELINE *
Topic Due Date Submit to/Contact Information
CDA Security Awareness Training 31st of July [email protected] Full Contract Compliance
120 days of the
start of the
contract
[email protected]
Audited financials including Single
Audit
1st day of February
of the following
year
[email protected]
Financial Closeout Report 15th day of July [email protected] Program & Fiscal Monitoring** August - -- June Sourcewise Planner Analyst will schedule/arrange
* Annual program monitoring is required for all Title III C Nutrition Service Programs; Every two years a program & fiscal monitoring is required for all Title III and Title VII programs & services. *includes emergency funding through FFCRA, CARES Act, CAA, and ARPA.

NON-REGISTERED TITLE III or TITLE VII SERVICES
Topic Due Date Submit to/Contact Information
Title III or Title VII Registered Service
unit reports
10th day of the
following month
after the quarter*
[email protected]
Quarter 1 (July 01 - -- September
30) October 10th
Quarter 2 (October 01 - --
December 31) January 10th
Quarter 3 (January 01 - -- March
31) April 10th
Quarter 4 (April 01 - -- June 30) July 10th
Exhibit F: Sourcewise Provider Manual
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Request for Funds Invoices
15th day of the
following month
after the quarter **
[email protected]
Closeout Report 15th day of July [email protected] * If the 10th day of the month is on a weekend date, the non-registered service unit report is due the Friday before the 10th day of the month.
** If the 15th day of the month is on a weekend date, the request for funds is due the Friday before the 15th day of the month.

REGISTERED TITLE III SERVICES
Topic Due Date Submit to/Contact Information
Title III or Title VII Registered Service
unit reports
10th day of the
following month* [email protected]
Request for Funds Invoices 15th day of the
following month** [email protected]
Q1 Demographic & Data Check
10 working days
from September
30th
[email protected] Q2 Demographic & Data Check
10 working days
from December
31st
Q3 Demographic & Data Check 10 working days
from March 31st
Q4 Demographic & Data Check 10 working days
from June 30th
Closeout Report 15th day of July [email protected] * If the 10th day of the month is on a weekend date, the registered service unit report is due the Friday before the 10th day of the month.
** If the 15th day of the month is on a weekend date, the request for funds is due the Friday before the 15th day of the month.
***or designated Q Database Administrator of Sourcewise

EMERGENCY FUNDED TITLE III & TITLE VII SERVICES*
Topic Due Date Submit to/Contact Information
Title III or Title VII Registered Service
unit reports
10th day of the
following month** [email protected]
Request for Funds Invoices 15th day of the
following month*** [email protected]
Closeout Report 15th day of
October [email protected]
* Includes FFCRA, CARES Act, CAA, ARPA by reference and also outlined in Section 2 of the service provider manual and executed service agreement.
** If the 10th day of the month is on a weekend date, the registered service unit report is due the Friday before the 10th day of the month.
*** If the 15
th day of the month is on a weekend date, the request for funds is due the Friday before the 15th day of the month.
***or designated Q Database Administrator of Sourcewise

Exhibit F: Sourcewise Provider Manual
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SECTION 3: SERVICE & CONTRACT COMPLIANCE REQUIREMENTS
Contract Requirements & Certifications
The below sub-list of contract requirements and certifications is not inclusive of all compliance requirements and the contractor is responsible for thoroughly reviewing the fully executed contract agreement to ensure all requirements are adhered to.

California Civil Rights Law Certification
Contractor with which the award for the Title III or Title VII program(s) is at or more than $100,000 is required to sign a separate certification along with the fiscal year service agreement.

Pursuant to Public Contract Code section 2010, a person that submits a bid or proposal to, or otherwise proposes to enter into or renew a contract with respect to any contract in the amount of $100,000 or above shall certify, under penalty of perjury, at the time the bid or proposal is submitted or the contract is renewed, all of the following:

 California Civil Rights Laws: For contracts executed or renewed after January 1, 2017, the contractor certifies compliance with the Unruh Civil Rights Act (Section 51 of the Civil Code) and the Fair Employment and Housing Act (Section 12960 of the Government Code); and
 Employer Discriminatory Policies: For contracts executed or renewed after January 1, 2017,if a Contractor has an internal policy against a sovereign nation or peoples recognized by the United States government, the Contractor certifies that such policies are not used in violation of the Unruh Civil Rights Act (Section 51 of the Civil Code) or the Fair Employment and Housing Act (Section 12960 of the Government Code).

Certification regarding Lobbying
All contractors are required to sign a separate certification along with the fiscal year service agreement for the Title III or Title VII program regardless of the contract amount.

(1) No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency; a Member of Congress; an officer of employee of Congress; or an employee of a Member of Congress in connection with the awarding of any federal grant; the making of any federal loan; the entering into any cooperative agreement; and the extension, continuation, renewal, amendment or modification of any Federal contract, grant, loan, or cooperative agreement.

(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard For-LLL, ‘‘Disclosure of Lobbying Activities,’’ in accordance with its instructions.

(3) The undersigned shall require that the language of this certification be included in the award documents and all sub-awards at all tiers (including subcontractors, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly.

(4) Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, United States Code. Any person who fails to file the Exhibit F: Sourcewise Provider Manual
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required certification shall be subject to a civil penalty of no less than $10,000 and no more than $100,000 for each such failure.

Information Integrity & Security

All contractors are required to sign a separate certification along with the fiscal year service agreement for the Title III or Title VII program regardless of the contract amount.

Data Security Policy & Procedure

Each contractor and its subcontractors/vendors, shall have in place operational policies, procedures, and practices to protect State information assets, including those assets used to store or access Personal Health Information (PHI), Personal Information (PI) and any information protected under the Health Insurance Portability and Accountability Act (HIPAA), (i.e., public, confidential, sensitive and/or personal identifying information) herein referred to as Personal, Sensitive and Confidential Information (PSCI) as specified in the State Administrative Manual, 5300 to 5365.3; Cal. Gov. Code § 11019.9, DGS Management Memo 06-12; DOF Budget Letter 06- 34; and CDA Program Memorandum 07-18 Protection of Information Assets and the Statewide Health Information Policy Manual. Information assets may be in hard copy or electronic format and may include but is not limited to:

i. Reports
ii. Notes
iii. Forms
iv. Computers, laptops, cellphones, printers, scanners
v. Networks (LAN, WAN, WIFI) servers, switches, routers vi. Storage, media, hard drives, flash drives, cloud storage vii. Data, applications, database

Security Awareness Training
The contractor employees, subcontractors/vendors, and volunteers handling PSCI must complete the required CDA Security Awareness Training module located at https://aging.ca.gov/Information_security/ within thirty (30) days of the start date of the Contract/Agreement, within thirty (30) days of the start date of any new employee, Subcontractor, Vendor or volunteer’s employment and annually thereafter. Contractor must maintain certificates of completion on file and provide to Sourcewise upon request.

Templ
ate Security Awareness Training Certificate located in Appendix A.

Transition Plan

In the RFP OAA Application, the contractor is required to submit a transition plan to assist the contractor with developing an initial plan for situations that may require Sourcewise and/or the contractor to transfer or terminate the funded service at any time during the contract period.

a. The contractor shall submit a transition plan to the Sourcewise within 15 days of delivery of a written Notice of Termination of a program funded either by Title III or Title VII. The transition plan must be approved by the AREA AGENCY and shall at a minimum include the following:

i. Description of how clients will be notified about the change in their service provider.

Exhibit F: Sourcewise Provider Manual
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ii. A plan to communicate with other organizations that can assist in locating alternative services.
iii. A plan to inform community referral sources of the pending termination of the service and what alternatives, if any, exist for future referrals. iv. A plan to evaluate clients in order to assure appropriate placement. v. A plan to transfer any confidential medical and client records to a new contractor. vi. A plan to dispose of confidential records in accordance with applicable laws and regulations.
vii. A plan for adequate staff to provide continued care through the term of the contract.
viii. A full inventory and plan to dispose or, transfer, or return to the AREA AGENCY all equipment purchased during the entire operation of the contract. ix. Additional information as necessary to affect a safe transition of clients to other community service providers.

b. The Contractor shall implement the transition plan as approved by the Sourcewise. Sourcewise and will monitor the contractors progress in carrying out all elements of the transition plan.

c. If the contractor fails to provide and implement a transition plan as required by this Agreement, the contractor will implement a transition plan submitted by Sourcewise to the contractor following the Notice of Termination.

Grievance Procedure
The contractor shall establish and maintain a written grievance process for reviewing and attempting to resolve complaints of older individuals or caregivers. Contractor is required to post the grievance procedure in a visible and accessible area. At a minimum, the process shall include all of the following:

i. Ten day time frames within which a complaint will be acted upon. ii. Written notification to the complainant of the results of the review, including a statement that the complainant may appeal to the AREA AGENCY if dissatisfied with the results of the Contractor’s review.
iii. Confidentiality provisions to protect the complainant’s rights to privacy. Only information relevant to the complaint may be released to the responding party without the older individual’s consent.

iv. The Contractor shall notify older individuals of the grievance process available to them by:
a. Posting notification of the process in visible and accessible areas, such as the bulletin boards in multipurpose senior centers. For areas in which a substantial number of older
* For individuals are non-English speaking, the notification shall also be posted in the primary language of a significant number of older individuals. b. Advising homebound older individuals of the process either orally or in writing upon the Contractor’s contact with the individuals.

v. Complaints may involve, but not be limited to, any or all of the following:
a. Amount or duration of a service.
b. Denial or discontinuance of a service.
c. Dissatisfaction with the service being provided or with the service provider. *If the complaint involves an issue of professional conduct that is under the jurisdiction of another entity, such as the California Medical Board or the State Bar Association, the complainant shall be referred to the proper entity.

Exhibit F: Sourcewise Provider Manual
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vi. Failure of the service provider to comply with any of the requirements set forth in CDA regulations or in your contract with Sourcewise.
*It is
imperative to note that nothing in the Grievance policy shall be construed as prohibiting older individuals from seeking other available remedies, such as presenting their complaints at an open meeting of the Contractor’s governing board.

The contractor shall en sure within the Grievance procedure that they will notify the Chief E
xecutive Officer of th e AREA AGENCY in writing within ten working days after a statement has been issued to complainant detailing the complaint, resolution and a copy of statement sent to complainant.

All grievances should be mailed to the following address:

Attn: Chief
Executive Officer
3100 De La Cruz Blvd, Suite 310
Santa Clara, CA 95054
Insurance
Contractor shall provide Sourcewise Planner Analyst at the start of the fiscal year, the active/ current insurance:
i. Gene
ral liability of not less than $1,000,000 per occurrence for bodily injury and property damage combined. Higher limits may be required by the State in cases of higher than usual risks.
ii. Automobile liability including non-owned auto liability, of not less than $1,000,000 for volunteers and paid employees providing services supported by this AGREEMENT. iii. If applicable, or unless otherwise amended by future regulation, the CONTRACTOR and subcontractors shall comply with the Public Utilities Commission General Order No. 115-F which requires higher levels of insurance for charter-party carriers of passengers and is based on seating capacity as follows:
a. $750,000 if seating capacity is under 8
b. $1,500,000 if seating capacity is 8 - -- 15
c. $5,000,000 if seating capacity is over 15
iv. Pro
fessional liability of not less than $1,000,000 as it appropriately relates to the services rendered. Coverage shall include medical malpractice cost with the AREA AGENCY named as an additional insured on the policy.
120 Day Con
tract Compliance Requirement and Guidance
Each contracted service provider of OAA Title III or Title VII program regardless of funding source shall ensure full contract compliance 120 days from the contract start date. Full compliance will be verified by the grant administer (or Sourcewise) between day 60 - -- 100 to ensure that by 120 days the elements below are accomplished by the contracted service provider.

The f
ollowing checklist was constructed to support contracted service providers achieve 120 day compliance. It highlights key elements or procedures to ensure contract compliance for the OAA Title III or Title VII service agreement and program administration.

Exhibit F: Sourcewise Provider Manual
DRAFT
Data Security Policy & Procedure - --Sourcewise OAA Service Agreement, Section 5.q & Section 15 Contractor should have procedures available that identify the following:
☐ All access codes which allow access to confidential information are properly safeguarded. ☐ Personal, Confidential or Sensitive Information (PSCI) shall be protected from disclosure in accordance with all applicable laws, regulations, and policies. ☐ PSCI data shall be protected by authorized access using the principles of least privilege. ☐ Outline how staff and volunteers may ensure the protection of PSCI information by:
- Accessing, inspecting, using, disclosing, or modifying PSCI information only for the purpose of performing official duties.
- Never accessing, inspecting, using, disclosing, or modifying PSCI information for curiosity, personal gain, or any non-business-related reason. - Securing PSCI information in approved locations.
- Never removing PSCI information from the work site without authorization.

Grievance Procedure - -- 22 CCR § 7400; 22 CCR § 7500; 45 CFR 1321.65 ; Sourcewise OAA Service Agreement Section 17
☐ A written a grievance process is established for reviewing and attempting to resolve complaints of older individuals receiving services funded by this agreement. ☐ Includes a 10-day time frame within which complaints will be acted upon by the service provider at each level of resolution. Note: the AAA is expected to respond to the complainant within 10-day timeframe and it should be included in the Grievance Policy & Procedure. ☐ Written notification to the complainant of the results of the review includes a statement that the complainant may appeal to the AAA if dissatisfied with results of contractor's review. ☐ Confidentiality provisions to protect the complainant's rights to privacy. ‘‘Only information relevant to the complaint may be released to the responding party without the older individual's consent.’’

Grievance Policy - -- 22 CCR § 7400; 22 CCR § 7500; 45 CFR 1321.65 ; Sourcewise OAA Service Agreement Section 17
The service provider shall notify older individuals of the grievance process available to them by:
☐ Posting notification of the process in visible and accessible areas, such as the bulletin boards in multipurpose senior centers.
☐ For individuals non-English speaking, notification is posted in primary language of significant number of older individuals.
☐ Advising homebound older individuals of the process either orally or in writing upon the Contractor's contact with the individuals.
☐ Ensure within the Grievance procedure that they will notify the CEO of AAA in writing within ten working days after a statement has been issued to complainant detailing the complaint, resolution and a copy of a statement sent to complainant.

Voluntary Contributions Request - -- 22 CCR § 7500; 45 CFR 1321.67 ☐ Service provider offers clients with opportunity to provide voluntary contributions confidentially to support the cost of the Title III/VII OAA program. ☐ Service Provider refers to contributions solicited and received from Title III/VII participants as voluntary contributions and not donations or other.
☐ Includes the amount of suggested client contribution, if defined.

Voluntary Contributions Policy & Procedure - -- 22 CCR § 7500; 45 CFR 1321.67 ☐ PROVIDER has written policy and procedure for collecting voluntary contributions INCLUDING:

Exhibit F: Sourcewise Provider Manual
DRAFT
☐ How clients will be informed of the opportunity to contribute to the cost of service. ☐ The amount of suggested client contribution and how it was determined. ☐ The method used to collect and record client contributions to ensure confidentiality.

Grantee Public Information & Outreach Materials developed to promote Sourcewise OAA Title III or Title VII Grant Funded Programs - -- Sourcewise OAA Service Agreement, Section 32 ☐ Public Information or promotional materials in use to promote the program within the targeted geographic region to target population
☐ Public Information or promotional materials acknowledges Sourcewise as the funder ☐ Public Information or promotional materials uses appropriate branding, logo and messaging as suggested per Sourcewise Style Guide guidelines available on the Sourcewise website at, https://mysourcewise.com/about/media-center/.
☐ If #3 is not accomplished, funding agency name included on public information or promotional materials is included.

SECTION 4: GENERAL OLDER AMERICAN ACT PROGRAM REQUIREMENTS & LOCAL

REQUIREMENTS
The authorizing Federal and State statutes governing Sourcewise as an Area Agency on Aging are found in the Older Americans Act as amended in 2020, Title 22 of the California Code of Regulations, and Division 8.5 of the California Welfare and Institutions Code.

Contracted service providers are required as a part of the Invitation for Bid (IFB) or Request for Proposal (RFP) procedure to ensure the minimum requirements per the funding specifications are upheld. The contractor defines the specific and measurable objectives to satisfy each goal requirement in the submitted proposal and annual renewal application using the defined Sourcewise application template provided by the Sourcewise Planner Analyst. Contractors are unable to modify the requirements; these requirements
become a condition of any contract
awarded for the service. Sourcewise may negotiate modifications after the bid/proposal and/or renewal application is submitted to assure that all necessary program requirements are met and coord
inated prior to continuation. The awarded proposal and/or renewal application becomes a par
t of the contract agreement for services and monitored throughout the year by Sourcewise to ensu
re the minimum requirements for the award are satisfied.

Goals & Objectives
Goals and Objectives must be specific, measurable, and attainable.

Target Population --- Title III B, C, D, and Title VII services Service provider must have established methods, other than use of means testing to provide se
rvices to all eligible older individuals 60 and older. Prog rams, services, and activities must be ver
y specific and explicit about the communities they are attempting to address gaps in service delivery.

Additionally, demonstrate serving the target population (at-risk socially/economically), keeping in line with the intent of the Older Americans Act.

Service providers must show intent and methodology to s erve the needs of caregivers and care recipients:
 Age 7
5+
 Low Income (federal poverty)
 Minority
 Living Alone
Exhibit F: Sourcewise Provider Manual
DRAFT

Target Population - -- Title III E services
Service provider must have established methods, other than use of means testing to provide services to all eligible older individuals 60 and older and their informal caregivers aged 18 and older. Programs, services, and activities must be very specific and explicit about the communities they are attempting to address gaps in service delivery.

Additionally, demonstrate serving the target population (at-risk socially/economically), keeping in line with the intent of the Older Americans Act.

Service providers must show intent and methodology to serve the needs of caregivers and care recipients:
 Age 75+
 Low Income (federal poverty)
 Minority
 Living Alone
 Individuals with disabilities

Staffing and Volunteers - --
Title III B, C, D, E, and Title VII services
Service provider must demonstrate recruitment and training of staff & volunteers to support the program.

Staffing and Volunteers goal must describe specifically how many staff and volunteers will be required to support the Older Americans Act program and the kinds of tasks that will be performed by volunteers to further expand the provision of the Title III or Title VII program.

Coordination
Service provider shall form and administer cooperative agreements with other community-based agencies to demonstrate appropriate agency linkages and coordination to ensure comprehensive service delivery and avoid unnecessary duplication of services.

Public Information
Service provider must have planned information and outreach activities, including distribution printed materials co-branded with funding agency (Sourcewise) to promote services to target populations and geographic region in the community.

Service provider must ensure that programs and services are available to all older adults regardless of sexual orientation and gender identity. Evaluation of outreach efforts to gay, lesbian, bisexual, and transgender older adults will be included in the contract monitoring requirements.

Client Input
Service provider must have procedures in place for obtaining the views of the participants of the service being provided, including a written and distributed client grievance procedure.

Describe the annual process by which regular client input is received and areas that are monitored for quality service.

Client Contribution
Service provider must have provided clients with the opportunity to provide voluntary contributions confidentially to support the cost of the Title III/VII OAA program.

Exhibit F: Sourcewise Provider Manual
DRAFT
Service provider shall describe the process for collecting voluntary client contributions including (a) how clients will be informed of the opportunity to contribute to the cost of the service, (b) th e am
ount of suggested client contribution and how it was de termined, and (c) the method used to collect and record client contributions to ensure confidentiality.

SECTION 5: SERVICE PERFORMANCE
Service Performance Requirements
Thes
e requirements are included in the s ervice agreement. Contracted service providers are expected to meet the minimum 8.33% of servic e unit delivery (or one-twelfth the total contract amount) on a mo nthly basis for registered services and 3% of service units delivered on a qu
arterly basis for non-registered servi ces in order to meet the contracted service unit goal for t
he fiscal year be ginning on July 01 through June 30.

When the monthly/quarterly request for funds is submitted to Sourcewise and is accompanied by the month/quarterly service unit report Sourcewise will review and respond directly to those service providers which are not meeting the expected minimum level of service. The Sourcewise team urges our service providers to initiate contact if there are unforeseen changes or obstacles presented which are inhibiting your organization fr om meeting the expected service units for that month so Sourcewise may assist with finding a workable solution.

Requesting Technical Assistance
Contractors are expected t
o communication problems, successes, issues, etc. with the Sourcewise Planner
Analyst and Sourcewise. Contractors should request technical assistance for program, fiscal, or data matters whenever needed. Sourcewise is available and willing to provide technical assistance to service providers who request such assistance.

Tech
nical assistance may also be provided by Sourcewise, when Sourcewise d etermines that the service provider needs assistance in a particular area. Examples of tec hnical assistance include, but are not limited to:
(a) Ass
istance with financial or program reporting
(b) Clarification of service definitions
(c) Improving quality of service delivery
(d) Assistance in complying with Sourcewise assessment recommendations (e) Assistance in meeting the objectives of the contract Contractors have an opportunity to request technical assistance at any time, by submitting an email request to the Planner Analyst at Sourcewise by email.

Exhibit F: Sourcewise Provider Manual
DRAFT
SECTION 6: DATA & PROGRAM REPORTING
Data Management Overview
The Older American Act (OAA) requires a report of statistical data reflecting the number of service units provided and number of registered clients or the estimated clients/audience reached.

The data and information created from data elements contribute to valuable knowledge about service use and client demographics. It is a source for Area Agencies on Aging (AAA), California Department of Aging (CDA), and U.S. Administration for Community Living (ACL) performance measures.

Contractors are required to submit all Sourcewise requested reports in a timely manner including monthl
y program and fiscal, quarterly data verification, client surveys, self-assessments, and year- end closeout reports, and, if applicable to enter required data into AssureCare Q Database in a timely manner. Failure of a Contractor to provide timely and accurate reports and data entry is sanctionable under the Sourcewise policies.

Sourcewise contracted service providers are categories under two types of services delivered:

- Registered Services: Means data collection and reporting requirements include unduplicated client counts by characteristic, units of service, including in some cases ADLs/IADLs and Nutrition Risk assessment. Registered Services are client specific data using participant identification numbers for each client and include required client demographic elements for targeting and/or reporting purposes.

Required registered client level detail include participant ID to determine unduplicated count, birth date, zip code, rural designation, gender, sex at birth, sexual orientation or gender identity, race, ethnicity, poverty status, and living arrangement.

- Non-registered Services: Are those services where it is not practical to collect client specific information or where requiring the client to register may serve as a barrier to receiving a service. Reports include an estimated total client/audience reached by each service within each quarter of the fiscal year and is reported on a quarterly basis.

- Restrictive Services: Is a service provided using Older Americans Act funds in whole or in part for which demographic and consumer characteristics are reported in aggregate, and personal identifying information (PII) related to clients is not shared or recorded beyond the provider level.

Data Collection - -- Service Units
Contracted service providers must comply with the record keeping procedures required by Sourcewise, which are dictated by CDA and the National Aging Program Information System (NAPIS). Requirements include the following:

(a) The collection of all input units of service must be recorded and retained by the contractor. (b) Services, as reported, must comply with the requirements in the grant contract which will be consistent with the service/program definition contained in the original request for proposal or invitation for bid process and the contractors grant application.

Contractors entering data in
to the Q Database are expected to complete all entries by the 10th day of the following month of service. Reference the Q User Guide, Appendix C, for further instructions on how
to do this.

Exhibit F: Sourcewise Provider Manual
DRAFT
Data Collection - -- Assessments
Contracted service providers which the grant funded program or service requires select assessments including but not limited to ADL/IADL, Nutrition Risk Assessment, Employment Assessment, or Caregiver Relationship file must be included and updated annually during the contracted fiscal year by the contracted service provider at minimum.

Data Verification and Monitoring of Service Units
Each contracted service provider is responsible for ensuring that all of the required data elements, assessments, care plans and service units are completed and input into the required database system (Q Database) on or before the 10
th day of the following month for the most recent month.

Contracted service providers are primarily responsible for upholding the integrity of the grant funded program or service to ensure the program requirements are satisfied.

Client profiles shall be updated with the most accurate and up to date information on an ongoing basis or as received but at least one time within the fiscal year.

On a quarterly basis, the Sourcewise Q Database Administrator will complete a quarterly demographic data and assessment monitoring for all registered contracted services during the last month of the fiscal quarter. The Database Administrator will contact the contracted service provider contact person securely to share the questionable, outdated or null demographics or assessments to be updated within 10 working days or before the fiscal quarter concludes to ensure the quarterly data submission to the State is submitted on time and is approved.

Data Performance Management Process
The below table describes the entity and their role to ensure that the required statistical information is captured based on the type of Title III or Title VII program and services.

Entity Role
Service Provider or AAA

 Collects and tracks client/user information and service units
 Collects and manages the client required assessments
for the Title III program and service
 Reports service utilization units, consumer
demographics and expenditures
 Maintains records to uphold accuracy of data

AAA

 Plans and administers OAA data management
system(s)
 Implements CDA data reporting requirements
 Develops and maintains written procedures
 Analyzes, corrects, and verifies data
 Monitors and evaluates local services
 Trains staff and provides technical assistance to the providers, clients, and caregivers
 Reports data to CDA via the statewide California Aging Reporting System (CARS)

Exhibit F: Sourcewise Provider Manual
DRAFT
Registered Service Required Client Fields and Data Elements: Title III B & C Specifically related to Title III B and C required registered client fields, use the below table to identify what must be obtained upon initial intake and enrollment in the Title III B or C program.

Service Category Service Unit Registered
Client
ADL/IADL Nutrition
Risk
Funding
Source
Personal Care X HOUR X X Title III B
Homemaker X HOUR X X Title III B
Chore X HOUR X X Title III B
Adult Day Care/Health X HOUR X X Title III B
Case Management X HOUR X X Title III B
Congregate Meal X MEAL X X Title III C
Home Delivered Meals X MEAL X X X Title III C
Nutrition Counseling X Session per
participant X X Title III C
Assisted Transportation X One-way trip X Title III B
(X) required elements

Exhibit F: Sourcewise Provider Manual
DRAFT
Registered Service Required Client Fields and Data Elements: Title III E Specifically related to Title III E Family Caregiver Support Program services required registered caregiver and care recipient client fields, use the below table to identify what must be obtained upon initial intake and enrollment in the Title III E services for Caregivers of Older Adults & Older Adult Relative Caregiver.

CAREGIVER REQUIRED FIELDS (Caregivers of Older Adults & Older Adult Relative Caregiver) Service Category Service Unit Registered
Caregiver
Employment
Status
Caregiver
Relationship
Assessments X HOUR X X X
Counseling X HOUR X X X
Peer Counseling X HOUR X X X
Support Group X HOUR X X X
Training X HOUR X X X
Case Management X HOUR X X X
In-Home Supervision X HOUR X X X
Homemaker
Assistance X HOUR X X X
In-home Personal Care X HOUR X X X
Home Chore X HOUR X X X
Out-of-Home Day Care X HOUR X X X
Out-of-Home
Overnight Care X HOUR X X X
Assisted Devices X Device/Occurrence X X X
Home Adaptation X Modification/Occurrence X X X
Registry X Hour/Occurrence X X X
Emergency
Cash/Material Aid X Assistance/Occurrence X X X
(X) required elements

Exhibit F: Sourcewise Provider Manual
DRAFT

CARE RECIPIENT REQUIRED FIELDS (Caregivers of Older Adults & Older Adult Relative Caregiver)
Service Category Registered Care Receiver ADL & IADL * Assessments X X
Counseling X X
Peer Counseling X X
Support Group X X
Training X X
Case Management X X
In-Home Supervision X X
Homemaker Assistance X X
In-home Personal Care X X
Home Chore X X
Out-of-Home Day Care X X
Out-of-Home Overnight Care X X
Assisted Devices X X
Home Adaptation X X
Registry X X
Emergency Cash/Material Aid X X
(X) required elements
* There are NO ADL and IADL data collection requirements for Care Receivers in FCSP Caring for Child

Exhibit F: Sourcewise Provider Manual
DRAFT
Non-Registered Service Requirements: Title III B & C
Specifically related to Title III B and C non-registered services, use the below table to identify what must be obtained upon initial intake and enrollment in the non-registered Title III B, C, D program.

Service Category Service Unit Estimated
Clients/A udience
Funding
Source
Nutrition Education X Session per
participant X Title III C
Information & Assistance X Contact X Title III B
Health Promotion - -- Evidence
Based X Contact X Title III D
Elder Abuse Prevention and
Training X Session X Title VII
Elder Abuse Prevention &
Education Materials 1 Material X Title VII
Other* -- X --
(X) Required elements
* (Community Education, Disaster Preparedness Materials, etc.) Reference the Title III Intake and Assessment Guide

Non-Registered Service Requirements: Title III E
Specifically related to Title III E non-registered services, use the below table to identify what must be obtained upon initial intake and enrollment in the non-registered Title III E program.

Service Category Service Unit Estimated
Clients/Audience
Funding
Source
Outreach X Contact X Title III E
Information & Assistance X Contact X Title III E
Interpretation/Translation X Contact X Title III E
Legal Resources X Contact X Title III E
Public Information X Activity X Title III E
Community Education X Activity X Title III E
(X) Required elements

Restrictive Service Requirements: Title III B
Specifically related to Title III B, Legal Assistance restrictive services, use the below table to identify what must be obtained upon initial intake and enrollment in the restrictive Title III B program.

Service Category Service Unit Client
Level Data
Case Level
Data
Funding Source

Legal Assistance

X HOUR X X

Title III B

Exhibit F: Sourcewise Provider Manual
DRAFT
Database Requirements for Registered, Non-Registered, and Restrictive Services:

Type of Service Database
Requirement
Database Description
Registered Services (Title III

B/C/E) YES
For registered services client/user information
including demographics, health/client
assessments, and service unit reporting are
required to be uploaded and managed in the
Q System Database and due monthly.

Referen
ce the Q User Guide (Appendix C) for
additional information on how to use the
application for tracking client/user
demographic information, health/client
assessments, and service units.

Non-Registered Services (Title III

B/C/D/E) NO
Requires only aggregate quarterly service unit
reports is submitted to the AAA (Sourcewise)
on a predefined template on a quarterly basis.

Restrictive Service (Title III B) YES
For restrictive services client/case level-data
including demographics (not including name) and
service unit reporting are required to be
submitted to Sourcewise on a quarterly basis to
be uploaded to the CARS.

Legal
assistance providers will produce a report
containing aggregated and de-identified data for
each of the required SPR data elements. Legal
assistance data reported to AAAs/SUAs must be
aggregated and de-identified to ensure there is
no disclosure of personally identifiable client
information. This is required to preserve client
confidentiality in accordance with legal rules of
ethics.

Further, legal assistance is categorized as a
‘‘restricted service’’ in OAAPS, which ensures that
legal assistance data will not be improperly
combined with data associated with other Title III,
VI, or VII SPR services.

Further guidance on the required data and assessments for eac h type of service may be found in the Title III In take and Assessments Guide , Appendix D, which is a tool for contracted service providers to and AAA staff identify the required ACL and CDA Title III data elements and implement into the administration of the contracted service. If there are further clarification and/ or assistance, please contact the Sourcewise Planner Analyst by email or phone to further discuss the
situation so we may find a solution.

Exhibit F: Sourcewise Provider Manual
DRAFT
SECTION 7: FISCAL, ACCOUNTING, RECORDKEEPING & AUDITS
Contract awards include a performance standard clause with a specific, negotiated per unit cost reimbursement rate and remedies if performance (quality or quantity) falls below a specified level in a specified period of time.

Monthl
y Expenditure Request for Funds:

Monthly program expenditures excel workbooks and Request for Funds templates are emailed to each registered Title III, Title VII, or special reporting service providers* at the start of the fiscal year, along with instructions for completing and submitting the monthly request for funds.

Contractors are required to prepare and submit a Report of Expenditure Request and Request for Funds (RFF) and attach proof of expenditures by the 15th day of the following month. All costs presented on a monthly request for funds must be supported by financial documentation, regardless of if classified as grant costs, in-kind, match, non-match, income and allowable as outlined in Office of Management and Budget (OMB) circulars.

The f
ollowing documents must accompany the Monthly Request for Funds:
 Monthly Request for Funds Invoice
 Monthly Program Expenditures Report (excel spreadsheet)  Sub grantees Income Statement (their financial report)  Sub grantees Matching Contributions Report (outlining matching contributions source, non- federal matching contribution)
 Monthly Q Units Report (for monthly registered services) Quarte
rly Expenditure Request for Funds:

Quarterly Program Expenditures excel workbooks and Request for Funds templates are emailed to each non-registered Title III, Title VII or special reporting service providers* at the start of the fiscal year, along with instructions for completing and submitting the monthly request for funds.

Contractors are required to prepare and submit a Quarterly Report of Expenditure Request and Request for Funds (RFF) and attach proof of expenditures by the 15th day of the following month after the end of the fiscal quarter. All costs presented on a quarterly request for funds must be supported by financial documentation, regardless of if classified as grant costs, in-kind, match, non-match, income and allowable as outlined in Office of Management and Budget (OMB) circulars.

The f
ollowing documents must accompany the Quarterly Request for Funds:
 Monthly Request for Funds Invoice
 Monthly Program Expenditures Report (excel spreadsheet)  Sub grantees Income Statement (their financial report)  Sub grantees Matching Contributions Report (outlining matching contributions source, non- federal matching contribution)
 Quarterly Non-Registered Services Report (quarterly invoice) *Note: The type of service provided is out lined within the RFP docu mentation and CDA Data Dictionary for contracted service team to ensure that they are in compliance with th e expenditure reporting requirements of the Title III or Title VII service.

Sourcewise Internal Review and Corrective Action for Request for Funds The Planner
Analyst will review and approve all RFF(s). If there is a discrepancy in reporting, the Planner Analyst notifies
the service provider of the discrepancy and requests a corrected invoice be resubmitted in a timely manner --- within 1 business day. Once all calculations and details have been reviewed and approved by the Planner Analyst, the approved invoice accompanied with the Monthly Pr
ogram
Exhibit F: Sourcewise Provider Manual
DRAFT
Expenditures Report, service provider financial report and service units report is forwarded to the Sourcewise Finance Team for payment processing.

Matching requirements:

Each contractor is required to provide local match which is detailed in your approved budget and contract. The matching requirements are calculated on net costs, which are total costs less program income, and non-matching contributions. The local match requirement may be met either by allowable costs (non-federal matching contribution) or third-party in-kind contributions.

Allowable matching contributions are non-federal matching contributions; these are local cash and/or in-kind contributions that are not associated with federal funds/costs.

 Title III B/C : 11.11%
 Title III E: 35%

In-Kind Revenues and Expenses:

In-Kind contributions represent the value of third-party contributions of goods, services other than personnel, and personal services used by the Agency to achieve matching requirements. In addition, the In-Kind is identified as either a ‘‘match’’ or a ‘‘non-match’’ donation.

The California Department of Aging, Audit Department, has provided specific rules to follow in identifying what products and services, from which group of individuals, we can use in the match or non-match categories.

In-Kind Match: Contributions of property, equipment, or services by a non-federally funded third party. Examples are:
 Contributions from local city governments, county governments, businesses and private individuals and foundations.
 Contributions, other than services, from the Board of Directors.

In-Kind Non-Match: Contributions of property, equipment, or services from federally funded third party. Examples are:
 Contributions from federally funded employees

The value attached to the In-Kind donations is based on the value the Agency would have to pay for those goods or services if purchased and must be fair and reasonable. The following values are used by this Agency:
 Training based on the trainer’s hourly rate.
 Supervision based on the supervisor’s hourly rate.
 Professional services based on an estimated value.
 Volunteer services based on the minimum wage rate.
 Private automobile travel is reimbursed at the rate approved by the California Department of Aging. Actual odometer readings or standard mileage figures may be used for trips between cities. For trips within the city, only actual odometer readings may be accepted.  Equipment use based on an estimated value.
 Supply items/food based on an estimated value.
 Space based on an estimated value.
 Other items based on an estimated value.

Exhibit F: Sourcewise Provider Manual
DRAFT
Indirect Costs
Indirect costs are costs incurred for a common or joint purpose benefiting more than one cost objective and not readily assignable to the cost objective specifically benefiting the Project, without effort disproportionate to the results achieved. The maximum reimbursement amount allowable for indirect costs is ten percent (10%) of the contractors Modified Total Direct Costs (MTDC), excluding in-kind contributions and nonexpendable equipment.

Amount Contractors may request on a Monthly/Quarterly basis:

Contractors may request up to the maximum one-twelfth of the authorized total budget each month during the contract period. The OAA Title III, Title VII, or special reporting funding is performance based, thus the total number of units provided each month or quarter is associated with the maximum request for funds a contractor may request.

If contractor exceeds the monthly target unit, the contractor can claim up to an additional 5% of the one-twelfth maximum request available.

If the contract does not meet the one-twelfth monthly/quarterly target units, the contractor may only request costs/expenditures which equal the total monthly percent of units provided. To identify the maximum request when a contractor does not meet the monthly target units, take the unit percentage and multiply it against the maximum request amount to get the maximum available request for funds.

Contractors are urged to closely monitor the pace of how many service units are being provided and the dollars being spent. The below shown chart can be used as a rule of thumb in monitoring units and expenditures.

Portion of Fiscal Year
Completed Month
Target Percentages of the Number of
Service Units to be Provided and Grant
Funds to be Expended
1/12 July 8% FY
2/12 August 16% FY
3/12 September (end Q1) 25% FY
4/12 October 33% FY
5/12 November 42% FY
6/12 December (end Q2) 50% FY
7/12 January 58% FY
8/12 February 67% FY
9/12 March (end Q3) 75% FY
10/12 April 83% FY
11/12 May 92% FY
12/12 June (end Q4) 100% FY

NOTE: If there is an increase of 10% or decrease of 10% (for expenditures or service units being provided), immediate action must be taken to correct the problem. An excessive demand for services may require a Contractor to develop a waiting list as outlined in the executed service agreement.

Exhibit F: Sourcewise Provider Manual
DRAFT
Qualifications and exceptions:

Exceptions as provided by federal statute; the Local Match requirement may not be met by costs borne by another federal grant. Current federal statute allows the use of General Revenue Sharing funds to count towards satisfying the Local Match requirement.

Neither costs nor the values of cash and/or in-kind contributions may count toward satisfying the Local Match requirement if they have or will be counted toward satisfying a Local Match requirement of another federal grant or contract, or any other federal funds.

Cash and/or in-kind contributions counting towards satisfying a matching requirement must be verifiable from the records of the Contractor. These records must show how the value placed on matching contributions was determined.

To the extent feasible, volunteer services shall be supported by the same methods that the organization uses to support the allow-ability of its regular personnel costs.

In-kind contributions shall count towards satisfying a Local Match requirement only where if the Contractor receives the contributions.

Non-Utilization of Federal Funds for Local Match:

Non-federal resources used to match other federal grants or contracts may not be used to match Title III funds.

Federal cash or in-kind resources acquired during current or prior years may not be used to match funds provided under Title III unless otherwise specifically authorized by federal statute.

Non-federal resources shall be accepted as part of the Contractor match or cost sharing only when they are not borne by the federal government directly or indirectly under any other program.

Accounting Records, Recordkeeping & Retention:

The Contractor must maintain complete records which shall include, but not be limited to, accounting records, contracts, agree ments, a reconciliation of the ‘‘Financial Closeout Report’’ to the audited financial statements, single audit report, and general ledgers, and a summary worksheet identifying the results of performing an audit resolution. This includes the following: Letters of Agreement, insurance documentation, memorandums and/or Letters of Understanding, patient or client records, and electronic files of its activities and expenditures hereunder in a form satisfactory to Sourcewise and the California Department of Aging in compliance with the laws and regulations of the State of California. All records pertaining must be made available for inspection and audit by the State at any time during normal business hours.

All such records, including confidential records, must be maintained and made available by the contractor: (1) until an audit has occurred and an audit resolution has been issued or unless otherwise authorized in writing, (2) shall retain said records for a minimum of four (4 ) years or for such longer period, if any, as is required by applicable statute, by any other clause of this AGREEMENT, or by A and C of this section.

If the contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for the same periods as specified above. The contractor shall ensure that any resource directories and all client records remain the property of Sourcewise upon termination of and are returned to or transferred to another contractor as instructed by Sourcewise.

Exhibit F: Sourcewise Provider Manual
DRAFT
All records containing confidential information shall be handled in a confidential manner in accordance with the requirements for information integrity and security, and in accordance with guidelines set forth in the contract service agreement, and Section 5(q). & 15. After the authorized period has ex pired, confidential records shall be shredded and disposed of in a manner that will maintain confidentiality.

The contractor shall maintain accounting records for funds received under the terms and conditions of your contract with Sourcewise. These records shall be separate from those for any other funds administered by the and shall be maintained in accordance with Generally Accepted Accounting Principles and Procedures and the Office of Management and Budget’s (OMB) Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards. [2 CFR 200] [45 CFR 75]

Audits and Financial Closeouts

Funding Sources
It is important for all contractors and their team to understand the dollar amount, source of funds and the match requirement for your grant. This also includes the Catalog of Federal Domestic Assistance (CDFA) Number.

The funding source (Federal Grantor) for the following programs is the U.S. Department of Health and Human Services, Administration for Community Living. The passthrough is Sourcewise.

The funding source for OAA program funding and CDFA number is listed below for you to reference.

Older American Act (OAA) Federal Funding S ources with Descriptions, CDFA Numbers and Minimum Required In -Kind or Cash -Match
OAA Funding
Source Description CDFA No. Minimum Match
In-Kind or Cash
Title III B Adult Day Care/Health Center; Legal
Services; LTC-OMB; Case Management;
Transportation; Senior Center Activities;
Ombudsman Program

93.044 11.11%
Title III C Nutrition Services; Congregate Meal (C-1);
Home Delivered Meals (C-2)

93.045 11.11%
Title III D Disease Prevention & Health Promotion 93.043 0% Title III E
Family Caregiver Support Programs

93.052 35%
Title VII A Prevention of Elder Abuse - -- Ombudsman
Program

93.042 0%
Title VII B Prevention of Elder Abuse, Neglect and
Exploitation

93.041 0%
State LTCOMB 0%
NSIP Nutrition Services Incentive Program (NSIP);
United States Department of Agriculture
(USDA)

93.053 0%

Exhibit F: Sourcewise Provider Manual
DRAFT
The funding source for Families First Coronavirus Response Act (FFCRA) & Coronavirus Aid, Relief and Economic Security (CARES) Act, Consolidated Appropriates Act (CAA), Title XX Elder Justice, and American Rescue Plan Act (ARPA) program funding and CDFA number is listed below for you to reference. Emergency funding awarded to Title III and Title VII services started in March 2020 in response to the Coronavirus Disease (COVID19).

Families First Coronavirus Response Act (FFCRA) & Coronavirus Aid, Relief and Economic Security (CARES) Act , Consolidated Appropriates Act (CAA), Title XX Elder Justice, and American Rescu e Plan Act (ARPA) Federal Funding Sources with Descriptions, CDFA Numbers and Minimum Required In -Kind or Cash -Match
Emergency
Funding
Name/Type
Funding
Source Description CDFA No.

Minimum
Match In -
Kind or
Cash
CARES Title III B Special Programs for the Aging, Title III, Part B, Grants for Supportive Services 93.044 0%
FFCRA Title III C,
Part 1
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 93.045 0%
FFCRA Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 93.045 0%
CARES Title III C,
Part 2
Nutrition Services; Congregate Meal (C-
1); Home Delivered Meals (C-2) 93.045 0%
CARES Title III E Family Caregiver Support Programs 93.052 0% CARES Title VII Prevention of Elder Abuse - --
Ombudsman Program 93.042 0%
CAA Title III C,
Part 1
Consolidated Appropriations Act,
2021, Nutrition Services; Congregate
Meal (C-1); Home Delivered Meals (C-2)

93.045 0%
CAA Title III C,
Part 2
Consolidated Appropriations Act,
2021, Nutrition Services; Congregate
Meal (C-1); Home Delivered Meals (C-2)

93.045 0%
ARPA Title III B
American Rescue Plan, 2021, Special
Programs for the Aging, Title III, Part B,
Grants for Supportive Services

93.044 15%
ARPA Title III C,
Part 1
American Rescue Plan, 2021, Nutrition
Services; Congregate Meal (C-1); Home
Delivered Meals (C-2)

93.045 15%
ARPA Title III C,
Part 2
American Rescue Plan, 2021, Nutrition
Services; Congregate Meal (C-1); Home
Delivered Meals (C-2)

93.045 15%
ARPA Title III D American Rescue Plan, 2021, Health
Promotion - -- Evidence-Based 93.043 0%
Exhibit F: Sourcewise Provider Manual
DRAFT
ARPA Title III E American Rescue Plan, 2021, Family
Caregiver Support Programs 93.052 35%
ARPA Title VII
American Rescue Plan, 2021,
Prevention of Elder Abuse - --
Ombudsman Program

93.042 0%

Audited Financials and Single Audit Requirement
Contractors expending less than $750,000 in total federal funds (from all sources) are exempt from federal audit requirements, but records must be available for review. Sourcewise reserves the right to determine whether the Contractor expended the funds provided under their contract in accordance with applicable laws and regulations. This may be accomplished by reviewing an audit of the Contractor or through other means (e.g., monitoring reviews) if the Contractor has not had an audit.

Any Contractor receiving $750,000 or more in total federal funds must comply with the requirements of the Single Audit Act (OMB Circular A-133) and all applicable audit requirements.

The Contractor shall permit independent auditors to have access to the records and financial statements as necessary for the Contractor to comply with OMB Circular A-133. A copy of the audit must be provided to Sourcewise by February 1
st of the following year.

Contractors who expend $750,000 or more in Federal Awards shall arrange for an audit to be performed as required by the Single Audit Act of 1984, Public Law 98-502, Single Audit Act Amendments of 1996, Public Law 104-156, and Office of Management and Budget (OMB) Circular A-133. Contractor shall permit independent auditors to have access to records and financial statements as necessary for Contractor to comply with OMB Circular A-133.

The Contractor shall ensure that Federal-Funded expenditures are displayed discretely in the single audit report’s ‘‘Schedule of Expenditures of Federal Awards’’ (SEFA) under the appropriate Catalog of Federal Domestic Assistance (CFDA) number along with the related State-Funded expenditures. The Contractor shall ensure that the State-funded expenditures are discretely identified in the SEFA by the appropriate program name, identifying grant/contract number, and as passed-through Sourcewise.

The Contractor shall identify the CFDA titles and numbers to the independent auditor conducting the organization’s single audit. The funding source (Federal Grantor) for the following programs is the U.S. Department of Health and Human Services. CFDA numbers are listed in Section 7 under Audits and Financial Closeout.

Any money obligated under the grant (even if in the possession of Contractor) but not needed to meet incurred obligations shall be returned with the Closeout Financial Report to Sourcewise.

There is no provision to carryover unexpended grant funds at the end of the fiscal year.

Any money obligated under the grant (even if in the possession of Contractor) but not needed to meet incurred obligations shall be returned with the Closeout Financial Report to Sourcewise . There is no provision to carryover unexpended grant funds at the end of the fiscal year.

Closeout Report
Contractors shall comply with all program and fiscal reporting requirements set forth by Sourcewise. To complete the required fiscal year closeout report, the contractor will be supplied Exhibit F: Sourcewise Provider Manual
DRAFT
the necessary templates by no later than June 20. The annual fiscal year closeout due date is outlined in the fully executed service agreement and usually between the 15th and 20th day of July.

Contr
act Resolution
Within thirty (30) days after the project period has ended or when requested by Sourcewise (whichever comes earlier), the Contractor must provide ending Closeout Fiscal Report signed by the Contractor’s authorized signer.

Contrac
tors must provide the following items:

1. Subrecipient Audited Financial Report.

2. Program Statement of Revenue & Expenditures or a Program Functional Expense Matrix.

3. Subrecipient Fiscal Closeout Report.

If the contract resolution finds that payment is due to the subrecipient, payment should be initiated by
the Planner Analyst and issued within 30 days from the date of the audit resolution letter to the subrecipient.

If recoveries are requested, a demand for payment is included as part of the audit resolution letter.

Follow-up invoices should be sent monthly, and if payment has not been received within 60 days, the
Area Agency Chief Exec utive Officer should be n otified to discuss further progressive action.

SECTION 8: PROGRAM MONITORING
Sourcewise is required to conduct annual monitoring of local Older American Act, Title III and Title VII contracted agenc ies. This requirement is governed by both the California Code of Regu lation 22 CCR § 7250(b)(2), 7400, 7500, 7630-7638.13 and California Department of Aging, The monitoring visit is not intended to be punitive. There are three primary purposes for monitoring:

1. To ensu
re each service provider is following the requirements of the Older Americans Act and the California Code of Regulations.

2. To ensure each service provider is meeting the goals defined in their contract with Sourcewise.

3. To ensure each service provider is meeting the HIPAA Compliance regulations.

Monit
oring Schedule Requirements
Type of Program Frequency & Type of Monitoring
Title III B, D, E & Title VII A, B Program & Fiscal Monitoring every 2 years Title III C Program monitoring annually
Fiscal monitoring every 2 years
Notification of In-Person Monitoring
At leas
t ---4 --- 6 weeks in advance, the Sourcewise Planner Analyst will prepare two --- three different dates which the contractor may select from to complete the required program and/or fiscal monitoring
of the grant funded program. The fiscal year of focus will be identified in the email.

One an agreed upon date is selected, the Planner Analyst will send a Outlook calendar invitation to the Program Manager
of the grant funded service to reserve the date and time of the monitoring.

Exhibit F: Sourcewise Provider Manual
DRAFT
Pre-Program and Pre-Fiscal Monitoring
At least
4 weeks in advance, to prepare the contractor for the on-site program and/or fiscal monitoring visit, the Planner Analyst will share the below documents to begin preparation of the monitoring visit.

All completed documents are due at least 2 weeks or 10 business days in advance to the Sourcewise Planner Analyst by email.

Program Monitoring Only
 Progra
m Monitoring Contractor Checklist
Progra
m & Fiscal Monitoring
 AAA Program Monitoring Contractor Checklist
 AAA Fiscal Monitoring Contractor Checklist
 AAA Internal Controls Questionnaire
 AAA Fiscal Monitoring Questionnaire
Site Visit and Accommodations
On the date of the site visit, the contractor shall supply Sourcewise a private/secure area on-site for the time period outlined to review and ho ld interviews with nec essary personnel and/or volunteers.

The Contractor is expected to cooperate fully with the Sourcewise Planner Analyst during the scheduled evaluations
of the program. The Contractor will collect and make available all pertinent project information as needed and/or required and participate in any project site visits made by Sourcewise.

Post-Program and Post-Fiscal Monitoring
O
nce the program and/or fiscal monitoring concludes, the Sourcewise Planner Analyst and monitoring te
am will require at least 10 --- 12 weeks to prepare a monitoring report draft based on the program
questionnaires, staff interviews, and program documentation provided by the contractor.

To receive a copy of the Title III or Title VII Program or Fiscal Monitoring Report template, please contact the Sourcewise
Planner Analyst by email and the requested templates will be supplied.

Corrective Action Plan
The
draft monitoring report will be accompanied by a corrective action plan which the contractor must outline the
due date which the item will be revised, sign the document and submit back to Sourcewise. Essentially
the corrective action plan is meant to improve performance and/or reduce risk to ensure services are within compliance.

Failure to comply with an agreed-upon plan can result in suspension or termination of funding. If a contractor entity
fails to comply with federal, state statutes & regulations, or the terms and conditions of a Sourcewise grants, Sourcewise may impose additional conditions, as described in § 75.207. If Sourcewise monitor determines that noncompliance cannot be remedied by imposing additional conditions, Sourcewise may take one or more of the following actions, as appropriate in the circumstances:
 Tempo
rarily withhold cash payments pending correction of the deficiency.  Disallow (that is, deny both use of funds and any applicable matching credit for) all or part of the cost of the activity or action not in compliance.  Wholly or partly suspend (suspension of award activities) or terminate grant.

Exhibit F: Sourcewise Provider Manual
DRAFT
 Withhold further grants for the project or program.
 Take other remedies that may be legally available.

SECTION 9: GRANT MODIFICATIONS
To ensure that contracted service providers receive the necessary support required to provide the service outlined in the scope of work in the fully executed service agreement, the contractor has the ability to request modifications to the contracted units of service and the budget with prio r approval by Sourcewise. The fully executed service agreement outl ines in detail all required timelines and due dates for spec ific modifications to the project.

If the contractor does not identify the required steps to follow in the fully executed agreement or within this
manual, the contractor is encouraged to contact the Sourcewise Planner Analyst to discuss their
unique situation.

Contract Modifications
Requested by Contractor
The contractor agrees and understands that the units of service provided are subject to modifications only upon written authorization from the CEO of Sourcewise.

The contractor shall submit a written justification outlining the reasoning and rationale for the modification to be approved no later than 15 days fr om the requested date of modification.

Amendments to Service Agreement
Throughout the contract period , Sourcewise may deliver a contract amendment to ensure that the terms of the existing agreement are up to date and formally acknowledged by bot h parties.

Sour
cewise will administer contr act amendments for service agreements when there is a proposed in
crease or decrease in service units, grant fund award, or revisions/updates to the contract language outlined in the agreement. The Amendment will outline the s pecific increase or revision/update and require the contractor and So urcewise to si gn the amendment to be formally adopted.

No oral understanding or agreement not set forth herein shall b e binding on any of the parties hereto.

Budget Modifications and Revisions
The RFP OAA Application bud
get and/or renewal application budget is approved by Sourcewise prior to the start of the new contract period. Based on the approved budget submitted, it is n ot considered allowable for the contractor to alter, make variations or d eviate from any b udg et items/categories described without prior approval from the Sourcewise CEO.

If the contractor budgeted items/categories devia te or vary + 10% of the approved allocation, the contractor is required to submit a budget revision to Sourcewise at least 15 days prior to the upcoming monthly/quarterly request for funds.

The contractor shall submit an updated Prog ram budget template with the n ew program category/item allocation and a written justification outlining the cause/reasoning for the revision to the Sourcewise Pl
anner Analyst. The Sourcewise Planner Analyst may request additional information prior to submitting for approval. Once approved the Planner Analyst will provide the contractor with an updated monthly expenditure excel workbook to prepare the upcoming monthly/quarterly
Exhibit F: Sourcewise Provider Manual
DRAFT
request for fund. The approved budget revision will be amended to the application/service agreement.

SECTION 10: EQUIPMENT
Older Americans Act (OAA) funds can only be used toward the contractual service .

All equipment/property with a per unit cost of $5,000 or more requires justification and approval from the California Department of Aging (CDA) PRIOR to purchase.

Equip
ment/Property is defined by CDA as:

1. Has a
normal useful life of at least one (1) year. Item such as computer, monitor, printer, fax, telephone, furniture and lighting. (A desktop or laptop setup is considered a unit, if purchased as a unit).

2. All computing devices, regardless of cost (including, but not limited to: workstations, servers, laptops, personal digital assistants, notebook computers, tablets, smartphones, and cellphones.)

3. All portable electronic storage media regardless of cost (including, but not limited to:
thumb/flash drives and portable hard drives.)
Equi
pment/Property Approval Process

1. Equipment purchases must be included in the service providers approved budget. If the equipment purchase is
not included, contact Planner Analyst, Raul Corral at
[email protected]. Please note, planned equipment purchases not included in the program budget may result in delays in the approval process.

2. Fill out
an Equipment Request Justification Form (Equipment purchase of $5,000 or more.)

3. Submit the Equipment Justification
Form to the Planner Analyst, Raul Corral at
[email protected].

4. The Planner
Analyst will review the Equipment Justification Form for completion. Once complete, the P
lanner Analyst will forward the request to CDA.

5. CDA will review the Equipment Justification Form. When the Planner Analyst receives a response from
CDA, the Planner will contact you to provide a decision on the equipment request.

6. When a
pproved, the equipment/property purchased using OAA funding is required to be tagged with a
Sourcewise asset tag.

Equip
ment Disposal Process
Equipment that is no longer needed, defective, and/or stolen will require your organization to submit an Equipment/Property Disposal Form.

Prior t
o disposal of the equipment/property, the Equipment/Property Disposal Form needs to be submitted to CDA and approved by CDA.

Exhibit F: Sourcewise Provider Manual
DRAFT

1. To receive the Equipment/Property Disposal Form, contact Planner Analyst, Raul Corral at [email protected].

2. Complete the Equipment/Property Disposal Form.

3. Print th
e completed form, an authorized signer of the organization needs to sign the Disposal Form with ink.

4. Submit the completed Disposal Form to Sourcewise, 3100 De La Cruz Blvd, Suite 310 Santa Clara, CA 95054 and the equipment must be present at the time of the disposal.

5. Once Sourcewise received
a response from CDA that the equipment/property is
approved to be disposed,
the Planner Analyst will contact your organization to notify you.

Equipment/property remaining on the Sourcewise Program Prop erty Inventory List that is less than $5,000 and does n ot meet the criteria for a computing device or portable el ectronic storage, will still require CDA approval for disposal prior to removal from the inventory.

Equipment/Property Maintenance
All prior equipment/property purchased by the service provider and/or subcontractors of the servi
ce provider with funds from any prior Older American Act, Title III or Title VII Agreement will remain
on the Sourcewise Program Property Inventory List managed by Sourcewise.

Each year,
the Sourcewise Planner Analyst will survey the equipment/property Inventory List in the month
of June. The equipment/property inventory will require the contracted service pro
vider to submit:

1. List of
equipment and the condition of the item to Sourcewise

2. Location of the equipment

3. Picture of the equipment including the Sourcewise tag number Any questions, about equipment purchases, disposal and/or management of equipment can be sent directly to Raul Corral, Planner Analyst at [email protected].

Exhibit F: Sourcewise Provider Manual
DRAFT
SECTION 11: CO-BRANDING AND MEDIA
Our partnership to deliver essential supportive OAA services to Santa Clara County highlights the importance of community partnerships. As a contracted service, the program agrees to acknowledge the receipt of all funding support from Sourcewise in news releases (radio, television, and newspaper); printed materials such as brochures, pamphlets, newsletters; the contractors website; and any other printed documents. Such acknowledgement shall make accurate reference to the service for which funding is provided, in whole or in part, by Sourcewise.

Each
contractor has access to download a full-color and
black and white Sourcewise Logo via Dropbox.

Download by clicking here.

For b
randing guidelines on how to best utilize brand
elements, the contractor may access the Sourcewise
Style Guide on our website at:
https://www.mysourcewise.com/about/media-
center/.

The m
aterials published or transferred by the contractor and financed with funds under this agreement shall state:
(a) ‘‘The materials or product were a result of a project funded by Sourcewise and the California Department of
Aging.’’
(b) Name of the entity
(c) Include the following statement: ‘‘The conclusions and opinions expressed may not be those of the Area Agency/Sourcewise and/or California Department of Aging and this publication may not be based upon or inclusive of raw data.’’ Each contractor shall provide a copy of all products and materials developed in whole or in part with the funded service to Sourcewise for file.

It is the responsibility of the c ontractor to i nitiate and obtain approval of all products and materials w
here the Sourcewise logo is used prior to distribution. Providers can send final proofs to Sourcewise
by emailing [email protected] or the Sourcewise Planner Analyst.

Proofs will be
returned within 5 business days with a note of approval or recommendations to edit.

SECTION 12:

CONTRACTED SERVICES GRIEVANCE PROCEDURE & POLICY
A contracted service provider or potential provider of services has the right to appeal an adverse determination made by
the Sourcewise (Area Agency on Aging). Reference Sourcewise Service Provider Grievance Policy,
Appendix F, to view the Contracted Services Grievance Procedure.

Note: The Contracted Services Grievance Procedure is a unique procedure for contracted and potential service providers
to follow and NOT the public facing grievance policy for individuals who have received
services to submit a complaint or grievance. For the public facing grievance policy for
community members reference Section 3 of this Provider Manual.

Exhibit F: Sourcewise Provider Manual
DRAFT
SECTION 13: GLOSSARY OF TERMS
OAA Title III & Title VII Program Eligible Population and Program Definitions

Eligible Service Population for Title III B and D means individuals sixty (60) years of age or older, with emphasis on those in greatest economic and social need with particular attention to low- income minority older individuals, older individuals with Limited English Proficiency (LEP), and older individuals residing in rural areas. [OAA § 305 (a)(2)(E); 22 CCR 7119, 7125, 7127, 7130, 7135 and 7638.7]

Eligible Service Population for Title III C -1 and C-2 means individuals sixty (60) years of age or older, with emphasis on those in greatest economic and social need with particular attention to low-income minority older individuals, older individuals with LEP, and older individuals residing in rural areas. [OAA § 305 (a)(2)(E); 22 CCR 7125, 7127, 7130, 7135]

Individuals eligible to receive a meal at a congregate nutrition site are:
i. Any older individual.
ii. The spouse of any older individual
iii. A person with a disability, under age sixty (60) who resides in a housing facility occupied primarily by older individuals at which congregate nutrition services are provided. iv. A volunteer under age sixty (60), if doing so will not deprive an older individual sixty (60) or older of a meal. [CCR 7636.9(b)(3); CCR 7638.7(b) and OAA 339(H)]

Individuals eligible to receive a home-delivered meal are individuals who are:
i. Frail as defined by 22 CCR 7119, homebound by reason of illness or disability, or otherwise isolated. (These individuals shall be given priority in the delivery of services.) [45 CFR 1321.69(a)].
ii. A spouse of a person in 22 CCR 7638.7(c)(2), regardless of age or condition, if an assessment concludes that is in the best interest of the homebound older individual at discretion of AREA AGENCY with CONTRACTOR.
iii. An individual with a disability who resides at home with older individuals, if an assessment concludes that it is in the best interest of the homebound older individual who participates in the program at discretion of AREA AGENCY with CONTRACTOR.

Eligible Service Population for Title III E means an adult family member, or another individual, who is an informal provider of in-home and community care to an older individual or to an individual of any age with Alzheimer’s disease or a related disorder with neurological and organic brain dysfunction. [OAA § 302(3)]

i. Older relative caregiver means a caregiver who is - --  Is age 55 or older; and
 Lives with, is the informal provider of in-home and community care to, and is the primary caregiver for, a child or an individual with a disability.

ii. In the case of a caregiver for a child - --
 Is the grandparent, step grandparent, or other relative (other than the parent) by blood, marriage, or adoption, of the child;
 Is the primary caregiver of the child because the biological or adoptive parents are unable or unwilling to serve as the primary caregivers of the child; and  Has a legal relationship to the child, such as legal custody, adoption, or guardianship, or is raising the child informally
Exhibit F: Sourcewise Provider Manual
DRAFT
 In the case of a caregiver for an individual with a disability, is the parent, grandparent, or other relative by blood, marriage, or adoption, of the individual with a disability. [OAA § 372(a)(3)]

iii. Individual with a disability The term ‘‘individual with a disability’’ means an individual with a disability, as defined in Section 3 of the Americans with Disabilities Act of 1990 (42 U.S.C. 12102), who is not less than age 18 and not more than age 59. [OAA § 372(a)(2)]

iv. Nutrition Services Incentive Program (NSIP) means the program whose purpose is to provide incentives to encourage and reward effective performance by AAAs in the efficient delivery of nutritious meals to older individuals. The program consists of a cash allotment based on the ratio of the number of meals served by each Planning and Service Area (PSA) compared to the total number of meals served in the State in the prior-prior federal fiscal year.

v. One-Time-Only Funds means Titles III and VII federal funds allocated to the AAA in a State fiscal year that are not expended or encumbered for services and administration provided by June 30 of that fiscal year. [22 CCR 7314(a)(6)]

vi. Priority Services for Title III B means those services associated with access to services (transportation, outreach, information and assistance, and case management); in-home services including supportive services such as respite and visiting, for families of older individuals who are victims of Alzheimer’s disease and related disorders with neurological and organic brain dysfunction; and legal assistance.

vii. Priority Services for Title III E means services provided to:
 Caregivers who are older individuals with greatest social need, and older individuals with greatest economic need (with particular attention to low-income older individuals)
 Older relative caregivers of children with severe disabilities, or individuals with disabilities who have severe disabilities. [OAA§373(c)(2)(A-B)]  Family caregivers who provide care for individuals with Alzheimer’s disease and related disorders with neurological and organic brain dysfunction. [OAA § 372(b)]

viii. Program Development means activities that either establish a new service or expand or integrate existing services.

ix. Program Requirements means Title III program requirements found in the OAA [42 USC 3001-3058]; the Code of Federal Regulations [45 CFR 1321]; the California Code of Regulations [22 CCR 7000 et seq.]; and CDA Program Memoranda, and California Retail Food Code (CRFC).

x. ‘‘Subcontractor ’’ means the legal entity that receives funds from the CONTRACTOR to carry out part of the AREA AGENCY federal award identified in this Agreement with CONTRACTOR .

xi. ‘‘Subcontract ’’ means any form of legal agreement between the CONTRACTOR and the Subcontractor, including an agreement that the AREA AGENCY considers a contract, including vendor type Agreements for providing goods or services under this Agreement.

xii. Title III B (Supportive Services) means a variety of services including, but not limited to:
personal care, homemaker, chore, adult day health care, case management, assisted Exhibit F: Sourcewise Provider Manual
DRAFT
transportation, transportation, legal assistance, information and assistance, outreach, services that promote or support social connectedness and reduce negative health effects associated with social isolation, and long-term care ombudsman advocacy, as defined in the National Aging Programs Information Systems (NAPIS) categories and the National Ombudsman Reporting System (NORS). [OAA § 321(a)]

xiii. Title III C -1 (Congregate Nutrition Services) means nutrition services for older individuals in a congregate setting. Services include meals, nutrition education, health promotion programs, nutrition risk screening, and opportunities for socialization. Each meal shall provide one-third (1/3) of the Dietary Reference Intakes (DRI) and comply with the most current Dietary Guidelines for Americans (DGA). To be an eligible Title III C-1 congregate nutrition site, the site must meet all of the following criteria: [22 CCR 7638.7(a)]  Be open to the public. [45 CFR 1321.53(b)(3)]
 Not means test. [OAA § 315(b)(3)]
 Not receive funds from another source for the cost of the same meal, equipment, or services. [2 CFR 200.403(f)][45 CFR 75.403(f)]

xiv. Title III C -2 (Home-Delivered Nutrition Services) means nutrition services provided to homebound older individuals including meals, nutrition education, and nutrition risk screening. Each meal shall provide one-third (1/3) of the DRI and comply with the most current Dietary Guidelines for Americans. [22 CCR 7135, 22 CCR 7638.7(c)]

xv. Title III D ( Health Promotion - -- Evidence Based ) means disease prevention and health promotion programs that are based on scientific evidence and demonstrated through rigorous evaluation to be effective in improving the health of older adults. Title III D evidence-based health promotion programs include programs related to the prevention and mitigation of the effects of chronic diseases (including osteoporosis, hypertension, obesity, diabetes, and cardiovascular disease), infectious disease, and vaccine-preventable disease, and prevention of sexually transmitted diseases. Evidence-based services also include programs focused on alcohol and substance abuse reduction, chronic pain management, smoking cessation, weight loss and control, stress management, falls prevention, physical activity, and improved nutrition. [OAA 102 (14)(D)]

xvi. Title III E Family Caregiver Support Program (FCSP) Categories are:
 Information Services
 Access Assistance
 Support Services
 Respite Care
 Supplemental Services
[OAA 373(b)(1)(2)(3)(4)(5)]

xvii. ‘‘Vendor’’ means an entity selling goods or services to the Contractor or Subcontractor during the Contractor or Subcontractor’s performance of the Agreement.



Supplement Glossary of Terms
xviii. AAA: Area Agency on Aging is an identifiable private nonprofit or public agency designated by the Department of Aging which works for the interest of older Californians within the PSA (Planning and Service Area). This agency engages in community planning, coordination, and program development, and, through contractual arrangements, provides Exhibit F: Sourcewise Provider Manual
DRAFT
a broad array of social and nutritional services. Sourcewise is the designated AAA in Santa Clara County.

xix. CDA: California Department of Aging

xx. Focal Point: A designated senior center that provides a broad spectrum of senior services.

xxi. Greatest Economic Need: Having an income at or below the federal official poverty line defined by the federal Bureau of the Census and published annually by the Department of Health and Human Services.

xxii. Greatest Social Need: The need caused by noneconomic factors which include any of the following:
a. Physical and mental disabilities.
b. Language barriers.
c. Cultural, social, or geographical isolation, including isolation caused by racial or ethnic status, HIV status, sexual orientation, gender identity, or gender expression that does the following:
i. Restricts the ability of an individual to perform normal daily tasks. ii. Threatens the capacity of an individual to live independently. xxiii. Matching Contributions: The cash and/or in-kind contribution made by the bidding organization that qualifies as match for the applicable Title III service and outlined in the program standard. OAA is federal funding. Matching contributions for OAA may not include other federal funding it should be non-federal.

xxiv. Minority Provider: A nonprofit organization whose controlling board is comprised of at least 51% minority individuals who are African American, Hispanic, American Indian/Native Alaskan/Native Hawaiian, and/or Asian American/Pacific Islander.

xxv. Minority: A person of color who is any of the following:

Black/African American: a person having origins in any of the Black racial groups of Africa.

Hispanic: a person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish or Portuguese culture or origin regardless of race. Asian/Pacific Islander: a person whose origins are from India, Pakistan or Bangladesh, Japan, China, Taiwan, Korea, Vietnam, Laos, Cambodia, the Philippines, Samoa, Guam, or the United states Trust Territories of the Pacific including the Northern Marianas. American Indian/Alaskan Native: an American Indian, Eskimo, Aleut, or Native Hawaiian.

xxvi. Non-Profit: Any agency, institution, or organization that has been granted tax-exempt status by the Internal Revenue Service.

xxvii. Non-registered Services: Are those services where it is not practical to collect client specific information or when requiring the client to register may serve as a barrier to receiving service.

xxviii. Older Americans Act: The federal funding source for supportive service programs funded under this Request for Proposal.

xxix. Older Californians Act: The state funding source for Community-Based Services Programs.

Exhibit F: Sourcewise Provider Manual
DRAFT
xxx. Open and Competitive Process: The formal Sourcewise process followed to solicit proposals for the provision of services.

xxxi. PSA: Planning and Service Area (PSA). PSA defines the geographic region which the AAA encompasses.

xxxii. Registered Services: Means data collection and reporting requirements including unduplicated client counts by characteristics, units of service, including in some cases ADLs/IADLs. Registered Services are client specific data using participant identification numbers for each client.

xxxiii. Request for Proposal (RFP): An official document that requests community organizations to respond to a formal invitation to provide a specific program of services. It contains the terms and conditions an operating organization must comply with in order to fulfill its contract with Sourcewise.

xxxiv. Unit of service: The activity which describes the type of service to be contracted for; all Sourcewise funded programs must provide a required number of units for the specific program area of interest.

xxxv. Unduplicated Persons Count: Unique count of clients who receive services between July 1st and June 30th . Bidders submitting proposals are required to include an unduplicated person count to provide services. Reporting requirements are described and nonnegotiable for registered and nonregistered Older American Act funded services.

xxxvi. Voluntary Contributions: Providing clients with the opportunity to contribute monetarily to the cost of the service/program provided by the successful bidder. The successful bidder should (a) inform the client of the opportunity to voluntarily contribute to the cost of service, including but not limited to the cost-of-service delivery, related activities to facilitate access to meals, and/or supportive services of the service (b) describe the amount of suggested client contribution and how it was determined, and (c) explain the method used to collect and record client contributions.

Exhibit F: Sourcewise Provider Manual
DRAFT
SECTION 14: DATA & FISCAL TEMPLATES
At least 2 --- 4 weeks prior to the start of the contracted fiscal year, the Sourcewise Planner Analyst will provide all the
required data and fiscal reporting templates to the contracted agency.

Throughout the contract period, all contractors may request copies of the data and/or fiscal templates at any
time by email.

To receive expenditure or monthly request for funds templates, please email [email protected]
To receive data reporting
templates, please email [email protected]
For Q Database assistance, please email [email protected] Exhibit F: Sourcewise Provider Manual
DRAFT
Certificate of Completion
Print Name: ________________
This document certifies that the above mentioned individual has completed CDA’s Privacy and Information Security Awareness Training and u
nderstands his or her responsibility for
protecting CDA information assets.

Date Training Completed: _____________________
Empl
oyee Signature: _________________________
Company/Agency: _______________________
Exhibit F: Sourcewise Provider Manual
DRAFT

California Department of Aging (CDA)
CDA Service Categories and Data Dictionary
Revised July 2018

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Activities and CARS Reporting
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Personal Care 1 Hour
Personal assistance, stand-by assistance, supervision or cues. (such as with eating, bathing, toileting, transferring in/out of bed/chair, walking, dressing, grooming).

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 1
NAPIS
Div 4000
Unit 20
Title III B Yes Registered
Homemaker 1 Hour Assistance such as preparing meals, shopping for personal and household items, managing money, using the telephone or doing light housework.

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 2
NAPIS
Div 4000
Unit 50, Unit 27
Title III B Yes Registered
Chore 1 Hour Assistance such as heavy housework, yard work or sidewalk and other home maintenance for a person.

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 3 NAPIS
Div 4000 Unit 5 Title III B Yes Registered
Home-Delivered
Meals 1 Meal
A meal provided to an eligible individual in his or her place of residence, that meets all of the requirements of the Older Americans Act and State/Local laws, assures a minimum one-third of the current Dietary Reference Intake, and shall comply with Dietary Guidelines for Americans.

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 4
NAPIS
Div 4000
Unit 51
Title III C-
2 No Registered
Adult Day Care /
Adult Day Health 1 Hour
Personal care for dependent elders in a supervised, protective, and congregate setting during some portion of a day. Services offered in conjunction with adult day care/adult day health typically include social and recreational activities, training, counseling, and services such as rehabilitation, medications assistance and home health aide services for adult day health.

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 5
NAPIS
Div 4000
Pr 5, Pr 11,
Pr 17
Title III B Yes Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Case Management 1 Hour
Assistance either in the form of access coordination in circumstances where the older person is experiencing diminished functioning capacities, personal conditions or other characteristics which require the provision of services by formal service providers or family caregivers. Activities of case management include such practices as assessing needs, developing care plans, authorizing and coordinating services among providers, and providing follow-up and reassessment, as required.

Cluster 1 service: Reporting
requirements include
unduplicated client counts by
characteristic, ADLs/IADLs and
service units.

NAPIS 6 NAPIS
Div 4000 Pr 3 Title III B Yes Registered
Assisted Transportation 1 One Way
Trip
Assistance and transportation, including escort, to a person who has difficulties (physical or cognitive) using regular vehicular transportation.

Cluster 2 services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units. For FCSP,
ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only
NAPIS 7
NAPIS
Div 4000
Unit 10
Title III B No Registered
Congregate Meals 1 Meal
A meal provided to an eligible individual in a congregate group setting, that meets all of the requirements of the Older Americans Act and State/Local laws, and assures a minimum one-third of the Dietary Reference Intake, and shall comply with Dietary Guidelines for Americans.

Cluster 2 services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units. For FCSP,
ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only
NAPIS 8 NAPIS
Div 4000 Pr 20
Title III C-
1 No Registered
Nutrition Counseling 1 Session Per
Participant
Individualized guidance to individuals who are at nutritional risk because of their health or nutrition history, dietary intake, chronic illnesses, or medications use, or to caregivers. Counseling is provided one-on-one by a registered dietitian, and addresses the options and methods for improving nutrition status. Nutrition counseling may be made either in person or by any other means deemed appropriate (e.g., telephone, emails, etc.)
Cluster 2 services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units. For FCSP,
ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only
NAPIS 9 NAPISDiv
4000Unit 53
Title III C-
1Title III
C-2
No Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Transportation 1 One Way
Trip
Transportation from one location to another. Does not include any other activity. May include travel vouchers and transit passes.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 10 NAPIS
Div 4000 Pr 12 Title III B Yes Non-
Registered
Legal Assistance 1 Hour Legal advice, counseling and/or representation by an attorney or other person acting under the supervision of an attorney.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 11 NAPIS
Div 4000 Pr 14 Title III B Yes Non-
Registered
Nutrition Education 1 Session Per
Participant
A program to promote better health by providing accurate and culturally sensitive nutrition, physical fitness, or health (as it relates to nutrition) information and instruction to participants, caregivers, or participants in a group or individual setting overseen by a dietitian or individual of comparable expertise. Methods of education may include demonstrations, audio-visual presentations, or small group discussions for congregate program participants. Handout materials may be used, but not limited to, as the sole education component for home-delivered meal program participants.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 12
NAPIS
Div 4000
Unit 52
Title III C-
1 Title III C-
2 No Non-
Registered
Information
and
Assistance
1 Contact
A service that: (A) provides individuals with information on services available within the communities; (B) links individuals to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures.

Internet web site "hits" are to be counted only if information is requested and supplied, and (C) is satisfied. Maximum extent practicable includes offering a follow-up call to all individuals who were linked to a service.

Individuals can remain anonymous and refuse a follow-up call.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 13 NAPIS
Div 4000 Pr 1 Title III B Yes Non-
Registered
Outreach 1 Contact
Interventions (one-on-one contacts) with individuals initiated by an agency or provider for the purpose of identifying potential clients (or their age 60+ caregivers) and encouraging their use of existing services and benefits.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 14
NAPIS
Div 4000
Unit 19
Title III B Yes Non-
Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3

Health Promotion 1 Contact
An evidence-based health promotion program, including programs related to the prevention and mitigation of the effects of chronic disease (including, but not limited to, osteoporosis, obesity, diabetes, and cardiovascular disease), alcohol and substance abuse reduction, smoking cessation, weight loss and control, stress management, falls prevention, physical activity, and improved nutrition. For a list of ACL approved Evidence-Based programs, please visit the National Council on Aging website at https://www.ncoa.org/resources/ebpchart.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 16 -
Heath
Promotion
Older
Americans Act
Sec 102 (14)
Title III D
3 No Non-
Registered
Alzheimer'sDay Care
Services
1 Day of
Attendance
Day of attendance (four hours minimum) at a licensed Adult Day Care or Adult Day Health Care Center that provides Alzheimer's or dementia services.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 6 Title III B Yes Non-
Registered
Cash / Material Aid 1 Assistance
Arrange for and provide assistance to participants in the form of commodities, surplus food distribution, emergency cash assistance, and vouchers.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 15 Title III B No Non-
Registered
Community
Education 1 Activity
Educating groups of older persons, their families, friends, and community organizations/facility staff on rights, benefits, entitlements, and health and wellness information for older persons either residing at home or in an institutional setting.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Unit 9 Title III B No Non-
Registered
Comprehensive
Assessment 1 Hour
Evaluating a person's physical, psychological, and social needs, financial resources, and the strengths and weaknesses of their informal support system and the immediate environment as a basis for determining current functional ability and potential improvement in order to develop the appropriate services needed to maximize functional independence.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 32
CCR 7112
Title III B Yes Non-
Registered
Disaster
Preparedness
Materials
1 Product
Assemble and distribute disaster preparedness materials such as File of Life or preparedness kits that will assist seniors in the event of an emergency.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other No reference Title III B No Non-
Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Elder Abuse Prevention,
Education
and
Training
1 Session
Public education and training of professionals to develop, strengthen, and carry out programs for the prevention, detection, assessment, and treatment of, intervention in, investigation of, and response to elder abuse, neglect, and exploitation (including financial exploitation).

This includes training for Title III E caregivers.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 22 Title VII B No Non-
Registered
Elder Abuse
Prevention
Educational
Materials
1 Product
Educational materials and guidance kits distributed for the prevention, detection, assessment, and treatment of, intervention in, investigation of, and response to elder abuse, neglect, and exploitation (including financial exploitation).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 22 Title VII B No Non-
Registered
Employment 1 Activity
Activities designed to maintain or obtain part-time/full-time employment for older persons or to assist them in selecting and entering into a second career. This can be accomplished through activities including but not limited to career counseling, recruitment, assessment, training, job club, and job development.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 15 Title III B No Non-
Registered
Health 1 Hour
Activities such as, non-evidence-based medication management, health screening, physical fitness, therapy, and hospice to assist older individuals to improve or maintain physical health and secure necessary medical, preventive health, or health maintenance services. Health screening, therapy, and hospice must be provided by a licensed health professional or by a paraprofessional supervised by a licensed health professional.

Does not include services covered by Medicare, Medi-Cal, or other health insurance. Medication management means activities that facilitate safe and effective use of prescription and over-the-counter drugs. These activities may include medication screening and education to an individual and/or the caregiver to prevent incorrect medication administration and adverse drug reaction. Primary activities are normally on a one-to-one basis; if done as a group activity, each participant shall be counted as one contact unit.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000 Pr 9,
Unit 13, Unit
21, Unit 29,
Unit 37
Title III B Yes Non-
Registered
Housing 1 Hour Assistance in locating adequate housing through referral or placement.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 4 Title III B No Non-
Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Interpretation /
Translation 1 Contact Provide interpretation/translation services for older individuals and their caregivers.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Unit 4 Title III B No Non-
Registered
Mobility
Management
Activities
1 Hour
Activities related to increasing transportation and mobility options for older adults by providing assistance, information, travel training, trip planning, coordination of service public or private transit operators, scheduling, access to transit information, creation of new models of service such as volunteer driver programs and shuttles.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Title III B No Non-
Registered
Mental Health 1 Hour
Provide services such as screening, assessment, therapy, counseling, follow-up, and referral to maintain or improve the mental health of older individuals. Mental Health services must be provided by a licensed health professional or by a paraprofessional supervised by a licensed health professional. Does not include services covered by Medicare, Medi-Cal, or other health insurance.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000 Pr 10,
Unit 11,
Unit 23, Unit 29
Title III B Yes Non-
Registered
Peer Counseling 1 Hour
Use the skills and/or life experiences of trained volunteers, under qualified supervision, to provide advice, guidance, and support in a self- help approach in order to enhance well-being and enable clients to make informed choices.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other

Div 4000 Unit 7 Title III B No Non-
Registered
Personal Affairs
Assistance 1 Contact Provide assistance in writing letters and with the completion of financial forms, including tax forms, and other written or electronic documents.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000 Unit
12, Pr 16 Title III B No Non-
Registered
Personal /Home
Security 1 Product
Services for the security and safety of their home environment, by providing safety features such as: medical alert, alarms, assistive devices (including provision of assistive technology services and assistive technology devices).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other Div 4000 Pr 7 Title III B No Non-
Registered
Public
Information 1 Activity
Contact with multiple current or potential clients or caregivers through publications, publicity campaigns, and other mass media campaigns including Internet websites.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other NAPIS Title III B Yes Non-
Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Registry 1 Hour
Recruit workers, maintain a current list of qualified workers, refer workers to clients or clients to workers, and follow-up to assure that service was received.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 41 Title III B No Non-
Registered
Residential Repairs /
Modifications
1 Modification
Residential modifications of homes that are necessary to facilitate the ability of older individuals to remain at home and that are not available under other programs. Includes minor repairs/renovations in order to meet safety, health issues, and code standards.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 1, Unit 48 Title III B Yes Non-
Registered
Respite Care 1 Hour
Arrange for relief of the relatives or other caregivers of the frail elderly living at home by the coordination or direct provision of supportive services to the older person(s) while the primary caregiver is temporarily absent (includes Adult Day Care as a respite service for families).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000 Pr 18,
Unit 45 Title III B Yes Non-
Registered
Senior Center
Activities 1 Hour
Services designed to enable older individuals to attain and/or maintain physical and mental well-being such as recreation, music, creative arts, physical activity, education, leadership development and other supportive services not covered under other service categories.

Development and provision of new volunteer opportunities and services, and creation of additional services and programs to remedy gaps and deficiencies in existing services. Entertainment costs such as tickets to shows or sporting events, meals, lodging, rentals, transportation and gratuities, are not allowable.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000 Pr 13
OMB A-87 Title III B No Non-
Registered
Telephone
Reassurance 1 Contact Telephone a client to provide contact and safety checks to reassure and support older individuals.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 28 Title III B Yes Non-
Registered
Visiting 1 Hour Visit a client to provide contact and safety checks to reassure and support older individuals.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS 15 -
Other
Div 4000
Unit 31 Title III B Yes Non-
Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Support Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Assessment
(Caring for Elderly) 1 Hour
An FCSP Support Service conducted by persons trained and experienced in the skills required to deliver the service that should result in a plan that includes emergency back-up provisions and is periodically updated; and will explore options and courses of action for caregivers by identifying their: (A) willingness to provide care; (B) duration and care frequency preferences; (C) caregiving abilities; (D) physical health, psychological, social support, and training needs; (E) financial resources relative for caregiving; and (F) strengths and weaknesses within the immediate caregiving environment and (caregiver's) extended informal support system.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Counseling
(Caring for Elderly) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of support needed for stress, depression, and loss as a result of caregiving responsibilities. This service (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone consultations, and (C) may address caregiving-related financial and long- term care placement responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Peer
Counseling
(Caring for Elderly)
1 Hour
An FCSP Support Service provided by experienced volunteers on the condition that appropriate training and qualified supervision protocols are in place.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver
Support Group
(Caring for Elderly)
1 Hour
An FCSP Support Service provided to a group of 3 - 12 caregivers that is led by a competent facilitator; conducted at least monthly within a supportive setting or via a controlled access, moderated online or teleconference approach; for the purpose of sharing experiences and ideas to ease the stress of caregiving, and to improve decision-making and problem-solving skills related to their caregiving responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Training
(Caring for Elderly) 1 Hour
An FCSP Support Service consisting of workshops or one-on-one individually tailored sessions, conducted either in person or electronically by a skilled and knowledgeable individual, to assist caregivers in developing the skills and gaining the knowledge necessary to fulfill their caregiving responsibilities; and address the areas of health, nutrition, and financial literacy.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Case
Management
(Caring for Elderly)
1 Hour
An FCSP Support Service provided by a person who is trained and experienced in the skills that are required to coordinate and monitor the provision of formal caregiver-related services in circumstances where caregivers are experiencing diminished capacities due to mental impairment or temporary severe stress and/or depression.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

ADL/IADL information is
required for Care Receivers
served in "Caregiver Caring
for Elderly" component only.

NAPISFCSP
1Support Svs
OAA 373(b)(3)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Respite Care

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Respite
In-Home Supervision
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver day and/or overnight supervision and friendly visiting by an appropriately skilled provider or volunteer in order to prevent wandering and health or safety incidents.

FCSP Registered services:

Reporting requirements include
unduplicated client counts by
characteristic and service units for
Caregivers. ADL/IADL information is
required for Care Receivers served in
"Caregiver Caring for Elderly" component
only.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Homemaker Assistance
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with meal preparation, medication management, using the phone, and or light housework (along with care receiver supervision) by an appropriately skilled provider or volunteer.

FCSP Registered services:

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
In-Home
Personal Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with eating, bathing, toileting, transferring, and or dressing (along with care receiver supervision and related homemaker assistance) by an
appropriately skilled provider.

FCSP Registered services:

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Home Chore
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes an appropriately skilled provider or volunteer assisting a caregiver with heavy housework, yard work, and or sidewalk and other routine home maintenance (but not structural repairs) associated with caregiving responsibilities.

FCSP Registered services:

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Respite
Out-of-Home
Day Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service where the care receiver attends a supervised/protective, congregate setting during some portion of a day, and includes assess to social and recreational activities.

FCSP Registered services:

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Out-of-Home
Overnight Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service where the care receiver is temporarily placed in a supervised/protective, residential setting for one or more nights, and may include access to nursing and personal care.

FCSP Registered services:

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered

FCSP - Caregiver Caring for Elderly
Supplemental Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Assistive Devices
for Caregiving
(Caring for Elderly)
1 Device
is 1
Occurrence
An FCSP Supplemental Service that involves the purchase, rental and/or service fee of any equipment or product system (ranging from a lift chair or bathtub transfer bench to an electronic pill dispenser or emergency alert fall prevention device) in order to facilitate and fulfill caregiving
responsibilities.

FCSP Registered services:

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Home Adaptations
for Caregiving
(Caring for Elderly)
1 Modification
is 1
Occurrence
An FCSP Supplemental Service that makes any minor or major physical change to the home (ranging from installation of grab bars or replacement of door handles to construction of an entrance ramp or roll-in shower) in order to fulfill caregiving responsibilities.

FCSP Registered services:

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiving Services
Registry
(Caring for Elderly)
1 Hour is 1
Occurrence
An FCSP Supplemental Service that recruits, screens, and maintains a listing of dependable, qualified self-employed homemaker or respite care workers who may be matched with caregivers willing to use personal resources to pay for assistance with their caregiving responsibilities. Both the caregiver and the self-employed worker will be: (A) advised about appropriate compensation and workplace performance expectations; and (B) provided with follow-up to ensure the match is functioning effectively.

FCSP Registered services:

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiving Emergency
Cash / Material Aid
(Caring for Elderly)
1 Assistance
is 1
Occurrence
An FCSP Supplemental Service that arranges for and provides assistance to caregivers in the form of commodities, surplus food, emergency cash, transit passes, meals, and vouchers that will help meet identified needs associated with an individual caregiver's responsibilities.

FCSP Registered services:

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Access Assistance

Service
Category
Unit
Measure 1 Definitions
Reporting Requirements
NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Outreach
(Caring for Elderly) 1 Contact
An FCSP Access Assistance service involving interventions (one-on-one contacts with individuals) initiated by an agency or provider for the purpose of identifying caregivers and encouraging their use of existing caregiver support services (e.g., Caregiver InfoVan staff contacts outside of local market).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiving Information
and Assistance
(Caring for Elderly)
1 Contact
An FCSP Access Assistances service that: (A) provides caregivers with information on services available within the communities, including caregiving information related to assistive technology and caring for older individuals at risk for institutional placement; (B) links caregivers to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures (caregiver may remain anonymous and refuse follow-up contact).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiver Interpretation
/ Translation
(Caring for Elderly)
1 Contact
An FCSP Access Assistance Service for the provision of bilingual communication assistance to a caregiver in order to access assistance and receive support for his or her caregiving responsibilities (e.g., staff interpreting dialogue between caregiver and care consultant staff translating an elder's prescription drug label for his caregiver).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiver Legal
Resources
(Caring for Elderly)
1 Contact
An FCSP Access Assistance Service involving one-to-one guidance provided by an attorney (or person under the supervision of an attorney) in the use of legal resources and services when assisting a caregiver with caregiving - related legal issues.

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Information Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Public Information
on Caregiving
(Caring for Elderly)
1 Activity
An FCSP Information Service designed to provide information about available FCSP and other caregiver support resources and services by disseminating publications, conducting media campaigns, and maintaining electronic information systems (e.g., quarterly newsletter).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Community
Education
on Caregiving
(Caring for Elderly)
1 Activity
An FCSP Information Service designed to educate groups of current or potential caregivers and those who may provide them with assistance about available FCSP and other caregiver support resources and services (e.g., booth at a health fair).

Non-Registered services:

Reporting requirements
include estimated
unduplicated client counts
and service units.

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
FCSP - Grandparent Caring for Child
Support Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Assessment
(Caring for Child) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of counseling service, which may range from guidance with caregiving responsibilities to therapy for stress, depression, and loss; and (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone consultations, and (C) may address caregiving - related financial and long-term care placement responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Counseling
(Caring for Child) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of support needed for stress, depression, and loss as a result of caregiving responsibilities. This service (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

Caregiver Peer
Counseling
(Caring for Child)
1 Hour
An FCSP Support Service provided by experienced volunteers on the condition that appropriate training and qualified supervision protocols are in place.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver
Support Group
(Caring for Child)
1 Hour
An FCSP Support Service provided to a group of 3 - 12 caregivers that is led by a competent facilitator; conducted at least monthly within a supportive setting or via a controlled access, moderated online or teleconference approach; for the purpose of sharing experiences and ideas to ease the stress of caregiving, and to improve decision-making and problem-solving skills related to their caregiving responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Training
(Caring for Child) 1 Hour
An FCSP Support Service consisting of workshops or one-on-one individually tailored sessions, conducted either in person or electronically by a skilled and knowledgeable individual, to assist caregivers in developing the skills and gaining the knowledge necessary to fulfill their caregiving responsibilities; and shall address the areas of health, nutrition, and financial literacy.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
CaregiverCase
Management
(Caring for Child)
1 Hour
An FCSP Support Service provided by a person who is trained and experienced in the skills that are required to coordinate and monitor the provision of formal caregiver-related services in circumstances where caregivers are experiencing diminished capacities due to mental impairment or temporary severe stress and/or depression.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPISFCSP
1Support Svs
OAA 373(b)(3)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Respite Care

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Respite
In-Home Supervision
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver day and/or overnight supervision and friendly visiting by an appropriately skilled provider or volunteer in order to prevent wandering and health or safety incidents.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Homemaker Assistance
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with meal preparation, medication management, using the phone, and or light housework (along with care receiver supervision) by an appropriately skilled provider or volunteer.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
In-Home Personal Care
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with eating, bathing, toileting, transferring, and or dressing (along with care receiver supervision and related homemaker assistance) by an appropriately skilled provider.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Home Chore
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes an appropriately skilled provider or volunteer assisting a caregiver with heavy housework, yard work, and or sidewalk and other routine home maintenance (but not structural repairs) associated with caregiving responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Out-of-Home
Day Care
(Caring for Child)
1 Hour
An FCSP Respite Care service where the care receiver attends a supervised/protective, congregate setting during some portion of a day, and includes assess to social and recreational activities.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiver Respite
Out-of-Home
Overnight Care
(Caring for Child)
1 Hour
An FCSP Respite Care service where the care receiver is temporarily placed in a supervised/protective, residential setting for one or more nights, and may include access to nursing and personal care.

FCSP Registered services:

Reporting requirements
include unduplicated client
counts by characteristic and
service units for Caregivers.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Supplemental Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Assistive Devices
for Caregiving
(Caring for Child)
1 Device is 1
Occurrence
An FCSP Supplemental Service that involves the purchase, rental and/or service fee of any equipment or product system (ranging from a lift chair or bathtub transfer bench to an electronic pill dispenser or emergency alert fall prevention device) in order to facilitate and fulfill the caregiving responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated
client counts by
characteristic and service
units for Caregivers.

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Home Adaptations for
Caregiving
(Caring for Child)
1 Modification
is 1
Occurrence
An FCSP Supplemental Service that makes any minor or major physical change to the home (ranging from installation of grab bars or replacement of door handles to construction of an entrance ramp or roll-in shower) in order to facilitate and fulfill caregiving responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated
client counts by
characteristic and service
units for Caregivers.

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiving Services
Registry
(Caring for Child)
1 Hour is 1
Occurrence
An FCSP Supplemental Service that recruits, screens, and maintains a listing of dependable, qualified self-employed homemaker or respite care workers who may be matched with caregivers willing to use personal resources to pay for assistance with their caregiving responsibilities. Both the caregiver and the self-employed worker will be: (A) advised about appropriate compensation and workplace performance expectations; and (B) provided with follow-up to ensure the match is functioning effectively.

FCSP Registered services:

Reporting requirements
include unduplicated
client counts by
characteristic and service
units for Caregivers.

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered
Caregiving
Emergency
Cash / Material Aid
(Caring for Child)
1 Assistance is
1 Occurrence
An FCSP Supplemental Service that arranges for and provides assistance to caregivers in the form of commodities, surplus food, emergency cash, transit passes, meals, and vouchers that will help meet identified needs associated with an individual caregiver's responsibilities.

FCSP Registered services:

Reporting requirements
include unduplicated
client counts by
characteristic and service
units for Caregivers.

NAPIS
FCSP 3
Supplemental
Svs
OAA 373(b)(5)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Access Assistance

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Caregiver Outreach
(Caring for Child) 1 Contact
An FCSP Access Assistance service involving interventions (one-on-one contacts with individuals) initiated by an agency or provider for the purpose of identifying caregivers and encouraging their use of existing caregiver support services (e.g., Caregiver InfoVan staff contacts outside of local market).

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiving Information
and Assistance
(Caring for Child)
1 Contact
An FCSP Access Assistance service that: (A) provides caregivers with information on services available within the communities, including caregiving information related to assistive technology and caring for older individuals at risk for institutional placement; (B) links caregivers to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures (caregiver may remain anonymous and refuse follow-up contact).

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiver Interpretation
/ Translation
(Caring for Child)
1 Contact
An FCSP Access Assistance service for the provision of bilingual communication assistance to a caregiver in order to access assistance and receive support for his or her caregiving responsibilities (e.g., staff interpreting dialogue between caregiver and care consultant staff translating an elder's prescription drug label for his caregiver).

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Caregiver Legal
Resources
(Caring for Child)
1 Contact
An FCSP Access Assistance service involving one-to-one guidance provided by an attorney (or person under the supervision of an attorney) in the use of legal resources and services when assisting a caregiver with caregiving-related legal issues.

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Information Services

Service
Category
Unit
Measure 1 Definitions Reporting Requirements NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Public Information
on Caregiving
(Caring for Child)
1 Activity
An FCSP Information Service designed to provide information about available FCSP and other caregiver support resources and services by disseminating publications, conducting media campaigns, and maintaining electronic information systems (e.g., quarterly newsletter).

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered
Community Education
on Caregiving
(Caring for Child)
1 Activity
An FCSP Information Service designed to educate groups of current or potential caregivers and those who may provide them with assistance about available FCSP and other caregiver support resources and services (e.g., booth at a health fair).

Non-Registered services:

Reporting requirements include
estimated unduplicated client
counts and service units.

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS

CDA FCSP
Service Matrix
Title III E N/A Non-
Registered

Fiscally Allowable Administrative Activities

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Reporting
Requirements
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Program
Development N/A Activities that either establish a new service or expand or integrate existing services. Non-NAPIS Fiscally
allowable
administrative
activities
CDA Standard
Agreement
Exhibit A
Title III B No N/A
Coordination N/A
Activities that involve the active participation of the AAA staff to include liaison with non-OAA funded agencies and organizations for the purpose of avoiding duplication, improving services, resolving problems related to service delivery, and addressing the service needs of the eligible service population.

Non-NAPIS
Fiscally
allowable
administrative
activities
CDA Standard
Agreement
Exhibit A
Title III B No N/A
CARS / Data
Reporting Systems N/A
The purchase, development, and maintenance of software designed to meet the requirements of the California Aging Reporting System (CARS). Maintenance includes system patches and upgrades. Activities include training staff on data collection and systems.

Non-NAPIS
Fiscally
allowable
administrative
activities
Title III B No N/A
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Reporting
Requirements
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Emergency
Preparedness N/A Develop long-term emergency plans. Non-NAPIS Fiscally
allowable
administrative
activities
Title III B No N/A
Senior Center
Staffing N/A
Assist with the operation of the multipurpose senior center by meeting all or part of the costs of compensating professional and technical personnel required for the operation of the center.

Non-NAPIS
Fiscally
allowable
administrative
activities
Div 4000
Unit 42 Title III B No N/A

1 AAAs must track the actual time services provided in their local database (i.e. minutes, fractions). All service units that are measured in hours must be reported as whole numbers (no fractions/partial units can be reported).

When exporting this data to the California Aging Reporting System (CARS) the AAA’s software system must round total service units for each client by mon th and by service category to the nearest integer (i.e. can round up or down) ). This should not affect the actual data in the AAA database, only the service unit totals in the CARS export files. Due to rounding, CDA expects minor service unit discrepanci es (not to exceed 10 percent) between the AAA database and CARS. Also see "CARS Overview and Guidance" document. 2 All references to Division 4000 and CDA FCSP Service Matrix are for historical reference only. 3 In addition to reporting service units, AAAs must also report unduplicated client enrollments/estimated a udience size (see the color key above for further information).

Exhibit F: Sourcewise Provider Manual
DRAFT

Service Categories and Data Dictionary:

Glossary of Terms and Acronyms
Exhibit F: Sourcewise Provider Manual
DRAFT
AAA: Ar
ea Agency on Aging
ADL: Activities of Daily Living
IADL: Instrumental Activities of Daily Living
AoA: United States Administration on Aging http://www.aoa.gov/ CARS: A multi-phased, multi-year project started in June 2007 which will transform the existing Older Americans Act (OAA) and Older Californians Act (OCA) aggregate reporting system into a new web-based system capable of providing the State with client-level data from the Aging Services network.

The complete project envisions web-based access to one common database (standardized data specification across programs) on OAA and OCA fiscal, program performance (utilization), and client-level demographic profile data (Registered services only; a number of Non-Registered services remaining are aggregated data).

It will allow the California Department of Aging (CDA) to compare data across all programs, as opposed to having silos of data that are not comparable to one another.

CCR: California Code of Regulations http://www.oal.ca.gov/ccr.htm CDA: California Department of Aging http://www.aging.ca.gov/ DIV: Division (as in a section of law)
Division 4000: Division 4000 is used to specify the Other Title III B and Title III D services not defined in NAPIS, as well as elder abuse prevention activities related to Title VII. With the implementation of the Service Category and Data Dictionary Matrix, definitions from this source will no longer be used.

Estimated Unduplicated Client Count: The Administration on Aging has not provided a method to estimate an Unduplicated Count of Clients. Each AAA must supply its own methodology.

FCSP: Family Caregiver Support Program -- same as Title III E. FCSP provides support to (1) unpaid family caregivers of older adults and (2) grandparents or other older relatives with primary caregiving responsibilities for a child through five broad categories of services (see FCSP 1-5) FCSP 1: Support Services means the provision of caregiver assessment, caregiver counseling, caregiver peer counseling, caregiver support groups, caregiver training, and (if necessary) caregiver case management.

FCSP 2: Respite Care means a brief period of relief or rest from caregiving responsibilities, and is provided to caregivers on an intermittent, occasional, or emergency basis in a manner that responds to the individual needs and preferences of the caregivers and their care receivers, rather than a pre-established set amount offered on a “first come, first served” waiting list basis.

FCSP 3: Supplemental Services means caregiver-centered assistance offered on a limited basis to support and strengthen the caregiving efforts.

FCSP 4: Access Assistance means the provision of caregiving information and assistance, caregiver outreach, caregiver interpretation/translation, and caregiver legal resources; and links caregivers to the opportunities and services that are available.

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP
5: Information Services means the provision of public information on caregiving and/or community education on caregiving, including information about available services.

InfoVan: A specialized vehicle used by Area Agencies on Aging and their providers for outreach and education on services and information via oral communication and written information such as flyers, brochures, etc. http://www.cda.ca.gov/aaa/reporting_instructions/info_van.asp NAPIS: The National Aging Program Information System (NAPIS) through which the State Program Report (SPR) is reported annually. The report contains statistical compilation of performance data and expenditures for programs administered by CDA with OAA Title III and Title VII funds. The data is collected and reported by service providers, AAAs, and State Units on Aging (for California, CDA) (for State on quarterly basis) on an annual basis in CARS. Statistical data is reported to AoA per federal guidelines by January 31 of each year by CDA.

Non Registered Services: Non-registered services are those services where it is not practical to collect client specific information or where requiring the client to register may serve as a barrier to receiving a service (see Service Categories and Data Dictionary document).

OAA: The Federal Older Americans Act: Congress enacted in 1965 to promote and provide assistance in the development of programs of benefit to the elderly and to provide funding for such programs through State Units and Area Agencies on Aging. http://www.aoa.gov/AoARoot/AoA_Programs/OAA/index.aspx OCA: In 1974, the Burton Act established the California Department of Aging (CDA) as a department within the Health and Welfare Agency. Initially the CDA was known as the Office on Aging.

The Burton Act also established the California Commission on Aging (CCoA) as an advisory body to the Governor, Legislature, Department of Aging and other state departments, as well as provided funding and staffing.

Pr: Refers to "Program" type under Division 4000
Registered Services: Means data collection and reporting requirements include unduplicated client counts by characteristic, units of service, including in some cases ADLs/IADLs (see Service Categories and Data Dictionary document). Registered Services are client specific data using participant identification numbers for each client.

Service Categories and Data Dictionary: See Service Categories and Data Dictionary section.

Title III B: Title III B of the Older Americans Act that provides funding for supportive services such as, but not limited to, Information and Referral Services, In-home Services, Legal Services, Outreach, Respite Care/Respite Care Registries, and Transportation.

Title III C-1: Title III C-1 of the Older Americans Act that provides funding for the provision of Congregate Meals.

Title III C-2: Title III C-2 of the Older Americans Act that provides funding for the provision of Home Delivered Meals.

Title III D: Title III D of the Older Americans Act that provides funding for the provision of Disease Prevention and Health Promotion Services.

Title III E: See FCSP
Title VII B: Elder Abuse Prevention
Exhibit F: Sourcewise Provider Manual
DRAFT

Service Categories and Data Dictionary:

Summary of Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Activities and CARS Reporting

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Personal Care 1 Hour
Personal assistance, stand-by assistance, supervision or cues. (such as with eating, bathing, toileting, transferring in/out of bed/chair, walking, dressing, grooming).

NAPIS 1
NAPIS
Div 4000
Unit 20
Title III B Yes Registered No Changes
Homemaker 1 Hour
Assistance such as preparing meals, shopping for personal and household items, managing money, using the telephone or doing light housework.

NAPIS 2
NAPIS
Div 4000
Unit 50, Unit 27
Title III B Yes Registered No Changes
Chore 1 Hour Assistance such as heavy housework, yard work or sidewalk and other home maintenance for a person. NAPIS 3 NAPIS
Div 4000 Unit 5 Title III B Yes Registered No Changes
Home-Delivered
Meals 1 Meal
A meal provided to an eligible individual in his or her place of residence, that meets all of the requirements of the Older Americans Act and State/Local laws, assures a minimum one-third of the current Dietary Reference Intake, and shall comply with Dietary Guidelines for Americans.

NAPIS 4
NAPIS
Div 4000
Unit 51
Title III C-
2 No Registered No Changes
Adult Day Care /
Adult Day Health 1 Hour
Personal care for dependent elders in a supervised, protective, and congregate setting during some portion of a day. Services offered in conjunction with adult day care/adult day health typically include social and recreational activities, training, counseling, and services such as rehabilitation, medications assistance and home health aide services for adult day health.

NAPIS 5
NAPIS
Div 4000
Pr 5, Pr 11,
Pr 17
Title III B Yes Registered No Changes
Case Management 1 Hour
Assistance either in the form of access coordination in circumstances where the older person is experiencing diminished functioning capacities, personal conditions or other characteristics which require the provision of services by formal service providers or family caregivers. Activities of case management include such practices as assessing needs, developing care plans, authorizing and coordinating services among providers, and providing follow-up and reassessment, as required.

NAPIS 6 NAPIS
Div 4000 Pr 3 Title III B Yes Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Assisted Transportation 1 One Way Trip
Assistance and transportation, including escort, to a person who has difficulties (physical or cognitive) using regular vehicular transportation.

NAPIS 7
NAPIS
Div 4000
Unit 10
Title III B No Registered No Changes
Congregate Meals 1 Meal
A meal provided to an eligible individual in a congregate group setting, that meets all of the requirements of the Older Americans Act and State/Local laws, and assures a minimum one-third of the Dietary Reference Intake, and shall comply with Dietary Guidelines for Americans.

NAPIS 8 NAPIS
Div 4000 Pr 20
Title III C-
1 No Registered No Changes
Nutrition Counseling 1 Session Per
Participant
Individualized guidance to individuals who are at nutritional risk because of their health or nutrition history, dietary intake, chronic illnesses, or medications use, or to caregivers. Counseling is provided one-on-one by a registered dietitian, and addresses the options and methods for improving nutrition status. Nutrition counseling may be made either in person or by any other means deemed appropriate (e.g., telephone, emails, etc.)
NAPIS 9 NAPISDiv
4000Unit 53
Title III C-
1Title III
C-2
No Registered No Changes
Transportation 1 One Way Trip Transportation from one location to another. Does not include any other activity. May include travel vouchers and transit passes. NAPIS 10 NAPIS Div 4000 Pr 12 Title III B Yes Non-
Registered No Changes
Legal Assistance 1 Hour Legal advice, counseling and/or representation by an attorney or other person acting under the supervision of an attorney. NAPIS 11 NAPIS Div 4000 Pr 14 Title III B Yes Non-
Registered No Changes
Nutrition Education 1 Session Per
Participant
A program to promote better health by providing accurate and culturally sensitive nutrition, physical fitness, or health (as it relates to nutrition) information and instruction to participants, caregivers, or participants in a group or individual setting overseen by a dietitian or individual of comparable expertise. Methods of education may include demonstrations, audio-visual presentations, or small group discussions for congregate program participants.

Handout materials may be used, but not limited to, as the sole education component for home-delivered meal program
participants.

NAPIS 12
NAPIS
Div 4000
Unit 52
Title III C-
1 Title III C-
2 Title III D
4 No Non-
Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Information
and
Assistance
1 Contact
A service that: (A) provides individuals with information on services available within the communities; (B) links individuals to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures. Internet web site "hits" are to be counted only if information is requested and supplied, and (C) is satisfied. Maximum extent practicable includes offering a follow-up call to all individuals who were linked to a service. Individuals can remain anonymous and refuse a follow-up call.

NAPIS 13 NAPIS
Div 4000 Pr 1 Title III B Yes Non-
Registered No Changes
Outreach 1 Contact
Interventions (one-on-one contacts) with individuals initiated by an agency or provider for the purpose of identifying potential clients (or their age 60+ caregivers) and encouraging their use of existing services and benefits.

NAPIS 14
NAPIS
Div 4000
Unit 19
Title III B Yes Non-
Registered No Changes
Health Promotion 1 Contact
An evidence-based health promotion program, including programs related to the prevention and mitigation of the effects of chronic disease (including, but not limited to, osteoporosis, obesity, diabetes, and cardiovascular disease), alcohol and substance abuse reduction, smoking cessation, weight loss and control, stress management, falls prevention, physical activity, and improved nutrition. For a list of ACL approved Evidence-Based programs, please visit the National Council on Aging website at
https://www.ncoa.org/resources/ebpchart.

NAPIS 16 -
Heath
Promotion
Older Americans
Act Sec 102 (14) Title III D
3 No Non-
Registered No Changes
Alzheimer's
Day Care Services
1 Day of
Attendance
Day of attendance (four hours minimum) at a licensed Adult Day Care or Adult Day Health Care Center that provides Alzheimer's or dementia services.

NAPIS 15 -
Other Div 4000 Pr 6 Title III B Yes Non-
Registered No Changes
Cash / Material Aid 1 Assistance
Arrange for and provide assistance to participants in the form of commodities, surplus food distribution, emergency cash assistance, and vouchers.

NAPIS 15 -
Other
Div 4000
Unit 15 Title III B No Non-
Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Community
Education 1 Activity
Educating groups of older persons, their families, friends, and community organizations/facility staff on rights, benefits, entitlements, and health and wellness information for older persons either residing at home or in an institutional setting.

NAPIS 15 -
Other Div 4000 Unit 9 Title III B No Non-
Registered No Changes
Comprehensive
Assessment 1 Hour
Evaluating a person's physical, psychological, and social needs, financial resources, and the strengths and weaknesses of their informal support system and the immediate environment as a basis for determining current functional ability and potential improvement in order to develop the appropriate services needed to maximize functional independence.

NAPIS 15 -
Other
Div 4000
Unit 32
CCR 7112
Title III B Yes Non-
Registered No Changes
Disaster
Preparedness
Materials
1 Product
Assemble and distribute disaster preparedness materials such as File of Life or preparedness kits that will assist seniors in the event of an emergency.

NAPIS 15 -
Other No reference Title III B No Non-
Registered No Changes
Elder Abuse Prevention,
Education and Training 1 Session
Public education and training of professionals to develop, strengthen, and carry out programs for the prevention, detection, assessment, and treatment of, intervention in, investigation of, and response to elder abuse, neglect, and exploitation (including financial exploitation).This includes training for Title III E caregivers.

NAPIS 15 -
Other Div 4000 Pr 22 Title VII B No Non-
Registered No Changes
Elder Abuse
Prevention
Educational
Materials
1 Product
Educational materials and guidance kits distributed for the prevention, detection, assessment, and treatment of, intervention in, investigation of, and response to elder abuse, neglect, and exploitation (including financial exploitation).

NAPIS 15 -
Other Div 4000 Pr 22 Title VII B No Non-
Registered No Changes
Employment 1 Activity
Activities designed to maintain or obtain part-time/full-time employment for older persons or to assist them in selecting and entering into a second career. This can be accomplished through activities including but not limited to career counseling, recruitment, assessment, training, job club, and job development.

NAPIS 15 -
Other Div 4000 Pr 15 Title III B No Non-
Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Health 1 Hour
Activities such as non-evidence-based medication management, health screening, physical fitness, therapy, and hospice to assist older individuals to improve or maintain physical health and secure necessary medical, preventive health, or health maintenance services. Health screening, therapy, and hospice must be provided by a licensed health professional or by a paraprofessional supervised by a licensed health professional. Does not include services covered by Medicare, Medi-Cal, or other health insurance.

Medication management means activities that facilitate safe and effective use of prescription and over-the-counter drugs. These activities may include medication screening and education to an individual and/or the caregiver to prevent incorrect medication administration and adverse drug reaction. Primary activities are normally on a one-to-one basis; if done as a group activity, each participant shall be counted as one contact unit.

NAPIS 15 -
Other
Div 4000 Pr 9,
Unit 13, Unit 21,
Unit 29, Unit 37
Title III B Yes Non-
Registered No Changes
Housing 1 Hour Assistance in locating adequate housing through referral or placement.

NAPIS 15 -
Other Div 4000 Pr 4 Title III B No Non-
Registered No Changes
Interpretation /
Translation 1 Contact Provide interpretation/translation services for older individuals and their caregivers.

NAPIS 15 -
Other Div 4000 Unit 4 Title III B No Non-
Registered No Changes
Mobility Management
Activities 1 Hour
Activities related to increasing transportation and mobility options for older adults by providing assistance, information, travel training, trip planning, coordination of service public or private transit operators, scheduling, access to transit information, creation of new models of service such as volunteer driver programs and shuttles.

NAPIS 15 -
Other Title III B No Non-
Registered No Changes
Mental Health 1 Hour
Provide services such as screening, assessment, therapy, counseling, follow-up, and referral to maintain or improve the mental health of older individuals. Mental Health services must be provided by a licensed health professional or by a paraprofessional supervised by a licensed health professional. Does not include services covered by Medicare, Medi-Cal, or other health insurance.

NAPIS 15 -
Other
Div 4000 Pr 10,
Unit 11,
Unit 23, Unit 29
Title III B Yes Non-
Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Peer Counseling 1 Hour
Use the skills and/or life experiences of trained volunteers, under qualified supervision, to provide advice, guidance, and support in a self-help approach in order to enhance well-being and enable clients to make informed choices.

NAPIS 15 -
Other

Div 4000 Unit 7 Title III B No Non-
Registered No Changes
Personal Affairs
Assistance 1 Contact
Provide assistance in writing letters and with the completion of financial forms, including tax forms, and other written or electronic documents.

NAPIS 15 -
Other
Div 4000 Unit 12,
Pr 16 Title III B No Non-
Registered No Changes
Personal /
Home Security 1 Product
Services for the security and safety of their home environment, by providing safety features such as: medical alert, alarms, assistive devices (including provision of assistive technology services and assistive technology devices).

NAPIS 15 -
Other Div 4000 Pr 7 Title III B No Non-
Registered No Changes
Public
Information 1 Activity
Contact with multiple current or potential clients or caregivers through publications, publicity campaigns, and other mass media campaigns including Internet websites.

NAPIS 15 -
Other NAPIS Title III B Yes Non-
Registered No Changes
Registry 1 Hour
Recruit workers, maintain a current list of qualified workers, refer workers to clients or clients to workers, and follow-up to assure that service was received.

NAPIS 15 -
Other
Div 4000
Unit 41 Title III B No Non-
Registered No Changes
Residential Repairs /
Modifications 1 Modification
Residential modifications of homes that are necessary to facilitate the ability of older individuals to remain at home and that are not available under other programs. Includes minor
repairs/renovations in order to meet safety, health issues, and code standards.

NAPIS 15 -
Other
Div 4000
Unit 1, Unit 48 Title III B Yes Non-
Registered No Changes
Respite Care 1 Hour
Arrange for relief of the relatives or other caregivers of the frail elderly living at home by the coordination or direct provision of supportive services to the older person(s) while the primary caregiver is temporarily absent (includes Adult Day Care as a respite service for families).

NAPIS 15 -
Other
Div 4000 Pr 18,
Unit 45 Title III B Yes Non-
Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Senior Center
Activities 1 Hour
Services designed to enable older individuals to attain and/or maintain physical and mental well-being such as recreation, music, creative arts, physical activity, education, leadership development and other supportive services not covered under other service categories. Development and provision of new volunteer
opportunities and services, and creation of additional services and programs to remedy gaps and deficiencies in existing services.

Entertainment costs such as tickets to shows or sporting events, meals, lodging, rentals, transportation and gratuities, are not allowable.

NAPIS 15 -
Other
Div 4000 Pr 13
OMB A-87 Title III B No Non-
Registered No Changes
Telephone
Reassurance 1 Contact Telephone a client to provide contact and safety checks to reassure and support older individuals.

NAPIS 15 -
Other
Div 4000
Unit 28 Title III B Yes Non-
Registered No Changes
Visiting 1 Hour Visit a client to provide contact and safety checks to reassure and support older individuals.

NAPIS 15 -
Other
Div 4000
Unit 31 Title III B Yes Non-
Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Support Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Assessment
(Caring for Elderly) 1 Hour
An FCSP Support Service conducted by persons trained and experienced in the skills required to deliver the service that should result in a plan that includes emergency back-up provisions and is periodically updated; and will explore options and courses of action for caregivers by identifying their: (A) willingness to provide care; (B) duration and care frequency preferences; (C) caregiving abilities; (D) physical health, psychological, social support, and training needs; (E) financial resources relative for caregiving; and (F) strengths and weaknesses within the immediate caregiving environment and (caregiver's) extended informal support system.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Counseling
(Caring for Elderly) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of support needed for stress, depression, and loss as a result of caregiving responsibilities. This service (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone consultations, and (C) may address caregiving-related financial and long-term care placement responsibilities.

NAPISFCSP
1Support
Svs
OAA 373(b)(3)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered No Changes
Caregiver Peer Counseling
(Caring for Elderly) 1 Hour
An FCSP Support Service provided by experienced volunteers on the condition that appropriate training and qualified supervision protocols are in place.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver
Support Group
(Caring for Elderly)
1 Hour
An FCSP Support Service provided to a group of 3 - 12 caregivers that is led by a competent facilitator; conducted at least monthly within a supportive setting or via a controlled access, moderated online or teleconference approach; for the purpose of sharing experiences and ideas to ease the stress of caregiving, and to improve decision-making and problem-solving skills related to their caregiving responsibilities.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Training
(Caring for Elderly) 1 Hour
An FCSP Support Service consisting of workshops or one-on-one individually tailored sessions, conducted either in person or electronically by a skilled and knowledgeable individual, to assist caregivers in developing the skills and gaining the knowledge necessary to fulfill their caregiving responsibilities; and address the areas of health, nutrition, and financial literacy.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver
Case Management
(Caring for Elderly)
1 Hour
An FCSP Support Service provided by a person who is trained and experienced in the skills that are required to coordinate and monitor the provision of formal caregiver-related services in circumstances where caregivers are experiencing diminished capacities due to mental impairment or temporary severe stress and/or depression.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Respite Care

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Respite
In-Home Supervision
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver day and/or overnight supervision and friendly visiting by an appropriately skilled provider or volunteer in order to prevent wandering and health or safety incidents.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Homemaker Assistance
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with meal preparation, medication
management, using the phone, and or light housework (along with care receiver supervision) by an appropriately skilled provider or volunteer.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
In-Home
Personal Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with eating, bathing, toileting, transferring, and or dressing (along with care receiver supervision and related homemaker assistance) by an appropriately skilled provider.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Home Chore
(Caring for Elderly)
1 Hour
An FCSP Respite Care service that includes an appropriately skilled provider or volunteer assisting a caregiver with heavy housework, yard work, and or sidewalk and other routine home maintenance (but not structural repairs) associated with caregiving responsibilities.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Out-of-Home
Day Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service where the care receiver attends a supervised/protective, congregate setting during some portion of a day, and includes assess to social and recreational activities.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Out-of-Home
Overnight Care
(Caring for Elderly)
1 Hour
An FCSP Respite Care service where the care receiver is temporarily placed in a supervised/protective, residential setting for one or more nights, and may include access to nursing and personal care.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Supplemental Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Assistive Devices
for Caregiving
(Caring for Elderly)
1 Device is 1
Occurrence
An FCSP Supplemental Service that involves the purchase, rental and/or service fee of any equipment or product system (ranging from a lift chair or bathtub transfer bench to an electronic pill dispenser or emergency alert fall prevention device) in order to facilitate and fulfill caregiving responsibilities.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Home Adaptationsfor
Caregiving(Caring for
Elderly)
1 Modification
is 1 Occurrence
An FCSP Supplemental Service that makes any minor or major physical change to the home (ranging from installation of grab bars or replacement of door handles to construction of an entrance ramp or roll-in shower) in order to fulfill caregiving responsibilities.

NAPISFCSP
3Supplemen
tal Svs
OAA 373(b)(5)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered No Changes
Caregiving Services
Registry
(Caring for Elderly)
1 Hour is 1
Occurrence
An FCSP Supplemental Service that recruits, screens, and maintains a listing of dependable, qualified self-employed homemaker or respite care workers who may be matched with caregivers willing to use personal resources to pay for assistance with their caregiving responsibilities. Both the caregiver and the self-employed worker will be: (A) advised about appropriate compensation and workplace performance expectations; and (B) provided with follow- up to ensure the match is functioning effectively.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiving
Emergency
Cash / Material Aid
(Caring for Elderly)
1 Assistance is 1
Occurrence
An FCSP Supplemental Service that arranges for and provides assistance to caregivers in the form of commodities, surplus food, emergency cash, transit passes, meals, and vouchers that will help meet identified needs associated with an individual caregiver's responsibilities.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Access Assistance

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Outreach
(Caring for Elderly) 1 Contact
An FCSP Access Assistance service involving interventions (one-on- one contacts with individuals) initiated by an agency or provider for the purpose of identifying caregivers and encouraging their use of existing caregiver support services (e.g., Caregiver InfoVan staff contacts outside of local market).

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Caregiving Information
and
Assistance
(Caring for Elderly)
1 Contact
An FCSP Access Assistances service that: (A) provides caregivers with information on services available within the communities, including caregiving information related to assistive technology and caring for older individuals at risk for institutional placement; (B) links caregivers to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures (caregiver may remain anonymous and refuse follow-up contact).

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Caregiver Interpretation
/Translation(Caring for
Elderly)
1 Contact
An FCSP Access Assistance Service for the provision of bilingual communication assistance to a caregiver in order to access assistance and receive support for his or her caregiving responsibilities (e.g., staff interpreting dialogue between caregiver and care consultant staff translating an elder's prescription drug label for his caregiver).

NAPISFCSP
4Access
Assistance
OAA 373(b)(2)

NAPISCDA FCSP
Service Matrix
Title III E N/A Non-
Registered No Changes
Caregiver Legal Resources
(Caring for Elderly) 1 Contact
An FCSP Access Assistance Service involving one-to-one guidance provided by an attorney (or person under the supervision of an attorney) in the use of legal resources and services when assisting a caregiver with caregiving-related legal issues.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Caregiver Caring for Elderly
Information Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Public Information
on
Caregiving
(Caring for Elderly)
1 Activity
An FCSP Information Service designed to provide information about available FCSP and other caregiver support resources and services by disseminating publications, conducting media campaigns, and maintaining electronic information systems (e.g., quarterly newsletter).

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Community Education
on
Caregiving
(Caring for Elderly)
1 Activity
An FCSP Information Service designed to educate groups of current or potential caregivers and those who may provide them with assistance about available FCSP and other caregiver support resources and services (e.g., booth at a health fair).

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes

FCSP - Grandparent Caring for Child
Support Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Assessment
(Caring for Child) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of counseling service, which may range from guidance with caregiving responsibilities to therapy for stress, depression, and loss; and (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone consultations, and (C) may address caregiving-related financial and long-term care placement responsibilities.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Counseling
(Caring for Child) 1 Hour
An FCSP Support Service provided to a caregiver by a person appropriately trained and experienced in the skills required to deliver the level of support needed for stress, depression, and loss as a result of caregiving responsibilities. This service (A) may involve his or her informal support system; (B) may be individual direct sessions and/or telephone consultations, and (C) may address caregiving-related financial and long-term care placement responsibilities.

NAPISFCSP
1Support
Svs
OAA 373(b)(3)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered No Changes
Caregiver Peer Counseling
(Caring for Child) 1 Hour
An FCSP Support Service provided by experienced volunteers on the condition that appropriate training and qualified supervision protocols are in place.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver
Support Group
(Caring for Child)
1 Hour
An FCSP Support Service provided to a group of 3 - 12 caregivers that is led by a competent facilitator; conducted at least monthly within a supportive setting or via a controlled access, moderated online or teleconference approach; for the purpose of sharing experiences and ideas to ease the stress of caregiving, and to improve decision-making and problem-solving skills related to their caregiving responsibilities.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Training
(Caring for Child) 1 Hour
An FCSP Support Service consisting of workshops or one-on-one individually tailored sessions, conducted either in person or electronically by a skilled and knowledgeable individual, to assist caregivers in developing the skills and gaining the knowledge necessary to fulfill their caregiving responsibilities; and shall address the areas of health, nutrition, and financial literacy.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver
Case Management
(Caring for Child)
1 Hour
An FCSP Support Service provided by a person who is trained and experienced in the skills that are required to coordinate and monitor the provision of formal caregiver-related services in circumstances where caregivers are experiencing diminished capacities due to mental impairment or temporary severe stress and/or depression.

NAPIS
FCSP 1
Support Svs
OAA 373(b)(3)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Respite Care

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Respite
In-Home Supervision
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver day and/or overnight supervision and friendly visiting by an appropriately skilled provider or volunteer in order to prevent wandering and health or safety incidents.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Homemaker Assistance
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with meal preparation, medication
management, using the phone, and or light housework (along with care receiver supervision) by an appropriately skilled provider or volunteer.

NAPISFCSP
2Respite
Care
OAA 373(b)(4)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered No Changes
Caregiver Respite
In-Home
Personal Care
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes the provision of care receiver assistance with eating, bathing, toileting, transferring, and or dressing (along with care receiver supervision and related homemaker assistance) by an appropriately skilled provider.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Home Chore
(Caring for Child)
1 Hour
An FCSP Respite Care service that includes an appropriately skilled provider or volunteer assisting a caregiver with heavy housework, yard work, and or sidewalk and other routine home maintenance (but not structural repairs) associated with caregiving responsibilities.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Out-of-Home
Day Care
(Caring for Child)
1 Hour
An FCSP Respite Care service where the care receiver attends a supervised/protective, congregate setting during some portion of a day, and includes assess to social and recreational activities.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiver Respite
Out-of-Home
Overnight Care
(Caring for Child)
1 Hour
An FCSP Respite Care service where the care receiver is temporarily placed in a supervised/protective, residential setting for one or more nights, and may include access to nursing and personal care.

NAPIS
FCSP 2
Respite Care
OAA 373(b)(4)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Supplemental Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Assistive Devices
for Caregiving
(Caring for Child)
1 Device is 1
Occurrence
An FCSP Supplemental Service that involves the purchase, rental and/or service fee of any equipment or product system (ranging from a lift chair or bathtub transfer bench to an electronic pill dispenser or emergency alert fall prevention device) in order to facilitate and fulfill the caregiving responsibilities.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Home Adaptations for
Caregiving
(Caring for Child)
1 Modification
is 1 Occurrence
An FCSP Supplemental Service that makes any minor or major physical change to the home (ranging from installation of grab bars or replacement of door handles to construction of an entrance ramp or roll-in shower) in order to facilitate and fulfill caregiving responsibilities.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes
Caregiving Services
Registry
(Caring for Child)
1 Hour is 1
Occurrence
An FCSP Supplemental Service that recruits, screens, and maintains a listing of dependable, qualified self-employed homemaker or respite care workers who may be matched with caregivers willing to use personal resources to pay for assistance with their caregiving responsibilities. Both the caregiver and the self-employed worker will be: (A) advised about appropriate compensation and workplace performance expectations; and (B) provided with follow- up to ensure the match is functioning effectively.

NAPISFCSP
3Supplemen
tal Svs
OAA 373(b)(5)

NAPISCDA FCSP
Service Matrix
Title III E N/A Registered No Changes
Caregiving Emergency
Cash / Material Aid
(Caring for Child)
1 Assistance is 1
Occurrence
An FCSP Supplemental Service that arranges for and provides assistance to caregivers in the form of commodities, surplus food, emergency cash, transit passes, meals, and vouchers that will help meet identified needs associated with an individual caregiver's responsibilities.

NAPIS
FCSP 3
Supplement
al Svs
OAA 373(b)(5)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Access Assistance

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Caregiver Outreach
(Caring for Child) 1 Contact
An FCSP Access Assistance service involving interventions (one-on- one contacts with individuals) initiated by an agency or provider for the purpose of identifying caregivers and encouraging their use of existing caregiver support services (e.g., Caregiver InfoVan staff contacts outside of local market).

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Caregiving Information
and Assistance
(Caring for Child)
1 Contact
An FCSP Access Assistance service that: (A) provides caregivers with information on services available within the communities, including caregiving information related to assistive technology and caring for older individuals at risk for institutional placement; (B) links caregivers to the services and opportunities that are available within the communities; (C) to the maximum extent practicable, establishes adequate follow-up procedures (caregiver may remain anonymous and refuse follow-up contact).

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Caregiver Interpretation /
Translation
(Caring for Child)
1 Contact
An FCSP Access Assistance service for the provision of bilingual communication assistance to a caregiver in order to access assistance and receive support for his or her caregiving responsibilities (e.g., staff interpreting dialogue between caregiver and care consultant staff translating an elder's prescription drug label for his caregiver).

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Caregiver Legal Resources
(Caring for Child) 1 Contact
An FCSP Access Assistance service involving one-to-one guidance provided by an attorney (or person under the supervision of an attorney) in the use of legal resources and services when assisting a caregiver with caregiving-related legal issues.

NAPIS
FCSP 4
Access
Assistance
OAA 373(b)(2)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes

Exhibit F: Sourcewise Provider Manual
DRAFT
FCSP - Grandparent Caring for Child
Information Services

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Public Information
on Caregiving
(Caring for Child)
1 Activity
An FCSP Information Service designed to provide information about available FCSP and other caregiver support resources and services by disseminating publications, conducting media campaigns, and maintaining electronic information systems (e.g., quarterly newsletter).

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes
Community Education
on Caregiving
(Caring for Child)
1 Activity
An FCSP Information Service designed to educate groups of current or potential caregivers and those who may provide them with assistance about available FCSP and other caregiver support resources and services (e.g., booth at a health fair).

NAPIS
FCSP 5
Information
Svs
OAA 373(b)(1)
NAPIS
CDA FCSP Service
Matrix
Title III E N/A Non-
Registered No Changes

Fiscally Allowable Administrative Activities

Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
Program
Development N/A Activities that either establish a new service or expand or integrate existing services. Non-NAPIS
CDA Standard
Agreement
Exhibit A
Title III B No N/A No Changes
Coordination N/A
Activities that involve the active participation of the AAA staff to include liaison with non-OAA funded agencies and organizations for the purpose of avoiding duplication, improving services, resolving problems related to service delivery, and addressing the service needs of the eligible service population.

Non-NAPIS
CDA Standard
Agreement
Exhibit A
Title III B No N/A No Changes
Exhibit F: Sourcewise Provider Manual
DRAFT
Service
Category
Unit
Measure 1 Definitions NAPIS
Reference
Definition /
Historical
Reference 2
Primary
Funding
Source
Priority
Service
Registered
or
Non-
Registered 3
Summary of Changes
CARS / Data
Reporting Systems N/A
The purchase, development, and maintenance of software designed to meet the requirements of the California Aging Reporting System (CARS). Maintenance includes system patches and upgrades.

Activities include training staff on data collection and systems.

Non-NAPIS Title III B No N/A
New definition: the definition
was revised to specify
allowable activities for staff
training on data collection
and systems for AB 959 and
other topics. The definition
also clarifies that
maintenance includes system
patches and upgrades.

Emergency
Preparedness N/A Develop long-term emergency plans. Non-NAPIS Title III B No N/A No Changes Senior Center
Staffing N/A
Assist with the operation of the multipurpose senior center by meeting all or part of the costs of compensating professional and technical personnel required for the operation of the center.

Non-NAPIS Div 4000
Unit 42 Title III B No N/A No Changes

For ADA compliance, additional notes for reporting requirements have been moved into a column titled “Reporting Requirements” as needed for each service category, instead of the color coordinated sections as follows:
• Light Blue: Denotes Cluster 1 services. Reporting requirements include unduplicated client counts by characteristic, ADLs/IADLs and service units. • Dark Blue: Denotes Cluster 2 services. Reporting requirements include unduplicated client counts by characteristic and service units. Fo r FCSP, ADL/IADL information is required for Care Receivers served in "Caregiver Caring for Elderly" component only.
• White: Denotes Non-Registered services. Reporting requirements include estimated unduplicated client counts and service units. • Yellow: Denotes FCSP Registered services. Reporting requirements include unduplicated client counts by characteristic and service uni ts for Caregivers. ADL/IADL information is required for Care Receivers served in "Caregiver Caring for Elderly" component only.
• Green: Denotes fiscally allowable administrative activities.

When exporting this data to the California Aging Reporting System (CARS) the AAA’s software system must round total service units for each client by month and by service category to the nearest integer (i.e. can round up or down) ). This should not affect the actual data in the AAA database, only the service unit totals in the CARS export files. Due to rounding, CDA expects minor service unit discrepancies (not to exceed 10 percent) between the AAA database and CARS. Also see "CARS Overview and Guidance" document. 2 All references to Division 4000 and CDA FCSP Service Matrix are for historical reference only. 3 In addition to reporting service units, AAAs must also report unduplicated client enrollments/estimated audie nce size (see the color key above for further information).

Exhibit F: Sourcewise Provider Manual
DRAFT
Opening IE Mode in Microsoft Edge

1. Download the most current version of Edge.

2. In Edge, go to Settings, select Default browser, change the "Allow sites to be reloaded in Internet Explorer mode" setting to "Allow".

Exhibit F: Sourcewise Provider Manual
DRAFT

3. After selecting ‘Allow’ from the dropdown menu, click ‘Add’ within the row labeled ‘Internet Explorer mode pages’.

Exhibit F: Sourcewise Provider Manual
DRAFT

4. Enter the Q Portal address. (https://qhost.assurecare.com/RDWeb) . Click ‘Add’

5. Close the Edge window and then reopen Microsoft Edge.

6. Enter the Q Portal address. (https://qhost.assurecare.com/RDWeb)

7. The Q Portal Log-in webpage should load. If it does not follow steps #8 and #11.

8. Click the ... (elipsis) button in the upper right corner of the Edge screen.

Exhibit F: Sourcewise Provider Manual
DRAFT

9. Select "Reload in Internet Explorer mode".

10. Log in to the Q Portal and then into Q like normal.

Exhibit F: Sourcewise Provider Manual
DRAFT

11. You might get this window:

I recommend clicking on the blue button so it knows to open this page in IE mode.

Exhibit F: Sourcewise Provider Manual
DRAFT

AAA Provider Workbook
Exhibit F: Sourcewise Provider Manual
DRAFT
2 CareAccess

ALL RIGHTS RESERVED
This material contains proprietary and confidential information and is protected by copyright and trade secret laws. Unauthorized reproduction, distribution, or transfer of this material, or any portion of it, is strictly prohibited and may result in civil and criminal penalties. Known violators will be prosecuted to the maximum extent possible under the law.

DISCLAIMER
CareAccess Incorporated has taken care in preparing this material. Nothing contained in this material alters in any way the terms and conditions of the license agreement by which the product was acquired, nor increases in any way CareAccess Incorporated liability to the user.

The text discussed in the guide is the Q System's default settings. Please see your System administrator for any questions that might arise.

Note: The pages in this document were formatted so that the document can be printed as a two-sided document. The blank pages in this document are intentional in order to maintain a format conducive to printing in such a manner.

Document revision date – 5/11/2016
Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 3

TABLE OF CONTENTS
Lesson 1: Discovering Q Features
Understanding the Q database ...................................................................................................... 7 About the Q database system ..................................................................................................... 7 Q database model ...................................................................................................................... 7 Transacional processing vs. analytical processing ...................................................................... 8 Business intelligence .................................................................................................................. 8 Starting a Q database session ....................................................................................................... 9 Do it! Start Q database session ................................................................................................ .. 9 Install the client software ............................................................................................................ 9 Start Q demo database session ................................................................................................ 10 Lesson 2: Exploring the Q Workspace
Q workspace components ........................................................................................................ 11 Lesson 3: Navigating with Q Grids
Exploring the launcher ................................................................................................................. 13 Overview ................................................................................................................................ .. 13 Displaying the launcher: two views ........................................................................................... 13 Opening the launcher ............................................................................................................... 14 Command buttons in launcher ................................................................................................ .. 14 Objects ..................................................................................................................................... 14 Exploring Q grids ......................................................................................................................... 15 Locating objects in a grid .......................................................................................................... 15 The scroll bar ............................................................................................................................ 15 Quick jump ............................................................................................................................... 15 The Find command ................................................................................................................... 15 Do it! Open an object's grid ....................................................................................................... 16 The Client's Query .................................................................................................................... 16 Use the Process Center............................................................................................................ 16 Navigating through records in a grid ......................................................................................... 16 The Close button ...................................................................................................................... 17 The toolbar navigation buttons ................................................................................................ .. 17 Opening a new window............................................................................................................. 17 Grid toolbar ............................................................................................................................... 17 Customizing grids ........................................................................................................................ 17 Customizing Options ................................................................................................................. 17 Do it! Add and remove columns in a grid .................................................................................. 18 Re-arranging columns............................................................................................................... 19 Re-sizing columns .................................................................................................................... 19 Remove a column..................................................................................................................... 19 Do it! Sort and group your grid ................................................................................................ .. 19 Simple sorting ........................................................................................................................... 19 Complex sorting ........................................................................................................................ 20 Grouping ................................................................................................................................ .. 20 Lesson 4: The Client Record
Unique client record .................................................................................................................. 23 Do it! Search for a client ........................................................................................................... 23 Do It! Search the inactive clients list ......................................................................................... 23 Do It! Reactivate a client record ................................................................................................ 23

Exhibit F: Sourcewise Provider Manual
DRAFT
4 CareAccess
Do It! Create a new client record ............................................................................................... 24 Client Main Demographic Screen (MDS) ................................................................................... 24 Do It! Enter client demographics ................................................................................................ 25 Annotations ............................................................................................................................... 25 Lesson 5: Client Assessments
Overview ................................................................................................................................ ... 27 Do it! Enter assessment information .......................................................................................... 27 ADLs/IADLS Assessment screen .............................................................................................. 27 Making changes ........................................................................................................................ 28 Lesson 6: Client Service Plans
Overview ................................................................................................................................ ... 29 Do it! Create a Personal Care Service Plan ............................................................................... 29 Lesson 7: Entering Authorized & Delivered Units
Do it! Create a weekly authorization schedule ........................................................................... 31 Do it! Enter delivered units ........................................................................................................ 32 Service units monthly calendar ................................................................................................ .. 32 Lesson 8: Other Service Unit Entry Methods
Service Unit Entry ......................................................................................................................... 35 Overview ................................................................................................................................ ... 35 Do it! Query for service recipients ............................................................................................. 35 Do It! Service Unit Entry ............................................................................................................ 35 Service Unit Logging .................................................................................................................... 36 Do it! Query for an Agency's clients ........................................................................................... 36 Service Unit Logging Query....................................................................................................... 36 Do it! Log personal care units .................................................................................................... 37 Commit all units ........................................................................................................................ 37 Verify your work ........................................................................................................................ 37 Lesson 9: Disenrolling and Deactivating Clients
Overview ................................................................................................................................ ... 39 Do It! Disenroll a client .............................................................................................................. 39 Client care plans grid ................................................................................................................ 39 Do It! Disenroll multiple clients................................................................................................ ... 40 Do It! Deactivate a client............................................................................................................ 40 Lesson 10: Common Queries
Overview ................................................................................................................................ ... 41 Clients with Active Care Plans ..................................................................................................... 42 Overview ................................................................................................................................ ... 42 Common use(s): ....................................................................................................................... 42 Query criteria: ........................................................................................................................... 42 Results: ..................................................................................................................................... 42 Clients with Service Units by time interval ................................................................................. 43 Overview ................................................................................................................................ ... 43 Common use(s): ....................................................................................................................... 43 Query criteria: ........................................................................................................................... 43 Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 5

Results: ..................................................................................................................................... 43 :

Clients Receiving Service (Detailed) ............................................................................................ 44 Overview ................................................................................................................................ ... 44 Common use(s): ....................................................................................................................... 44 Query criteria: ........................................................................................................................... 44 Results: ..................................................................................................................................... 44 Service Units Entered vs. Authorized .......................................................................................... 45 Overview ................................................................................................................................ ... 45 Common use(s): ....................................................................................................................... 45 Query criteria: ........................................................................................................................... 45 Results: ..................................................................................................................................... 45 Service Units in a Date Range ...................................................................................................... 46 Overview ................................................................................................................................ ... 46 Common use(s): ....................................................................................................................... 46 Query criteria: ........................................................................................................................... 46 Results: ..................................................................................................................................... 46 Lesson 11: Advanced Queries: QBE & Ad Hoc
Overview ................................................................................................................................ ... 47 QBE .......................................................................................................................................... 47 Ad Hoc ...................................................................................................................................... 47 How to run these queries .......................................................................................................... 47 Do it! Run a QBE search ........................................................................................................... 48 Lesson 12: Printing Reports
Print Preview Window Toolbar ................................................................................................ .. 49 Using the Copy Command ........................................................................................................ 50 Using the Export Command ...................................................................................................... 50 Exporting a Report .................................................................................................................... 51 Lesson 13: Customizing and Saving Reports
Customizing Reports .................................................................................................................... 53 Overview ................................................................................................................................ ... 53 Run a query .............................................................................................................................. 53 Do It! Generate the print preview ............................................................................................... 53 Do It! Adjust the report layout .................................................................................................... 54 The Layout tab .......................................................................................................................... 54 Hiding record detail ................................................................................................................... 54 Column headings ...................................................................................................................... 54 Attributes tab ............................................................................................................................. 55 Do It! Modify the report attributes .............................................................................................. 55 Creating Report Column Settings .............................................................................................. 56 Lesson 14: The Waiting Room
Overview ................................................................................................................................ ... 57 Do it! Add a client record to your waiting room .......................................................................... 57 Re-name a waiting room icon .................................................................................................... 57

Exhibit F: Sourcewise Provider Manual
DRAFT
6 CareAccess

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 7
Lesson 15: Q Extras
Q Links .......................................................................................................................................... 59 Overview ................................................................................................................................ ... 59 To-Do Lists .................................................................................................................................... 59 Do it! Create a To-Do List .......................................................................................................... 59 Q E-Mail ......................................................................................................................................... 60 Overview ................................................................................................................................ ... 60 Do it! Check your e-mail ............................................................................................................ 60 Create a new e-mail folder ........................................................................................................ 60 Move your message .................................................................................................................. 60 Do it! Send a Q e-mail with a link .............................................................................................. 61 Lesson 16: Videx Bar Code Scanner
Printing a Service Roster for Scanning ....................................................................................... 63 Printing a Monthly Service Roster ............................................................................................... 66 Printing Client Bar Code Labels ................................................................................................ ... 69 Q ScanMate Utility ........................................................................................................................ 74 Downloading data from Scanner ............................................................................................... 74 Scanned Data Service Unit Import ............................................................................................... 74 Importing Data into Q ................................................................................................................ 74 Import Service Units ..................................................................................................................... 77 Import Errors ................................................................................................................................ . 78 Units Imported .............................................................................................................................. 79 Exhibit F: Sourcewise Provider Manual
DRAFT
Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 1: Discovering Q Features
AAA Provider Workbook 7

LESSON 1: Discovering Q Features
Understanding the Q database
About the Q
database system

Q database

model

The CareAccess Portal is comprised of the Q Continuum Database software, the portal session, and the site database itself. Q Continuum is the database that stores and organizes information. The CareAccess application portal provides communication between the Q database session and the end user.

Q is built on SQL Server 2000 technology. Q combines the best characteristics of both traditional relational and multidimensional data models. The Q relational database contains several features for the design and maintenance of data warehouse style applications, such as the application you'll be using, CareAccess.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 1: Discovering Q Features
8 CareAccess

Transacional
processing vs.
analytical
processing
The traditional relational database structure is based on a two-dimensional model of data organized in rows and columns. This structure lends itself well to online transactional processing (OLTP), but is too inflexible for complex data analysis.

OLTP provides answers to simple questions, such as "What was the total expenditure for all services in May 2005?"

Business
intelligence
A multidimensional database supports online analytical processing (OLAP) through data mining. You can explore and analyze large quantities of data in order to discover meaningful patterns and trends using ad hoc queries. For example, you can find answers to complex, multi-layered questions, such as "Who are all clients over the age of 64 who have received a unit of waived services in January 2009?

You see the answer is four clients over the age of 64 have received a unit of waived services in January 2009. The answer is indicated where the dimensions intersect on the data cube. While a three-dimensional cube is often used to graphically represent multidimensional data, the total number of dimensions is not limited to three!

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 1: Discovering Q Features
AAA Provider Workbook 9

Starting a Q database session

Do it! Start Q
database
session
After the client software is installed, you are ready to start a Q database session.

The CareAccess Application Portal available on the internet. So you can access the Q database using a web browser, such as Internet Explorer.

To begin a Q database session using Internet Explorer:

1. Click the Internet Explorer icon on your desktop. The browser is opened.

2. In the Address field, type https://www.careaccess-ca.com and click the Go button.

The CareAccess portal site is displayed. The CareAccess Application Portal login fields are located in the upper left of the browser window.

3. Type your user name in the User name field. Click Tab to advance to the Pass- word field.

4. Type your password in the Password field, and click the sign in button.

The CareAccess "Member Area" is displayed.

Install the client
software
You install the client software one time only. To install the client software on your workstation:

1. Click the "Download the Citrix Presentation Server Client for 32-bit Windows" link.

2. When the File Download dialog box is displayed, click Run, and follow the directions to install the client.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 1: Discovering Q Features
10 CareAccess

Start Q demo
database
session
To start Q demo database session after the client is installed:

1. In the Application Portal, click your site's Q icon. (This icon will be labeled with your site name or county.)

2. The Q Login screen is displayed.

3. Type your user name in the User ID field. Notice that the system forces your user name to all upper case. Click Tab to advance to the Password field.

4. Type your password in the Password field, and click OK The Q demo database session is started. The Q workspace with the Open Launcher is displayed.

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 11

Lesson 2: Exploring the Q Workspace
LESSON 2: Exploring the Q Workspace

Q workspace
components
The Q workspace includes the following components:

Menu bar Contains command options for accessing files, views, data, tools, opened windows, and help.

Toolbar Provides quick access to commonly used commands. To display or hide the Toolbar, click the View menu.

Launcher Lists objects that are in the Q database.

Process Center Lists any opened objects in hierarchical navigation list. To display or hide the Process Center, click the View menu.

Waiting Room Lets you create links to frequently used information. To display or hide the Waiting Room, click the View menu. To add items to your waiting room, right-click on the Title Bar and choose Send To>Waiting Room from the popup menu.

Status Bar Identifies information about the current Q database session. To display or hide the Status Bar, click the View menu.

Exhibit F: Sourcewise Provider Manual
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12 CareAccess

Lesson 2: Exploring the Q Workspace

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Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 13
Lesson 3: Navigating with Q Grids

LESSON 3: Navigating with Q Grids

Exploring the launcher
Overview In a database, records are stored in lists or "tables." These tables can include agencies, clients, service unit records, care plans, etc. In Q we call these tables "grids." This lesson will cover how to work with grids.

Displaying the
launcher: two
views
The Launcher is the most important grid in the Q system. This is the starting point for the work you will be doing in the system. The Launcher is a list of all of the grids, queries and functions in the system.

There are two ways to view objects in the Launcher: List view and Tab view. • By default, Q is displayed in tab view the first time you log in. • To switch to list view (alphabetical) click the "Show items as a list" check- box in the lower left corner of the Launcher.

In this workbook we will use the Launcher in list view.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
14 CareAccess

Opening the
launcher
Once you double-click on one of the Launcher items, the Launcher will disappear.

If you need to open the Launcher to access a new item, simply open it up!

• Click the Open button on the toolbar
• Click File > Open from the Q menu bar.
• With your keyboard, enter CTRL + O

Command
buttons in
launcher
When you select an object in the launcher list, there are up to six command buttons available, depending on the type of object selected.

Displays either a grid list of items or a query dialog box to search for items to include in a grid.

Opens a dialog box to create a new record for the selected object. The New button is disabled for report objects.

Opens either a formatted document or a query dialog box to search for items to include in a formatted document.

Opens the query by example (QBE) dialog box to display records or sets of records that match criteria that you specify.

Opens the ad hoc query dialog box. Similar to QBE, with more control. Ad hoc queries answer questions, such as: "Who are all clients born July 20, non-minority, female, widowed, with an annual income less than $10,000 living in Zip Code 12345?" Also you can query for Null values using the Ad hoc dialog box.

Not used in our version of Q.

Objects When a database session is communicating with Q, you use the application to view, modify, create, and deleted objects.

There are several different types of objects in Q, each with a different purpose.

Tables are objects in the relational database that actually store the data.

Grids display lists of Q objects. Double-click any object in the list to display its dialog box

Dialog boxes (sometimes called data input screens) are used to created objects and input data values and information into objects.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
AAA Provider Workbook 15

Code tables assign data validation values to fields in dialog boxes to ensure that users input the correct data in the right fields. They also populate drop-down lists with data values so users can easily select data instead of typing it.

Query screens are dialog boxes used to search for specified information stored in tables.

Exploring Q grids

Locating objects
in a grid
The Launcher itself is a grid. Every table in Q is displayed in a grid view which resembles a spreadsheet. In some smaller grids, it may be easy to locate the item you desire. Other times you may want to use other methods to find items.

There are three ways to locate an item on a grid:

The scroll bar Use the scroll bar on the right side to locate the item. In the Launcher's list view, the objects are always listed alphabetically. In other grids, the items may be sorted by other columns, such as Date or ID number.

Quick jump For grids that are sorted alphabetically, quickly type the first three letters of the item you are looking for. Q will search the first column for items that begin with those first three letters and "jump" there.

The Find
command
Use the Find function:

1. Click Edit > Find in the Menu bar.

2. The Find in Grid dialog box is displayed. Enter a description of what you are looking for in the "Find What" field.

3. Click the Find button.

4. Q will find all items that match the text. You may need to click "Find" multiple times before Q locates the item you are looking for.

5. When Q finds the item you are looking for, click the Close button on the "Find in Grid" dialog box.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
16 CareAccess

Do it! Open an
object's grid
You can open the grid associated with an object by double-clicking the object name in the Launcher. When you double-click some objects a grid is displayed, while double-clicking other objects opens a query dialog box. When a query dialog box is displayed, you can type a search string in any of the text fields to retrieve a specific record, or simply click the Query button to fetch all records.

The Client's
Query
To view the grid for the Clients object:

1. If necessary, click the Open button in the workspace toolbar to display the Open Launcher.

2. In the Open Launcher, locate and double-click the Clients object. The Clients query dialog box is displayed.

3. Leave the fields blank, and click the Query button. Leaving the fields blank will list all active clients in the table.

Use the Process
Center
Notice that the clients grid is displayed and the objects are also listed on the left, in the Process Center.

Navigating
through records
in a grid

4. Double-click on one of the clients listed in the Process Center.

5. When the client record is opened, the preceding Clients grid is no longer visi- ble. However, there are two ways of navigating through the client list from here:
• Double-click on a client record in the Process Center.

• Use the buttons on the toolbar: .

6. Close the record by clicking the Close button located at the bottom right. You will be returned to the list of clients.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
AAA Provider Workbook 17

The Close button Pressing the Close button will close the record and return to the grid.

If you click the button, Q will close the current record and the preceding Clients grid in one step, and return you to the Launcher.

The toolbar
navigation
buttons
You can also press the "up" button on the toolbar to go up one level, which would return you to the grid that you started with.

Opening a new
window
Notice that when you open a record in a grid, the grid window disappears. If you would like to keep the grid window open when the selected record is opened, hold down the SHIFT key before opening the object.

Grid toolbar When you open a Q object, a small toolbar is displayed at the top-left of the grid window. After selecting an object in the grid list, you can click the toolbar buttons to perform the following tasks:

Displays the New dialog box for adding new records to the selected object.

Displays the Open dialog box for editing existing records in the selected object.

Deletes the selected object.

Copies the selected object.

Customizing grids

Customizing
Options
You can right-click in a grid list to display the menu options for the grid. The menu options may vary depending on the grid displayed, but the typical menu options always include options to change the appearance of the grid, such as adding and removing columns in the grid.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
18 CareAccess

Do it! Add and
remove columns
in a grid
To change the appearance of a grid, add columns that are displayed:

1. Right-click in the list area of the Clients grid. The grid's popup menu options are dis-
played.

2. Click the Add Columns popup menu option. The Add Columns dialog box is displayed.

3. Click the check box for Age, Living Status, Poverty Status, Race, and Sex.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
AAA Provider Workbook 19

4. Click the Save button. The columns you checked are added to the grid.

Re-arranging
columns

5. Notice that the columns appear in the same order that you checked them.

Change the order by dragging and dropping the Race column next to the Name column so that it appears as the second column on the grid.

Re-sizing
columns

Remove a

column

6. Click and drag the vertical line divider between the Name and Race columns to make the Name column wider.

7. Right-click and select Add Columns from the popup menu.

8. Clear the checkbox next to SSN and Birthdate to remove these columns.

Do it! Sort and
group your grid
Q allows you to sort by any field displayed on the grid. You can do a simple sort by just one column, or set up a sorting hierarchy of two or more columns.

In addition to sorting, you can also group records by one of the columns.

Grouping allows you to collapse and expand a large list for easier navigation.

Grouping also allows you to display the number of records in each group (subtotal.)

Simple sorting To sort the grid by one column (simple sort):

1. Click on the Age column header to sort by that column. Notice that Q sorts it an ascending order first.

2. Click on Age again to change the sort order from ascending to descending.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
20 CareAccess

Complex sorting To sort the grid by two or more columns (complex sort):

1. Right-click in the grid and select Sorting and Grouping from the popup menu.

2. Click the button to move everything (Age) from the Selected box to the Available box.

3. Select Race and click to move it from Available to Selected.

4. Repeat for the Sex column and then the Name column.

5. Click the OK button to save settings and return to the grid.

The grid is displayed sorted first by race, then sex, and then name.

Grouping Turn on grouping by Race:

1. Right-click in the grid and choose Sorting and Grouping from the menu.

2. Click the word Off in the top line until it turns into On.

Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 21
Lesson 3: Navigating with Q Grids

3. Click the OK button to save settings and return to the grid.

The grid is displayed with groups by Race. Within the Race groups, the records are sorted first by sex and then by name.

Exhibit F: Sourcewise Provider Manual
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Lesson 3: Navigating with Q Grids
22 CareAccess

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Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 23
Lesson 4: The Client Record

LESSON 4: The Client Record

Unique client
record
In Q every client has a unique client record. No matter how many case managers the client has, or how many services he is receiving, he will only have one Q client record. Case managers, fiscal staff and providers will all work with the same client record. Client assessments, case notes and care plans are accessible by first opening the client record. (You will work with these in later lessons.)

Do it! Search for
a client
Remember that in Q there are thousands of clients already in the database.

Before creating a new client record, you should always query for the client to see if he or she already has been entered into the database.

To search for a client:

1. Display the Launcher in List view.

2. Locate and double-click Clients. The clients query screen is displayed.

3. Enter "D" in the Last Name field of the query box.

4. Press the Query button. Q displays all of the active clients whose last names begin with "D."

Do It! Search the
inactive clients
list
But Wait! Let's assume that you do not see your client in this list. There is one more place to check!
To search for the client in the Inactive Clients list:

1. Without closing the current List of Clients, click the Open button in the workspace toolbar to display the Launcher.

2. Locate and double-click the "Inactive Clients" object on the Launcher.

3. Enter "D" in the Last Name field of the query box.

4. Press the Query button. Q displays all of the inactive clients whose last names begin with "D."

Do It! Reactivate
a client record
If your client is in the inactive clients list, you should re-activate his or her record.

To re-activate a client record:

1. Right-click on the client record and select Activate Inactive Client.

2. Click the Close button at the bottom of the List of Inactive Clients.

Exhibit F: Sourcewise Provider Manual
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24 CareAccess
Lesson 4: The Client Record

Do It! Create a
new client record

Client Main

Demographic
Screen (MDS)
Let's assume that you did not find your client in the list of active or inactive clients.

In this case, you will create a new client record:

1. Click the New button in the grid toolbar to create a new Client record:

A new client record is displayed in Edit mode:

The client record has many different types of input fields:

Text fields Enter text or numbers in these fields. Examples: First Name, Street/Address and Directions.

Date fields Date fields can be entered in MMDDYYYY format, or you can use the pop-up calendar next to it. Do not type in slash (/) marks when entering dates with your keyboard.

Drop-down fields In these fields, choose from one of the options in the list.

Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 25
Lesson 4: The Client Record

Do It! Enter
client
demographics

1. Enter information into all required fields:

• First & Last Name
• Address, City, and Zip
• Birth Date (to calculate age)
• Sex
• Race
• Ethnicity

• SSN (if available)
• Marital Status
• Rural Status
• Poverty Status
• Living Status

2. Click the Save button at the bottom of the client demographic screen (MDS.) Do not close the client record!

Annotations When working with client data, you can place a comment on almost any field.

This function is called Annotate…, and it is accessed from the right-click shortcut menu of a field. Annotate enables you to leave reminders about work that needs to be completed or to make comments intended to be read by others working with the client. After you create the annotation, a flag denotes that there is a comment attached to the field; this flag is circled in the example below.

Note: If a field is a read-only field, you will not be able to enter an annotation for that field. If you feel you should have access to a read-only field, contact your system administrator.

Exhibit F: Sourcewise Provider Manual
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26 CareAccess
Lesson 4: The Client Record

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Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 27

LESSON 5: Client Assessments
Lesson 5: Client Assessments

Overview The California Department on Aging requires that providers collect assessment information on clients depending on the service provided: These assessments must be updated once per fiscal year:

Service ADLs/IADLs Nutrition Risk
Personal Care 
Homemaker 
Chore 
Home Delivered Meals  
ADC/H 
Case Management  
Congregate Meals 
Nutritional Counseling 

Do it! Enter
assessment
information
To enter ADLs and IADLs:

1. Click the Assessments button at the bottom of the client demographic screen.

2. Locate and double-click California ADLs and IADLs to open the assessment.

3. Click the Edit button located in the lower right of the dialog box.

Notice when you click Edit that today's date is automatically filled in the "Last Updated" field. Only assessments updated within the fiscal year will be reported on that year's annual client report.

For example, let's imagine that Tony Curtis' record was updated on May 12, 2006.

That date is within FY 05-06, so the ADL and IADL counts will be properly reported on the FY 05-06 annual reports. However, if the assessment was not updated between July 1, 2006 and June 30, 2007, this client will be reported as having MISSING ADLs on the FY 06-07 annual reports.

ADLs/IADLS
Assessment
screen
Exhibit F: Sourcewise Provider Manual
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28 CareAccess

Lesson 5: Client Assessments

4. For the Eating ADL, select Some Human Help from the Safe Functioning Level drop-down list.

5. Skip the other checkboxes and drop-down lists.

6. Continue filling in the Safe Functioning Levels for the remaining ADLs.

7. Click the IADLs (Part 1) tab and fill in the Safe Functioning Levels for the IADL information.

8. Click the IADLs (Part 2) tab and fill in the Safe Functioning Levels for the IADLs.

9. Click the Save button. The Providers of Care tab is not required.

Making changes In Q, to update the assessment you will simply return to the form and make changes to the existing information. There is no need to start from scratch every time you make a change!

1. Click the Edit button at the bottom of the California ADLs/IADLs assessment.

Notice that Q populates the "Last Updated" field with today's date.

2. For the Eating ADL, select Independent from the Safe Functioning drop-down list.

3. Click the Save button.

4. Click the History button. The History grid is displayed. Notice that there is a record displayed for every instance that this assessment was changed.

5. Double-click on the last row in the grid.

Notice that Q uses yellow to highlight the changes that were made to the record.

Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 29

Lesson 6: Client Service Plans
LESSON 6: Client Service Plans

Overview Your clients will have an individual service plan for every service that they receive from your agency. The service plan will serve as the placeholder for all information about the provider, service, rate, authorization and delivered units.

For example, the client will only have one Assisted Transportation service plan for his/her entire enrollment period. You will simply add information to it on a monthly basis.

This is also called client service "enrollment."

Do it! Create a

Personal Care
Service Plan
Open the client's care plan:

1. Display the Process Center (if necessary) by clicking on the View menu and clicking on Process Center until it is checked.

2. Use the Process Center scroll bar to find the "Care Plan" section of your cli- ent's record:

3. Click on "Care Plan." The first tab of the care plan is the Service Plan tab where you will add services.

4. Click the New button to create a new service plan.

5. Select Assisted Transportation from the Service drop-down list. *The Unit of Measure is auto-populated! This is not related to Title III Service.

6. Skip the Social Service Program drop-down list.

7. Select Title IIIB from the Funding Source drop-down list.

8. Select Custom Transports from the Agency drop-down list.

9. Enter 09/01/2009 in the Start Date field. (Leave the End Date empty!)

10. Press the Save button.

Exhibit F: Sourcewise Provider Manual
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30 CareAccess

Lesson 6: Client Service Plans

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Exhibit F: Sourcewise Provider Manual
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Lesson 7: Entering Authorized & Delivered Units
AAA Provider Workbook 31

LESSON 7: Entering Authorized & Delivered Units

Do it! Create a
weekly
authorization
schedule
Now that we have created the basic service plan, we will enter a weekly authorization schedule. This client receives service every Tuesday and Thursday.

Once we set up this schedule, Q will calculate the number of authorized units based on the number of Tuesdays and Thursdays every month. This will repeat every month until the care plan is disenrolled.

1. Click the New button to create a new service plan.

2. Select Personal Care from the Service drop-down list.

3. Select Title IIIB from the Funding Source drop-down list.

4. Select Home Care Specialists from the Agency drop-down list.

5. Select Min. 2 hours from the Rate Condition drop-down list.

6. Enter 09/01/2009 in the Start Date field. (Leave the End Date empty!)

7. Press the Save button.

To enter a weekly authorization schedule for personal care:

1. Click on the Schedules tab of the care plan.

2. Click the New button to create a new schedule.

3. Select Weekly from the Frequency drop-down list.

4. Double-click on the Tuesday row.

5. Enter 4 in the Units field.

6. Click the Save button. You will be returned to the previous screen.

7. Double-click on the Thursday row.

Exhibit F: Sourcewise Provider Manual
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Lesson 7: Entering Authorized & Delivered Units
32 CareAccess

8. Enter 4 in the Units field.

9. Click the Save button. You will be returned to the weekly screen.

10. Click the Save button to save the new schedule. Note that the "Units/Month" field has now been populated.

11. Click the Close button to return to the service plan.

Do it! Enter
delivered units

Service units

monthly
calendar
In Q, all delivered service units must be entered manually. In this exercise we will practice entering units directly on the client service plan. However, in a later lesson we will learn how to log units for all clients at once.

To enter delivered personal care units on the client care plan:

1. Click on the Service Units tab of the care plan:

2. Click the New button to create a new service unit month record.

3. Select September from the Month drop-down list.

Exhibit F: Sourcewise Provider Manual
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Lesson 7: Entering Authorized & Delivered Units
AAA Provider Workbook 33

4. Select 2009 from the Year drop-down list.

Notice that all of the Tuesdays and Thursdays are emboldened!

5. Enter 4 in the date box for September 1st, 3rd, 8th, & 10th.

6. Click the Save button.

7. Click the in the upper corner of the care plan service window to close the client's record completely.

You are now finished with creating a service plan, authorizing units, and logging delivered service units!

Exhibit F: Sourcewise Provider Manual
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Lesson 7: Entering Authorized & Delivered Units
34 CareAccess

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Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 35
Lesson 8: Other Service Unit Entry Methods

LESSON 8: Other Service Unit Entry Methods

Service Unit Entry
Overview Use this service unit entry method for entering units for the same agency, but (possibly) different services and different dates.

In this exercise you will use a query to find all clients who receive service from Home Care Specialists, and access their service plans directly from the grid. This will make the monthly service entry much quicker!

Do it! Query for
service
recipients

Do It! Service

Unit Entry
To find clients who receive service from the same agency:

1. Display the Launcher in list mode.

2. Double-click Service Unit Entry.

3. Select Home Care Specialists from the Agency drop-down list.

4. Enter 09/2009 in the Month/Year field.

5. Click the Query button. You will be presented with a list of client care plan records which match the criteria you entered in the query.

1. Double-click on the care plan record for your client. You will be presented with the September 2009 service month record, ready for data entry!

2. If you do not see the calendar view, click the Calendar View checkbox.

3. Click the Edit button.

4. Click in the 09/15/09 date box.

5. Enter 4.

6. Click the Save button.

7. Click the Close button to return to the list of other Service Entry records.

8. Click the Close button again.

Exhibit F: Sourcewise Provider Manual
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36 CareAccess
Lesson 8: Other Service Unit Entry Methods

Service Unit Logging

Do it! Query for
an Agency's
clients

Service Unit

Logging Query
Use this service unit entry method for entering units for the same agency, same service and same date.

In this exercise you will use a query to find all active Personal Care clients and log all service units at the same time!
To query for all active clients for September 2009:

1. Display the Launcher in list mode.

2. Locate and double-click Service Unit Logging to open the Service Unit Log- ging query dialog box.

3. Select Home Care Specialists from the Agency drop-down list.

4. Select Personal Care from the Service drop-down list.

5. Enter today's date in the Date field (or hit the space bar).

6. Select All Clients Receiving Service from the Clients to Select field.

7. Check the Fill in new Service Units… checkbox.

8. Enter 4 in the Units field since most clients receive 4 hours per day.

9. Select Default from Care Plan from the Funding Source drop-down list.

10. Press the Query button. The service unit logging grid is displayed.

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 37
Lesson 8: Other Service Unit Entry Methods
Do it! Log
personal care
units
Q has now displayed the full list of clients who can receive service and has pre- populated the grid with four (4) units for every client. Now you are ready to log the delivered units with one click!
But wait! Let's imagine that Elizabeth Taylor is listed on the service unit logging grid, but she should NOT receive a unit today. To make an adjustment to Ms.

Taylor's record:

1. Double-click on the row for Ms. Taylor.

2. Use the delete key to clear out the quantity field.

3. Use the delete key to clear out the funding source field until it is blank.

4. Press the Save button. Q will return you to the service unit logging grid.

Commit all units Now that you have made the necessary adjustments, commit (log) the units!

1. Click the Commit button in the lower left corner.
* Notice that the hourglass will appear while Q is committing units.

2. Click the Close button.

Verify your work That's it! You have logged units for all clients. To verify that the units have been committed:

1. Display the Open Launcher in list mode.

2. Locate and double-click Service Units in a Date Range

3. Select Home Care Specialists from the Agency drop-down list.

4. Enter Personal Care in the Services field.

5. Enter today's date in the Start Date and End Date fields.

6. Click the Query button. The report shows the units that you committed by doing service unit logging.

7. Click the Close button to return to the launcher.

Exhibit F: Sourcewise Provider Manual
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38 CareAccess
Lesson 8: Other Service Unit Entry Methods

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Exhibit F: Sourcewise Provider Manual
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AAA Provider Workbook 39

Lesson 9: Disenrolling and Deactivating Clients

LESSON 9: Disenrolling and Deactivating Clients

Overview When a client is no longer receiving service from your agency, you will disenroll the client by putting an end date on the care plan. You can either do this by:
• Opening the client's record and navigating to the specific service plan or • Querying for a list of all clients who are receiving service.

To use the second method, it is ideal to use a report which will allow us to access the client's care plan just by double-clicking. Therefore, we will use the query called "Clients Receiving Service (Detailed.)"

Do It! Disenroll a
client
To disenroll a client from a list:

1. Display the Launcher, if necessary.

2. Locate and double-click Clients Receiving Service (Detailed)

3. Enter Personal Care in the Services field.

4. Enter Home Care Specialists in the Agencies field.

5. Click the space bar in the Start Date field to auto-enter today's date.

6. Repeat in the End Date field.

7. Click the Query button.

Client care plans
grid

Q displays a row for every care plan record found. If the client has two care plans for the same service, you will see a row for each.

8. Double-click on the row for your client. Q will display his/her care plan.

9. Click the Edit button.

10. Enter yesterday's date in the End Date field.

11. Click the Save button.

12. Click the Close button to return to the grid. The client is no longer listed.

You have now disenrolled the client, and he will no longer appear on your service roster, list of active clients, or the service unit logging list.

Exhibit F: Sourcewise Provider Manual
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40 CareAccess

Lesson 9: Disenrolling and Deactivating Clients

Do It! Disenroll
multiple clients
But wait! What if you need to disenroll multiple clients at once? You will use the "Mass Disenroll" option:

To disenroll multiple clients:

1. Open the list of Clients Receiving Service (Detailed) if necessary.

2. Highlight the service plan records that need to be disenrolled. *Tip: Hold down your CTRL key to select more than one row!

3. Place your mouse over one of the highlighted rows and right-click.

4. Select "Mass Disenroll."

5. Enter an appropriate End Date.

Do It! Deactivate
a client
If the client is still alive and living in the county, DO NOT deactivate the client.

Other providers in the county may still be serving this client.

However, IF the client is deceased, moved out of county, or institutionalized, you should DEACTIVE his/her record after disenrolling the care plan.

To deactivate a client:

1. Query for the client's record.

2. When the client's record is displayed, click the Edit button.

3. Enter the date, your name and a brief description of why you are deactivating the client in the Directions/Identifiers field.

4. Click the Save button.

5. Right-click on the blue title bar and select Deactivate Client.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
AAA Provider Workbook 41

LESSON 10: Common Queries

Overview Q has many different reports that you can use for different tasks. In order to get the results that you want, it is important to start with the right report. Here is a brief explanation of the different reports:

Report Name

Results Unduplicated
clients?
Care
plan
details?
Inactive
clients?
Clients with
Active Care
Plans
List of client records
for clients who have
active care plans
matching the query
criteria
Yes No No
Clients with
Service Units
by Time
Interval
List of client records
for clients who have
one or more deliv-
ered service units
matching the query
criteria
Yes No Yes
Clients
Receiving Ser-
vice (Detailed)
List of service plan
records matching
the query criteria
No Yes No
Service Units
Entered vs.

Authorized
List of service plan
records matching
the query criteria
and an aggregate
total of authorized
and delivered units
for the month
No Yes Yes
Service Units
in a Date
Range
List of service unit
records matching
the query criteria
No Yes Yes

Details on each of these reports are included in the following pages.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
42 CareAccess

Clients with Active Care Plans
Overview Q queries for active clients who have a care (service) plans that match the criteria entered. The results will be a list of unduplicated client records.

Common use(s): • Reporting client demographics for clients who are receiving particular ser- vice(s).
• Reviewing active "roster" and removing clients from it.

Query criteria:

(required fields are marked with an asterisk *)
In the example above, Q will find any client who has a care plan for personal care

OR chore OR homemaker services from Home Care Specialists agency. Q filters the results by care plan dates; Clients whose care plan start date is AFTER 7/1/06 or whose end date is BEFORE 7/1/06 will be filtered out.

Results:

Grace Jones appears once even though she has two matching care plans for Home Care Specialists: one for Personal Care and one for Chore.

Accessible table(s): Client record (Double-click) No automatic access to service plans.

Special Functions: Care Plan Mass Creation.

Q: Why can't I see the matching service plans that Q found? A: The purpose of this report is to display an unduplicated list of clients. Since one client may have many matching care plans, Q is unable to display care plan details for care plans without listing the client more than once. To view service plan details, open the client record (double-click) and click his/her care plan button. Consider using the "Clients Receiving Service (Detailed)" query if you would like to view care plan details such as Start Date and End Date.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
AAA Provider Workbook 43

Clients with Service Units by time interval
Overview Q queries for clients (active, inactive or both) who have at least one (delivered) service unit record that matches the criteria entered. The results will be a list of unduplicated client records.

Common use(s): • Verifying client totals on quarterly (SPR) reports. • Reporting unduplicated client demographics for a particular service cate- gory.

Query criteria:
(required fields are marked with an asterisk *)
In the example above, Q will look for all clients who have at least one unit of delivered congregate meals recorded on his/her care plan with service dates between 7/1/06 and 6/30/07. (Please note that you may enter a future date.) It will not filter by agency or funding source or meal site.

Results:

Accessible table(s): Client record (Double-click) No automatic access to service

plans.

Special Functions: Care Plan Mass Creation.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
44 CareAccess

Clients Receiving Service (Detailed)
Overview Q queries for care (service) plans for active clients that match the criteria entered. The results will be one row for every matching care plan. This is NOT an unduplicated clients query.

Common use(s): • Viewing current service "roster."
• Disenrolling all care plans at once.

Query criteria:

(required fields are marked with an asterisk *)
In the example above, Q will find any care plan where the service is Personal

Care OR Chore OR Homemaker. It will NOT filter by agency or funding source. It will only find care plans that were active at least one day in the first quarter of FY06-07.

Results: Accessible table(s): Service plan record (Double-click) and Client record (right- click on name).

Special Functions: Mass Disenroll and Mass Copy.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
AAA Provider Workbook 45

Service Units Entered vs. Authorized
Overview Q queries for care plans that match the criteria entered for active and inactive clients. One row will be displayed for each active care plan found, even if there are zero authorized and zero delivered. It displays the total number of service units entered and authorized recorded on each care plan.

Common use(s): • Reporting monthly service unit totals for a particular agency in a single month.
• Identifying clients who are on a roster, but NOT receiving service.

Query criteria:

(required fields are marked with an asterisk *)
In the example above, Q will find all care plans for Home Care Specialist agency

that were active during at least one day in the month of July 2006 and display the total number of units authorized and total units delivered for the month. If the client is receiving two different services from this agency, Q will display a row for both.

Results:

Accessible table(s): Service plan record (Double-click) and Client record (right- click on name)
Special Functions: None (However, you can mass disenroll by using the "Open Multiple Service Units Entered vs. Authorized" and changing the End Date for all).

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 10: Common Queries
46 CareAccess

Service Units in a Date Range
Overview Q queries for service unit records matching the criteria entered for active and inactive clients. One row will be displayed for each service unit record found.

Records with negative quantities will also be displayed.

Common use(s): • Reporting service unit totals and/or costs for specific services or agencies.

Query criteria:

(required fields are marked with an asterisk *)
In the example above, Q will look for all service unit records (delivered units)

entered for Home Care Specialist agency for Personal Care OR Chore OR Homemaker service with service dates between 7/1/06 and 9/30/06.

Results: Accessible table(s): Service Unit record (Double-click) and Client record (right- click on name).

Special Functions: None

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 47

Lesson 11: Advanced Queries: QBE & Ad Hoc
LESSON 11: Advanced Queries: QBE & Ad Hoc

Overview Standard client searches allow users to query for all clients by ID number, SSN, Birth Date, Name (or partial name), Phone, or Case Manager. Using the five common Q queries, you can also query for clients who receive certain services.

However, you can build more complex queries using the Query By Example (QBE) and ad-hoc functions in Q.

QBE The QBE query allows users to pull up a sample Client Main Demographic Screen (MDS) and fill in what they are looking for. Users are limited to fields from the main tab Client MDS. Users can fill in ONE value in each field, but can fill in multiple fields.

Use QBE for the following types of client queries:
• Clients whose age = 65
• Clients whose race = "African-American"
• Clients whose race = "African-American" and City= "San Jose" • Clients whose City = "San Jose" and rural = "Yes"

Ad Hoc The ad-hoc query function allows users to query on almost all fields in the database, including assessment fields, SSP enrollment fields and demographic fields. It also allows users to search for information in a range, multiple values for the same field and also missing (null) data. Use the ad-hoc method to perform the following types of queries:
• Clients whose age > 65 AND < 85
• Clients whose race = "African-American" OR "Asian-American" • Clients whose race = "African-American" OR "Asian-American" AND City = "San Jose" OR "Palo Alto"
• Clients whose rural status = "Yes" and "NAPIS ADL Count >= 3 • Clients whose race = NULL (missing) OR age = NULL (missing)

How to run these
queries
To run one of these advanced queries, you will use a basic Q query and combine it with the QBE or Ad Hoc function.

Identify the basic client population that you want to find and then choose a basic query to work with. For example:
• All active clients: use the basic Clients query
• MSSP clients: use the "Clients Assigned to SSP Case Manager" query • MOW recipients: use the "Clients with Service Units by Time Interval." You will use this basic query in combination with the QBE or Ad Hoc function.

Exhibit F: Sourcewise Provider Manual
DRAFT
48 CareAccess

Lesson 11: Advanced Queries: QBE & Ad Hoc

Do it! Run a QBE
search
Query 1: All female, African-American clients who received Home Delivered Meals since the beginning of the fiscal year.

This query requires that the database search for one value in the "Race" field and one value in the "Sex" field. The QBE query can be used to provide this information. The QBE will be used in combination with the "Clients with Service Units by Time Interval" report.

1. Highlight "Clients with Service Units by Time Interval" on the Launcher. Click the "QBE" button in the upper-right. A sample Client MDS screen will be pre- sented.

2. Select Black African-American from the Race drop-down list

3. Select Female from the Sex drop-down list.

4. Press "Query." You will be presented with a standard "Clients with Service Units by Time Interval" query window.

5. Fill in service, start date, end date, active status and funding source.

6. Click the Query button.

Q will present a list of all African-American female clients who received a Home Delivered Meal funded by Title IIIC2 between 7/01/2004 and 3/31/05.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 12: Printing Reports
AAA Provider Workbook 49

LESSON 12: Printing Reports

Print Preview
Window Toolbar
The table below describes the functions of the commands displayed in the Print Preview window toolbar.

Icon Command Function

Table of
Contents
When grouping columns together, this
tool allows you to quickly navigate to a
particular group in your list.

Print This command sends the document to
your default printer.

Copy This command copies the report so
that it can be pasted into another
application such as MS Word or MS
Excel.

Find This command opens the familiar Find
window which you can use to locate
key words within the report.

Single Page This command is used to change the
display from a multiple sheet preview
to a single sheet preview.

Multiple Pages This command is used to change the
display from a single sheet preview to
a multiple sheet preview.

Zoom This command is used to make the
preview image larger or smaller.

Page Up/Down These commands allow you to scroll
through the pages of the report.

Navigation
Arrows
These commands allow you to move
back and forth through the pages of
the report.

Export This command enables the export
function described later in this section.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 12: Printing Reports
50 CareAccess

Using the Copy
Command
Located within the print preview window toolbar, the Copy command can be helpful in copying a report from Q to another application. The steps below describe how to copy a report from Q to MS Word document.

1. Print the list of data using one of the Q system print options.

2. Click in the print preview window toolbar.

3. With Q still open, open the other application (MS Word) where you want to copy the Q report.

4. With your new MS Word document open, click or click Edit in the menu bar and select Paste.

Using the Export
Command
The Export command found in the Q print preview window toolbar enables you to export the data of the report to create:
• A MS Excel document
• An HTML document
• An RTF (rich-text) or Text file that can then be imported into other applica- tions.
• A read-only PDF document others can view using Adobe Reader. • A TIFF file that can be inserted into a MS Word or MS PowerPoint docu- ment.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 12: Printing Reports
AAA Provider Workbook 51

Exporting a
Report
Despite the many different uses for all of these export types, the Export command itself is very straight-forward. The steps below explain how to export a report from the Q system.

1. Print the list of data using one of the Q system print options.

2. Click in the print preview toolbar.

3. Select the format in which you want the resulting export.

4. Click .

5. In the Save As window that opens, use the Save In: field to locate the correct drive where your file will be saved.

NOTE: Your C drive is listed as C$. Normal file order is shown to navigate to the user's Desktop.

6. Enter the name of your new document in the File Name: field.

7. Click .

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 12: Printing Reports
52 CareAccess

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Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 13: Customizing and Saving Reports
AAA Provider Workbook 53

LESSON 13: Customizing and Saving Reports

Customizing Reports
Overview Q allows users to customize (printed) grid reports by adding or removing columns, adding summary information and updating the formats.

Run a query 1. Display the Open Launcher in list mode.

2. Locate and double-click Service Units in a Date Range on the Launcher to open the Service Units in a Date Range Query dialog box.

3. Enter City Senior Center in the Agencies field.

4. Enter Title III C1 in the Funding Sources field.

5. Enter Congregate Meals in the Services field.

6. Enter Start Date of 07/01/2005 and an End Date of 06/30/2006.

7. Click the Query button. The Service Units in a Date Range grid is presented.

Do It! Generate
the print preview
To display the print preview, right-click and select Print Report.

The print preview window also has buttons in the lower left corner for adjusting the columns (Add Columns button) Sorting and Grouping, Formatting, and Column Settings.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 13: Customizing and Saving Reports
54 CareAccess

Do It! Adjust the
report layout
In this exercise, you will be adjusting your own column settings.

1. Click the button on the lower left.

2. Following steps from Lesson 3 (page 19), sort and group the grid by Client.

The Layout tab The first tab that you will be presened with is the Layout tab where you can adjust the overall layout of the report, including orientation, margins and column detail.

To adjust the report layout:

1. If necessary, return to the print preview window by right-clicking in your grid and selecting Print Report from the popup menu.

2. Click the Format button in the lower left corner.

3. Select Landscape from the Orientation drop-down list.

4. Check the Show Number of Records, Show Totals, and Show Averages checkboxes.

Hiding record
detail
To hide the record details and only view the number of records in each group:

5. Check the Show Only Group Headers checkbox* in the Miscellaneous box shown above.

*This checkbox is only available if your report has grouping applied. If the checkbox is unavailable, return to the print preview and turn on grouping by client! The grid is displayed with only the Group Headers and the totals.

Column
headings
To alter the name of the "Agency Total Cost" column to simply read "Cost:"

6. Highlight the "Agency Total Cost" column on the left

7. Enter Cost in the Column Title field on the right.

8. Check the Bold checkbox to enbolden the entire Cost column.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 13: Customizing and Saving Reports
AAA Provider Workbook 55

Attributes tab 1. Click the Attributes tab.

Do It! Modify the
report attributes

2. Select Column Detail from the Element to Modify drop-down list or click on the column detail on the report preview image.

3. Select Verdana from the Font drop-down list.

4. Select Blue from the Foreground drop-down list.

5. Click the OK button. The Print preview is displayed as below:

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 13: Customizing and Saving Reports
56 CareAccess

Creating Report
Column Settings
Once you have changed the formatting for a report, you may save the changes.

Users may save as many report column settings as desired-or use settings that the System Administrator has made accessible to all.

1. Click the Column Settings button on the print preview window to open your column settings.

2. Click on the New icon

3. Enter a name for your Column setting in the Description field

4. Click on Save and then Close.

5. Click on the Close button to close the Column Settings window.

Note: The Column Settings command button is available when you initiate a report using the print command found in the Q toolbar ( ) or when using the right click menu print options.

Exhibit F: Sourcewise Provider Manual
DRAFT
AAA Provider Workbook 57

LESSON 14: The Waiting Room
Lesson 14: The Waiting Room

Overview The Waiting Room is a part of the Q workspace where you can keep shortcuts to objects in Q that you access frequently. Any object can be added to the waiting room. Here are some examples:
• Client Smith's Nutritional Risk assessment
• A full list of your current clients
• A query box for running a report

Do it! Add a
client record to
your waiting
room

Re-name a

waiting room
icon
Let's imagine that you would like a quick way of accessing a client's record.

To add a shortcut to your client record to your waiting room:

1. Display your Waiting Room if necessary by clicking on the View menu and clicking on Waiting Room until it is checked.

2. Place your mouse on the blue title bar at the top of the client record.

3. Right-click and select Send To> Waiting Room from the popup menu.

Q has now added an icon to your waiting room:

Re-name the waiting room icon:

1. Right-click on the icon that was just placed in your waiting room and select Rename from the popup menu.

2. Enter your client's name in Last, First format in the text box.

3. Click away from the text box to save it.

Exhibit F: Sourcewise Provider Manual
DRAFT
58 CareAccess

Lesson 14: The Waiting Room

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Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 15: Q Extras
AAA Provider Workbook 59

LESSON 15: Q Extras

Q Links
Overview In Lesson 14, you learned how to add shortcuts to your Waiting Room for quick access. These shortcuts can also be called "Links" in the Q system. There are other places in the system where you can add links:
• Client MDS (Confidentiality/Billing tab)
• Case Notes
• Q E-Mail Messages
• To-Do Items
There are four ways to add a link to one of these records:

1. Click on the gray area of any form and drag it into a Links field.

Example: Click on the gray area of a client assessment form and drag into the Links field of a To-Do Item.
*Note: This does not work for grids!

2. Right-click on the title bar of any window and select Send To… and then Wait- ing Room, To-Do Item, or Message Recipient.

3. Right-click in the Links field and click on the name of any open window.

4. Drag a link from one record (including the waiting room) to another.

Example: Create a new mail message and drag a waiting room shortcut into the "Links" field of the message.

To-Do Lists

Do it! Create a
To-Do List
In Q you can create a to-do list, and be reminded when those items become overdue!
To create a to-do item:

1. Display the Launcher.

2. Locate and double-click To Do Items.

3. Click the new icon to create a new To Do Item.

4. Enter yesterday's date in both of the Date fields.

5. Enter Follow-Up Call in the Narrative field.

6. Drag the waiting room item for your client into the Links field.

7. Click the Save button.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 15: Q Extras
60 CareAccess

Q E-Mail

8. Click the Close button to return to the To Do List.

Notice that Q is now displaying a warning message about your overdue item!

Overview You can send e-mails to other Q users through the Q system. This is a safe, confidential way of sharing client information. You can create a message on the fly with a link to the form you are working with, or send a message from your Inbox.

Do it! Check
your e-mail
To open your Inbox:

1. Turn on your Process Center using the View menu.

2. Click on the Tools Menu and select Messages. Q will display your Q Inbox.

3. Double-click the new message you have received!

4. Forward this message to another recipient by clicking on the "Forward" icon:

Notice your other options for reply, reply to all, print, flag or delete the mes- sage!
To create a new folder and move the message there:

Create a new e-
mail folder

5. Right-click on the Inbox folder in your Process Center and select New Folder.

6. Enter Saved Messages as the new folder name.

7. Click the Save button.

Move your
message

8. Highlight the original message you received by clicking on it with your mouse.

9. Click the move to folder icon.

10. Click on the Saved Messages folder.

11. Click the Move button.

The message has now been moved to your Saved Messages folder!

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 15: Q Extras
AAA Provider Workbook 61

Do it! Send a Q
e-mail with a link
To create a new Q E-Mail message:

1. Click the button in the Inbox toolbar.

2. Click the ellipse button to the right of the To: field. Select a user from the list.

3. Enter Please review this client record in the Subject field.

4. Enter See attached in the message field.

5. Click and drag a Waiting Room link into the Links field of the message.

6. Click the Send button.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 15: Q Extras
6 2
CareAccess

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Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 63

LESSON 16: Videx Bar Code Scanner

Printing a Service Roster for Scanning
This report is intended to be used for logging service units for clients schedule to receive a service.

1. From the Launcher, open the object labeled Service Roster for Scanning.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
64 CareAccess

The following screen will appear:

2. Choose the appropriate selections in each of the fields:
• Agency - Select the Service Provider
• Service - Select the service being provided
• Route - Select the Home Delivered Meals route.
• Site - Select the Congregate meal site(s).
• Combined Roster for all Routes/Sites - Check this box if a single roster is to be produced combining the scheduled clients for all the selected routes or sites. If not selected, separate rosters are printed for each route/ site. The check box is only available when “multiple” routes or sites are selected in the above fields.
• Roster Type - Select the type of roster (All Active Clients, Daily, or Weekly).
• Date - Select the date of service or start of the week. This field is only enabled if the roster type is “Daily” or “Weekly”.
• Include section with unscheduled clients - Select whether an additional section of the roster is needed to list all active clients not scheduled to receive service on the selected day or during the selected week. • Unit Quantities for Scanning - Enter the option(s) that should appear in the heading of the roster’s first page to be scanned for the quantity of units. A comma or semicolon should separate the numbers between 1 and 9.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 65

An example of a completed query screen is shown below:

3. When finished completing the desired fields, click on the button.

An example of a roster is below:

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
66 CareAccess

Printing a Monthly Service Roster
This report is intended to be used for logging service units for clients scheduled to receive a service.

This roster can be used for manual entry at time of service with the intention of manipulating the data once it is imported into Q.

From the Launcher, open the object labeled Monthly Service Roster.

The next screen will appear:

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 67

Choose the appropriate selections in each of the fields:
• Agency - Select the Service Provider
• Service - Select the service being provided
• Route - Select the Home Delivered Meals route.
• Site - Select the Congregate site(s).
• Combined Roster for all Routes/Sites - Check this box if a single roster is to be produced combining the scheduled clients for all the selected routes or sites. If not selected, separate rosters are printed for each route/ site. The check box is only available when “multiple” routes or sites are selected in the above fields.
• Roster Type - Select the type of roster (All Active Clients, or Monthly). • Date - Select the month and year of service.
• Include section with unscheduled clients - Select whether an additional section of the roster is needed to list all active clients not scheduled to receive service on the selected day or during the selected week.

An example of a completed query screen is shown below:

When finished completing the desired fields, click on the button.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
68 CareAccess

An example of a roster is below:

Q Monthly Service Roster (8 1/2 x 14)
Provider: City Senior Center
Service: Congregate Meals

Au
gust 2010: Fi

Client 1 2 3 4 5 6 7 8 9 10 1

111111111111 11111111111111111111111
Andrews,Julie
56 111111111111 11111111111111111111111
Beatty, Warren
32 1111111111 11111111111 11111111
Bennett, Tony
60 111111111111 11111111111111111111111
Brooks, Mel
15 Ill llIIIlllllllllllllllllllll ll
Connery, Sean
27 Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 69

Printing Client Bar Code Labels
This report is intended to be used to produce labels for Client ID cards. The labels will include the client name, Q ID number, and a bar code (for scanning) of the Q ID number.

The format for output will be identical to the Avery 5160 laser printer labels. (1”h by 2 5/8”h)
There are two ways to print labels:

1. Using the right click menu off a client record or a list of clients. See Figures below
Using right click menu from a list of clients

Using right click menu off the individual client record

Exhibit F: Sourcewise Provider Manual
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Lesson 16: Videx Bar Code Scanner
70 CareAccess

2. Using the Client Bar Code Label object off the Launcher. See below.

To use the above object off the Launcher, follow these steps:

1. Open the object from the Launcher. The
following window will be presented:

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 71

2. Fill out the desired fields.
• Agency - Select the Service Provider
• Service - Select the service being provided
• Route -Select the Home Delivered Meals route.
• Site - Select the Congregate site(s).
• Date - Select the Start & End date of the service.
• Clients Scheduled or Served - Indicate whether clients are to be retrieved based on being scheduled to receive service beginning during the date range, or clients with their initial billing (first unit billed for the ser- vice) during the date range.

The following is an example of a completed query:

3. Click on Query when finished filling out the screen.

Exhibit F: Sourcewise Provider Manual
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Lesson 16: Videx Bar Code Scanner
72 CareAccess

You will be presented with a list of clients that meet the entered criteria:

4. From this list, select all the clients for which a label is to be printed. Use the right click menu to access the printout. See Example below:

5. Choose where the labels are to start printing.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 73

After saving the window, users are presented with the labels in print preview mode:

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
74 CareAccess

Q ScanMate Utility

Downloading
data from
Scanner
This utility is used to import the information from the scanner into your hard drive.

Users will then download the file into Q.

Make sure the scanner is connected to the computer you are using to download the data into.

Turn the scanner on when ready to download the data.

1. When you are ready to download the scanner information, you will need to run the utility located in Start Programs Q ScanMate Utility VxComm.

2. When the first window appears, click on Tools, Transfer Applicaton.

3. You will be presented with a window. The options you should select are as fol- lows:

Base Station
COMM1

4. After making sure the proper selections are chosen, click on Transfer Applica- tion.

5. Once the application has completed its transfer, all windows will disappear from your monitor.

6. You can then locate the file in your C:\Windows folder. The name of the file will be QscanMate.txt. At this point, the data contained in the scanner is cleared.

NOTE: it is advisable to change the name of the QscanMate.txt file to one that is descriptive of the Agency/Meal Site/ Date for historical purposes. An example is 13street98012010.txt.

Scanned Data Service Unit Import

Importing Data
into Q
The data collected and stored in the Videx Laserlite scanners are currently programmed and extracted using the VXCOMM utility.

The service unit import file’s format and contents are described in detail in Q’s documentation. The file must contain sufficient information to identify the client, provider agency, service, and unit provision information. Specifically, the provider agency code, service code, date of service, quantity of units, unit cost, client’s last name, and client’s social security number or Q ID number must be included.

To import your data from the file you created previously into Q, follow these steps:

Exhibit F: Sourcewise Provider Manual
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Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 75

1. From the Launcher, open the utility labeled, Import Videx Scanner Data.

2. Choose the Agency from the query window.

3. You will be presented with a list of service units to be imported. **NOTE**: Once imported, unit information can be reviewed and revised using Q’s standard manual entry functions (including Service Unit Entry and Service Unit Logging). Additionally, batches and their accompanying units can be com- pletely deleted and resubmitted until the units are posted for accounting pur- poses (an administrative function within Q necessary for billing processes, typically occurring on a monthly cycle). After posting occurs, the units are locked down and can be adjusted only via the manual entry functions and only if the appropriate authorization has been granted to the user.

Exhibit F: Sourcewise Provider Manual
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Lesson 16: Videx Bar Code Scanner
76 CareAccess

4. After being presented with the table and list of units to be imported, You can right click, or double click on the record, and choose the appropriate selection as described in this chapter.

Right click view.

Double click view

Exhibit F: Sourcewise Provider Manual
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Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 77

Import Service Units

When selecting Import Service Units, you will be presented with another window as seen below:

• File to Import - Specify where the file is located to be imported. Clicking on the ellipses button allows users to browse their PC for the desired file.
• Service - Select the service. The choices offered reflect the services pro- vided by the Agency that was chosen in Step 2 of this Lesson. • Funding Source - Select the funding source for the Service Unit records to be created. Combo box allowing only one selection, containing the option “Default from Care Plan” (which is the default selection) as well as any funding sources for the selected agency/service combination that has the “Suppress Schedule Cap Enforcement” option enabled (i.e. the Title III funding sources.)
• Date of Service - Enter the service unit delivery date. Date control. The user must indicate the date for which units are to be entered/edited. If the service is a simplified entry service entry method, only the month and year of the date supplied are consulted.
• Unit Cost - Enter the unit cost for the Service Unit records to be created.

Numeric text control for currency entry; not enabled if the service is a cost entered at billing time service entry method.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
78 CareAccess

Import Errors

5. Click to start the import process. The process is complete when the query window disappears and the record has an X in the Imported column as seen below.

This function allows you to view any errors in the import process.

After selecting this item from the right click menu, you will be presented with another window as seen below. Any errors will show up as rows in this table.

Exhibit F: Sourcewise Provider Manual
DRAFT
Lesson 16: Videx Bar Code Scanner
AAA Provider Workbook 79

Units Imported
This item off the right click menu will allow you to view a table of all imported service units.

A window similar to the one below will be presented. Open each record by double clicking on the row to view the details of the import.

Exhibit F: Sourcewise Provider Manual
DRAFT

CareAccess
www.careaccess-ca.com
[email protected]

877-262-9322
Exhibit F: Sourcewise Provider Manual
DRAFT

Caregivers & Care Receivers in Q
Quick Reference Guide

You can think of the process of entering Caregiver and Care Receiver/Recipient information in Q as a 5-step process with a 6th step that’s highly recommended:

1. Find/Create a Client record for the caregiver, and enter an Employment Assessment

2. Find/Create a Client record for the care receiver, and enter an ADL/IADL Assessment

3. Find/Create a Caregiver record

4. Synchronize the Caregiver record with the caregiver’s Client record

5. Link the Caregiver record to the care receiver.

6. Highly Recommended: Create Dummy Care Plan for Care Receiver

This guide will give you a quick reference for each step.

Updated: 8/6/18
STEP 1
Client record
for the
Caregiver
STEP 2
Client
record for
the Care
Receiver
STEP 3
Caregiver
Record
STEP 4
Synchronize
the records
STEP 5
Link the
records
STEP 6 (Recmnd)
Dummy Care plan
for Care Receiver
Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 2

Step 1
Client Record for the Caregiver

Create a new Client record for the Caregiver. Enter information in the following fields highlighted in yellow:

 Name
 Address, City, State,
and Zip
 Birth date
 Race
 Ethnicity
 Marital Status
 Sex at Birth
 Gender
 Sexual Orientation
 Rural
 Poverty Status
 Living Status

Caregivers require an Employment Assessment. Click the Assessments button in the lower left, double click on the Employment Data Assessment, enter a Status, then click Save:

Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 3

Step 2
Client Record for the Care Recipient

Create a new Client record for the Care Recipient . Enter information in the following fields highlighted in yellow:

 Name
 Address, City, State,
and Zip
 Birth date
 Race
 Ethnicity
 Marital Status
 Sex at Birth
 Gender
 Sexual Orientation
 Rural
 Poverty Status
 Living Status

Care Recipients require an ADL/IADL Assessment. Click the Assessments button in the lower left, double click on California ADLs/IADLs, enter the Safe Functioning Levels on all tabs, then click Save:

Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 4

Step 3
Caregiver record

The Caregiver record is completely different from the caregiver’s Client record. You need to create both.

1. From the Launcher, open the Caregivers query.

2. Leave all the fields blank and click on the Query button.

A list of all the current Caregivers is displayed.

3. Check the list for your new Caregiver to ensure they are not already in the list.

4. Assuming they are not a Caregiver, Click the
New button.

The new Caregiver window is displayed.

5. Fill in the First and Last name, gender, setting, and location. These are required fields. You don’t have to fill in address, DOB, or other fields. You will synchronize this record with this caregiver’s existing Client record.

Click the Save button to save the record, but do not close the record.

Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 5

Step 4
Synchronize the Records

This step allows our Caregiver record to talk to our caregiver Client record.

1. Right-click on the title bar of the caregiver record.

2. Click on the Synchronize Caregiver with a Client option.

3. Enter the name of the caregiver and press the Save button.

The Caregiver’s name will populate the Select Client field.

4. Click the Save button (a second time).

Notice that the DOB, age, gender, and other fields are now populated in the Caregiver record. Leave the Caregiver record open.

Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 6

Step 5
Link the Caregiver and Care Receiver

The next step of the process is to link the Caregiver and Care Receiver in Q, using the Care Recipients button:

1. On the Caregiver record, click the Care Recipients button.

2. Click the New button.

The New Caregiver/Care Receiver Relationship & Assessments dialog box appears.

3. Click on the Ellipse button next to the Care Recipient field to search the Client list.

4. Enter the first and last name of the Care Recipient and click the Query button.

5. Highlight the correct Client and click the Apply button.

6. Choose a relationship from the Caregiver Relationship drop-down list.

7. Click the Save button.

Now that you have completed the Caregiver Process you can generate the Care Plan for the FCSP Service(s) for the Caregiver.

Step 6 (Highly Recommended)
Dummy Care Plan for Care Receiver/Recipient

It is highly recommended that you generate a “Dummy” Care Plan for the Care Recipient. This will allow you to manage your Care Recipients as a group and find missing demographic and assessment data easily and quickly. The Service is called FCSP-Care Recipient.

Exhibit F: Sourcewise Provider Manual
DRAFT

Caregiver Quick Reference Page 7

Troubleshooting

If you find a Client has FCSP Service units (Title IIIE) but are missing some portion of the Caregiver Process, check the following:

 See if there is a Caregiver Record. This is the most common problem. The user forgot to add a Caregiver Record (Step 3).

 If there is a Caregiver Record, make sure it is synchronized to the correct Caregiver Client Record (Step 4).


If there is a Caregiver Record and it is synchronized to that Caregiver’s Client record, then the problem must be with the Association of the Caregiver Record with the Care Recipient (Step 5).

 Is the Care plan for a Title III E service in the Care Receiver Client Record? If so, you must delete/remove the care plan from the Care Receiver along with all service units and enter this information in the Caregiver’s Client Record. (Dummy Care Recipient care plans are allowed, but no service units are ever entered.)

All problems must be one (or more) of those listed. Correcting the problem will allow the CARs submission to be accepted.

Exhibit F: Sourcewise Provider Manual
DRAFT
Q Reports Guide ⎯ 1
rev 1/07 ME
Q Reports Guide

Overview Q has many different reports that you can use for different tasks. In order to get the results that you want, it is important to s
tart with the right report.

Here is a brief explanation of the different reports:

Report Name Results Unduplicated
clients?
Care plan
details?
Inactive
client
s?
Clients with Active Care
Plans
List of client records for clients who have
active care plan
s matching the query criteria
Yes No No
Clients with Service
Units by Time Interval
List of client records for clients who have one
or mo
re delivered service units matching the
query criteria
Yes No Yes
Clients Receiving
Service (Detailed)
List of service plan records matching the
query criteria
No
Yes No
Service Units Entered vs.

Authorized
List of service plan records matching the
query criteria an
d an aggregate total of
authorized and delivered units for the month
No Yes Yes
Service Units in a Date
Range
List of service unit records matching the query
criteria
No Yes Yes

Details on each of these reports are included in the following pages.

Exhibit F: Sourcewise Provider Manual
DRAFT
Clients with Active Care Plans

Overview Q queries for active clients who have a care (service) plans that match the criteria entered. The results will be a list of unduplicated client records.

Common use(s) • Reporting client demographics for clients who are receiving particular service(s.) • Reviewing active “roster” and removing clients from it.

Query criteria

Services (one / many / all)
Agencies (one / many / all)

As Of (Date) *
Case Managers (one / many / all)
Required fields are marked with an (*) asterisk.

In the example above, Q will find any client who has a care plan for personal care OR chore OR homemaker services from Home Care Specialists agency. Q filters the results by care plan dates; Clients whose care plan start date is AFTER 7/1/06 or whose end date is BEFORE 7/1/06 will be filtered out.

Results

Grace Jones appears once even though she has two matching care plans for Home Care Specialists: one for Personal Care and one for Chore.

Accessible table(s): Client record (No automatic access to service plans.)

Special Functions: Care Plan Mass Creation

Q: Why can’t I see the matching service plans that Q found? A: The purpose of this report is to display an unduplicated list of clients. Since one client may have many matching care plans, Q is unable to display care plan details for care plans without listing the client more than once. To view service plan details, open the client record (double-click) and click his/her care plan button. Consider using the “Clients Receiving Service (Detailed)” query if you would like to view care plan details such as Start Date and End Date. 2 ⎯ Q System Administrator Workbook
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
DRAFT
Clients with Service Units by Time Interval

Overview Q queries for clients (active, inactive or both) who have at least one (delivered) service unit record that matches the criteria entered. The results will be a list of unduplicated client records.

Common use(s) • Verifying client totals on quarterly (SPR) reports • Reporting unduplicated client demographics for a particular service category.

Query criteria

Services (one / many / all)
Agencies (one / many / all)
Start Date & End Date*: Service unit
“Date of Service” must fall between
these two dates.

Active*: client record status: active,
inactive or both.

Funding Sources (one / many / all)
(Meal) Sites (one / many / all)
Required fields are marked with an (*) asterisk.

In the example above, Q will look for all clients who have at least one unit of delivered congregate meals recorded on his/her care plan with service dates between 7/1/06 and 6/30/07. (Please note that you may enter a future date.) It will not filter by agency or funding source or meal site.

Results

Accessible table(s): Client record (No automatic access to service plans.)

Special Functions: Care Plan Mass Creation

Q Reports Guide ⎯ 3
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
DRAFT
Clients Receiving Service (Detailed)

Overview Q queries for care (service) plans for active clients that match the criteria entered.

The results will be one row for every matching care plan. This is NOT an unduplicated clients query.

Common use(s) • Viewing current service “roster.”
• Disenrolling all care plans at once
Query criteria

Services (one / many / all)

Agencies (one / many / all)

Funding Sources (one / many / all)

Start Date & End Date*: The care
plan must have been active at least
one day in this date range

Required fields are marked with an (*) asterisk.

In the example above, Q will find any care plan where the service is Personal Care OR Chore OR Homemaker. It will NOT filter by agency or funding source. It will only find care plans that were active at least one day in the first quarter of FY06-07.

Results

Accessible table(s): Service plan record and Client record (right-click on name)

Special Functions: Mass Disenroll and Mass Copy

4 ⎯ Q System Administrator Workbook
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
DRAFT
Service Units Entered vs. Authorized

Overview Q queries for care plans that match the criteria entered for active and inactive clients. One row will be displayed for each active care plan found, even if there are zero authorized and zero delivered. It displays the total number of service units entered and authorized recorded on each care plan.

Common use(s)
• Reporting monthly service unit totals for a particular agency in a single month. • Identifying clients who are on a roster, but NOT receiving service Query criteria

Agency (one or all)
Service (one or all)
Month/Year*
Funding Sources
(one / many / all)

Required fields are marked with an (*) asterisk.

In the example above, Q will find all care plans for Home Care Specialist agency that were active during at least one day in the month of July 2006 and display the total number of units authorized and total units delivered for the month. If the client is receiving two different services from this agency, Q will display a row for both.

Results

Accessible table(s): Service plan record (Double-click) and Client record (right- click on name)

Special Functions: None (However, you can mass disenroll by using the “Open Multiple Service Units Entered vs. Authorized” and changing the End Date for all.)

Q Reports Guide ⎯ 5
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
DRAFT
Service Units in a Date Range

Overview Q queries for service unit records matching the criteria entered for active and inactive clients. One row will be displayed for each service unit record found.

Records with negative quantities will also be displayed.

Common use(s) • Reporting service unit totals and/or costs for specific services or agencies.

Query criteria Required fields are marked with an (*) asterisk.

Agency (one or all)
Funding Sources (one / many / all)
Services (one / many / all)
Start Date & End Date*: “Date of
Service” must fall between these two
dates.
(Meal) Sites (one / many / all)
In the example above, Q will look for all service unit records (delivered units) entered for Home Care Specialist agen cy for Personal Care OR Chore OR Homemaker service with service dates between 7/1/06 and 9/30/06.

Results

Accessible table(s): Service Unit record and Client record (right-click on name)

Special Functions: None

6 ⎯ Q System Administrator Workbook
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
DRAFT
Title III
- Intake and Assessment
Forms Guide

CALIFORNIA DEPARTMENT OF AGING

HOME AND COMMUNITY LIVING DIVISION
www.aging.ca.gov
July 202
1 Exhibit F: Sourcewise Provider Manual
DRAFT
Table of Contents
Overview ................................................................................................................................................... 3 Data Performance Reporting Requirements ............................................................................................ 4 Designing Forms that Work ...................................................................................................................... 6 Required Title III B, C, and D (Clusters I & II), Registered Client Fields ..................................................... 7 Required Title III E, Registered Caregiver Fields (Group 1) ....................................................................... 9 Required Title III E, Registered Care Receiver Fields (Group 1) ................................................................ 12 Required Registered Client Level Detail .................................................................................................... 13 Federal Poverty Determination ................................................................................................................ 18 Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) Functional Impairment Status .................................................................................................................................... 20 Nutritional Risk Assessment ..................................................................................................................... 31 Legal Assistance Service Category - Case Information ............................................................................. 33 Optional Client Level Detail ...................................................................................................................... 34 Required Title III B, C, D and VII B (Cluster III), Non-Registered Client Fields........................................... 40 Required Title III E, Non-Registered Client Fields ....................... .............................................................. 42 Data Performance References .................................................................................................................. 43 Exhibit F: Sourcewise Provider Manual
DRAFT
Overview
Introduction
Data and the information created from data elements contribute to valuable knowledge about service use and clien
t demographics. It is a source for Area Agencies on Aging (AAA), California Department of Aging (CDA), and U.S. Administration for Community Living (ACL) performance m easures.

Backgr
ound
AAA staff spends a large percentage of their time reading, completing, proc essing, and retrieving forms created or received by the agency.

Forms are an important part of th e operations that aid in the collection and documentation of information. Well-designed and well-managed forms can reduce errors and save time and money.

Purpose
The purpose of this guide is to help AAA staff identify the required ACL and CDA Title III data elements.

This guide provides AAAs with guidance, resources, and sample layouts and forms to help AAAs evaluate and design agency intake forms.

NOTE:

This guide does not address Community Based Service Programs (CBSP), Health Insurance Counse
ling and Advocacy Program (HICAP), Long-Term Ombudsman Program, Se nior Community Services Employment Program (Title V), or fiscal forms.

Exhibit F: Sourcewise Provider Manual
DRAFT
Purpose
The O
lder Americans Act (OAA) requires a report of statistical data reflecting the number of service units provided and the number of registered clients or the estimated clients/audience reached.

Process
Data P
erformance Management Process
Entity Role
Provider
or
AAA
• collects and tracks client/user information and service units • reports service utilization units, consumer demographics and expenditures
• maintains records
AAA
• plans and administers OAA data management system(s)
• implements CDA data reporting requirements
• develops and maintains written procedures
• analyzes, corrects, and verifies data
• monitors and evaluates local services
• trains staff and provides technical assistance to the providers, clients, and caregivers
• reports data to CDA via the statewide California Aging Reporting System (CARS)
CDA
• sets data reporting standards
• monitors and evaluates AAA programs
• plans and administers the CARS
• provides AAAs with training and technical assistance as needed • reports data and program information to ACL and the California State Legislature
ACL
• provides Congress, states and other stakeholders with National Aging Program Information System (NAPIS) data
CARS Approval
AAAs shall assure that all data submitted is complete, accurate, timely, and verifiable.

AAA staff
must approve CARS File Upload quarterly data and NAPISCare annual data within 10 days of notice of
passed status. If the data cannot be corrected wi thin 10 days, AAA s taff must provide an explanation in the comments box in the report screen. CDA will be able to review the data after the 10- day approval period.

Exhibit F: Sourcewise Provider Manual
DRAFT
NAPIS Validation
As par
t of the annual year-end performance reporting process, the AAA Director, or designee, will be required to validate the NAPIS data.

What is Reviewed?
CDA rev
iews the accuracy and completeness of the reported data on a regular basis. CDA reviews intake and assessment forms, reporting performance information, supporting documents, and reporting procedures during the CDA monitoring process.

AAAs
shall keep complete records/documents on file to support all reports submitted to CDA. All paper and electronic client information records, data elements, and printouts collected are confidential and shall be secured and remain protected from unauthorized disclosure.

Exhibit F: Sourcewise Provider Manual
DRAFT
Introduction
The a
rrangement of the questions on the form will make it easier to enter, complete, and retrieve information.

Group Data
Group
related items with clearly defined sections to make the form easier to fill out. It can also eliminate the need for backtracking and reduces incomplete or missing data elements.

Databas
es may have separate data entry screens for
• Client D
etail Identification
• Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), and/or • Nutritional Risk Assessment
Establish Item Sequence
Arra
nge questions in a sequence that will match the structure of the database configuration. This will allow for easier data entry from one section to the next without having to search the form for the correct entry area.

Make Required Questions Clear
Make re
quired data elements clear and visible. Design forms to clearly define form fields with bound boxes and headers.

What is Reviewed?
CDA rev
iews AAA forms to ensure all required data collection elements are integrated. See Chart Guidelines.

Exhibit F: Sourcewise Provider Manual
DRAFT
Required Title III B, C, and D (Clusters I & II),
Registered Client Fields
Chart Guidelines
Apply the following chart to determine if intake form(s) have required data collection and reporting elements for Title III B, C, and D (Clusters I and II) Programs. See page 41 for Non- Registered
fields.

CARS Titl
e III B, C, and D (Clusters I and II) Required Registered Client Fields Service Category Service Units Registered
Client 1
ADL &
IADL 2
Nutritional
Risk 3
Case
Information 4
Funding
Source
Personal Care X Hour X X III B
Homemaker X Hour X X III B
Chore X Hour X X III B
Adult Day
Care/Health X Hour X X III B
Case Management X Hour X X III B
Congregate Meals X Meal X X III C
Home-Delivered
Meals X Meal X X X III C
Nutritional
Counseling
X Session per
Participant X X III C
Assisted
Transportation
X One-way
Trip X III B
Legal Assistance X Hour X X III B
(X) Required Element1
Registered C
lient
Required Client Level Detail
• Participant ID to
Determine
Unduplicated Count
• Birth Date
• Zip Code
• Rural Designat
ion
• Gender
• Sex at Birth
• Sexual Orientation or
Sexual Identity
• Race
• Ethnicity
• P
overty Status
• Living Arrangement
Exhibit F: Sourcewise Provider Manual
DRAFT
2 ADL/IADL Required Functional Rating Scale for each of the following:
• ADL: Eating
• ADL: Bath
ing
• ADL: Toileting
• ADL: Transferring
in/out of bed/chair
• ADL: Walking
• ADL: Dressing
• IADL: Meal Preparation
• IADL: Shopping
• IADL: Medication
Management
• IADL: Money
Management
• IADL: Using Telephone
• IADL: Heavy Housework
• IADL: Light Housework
• IADL: Transportation
ADL & IADL Functio
nal Impairment Rating Scale
(1) Independent: Can perf
orm a task without human assistance.
(2) Verbal Assistance: Requires verbal prompting to begin or complete a task. (3) Some Human Help: Requires some physical assistance to perform a task. (4) Lots of Human Help: Requires substantial assistance to perform a task. (5) Dependent: Totally dependent on another person to perform a task. (6) Declined to State
(0) Missing
Or as default, report only three levels: 1, 3, or 5 (and 6 – Declined to State). 3 Nutritional Risk - Required Score
(1) Yes: Nutritional risk with s
core of 6 or higher.
(2) No: Nutritional score with 5 or lower.
(3) Declined to State
(0) Missing
Scores are based on the Determine Your Nutritional Health checklist. 4 Case Information
• Case ID
• Case Opened Date
• Case Closed Date
• Service Type
• Service Level
Refer to CARS Specifications spreadsheet for file reporting structure and optional data elements.

Refer to Services Categories and Data Dictionary document for category definitions. All documents can be found at www.aging.ca.gov/Providers_and_Partners/ Area_Agencies_on_Aging/.

Exhibit F: Sourcewise Provider Manual
DRAFT
Required Title III E, Registered Caregiver Fields (Group 1) Chart Guidelines
Apply the following chart to determine if intake form(s) have the required data collection and reporting elements for the Title III E Family Caregiver Support Program (FCSP) Caregivers of Older Adults and Older Elderly Relative. See page 42 for Non-Registered fields.

CARS Title III E, FCSP Caregivers of Older Adults/Older Elderly Relative, Required Registered Caregi ver Fields
Family Caregiver
Service Category Service Units Registered Caregiver 1
Assessment X Hour X
Counseling X Hour X
Peer Counseling X Hour X
Support Group X Hour X
Training X Hour X
Case Management X Hour X
In-Home Supervision X Hour X
Homemaker Assistance X Hour X
In-Home Personal Care X Hour X
Home Chore X Hour X
Out-of-Home Day Care X Hour X
Out-of-Home Overnight Care X Hour X
Assistive Devices X Device/Occurrence X
Home Adaptations X Modification/Occurrence X
Registry X Hour/Occurrence X
Emergency Cash/Material Aid X Assistance/Occurrence X
(X) Required Element
1 Registered Caregiver Required Client Level Detail
• Participant ID to Determine
Unduplicated Count
• Birth Date
• Zip Code
• Rural Designation
• Gender
• Sex at Bi
rth
• Sexual Orientation or
Sexual Identity
• Race
• Ethnicity
• Poverty Status
• Living Arrangement
• Relationship Status
• Employment Status
• Caregiver Relationship
Exhibit F: Sourcewise Provider Manual
DRAFT
Required Title III B, C, and D (Clusters I & II),
Registered Client Fields
Chart Guidelines
Apply the following chart to determine if intake form(s) have required data collection and reporting ele
ments for the Care Receiver in the Title III E, Family Caregiver Support Program (FCSP), Caregivers of Older Adults.

CARS Title III E, FCSP Caregivers of Older Adults, Required Registered Care Receiver Fields Caregivers of Older Adults Service Category Registered Care Receiver 2 ADL & IADL 3 Assessment X X
Counseling X X
Peer Counseling X X
Support Group X X
Training X X
Case Management X X
In-Home Supervision X X
Homemaker Assistance X X
In-Home Personal Care X X
Home Chore X X
Out-of-Home Day Care X X
Out-of-Home Overnight Care X X
Assistive Devices X X
Home Adaptations X X
Registry X X
Emergency Cash/Material Aid X X
2 Registered Care Receiver Required Client Level Detail (X) Required Element
• Participant ID to
Determine
Unduplicated Count
• Birth Date
• Zip Code
• Rural Designation
• Gender
• Sex at Bir
th
• Sexual Orientation or
Sexual Identity
• Race
• Ethnicity
• Poverty Status
• Living Arrangement
• Relationship Status
Exhibit F: Sourcewise Provider Manual
DRAFT
3 ADL/IADL Required Functional Rating Scale for each of the following:
• ADL: Eating
• ADL
: Bathing
• ADL: Toileting
• ADL: Transferring
in/out of bed/chair
• ADL: Walking
• ADL: Dressing
• IADL: Meal Preparation
• IADL: Shopping
• IADL: Medication
Management
• IADL: Money
Management
• IADL: Using Telephone
• IADL: Heavy Housework
• IADL: Light Housework
• IADL: Transportation
ADL & IADL Fun
ctional Impairment Rating Scale
(1) Independen
t: Can perform a task without human assistance.
(2) Verbal Assistance: Requires verbal prompting to begin or complete a task. (3) Some Human Help: Requires some physical assistance to perform a task. (4) Lots of Human Help: Requires substantial assistance to perform a task. (5) Dependent: Totally dependent on another person to perform a task. (6) Declined to State
(0) Missing
Or as defa
ult, report only three levels: 1, 3, or 5 (and 6 – Declined to State).

Exhibit F: Sourcewise Provider Manual
DRAFT
Required Title III E, Registered Care Receiver Fields
(Group 1), Continued
Chart Guidelines
Apply the following chart to determine if intake form(s) have required data collection and reporting elements
for the Care Receiver in the Title III E FCSP Older Elderly Relative.

CARS Title III E, FCSP Older
Elderly Relative Required Registered Care Receiver Fields Older Elderly Relative Service Category Registered Care Receiver 2 Assessment (Supportive Services) X
Counseling (Supportive Services) X
Peer Counseling (Supportive Services) X
Support Group (Supportive Services) X
Training (Supportive Services) X
Case Management (Supportive Services) X
In-Home Supervision (Respite Care) X
Homemaker Assistance (Respite Care) X
In-Home Personal Care (Respite Care) X
Home Chore (Respite Care) X
Out-of-Home Day Care (Respite Care) X
Out-of-Home Overnight Care (Respite Care) X
Assistive Devices (Supplemental Services) X
Home Adaptations (Supplemental Services) X
Registry (Supplemental Services) X
Emergency Cash/Material Aid (Supplemental Services) X
(X) Required Element
2 Registered Care Receiver Required Client Level Detail • Participant ID to
Det
ermine
Unduplicated Count
• Birth Date
• Zip Code
• Rural Designation
• Gender
• Sex at Birth
• Sexual Orientation or
Sexual Identity
• Race
• Ethnicity
• Poverty Status
• Living Arrangement
• Relationship Status
NOTE: There are no ADL or IADL data collection requirements for Care Receivers in FCSP Caring for Child.

Refer to CARS Specifications spreadsheet
for file reporting structure and optional data elements.

Refer to Services Categories and Data Dictionary document for category definitions. All documents can be found at www.aging.ca.gov/Providers_and_Partners/Area_Agencies_on_Aging/.

Exhibit F: Sourcewise Provider Manual
DRAFT
Required Registered Client Level Detail
Introduction
OAA programs use client demographic elements for targeting and/or reporting purposes. The required registered client level details are birth date, zip code, rural designation, gender, sex at birth, sexual orientation or gender identity, race, ethnicity, poverty status, and living arrangement.

Service Categories Required
The following are the programs that require collecting client level detail for registered clients, or FCSP caregivers and care receivers.

Title III B, C, and D, Supportive and Nutrition Services • Perso
nal Care
• Homemaker
• Chore
• Home-Delivered Meals
• Adult Day Care/Health
• Case Management
• Congregate Meals
• Nutritional Counseling
• Assisted Transportation
• Legal Assistance
Titl
e III E, FCSP Caregivers of Older Adults/Older Elderly Relative:

Caregiver & Care Receiver
SUPPLE

MENTAL SERVICES
• Assessment
• Counseling
• Peer Counseling
• Support Group
• Training
• Case Management
RESPI

TE CARE
• In-Home Supervision
• Homemaker Assistance
• In-Home Personal Care
• Home Chore
• Out-of-Home Day Care
• Out-of-Home Overnight
Care

SUPPLEMENTAL SERVICES
• Assistive Devices
• Home Adaptations
• Registry
• Emergency Cash/ Material Aid
Exhibit F: Sourcewise Provider Manual
DRAFT
What is Reviewed?

CDA reviews registered client level details for completeness. The client’s information is self- reported and collected annually. If a client declines to provide information, document the action. Service cannot be denied to eligible clients declining to provide information.

All the listed data elements, except for birth date, include a “Declined to State” option which is calculated separately from “missing” information. Missing information occurs when a client is not asked to identify the required demographic data element or information was not entered into the AAA database.

Birthday

Collect the month (##), day (##), and year (####) of birth.

Elements Zip Code

Zip Code can be collected as ##### or ##### - ####.

Sexual Orientation and Gender Identity (SOGI)

The following lists contain the various options available to report SOGI data to CARS:

GENDER CARS

OPTIONS
• Male
• Female
• Transgender Female to
Male
• Transgender Male to
Female
• Genderqueer/Gender
Non-binary
• Not listed.

Please specify:
• Declined to State
• Missing

SEX AT BIRTH CARS

OPTIONS
• Male
• Female
• Declined to State
• Missing

SEXUAL ORIENTATION

OR SEXUAL IDENTITY CARS

OPTIONS
• Straight/ Heterosexual
• Bisexual
• Gay/Lesbian/Same- Gender Loving
• Questioning/ Unsure
• Not listed.

Please specify:
• Declined to State
• Missing
Exhibit F: Sourcewise Provider Manual
DRAFT
Rural Designation

The Administration of Community Living (ACL) requires that rural designation now be determined by Rural-Urban Commuting Area (RUCA) codes. These codes classify census tracts using measures such as population density, urbanization, and daily commuting. Each zip code has a corresponding RUCA code.

The zip code files are available on the resource page of the OAAPS.

Rural RUCA codes: 4.0, 4.2, 5.0, 5.2, 6.0, 6.1, 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, 9.2, 10.0, 10.2,

10.3, 10.4, 10.5, and 10.6.

Non-Rural RUCA codes: 1.0, 1.1, 2.0, 2.1, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1.

To find more information on RUCA codes visit the USDA Economic Research Service’s Rural-Urban Commuting Area codes website at www.ers.usda.gov/data-products/ .

Rural CARS Options

• Rural
• Urban
• Declined to State
• Missing

Race

The following reflects the Office of Management and Budget’s (OMB) reporting requirement for collecting race, and California’s Government Code Section 8310.5 reporting requirement for collecting different Asian and Native Hawaiian/Other Pacific Islander groups.

Race CARS Options

• White
• American
Indian or Alaska
Native
• Black or
African
American
• Chinese
• Japanese
• Filipino
• Korean
• Vietnamese
• Asian Indian
• Laotian
• Cambodian
• Other Asian
• Guamanian
• Hawaiian
• Samoan
• Other Pacific Islander
• Declined to State
• Missing

Exhibit F: Sourcewise Provider Manual
DRAFT
Required Registered Client Level Detail, Continued
Ethnicity
The following reflects the OMB’s ethnicity reporting requirement. Hispanic o r Latino origin is a separate question from the race category.

Ethnici
ty CARS Options
• Not Hispa
nic/Latino
• Hispanic/Latino
• Declined to State
• Missing
Living Arrangement
ACL defines “living alone” as a one-p erson household (using the Census definition of household) where the householder lives by his or herself in an owned or rented place of residence in a non- institutional setting.

Livi
ng Arrangement CARS Options
• Alone
• Not Alon
e
• Declined to State
• Missing
Exhibit F: Sourcewise Provider Manual
DRAFT
Unique Participant ID

ACL requires that State Units on Aging (SUA) report the total unduplicated clients who were served in registered services. The most accurate method to avoid duplicating information is by assigning a unique participant identifier to a client (generally, each AAA data management system creates this identifier once the minimum data elements are entered into the system). All services received by the client can be tracked by tying them to the client’s unique participant identifier.

When developing a unique identification number, AAAs must ensure that personal, sensitive, and confidential information is protected from inappropriate or unauthorized access or disclosure. AAAs must have written confidentiality procedures to ensure that no personal information is disclosed by the AAA or provider without informed consent of the client.

OAA services cannot be denied to eligible clients if they do not wish to disclose their information.

The unique “Participant ID” must be collected as an integer.

Termination Date

This is the date on which the participant stopped receiving a service. This date must be collected as YYYY-MM-DD.

Termination Reason

This field identifies the reason for terminating services (i.e., deactivating a client).

Reason for Deactivation CARS Options

• Deceased
• No Longer MSSP Eligible
• Moved out of Service Area
• Will not Follow Care Plan
• No Longer Desires Services
• On Hold
• No Longer SNF Certifiable
• Past Active
• Institutionalization
• On Waiting List
• High Cost of Services
• Other Reason

Exhibit F: Sourcewise Provider Manual
DRAFT
Federal Poverty Determination
Introduction
While the OAA is concerned with the provision of services to all older persons, it requires assurance that preference is given to older individuals with greatest economic or social need, with particular attention to low-income minority individuals.

Under the OAA, “greatest economic need” means the need resulting from an income level at or below poverty levels established by OMB.

ACL
uses the Federal Poverty Guideline s for targeting and reporting.

Service Categories Required
The following are the programs that require collecting that require coll ecting poverty status for registered clients, or FCSP caregivers and care receivers.

Title III B, C, and D, Supportive and Nutrition Services • Perso
nal Care
• Homemaker
• Chore
• Home-Delivered Meals
• Adult Day Care/Health
• Case Management
• Congregate Meals
• Nutritional Counseling
• Assisted Transportation
• Legal Assistance
Title
III E, FCSP Caregivers of Older Adults/Older Elderly Relative (Caregiver and Care Receiver)

SUPPORTIVE SERVICES
• Assessment
• Counseling
• Peer Counseling
• Support Group
• Training
• Case Management

RESPITE CARE
• In-Home Supervision
• Homemaker Assistance
• In-Home Personal Care
• Home Chore
• Out-of-Home Day Care
• Out-of-Home Overnight
Care

SUPPLEMENTAL SERVICES
• Assistive Devices
• Home Adaptations
• Registry
• Emergency Cash/Material
Aid
Exhibit F: Sourcewise Provider Manual
DRAFT
What to Include?
Create a quest
ion to determine if the client, caregiver, or care receiver is at or below 100 percent of the federal poverty level.

Information is self-r
eported and collected annually.

What is Reviewed?
CDA will review d
emographic data to determine if AAAs are reaching individuals who are at or below the federal poverty line.

Use one of
the examples below or create one. If the form does not list the federal poverty amounts, include an instructional sheet.

Example 1
 At or
Below FPL (Low Income)
 Above FPL
 Declined to State
Example 2
Total # Living in Household:

Approx. Monthly Gross Income: $
 Declined to State
Example 3
# of Hou
sehold Members (Circle One) 1 2 3 4 5 6 7 8+
What is Your Approximate Household Income? $ Per Month/ Per Year  Declined to State
Example 4
 Livin
g Alone: Less than $#,### Per Month
 Two Person Household: Less than $#,### Per Month
 Other
 Declined to State
Resources
The U.S. Department of Health and Human Services (HHS) updates information periodically.

The Federal Register Poverty Guidelines are normally published in late January each year. The guidelines can also be found on the Assistant Secretary for Planning and Evaluation website at www.aspe.hhs.gov/poverty-guidelines.

CDA Title
III Forms Guide (July 2021)
Exhibit F: Sourcewise Provider Manual
DRAFT
Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) Functional Impairment Status
Introduction
OAA programs use the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) functional impairment scale to identify individuals with functional limitations. AAAs must also review functional limitations to
determine eligibility for the provision o f FCSP Caring for Elderly Respite Care and Supplemental Services.

The OAA p
reference is to give services to older individuals with greatest social need. The term “greatest social need” means the need caused by non-economic factors that include:
(A) phys
ical and mental disabilities
(B) language barriers
(C) cultural, social, or geographical isolation, including isolation caused by racial or ethnic status that
(i) restricts an individuals’ ability to perform normal daily tasks (ii) threatens such individuals’ capacity to live independently ACL use
s ADL and IADL characteristics for targeting frail older individuals and reporting purposes.

Service Categories Required
The tabl
e below lists the programs that require ADL and IADL limitation status for registered clients.

Title III
B and C-2, Supportive and Nutrition Services
• Person
al Care
• Homemaker
• Chore
• Home-Delivered Meals
• Adult Day Care/Health
• Case Management
Exhibit F: Sourcewise Provider Manual
DRAFT
Service Categories Required, Continued
The table
below lists the programs that require ADL and IADL limitation status for registered care receivers in the FCSP Caregivers of Older Adults.

Title III E, FCSP C
aregivers of Older Adults (Care Receiver)

SUPPORT

IVE SERVICES
• Assessment
• Counseling
• Peer Counseling
• Support Group
• Training
• Case Management

RESPITE CARE
• In-Home Supervision
• Homemaker Assistance
• In-Home Personal Care
• Home Chore
• Out-of-Home Day Care
• Out-of-Home Overnight
Care

SUPPLEMENTAL SERVICES
• Assistive Devices
• Home Adaptations
• Registry
• Emergency Cash/Material Aid
What to Include?
Create s
ix (6) ADL and eight (8) IADL questions with the functional ability rating scale to determine the impairment level of the applicant or client.

Informat
ion is self-reported and collected annually. Conduct reassessment as needed, based on changes in the client’s status within the year.

NOTE: Arr
ange questions to match database entry sequence.

How to Determine Score?
ACL defi
nes “impairment in Activities of Daily Living (ADL)” as the inability to perform one or more of the following six activities of daily living without personal assistance, stand-by assistance, supervision or cues: eating, dressing, bathing, toileting, transferring in and out of bed/chair, and walking.

ACL defi
nes “impairment in Instrumental Activities of Daily Living (IADL)” as the inability to perform one or more of the following eight instrumental activities of daily living without personal assistance, or stand-by assistance, supervision or cues: preparing meals, shopping for personal items, medication management, managing money, using the telephone, doing heavy housework, doing light housework, and transportation ability (transportation ability refers to the individual's ability to make use of available transportation without assistance).

Exhibit F: Sourcewise Provider Manual
DRAFT
The ADL and IADL functional ability rating scale is applied to each question. The CARS system will count the number of ADLs and IADLs where verbal or human assistance is required. An applicant’s or client’s sum determines the overall level of functional impairment. • If the Combined Total Number of ADLs & IADLs is 0
Then Client is independent, has no functional limitations. • If the
Combined Total Number of ADLs & IADLs is 1-2
Then Client is frail, has minimal or mild functional impairments. • If the Combined Total Number of ADLs & IADLs is 3 or greater Then Client is severely disabled and vulnerable to loss of independence.

What is Reviewed?
CDA will re
view demographic data to determine if the AAA is reaching individuals who are functionally impaired.

To quali
fy for Title III E, FCSP Caring for Elderly Respite Care and Supplemental Services care receivers must have two or more ADL limitations or a cognitive impairment.

Exhibit F: Sourcewise Provider Manual
DRAFT
Example 1:

Displays descriptive questions with ADL and IADL examples.

ADLs and IADLs
- How would you rate your ability to perform the following daily activities? 1=No Assistance Needs, 2=Requires Verbal Assistance, 3=Some Human Help, 4=Lots of Human Help, 5=Cannot Do It At All
ACTIVITIES OF DAILY LIVING (RATE 1-5)
Can you manage eating without any help?
Can you bathe or shower without any help?
Can you use the toilet without any help?
Can you get in and out of bed or chair without any help? Can you walk around inside without any help?
Can you dress without any help?

INSTRUME
NTAL ACTIVITIES OF DAILY LIVING (RATE 1-5)
Can you prepare meals for yourself without help?
Can you shop for food and other things you need without help? Can you take your medications without help?
Can you handle your own money, like keeping track of bills without help? Can you answer the telephone or make a phone call without help? Can you do heavy housecleaning, like yard work and laundry, without any help? Can you do light housekeeping, like dusting or sweeping, without help? Can you use public transportation or drive beyond walking distances without help? Notes:
 Declined to State
Example 2:

Displays a list of the ADLs and IADLs. Staff may provide description information.

ADLs and IADLs (
Activities of Daily Living and Instrumental Activities of Daily Living) Please rate your functional abilities for the following activities.

RATING SCALE: 1 = Independent, 2 = Verbal Assistance, 3 = Some Human Help, 4 = Lots of Human Help, 5 = Dependent, 6 = Declined to State
ADLS:

Eating ___________

Dressing ___________
Transferring ___________
In/Out of Chair ___________
Walking ___________
Toileting ___________
IADLs
Meal Preparation ___________
Shopping ___________
Medication Management ___________
In/Out of Chair ___________
Walking ___________
Toileting ___________
Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT
Example 3:

Displays descriptive questions with ADL and IADL examples.

Displays all
5 functional ability rating scale options plus “Declined to State.” Staff may provide descriptive information.

Client ADL
and IADL
(Activities of Daily Living and Instrumental Activities of Daily Living – Annual Assessment) Please check level of functional ability.

ADLs: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
Eating
Bathing
Toileting
Transferring In/
Out of Bed/ Chair
Walking
Dressing
Notes:

IADLs: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
Meal Preparation
Shopping
Medication
Management
Money
Management
Using Telephone
Heavy Housework
Light Housework
Transportation
Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT
Example 4:

Displays the minimum functional ability 3-option rating scale plus “Declined to State.” Activities of Daily Living (ADL
):

Circle One For Each
1=No Assistance, 3=Some Human Help,
5=Cannot Perform (Dependent),
Instrumental of Daily Living (IADL):

Circle One For Each
1=No Assistance, 3=Some Human Help, 5=Cannot Perform
(Dependent)
Eating ................................................. 1 3 5 Meal Preparation ............................... 1 3 5 Bathing .............................................. 1 3 5 Shopping ............................................ 1 3 5 Toileting ............................................. 1 3 5 Medication Management .................. 1 3 5 Transferring In/Out of Bed/Chair ...... 1 3 5 Money Management ......................... 1 3 5 Walking .............................................. 1 3 5 Using Telephone ................................ 1 3 5 Dressing ............................................. 1 3 5 Heavy Housework .............................. 1 3 5 Light Housework ............................... 1 3 5
1 3 5 Declined to State Transportation ..................................

Example 5:

Displays ADL and IADLs with descriptive functional ability rating scales.

ADLs and IADLs (Activities of D
aily Living and Instrumental Activities of Daily Living) Please rate your functional ability for the following activities.

Client/Elderly Care Receiv
er Activities of Daily Living (ADL) Fields
Eating (Rated Level )
Reaching for, picking up, grasping utensil and cup; getting food on utensil, bringing food, utensil, cup to mouth, chewing, swallowing food and liquids, manipulating food on plate. Cleaning face and hands as necessary following a meal.
(1) Independent (able to feed self)
(2) Verbal assistance (able to feed self but needs verbal assistance such as reminding or encouragement to eat)
(3) Some human help (
assistance needed during meal, e.g., to apply assistive device, get beverage or push more food to within reach, etc., but constant presence of another person not required) (4) Lots of human help (able to feed self but cannot hold utensils, cups, glasses, etc., constant presence
of another person is required)
(5) Dependent (unable to feed self at all)
Declined to State
Exhibit F: Sourcewise Provider Manual
DRAFT
Example 5, Continued
Bathing (Rated Level )
Bathing means cleaning the body using a tub, shower, or sponge bath including getting a basin of water, managing faucets, getting in and out of a tub, reaching head and body parts for soaping, rinsing, and drying.
(1) Independent (able to bathe self safely)
(2) Verbal assistance (able to bathe self with direction or intermittent monitoring; may need reminding to maintain personal hygiene)
(3) Some human help
(generally able to bathe self, but needs assistance)
(4) Lots of huma
n help (requires direct assistance with most aspects of ba thing; would be at risk if left alone)
(5) Dependent (totally dependent on others for bathing) Toileting (Rated Level )
Able to move to and from, on and off toilet or commode, empty commode, manage clothing and wipe and clean body after toileting, use and empty bedpans, ostomy and/or catheter receptacles and urinals, apply diapers and disposable barrier pads. Menstrual care: able to apply external sanitary napkin and clean body.
(1) Independent (no assistance needed)
(2) Verbal assistance (requires reminding and direction only) (3) Some human help (requires minimal assistance with some activities, but the const ant presence of the provider is not
necessary)
(4) Lots of human help (unable to carry out most activities without assistance) (5) Dependent (requires physical assistance in all areas of care) Transferring In/Out of Bed/Chair (Rated Level )
Moving from one sitting or lying position to another sitting or lying position; e.g., from bed to or from a wheelchair, or sofa, coming to a standing position and/or repositioning to prevent skin breakdown. (1) Independent (able to do all transfers safely)
(2) Verbal assistance (able to transfer but needs encouragement or direction) (3) Some human help (requires some help from another person; e.g., routinely requires a boost or assistance with positioning)
(4) Lots of human help (unable to complete most transfers wi thout physical assistance; would be at risk if unassisted)
(5) Dependent (totally dependent upon another person for all transfers) Exhibit F: Sourcewise Provider Manual
DRAFT
Example 5, Continued
Walking (Rated Level )
Walking or moving inside, moving from one area of indoor space to another without necessity of handrails. Can respond adequately to the presence of obstacles that must be stepped around.

Includes ability to go from inside to outside and back. (1) Independent (no assistance needed)
(2) Verbal assistance (able to walk or move with encouragement, or reminders to watch for steps, or to use a cane or walker)
(3) Some human help (requires minimal assistance from another person to negotiate a wheelchair or to steady the person or guide them in the desired direction) (4) Lots of human help (requires constant attention from another person, at risk of being lost or unsafe if not accompanied)
(5) Dependent (totally dependent upon a nother person, must be c arried, lifted, or pushed in a wheelchair or
on a gurney at all times)
Dressing (Rated Level )
Putting on and taking off, fastening and unfastening garments and undergarments, special devices such as back braces, corsets, elastic stockings/garments and artificial limbs or splints. (1) Independent (able to put on, fasten and remove all clothing and devices without assistance; clothes self appropriately for health and safety)
(2) Verbal assistance (able to dress self, but requires reminding or directions with clothing selection) (3) Some human help (unable to dress self completely, without the help of another person, e.g., tying shoes, buttoning, zipping, putting on hose or brace, etc.) (4) Lots of human help (unable to put on most clothing items by self; without assistance would be inappropriately or inadequately clothed)
(5) Dependent (unable to dress self at all)
Exhibit F: Sourcewise Provider Manual
DRAFT
Example 5, Continued
Client/
Elderly Care Receiver Instrumental Activities of Daily Living (IADL) Fields Meal Preparation (Rated Level )
Planning menus. Washing, peeling, slicing vegetables, opening packages, cans, and bags, mixing ingredients, lifting pots and pans, re-heating food, cooking, safely operating stove, setting the table, serving the meal, cutting food into bite-sized pieces. Washing, drying, and putting away the dishes. (1) Independent (no assistance needed)
(2) Verbal assistance (needs only reminding or guidance in menu planning, meal preparation, and/or cleanup)
(3) Some human help (requires another person to prepare and clean up main meals on less than a daily basis; e.g., can reheat food prepared by someone else, can prepare simple meals and/or needs help with cleanup on a less than daily basis)
(4) Lots of human help (requires another person to prepare and clean up main meal(s) on a daily basis) (5) Dependent (totally dependent upon another person to prepare and clean up all meals) Shopping (Rated Level )
Compile list, bending, reaching, and lifting, managing cart, or basket, identifying items needed, transferring items to home, putting items away, ordering prescriptions over the phone and picking them up, and buying clothing.
(1) Independent (can perform all tasks without assistance) (2) Verbal assistance (able to perform tasks, but needs only reminding or direction, guidance or reminder)
(3) Some human help (requires the help of another person for some tasks while shopping such as reaching and carrying items)
(4) Lots of human help (unable to carry out most activities without assistance) (5) Dependent (unable to perform any tasks for self)
Medication Management (Rated Level )
Physically and mentally able to identify, organize, schedule, handle, and consume (inject, instill or insert) the correct amount of the prescribed medication at the specified time according to a doctor's prescription.
(1) Independent (can identify, measure, organize, and self-administer prescribed medication) (2) Verbal assistance (able to perform tasks but needs verbal direction, guidance or reminder to do it, without risk to safety)
(3) Some human help (requires some human help such as scheduling medications, opening the container, measuring the amount of medication)
(6) Lots of human help (cannot perform some parts of this function; may require some human help with installing or injecting multiple medications)
(7) Dependent (cannot perform any part of this function) Exhibit F: Sourcewise Provider Manual
DRAFT
Example 5, Continued
Money Management (Rated Level )
Physically and mentally handles the receipt of monies, expenditures, and receipt and payment of bills in a timely and primarily correct manner.
(1) Independent (handles all financial matters)
(2) Verbal assistance (is able to perform all financial transactions but may need to be reminded to pay bills or obtain cash from bank)
(3) Some human help (for either physical or mental reasons may need assistance in doing banking, writing checks, etc.)
(4) Lots of human help (unable to carry out most activities without assistance) (5) Dependent (unable to attend to any part of the necessary financial transactions to receive and disburse funds to meet daily needs)
Using Telephone (Rated Level )
Obtains number, dials, handles receiver, can speak and hear response, and terminates call, may include use of instrument with loudspeaker or hearing devices. Able to use telephone during emergency situations to call 911 or other help.
(1) Independent (can obtain and dial number without assistance) (2) Verbal assistance (needs only reminder on how to use the phone) (3) Some human help (needs human assistance to obtain number or dial) (4) Lots of human help (currently not defined)
(5) Dependent (unable to use phone at all)
Heavy Housework (Rated Level )
Cleaning oven and stove, cleaning and defrosting refrigerator, moving light furniture to clean under and behind, vacuuming upholstery and under cushions, providing deep cleaning activities such as washing and cleaning baseboards, window tracks, cabinets, doors, drapes/blinds, etc. (1) Independent (able to perform all domestic chores)
(2) Verbal Assistance (able to perform domestic chores but needs direction) (3) Some human help (requires physical assistance from another person for some domestic chores) (4) Lots of human help (unable to carry out most domestic chores without assistance) (5) Dependent (totally dependent upon others for all domestic chores) Exhibit F: Sourcewise Provider Manual
DRAFT
Example 5, Continued
Light Housework (Rated Level )
Sweeping, vacuuming, mopping floors, washing kitchen counters and sinks, cleaning bathroom, taking out garbage, dusting and picking up.
(1) Independent (able to perform all light domestic chores) (2) Verbal assistance (able to perform domestic chores but needs direction) (3) Some human help (requires physical assistance from another person for some domestic chores) (4) Lots of human help (unable to carry out most domestic chores without assistance) (5) Dependent (totally dependent upon others for all domestic chores) Transportation (Rated Level )
Using private or public vehicles, cars, buses, trains, or other forms of transportation to get to medical appointments, purchase food, shop, pay bills, or arrange for services, to socialize and participate in entertainment or religious activities. Can arrange for getting and using public transportation; or get to, enter and operate a private vehicle.
(1) Independent (can arrange, get to, enter and travel in public or private vehicles) (2) Verbal assistance (can use public transportation or ride in a private vehicle when reminded to make arrangements)
(3) Some human help (requires physical assistance to make transportation arrangements; i.e., calling, writing instructions about time and place, can ride with others if assisted into and out of the vehicle)
(4) Lots of human help (unable to carry out most activities without assistance) (5) Dependent (unable to travel at all by self)
 Check if D
eclined to State ADL and IADL Functional Abilities
Resources
The OA
A defines “frail” as an older individual that is functionally impaired because the individual “is unable to perform at least two ADLs without substantial human assistance, including verbal reminding, physical cueing, or supervision; or due to a cognitive or other mental impairment, requires substantial supervision because the individual behaves in a manner that poses a serious health or safety hazard to the individual or to another person.” (Section 102(a) (22)) Exhibit F: Sourcewise Provider Manual
DRAFT
Introduction
Title III
C Congregate and Home-Delivered Meal programs are required to perform a nutrition risk screening to identify individuals at nutrition risk or at risk for malnutrition. NAPIS reporting requirements define a person at nutrition risk as one who scores six or higher on the Determine Your Nutritional Risk Checklist (hereafter referred to as the “DETERMINE Checklist”) published by the Nutrition Screening Initiative (NSI).

Service Categories Required
The followi
ng programs require collecting the nutritional risk scores for registered clients. • Home-Delivered Meals
• Congregate Meals
• Nutritional Counseling
What to Include?
Title III
C nutrition programs shall only use the DETERMINE Checklist to evaluate the client’s nutrition risk score.

The nut
rition risk questionnaire must be filled out at initial intake or registration along with other client information then reported through the data collection system. After initial intake/registration, annually update and report nutrition risk information and other basic client data.

How to Determine Score?
Each ques
tion has a weighted point value. The sum determines the reported nutritional risk score. • If score is 0-5, then client is not at nutritional risk. • If s
core is 6 or greater, then client is at nutritional risk.

Exhibit F: Sourcewise Provider Manual
DRAFT
What is Reviewed?
CDA will re
view data to determine if the AAA is serving individuals at nutritional risk. CDA bases its target ranges on statewide analysis of the average number of participants at nutritional risk. Target percentages may be adjusted on an annual basis.

Program Target percentage of all reported participants
For the Congregate Meals (C-1) 21% or higher at nutritional risk Home-Delivered Meals (C-2) 65% or higher at nutritional risk DETERMINE Checklist
The follow
ing is the DETERMINE Checklist with weighted/scored values. The interviewer may need to provide additional clarification.

Determine Your Nutritional Health Circle if
yes
I have an illness or condition that made me change the kind and/or amount of food I eat. 2
I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1
I take 3 or more different prescribed or over-the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the last 6 months. 2
I am not always physically able to shop, cook and/or feed myself. 2 Total Score:
(If equal to or greater than 6, the client is at nutritional risk) Declined to State
Exhibit F: Sourcewise Provider Manual
DRAFT
Case Information
Effectiv
e starting July 1, 2021, the Legal Assistance Service category is a registered service. In addition to required client data, the following case information is needed:
• Case ID
• C
ase Opened Date
• Case Closed Date
• Service Type
• Service Level
NOTE: Leg
al Assistance data will now be reported through CARS. The final required CDA 1022 form will cover the fourth quarter of State Fiscal Year 2021. Thereafter, the 1022 form will no longer be accepted.

Exhibit F: Sourcewise Provider Manual
DRAFT
Introduction
There ma
y be other questions added to provide more helpful client information. Some common ones are listed below. These are not required CARS elements and must not be reported in CARS.

Assessment Type
Assessment ty
pes (may be helpful) are as follows:
• New Client
• Annual Reassessment
• Significant Change in Condition
Office Notes
Identification of intake/ assessment date and the staff reviewing the information is useful.

Contact Information
To assign a unique identification number to each participant to be used internally only data management systems may use any combination of name, address, p hone number, or the last four digits of
the participant’s Social Security Number for record identification. This avoids duplicating information by re
cording client level detail for each participant and will enable tracking the client’s services by provider and program.
• First Name
• Middle N
ame
• Last Name
• Other name(s)
• Home Address
• City
• Mailing if Different
• Telephone Number
• Cell Number
• Email Address
Exhibit F: Sourcewise Provider Manual
DRAFT
Optional Client Level Detail, Continued
Living Arrangement with Others
This section can help to identify the following client living arrangements when not living alone:
 Lives w/Spo
use
 Lives w/Child
 Lives w/Relative
 Lives w/Other(s)
 Senior Apartment
Source of Support
This sectio
n can help to identify the following various types of caregiving support:
 Family
 Friend/ Neig
hbor
 Paid Help
 Unsure
 None
Transportation Services
The following o
ptions can help to identify type(s) of transportation assistance needed:
 Walks with No Assistance
(Non-Assisted)
 Walks with Assistance
(Assisted)
 Wheelchair ramp/lift
Other Characteristics
The following o
ptions can help to identify if other conditions or assistance are needed.

CHECK AIDS CURRE
NTLY USED:
 Cane
 Glasses/ Contacts
 Hearing Aid
 Oxygen
 Pacemaker
 TTY Phone
 Walker
 Wheelchair
 Other:

ABILITY TO
SPEAK ENGLISH:
 Speaks English  Non-English Language  Need Interpreter

DO YOU RECEIV
E HELP FROM OTHER ORGANIZATION(S)?
 Yes
 No
 If so, which
one(s):

Exhibit F: Sourcewise Provider Manual
DRAFT
Emergency Identification
This se
ction can allow the client to designate a contact person to call during or after an emergency event:

Emergency Contact Person
Name: __________________________________________________________________________ Address: _______________________________________
Relationship to Client: _____________________________
Telephone number: ( ) - _______
Disaster Registry
In case
of an emergency declaration, the following identification can help build a Disaster Registry to identify those high-risk clients that may need evacuation assistance.

A client is co
nsidered High Risk under Emergency Declaration if any of the following exists.

Check all that apply.
 Housebound seniors and people with physical disabilities that DO NOT have an existing network of
support
 Significant mobility, vision, or hearing impairment
 Elderly or
medically fragile
 Disabling mental
illness or developmental disability
 Requires refrigeration of medication and/or is insulin dependent  Reliance on life-support, oxygen, or dialysis
 Not applicable
Eligibility for Title III B Registered Services
To det
ermine eligibility for registered Supportive Services (Title III B) the following question can be asked: Are you age 60 or over?
 Yes
 No
Exhibit F: Sourcewise Provider Manual
DRAFT
Eligibility for Title III C-1 & C-2
To det
ermine eligibility for Congregate Meals (Title III C-1) and Home-Delivered Meals (Title III C-2) the following questions can be asked.

QUESTI
ONS FOR THE CONGREGATE MEALS (C-1) ELIGIBILITY:
 Are you over 60?
 Are you the spouse or domestic partner of an Elderly Nutrition Program (ENP) participant who is over the age of 60?
 Are you a person with a disability, who resides in housing where the congregate site is located?
 Are you a person with a disability who resides with and accompanies an ENP participant?  Are you a volunteer under the age of 60? (May have a meal if it does not deprive a senior of a meal.)
QUESTIONS FOR HOME-DELIVERED MEALS (C-2) ELIGIBILITY:
 Are you homebound due to an illness, disability, or isolation?  Are you a spouse of a person who is homebound?
 Are you an individual with a disability who resides with a homebound meal recipient? QUESTI
ONS TO DETERMINE EQUIPMENT CONDITIONS AND CLIENT ABILITIES:
 Does the client have any dietary restrictions?
 Does the client have a working refrigerator?
 Does the client have a working microwave?
 Is client physically and mentally able to open the food containers?  Is client physically and mentally able to reheat a meal?  Are there pets inside or outside the home?
Exhibit F: Sourcewise Provider Manual
DRAFT
Eligibility for Title III E
To determin
e eligibility for Title III E, FCSP Caregivers of Older Adults or Elderly Relative, the following questions may be asked.

CAREGIVER C

ARING OF OLDER ADULTS CRITERIA

1. Is the Care Receiver an older individual (60 ye ars of age or older) or an individual (of any age) with Alzheimer’s disease or related disorder with neurological and organic brain dysfunction? Yes No

2. Is the Caregiver an adult (18 years of age or older) family member or another individual (e.g., friend or neighbor) who is a
n informal (i.e., unpaid) provider of in-home or community care to an “elderly” Care Receiver?
Yes No
If answered “yes” to both questions above, the individual is qual ified for “Family Caregivers of Older Adults.” If requesting “Re
spite Care” or “Supplemental Services,” the Care Receiver must also have two or more ADL deficiencies or a cognitive impairment.

OLDER ELDER RELATIVE ELIGIBILITY CRITERIA

1. Is the Care Receiver an individual who is not more than 18 years of age or who is an individual (of any
age) with a disability?
Yes No

2. In the case of a caregiver for a child, is the Caregiver a grandparent, step-grandparent, pa rent, or other older relative by blood, marriage, o r adoption who is 55 years of age or older, living with the child, and identified
as the primary caregiver through a legal or informal arrangement? Biological and adoptive parents are exclude
d.

Yes No

3. In the case of a caregiver f or an individual with a disability, is the caregiver a parent, grandparent, or other relative by b
lood, marriage, or adoption who is 55 years of age or older, and living with the individual with a disability?
Yes No
If answered “yes” to either questions 1 and 2 or 1 and 3 above, the individual is qualified for "Older Elderly
Relative Services.”
If the Care Receiver does not meet any of the crite ria above, the Caregiver is ineligible to receive FCSP services, but may qualify to receive other services provided by the AAA.

Exhibit F: Sourcewise Provider Manual
DRAFT
Optional Client Level Detail, Continued
Resources to Determine Eligibility
The following links are to reference documents for the Title III E, Family Caregiver Support Program.

CDA Statistical Fact Sheets and Program Narratives
www.aging.ca.gov/Data_and_Statistics/#Statistical
Provide information on
the program purpose, eligibility requirements, and history.

CDA Service Categories Data Dictionary
www.aging.ca.gov/Providers_and_Partners/Area_Agencies_on_Aging Provides category definiti
ons.

Exhibit F: Sourcewise Provider Manual
DRAFT
Introduction
Some OAA
programs do not require collecting any client-level demographic information. These programs target groups or provide sensitive services that may make client-level data collection difficult.

What to Include?
Repo
rt estimated total clients/audience by each service category for each quarter. AAAs will be required to report at least:
• Nutritional Education
• Information and Assistance
• Disease Prevention and Health Promotion
• Elder Abuse Prevention, and
• Other NAPIS Services
There
are no required client fields in non-registered services. It is optional for AAAs to collect this information based on the guidelines described in the required client fields for Registered Services.

What is Reviewed?
CDA revie
ws the estimated enrollments and service units on a quarterly and annual basis.

Exhibit F: Sourcewise Provider Manual
DRAFT
Chart Guidelines
Apply
the following chart to determine if form(s) or records have the required data collection and reporting elements for Title III B, C, D, and VII B Non-Registered services.

CARS - Required Title III B, C, D, and VII Non-Registered Fields Service Category Service Units
Estimated
Clients/
Audience
Funding
Source
Transportation X One-way Trip X III B
Nutritional Education1 X Session per
Participant X III C
Information and Assistance1 X Contact X III B
Outreach X Contact X III B
Health Promotion1 X Contact X III D
Alzheimer's Day Care Services (“Other” NAPIS
Services)
X Day of
Attendance X III B
Cash/Material Aid (“Other” NAPIS Services) X Assistance X III B Community Education (“Other” NAPIS Services) X Activity X III B Comprehensive Assessment (“Other” NAPIS Services) X Hour X III B Disaster Preparedness Materials (“Other” NAPIS
Services)
X Product X III B
Elder Abuse Prevention, Education and Training 1
(“Other” NAPIS Services)
X Session X VII
Elder Abuse Prevention Educational Materials1
(“Other” NAPIS Services)
X Product X VII
Employment (“Other” NAPIS Services) X Activity X III B
Health (“Other” NAPIS Services) X Hour X III B
Housing (“Other” NAPIS Services) X Hour X III B
Interpretation/ Translation (“Other” NAPIS Services) X Contact X III B Mobility Management Activities (“Other” NAPIS
Services) X Hour X III B
Mental Health (“Other” NAPIS Services) X Hour X III B
Peer Counseling (“Other” NAPIS Services) X Hour X III B (X) Required Element
1Required service categories. Elder Abuse Prevention requires at least one reported service category.

Exhibit F: Sourcewise Provider Manual
DRAFT
CARS Required Title III B, C, D, and VII Non-Registered Fields, Continued Service Category Service Units
Estimated
Clients/
Audience
Funding
Source
Personal Affairs Assistance (“Other” NAPIS Services) X Contact X III B Personal/Home Security (“Other” NAPIS Services) X Product X III B Public Information (“Other” NAPIS Services) X Activity X III B Registry (“Other” NAPIS Services) X Hour X III B
Residential Repairs/Modifications (“Other” NAPIS
Services) X Modification X III B
Respite Care (“Other” NAPIS Services) X Hour X III B
Senior Center Activities (“Other” NAPIS Services) X Hour X III B Telephone Reassurance (“Other” NAPIS Services) X Contact X III B Visiting (“Other” NAPIS Services) X Hour X III B
(X) Required Element
1Required service categories. Elder Abuse Prevention requires at least one reported service category.

Chart Guidelines
Apply
the following chart to determine if form(s) or records have the required data collection and reporting elements for Title III E Non-Registered services.

CARS Title III E, FCSP Caring for Elderly or Caring for Child Required Non- Registered Fields
Service Category Service Units Estimated
Clients/Audience
Outreach (Access Assistance) X Contact X
Information and Assistance (Access Assistance) X Contact X Interpretation/Translation (Access Assistance) X Contact X Legal Resources (Access Assistance) X Contact X
Public Information (Information Services) X Activity X
Community Education (Information Services) X Activity X (X) Required Element
Exhibit F: Sourcewise Provider Manual
DRAFT
The following list contains web links of applicable laws/regulations/policies:
• Area Plan Contract - www.aging.ca.gov/Contracts_Download_Page • CCR - California Code of Regulations, Title 22 Division 1.8 - www.govt.westlaw.com/calregs • CFR - Code of Federal Regulations, Title 45 Part 1321 - www.ecfr.gov • OAA - Older Americans Act - www.acl.gov/about-acl/authorizing-statutes/older-americans-act • OCA - California Welfare and Institutions (W&I) Code, Division 8.5 Mello-Granlund Older Californians Act - www.leginfo.legislature.ca.gov
• NAPIS SPR – ACL National Aging Program Information System State Program Reports - www.acl.gov/programs/state-program-reports
• PM - CDA Program Memoranda - www.aging.ca.gov/PM
Exhibit F: Sourcewise Provider Manual
DRAFT

Title III - Intake and Assessment
Sample Forms

CALIFORNIA DEPARTMENT OF AGING

HOME AND COMMUNITY LIVING DIVISION
www.aging.ca.gov

July 2021

Exhibit F: Sourcewise Provider Manual
DRAFT

Introduction

Because each AAA has tailored programs to meet their community needs, CDA does not have required intake or assessment forms. CDA has designed these sample templates to help the AAAs evaluate and create their own forms for collecting and recording required performance data elements.

What is Reviewed

CDA reviews the forms to ensure all required data collection elements are integrated.

AAAs may use these forms, revise them, or create forms to meet local needs. AAAs do not have to use these sample templates.

Forms

This section contains the following templates:

Sample 1
• Title III B, C-1, C-2, and D (Cluster 1& 2, Registered) • Personal Care, Homemaker, Chore, Home-Delivered Meals, Adult Day Care/Health, Case Management, Congregate Meals, Nutritional Counseling, Assisted Transportation, Other Non-Registered Services

Sample 2
• Title III B, C-2 (Cluster 1)
• Personal Care, Homemaker, Chore, Home-Delivered Meals, Adult Day Care/Health, Case Management

Sample 3
• Title III B, C1, and D (Cluster 2)
• Congregate Meals, Nutritional Counseling, Assisted Transportation

Sample 4
• Title III C-2
• Home-Delivered Meals

Sample 5
• Title III C-1
• Congregate Meals

Exhibit F: Sourcewise Provider Manual
DRAFT

Sample 6
• Title III E (Group 1, Registered)
• Caring for Elderly, Caring for Child

Sample 7
• Title III E (Group 1)
• Caring for Elderly

Sample 8
• Title III E (Group 1)
• Caring for Child

Sample 9
• Title III B (Cluster III, Non-Registered)
• Information and Assistance

Sample 10
• Title III B
• Legal Assistance

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 2]
CDA Sample 1, Title III B, C-1, C-2, Registration-Assessment Form (2021) SAMPLE 1, TITLE III
Provider Name: Unique Participate ID: ___________________________ Registration/Assessment Date: ___________________
Termination Date: *Reason:

Region/Site Name:

Service Categories (Titles IIIB, IIIC and IIID):
*Personal Care (IIIB) (A, I) *Homemaker (IIIB) (A, I) *Chore (IIIB) (A, I) *Home-Delivered Meals (A, I, N) *Adult Day Care/Health (IIIB) (A, I) *Case Management (IIIB) (A, I) *Assisted Transportation (IIIB) *Congregate Meals (N) *Nutrition Counseling (N) Other: ____________________________

Notes: Reference the Data Dictionary for allowable “Other” service categories; Requires A-ADLs, I-IADLs, N-Nutritional Assessments on Page 2 SECTION 1 (Client)
(*) Required for All Registered Programs
PERSONAL DATA (Please print):

First Name:

Middle Initial:

Last Name:
*What is your
gender?
(Check only one)
Male Female
Transgender Male to Female
Transgender Female to Male
Genderqueer/Gender Non-binary
Not Listed, please specify:
______________________________
Declined/not stated
*What was your
sex at birth?
(Check only one)
Male Female
Declined/not stated
*How do you
describe your
sexual
orientation or
sexual identity?
(Check only one)
Straight/Heterosexual
Bisexual
Gay/Lesbian/Same-Gender Loving
Questioning/Unsure
Not Listed, please specify:
______________________________
Declined/not stated
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Race:
(Check all that
apply)
White Black
American Indian/Alaska Native
Asian:

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 2]
CDA Sample 1, Title III B, C-1, C-2, Registration-Assessment Form (2021) SECTION 2 – ADL and IADL (Activities of Daily Living and Instrumental Activities of Daily Living – Annual Assessment) *Required for (III-C): Home Delivered Meals; (III-B): Personal Care, Homemaker, Chore, Adult Day Care, Case Management ADLs: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
*Eating
*Bathing
*Toileting
*Transferring In/Out of
Bed/Chair
*Walking
*Dressing
Notes:

IADLS: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
*Meal Preparation
*Shopping
*Medication Management
*Money Management
*Using Telephone
*Heavy Housework
*Light Housework
*Transportation
Notes:

SECTION 3 – Nutritional Risk Assessment (Annual)
* Required for (IIIC): Home-Delivered Meals, Congregate Meals; Nutritional Counseling *Nutritional Risk Assessment: Circle if yes
I have an illness or condition that made me change the kind and/or amount of food I eat. 2 I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1
I take 3 or more different prescribed or over–the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the past 6 months. 2 I am not always physically able to shop, cook, and/or feed myself. 2 Total Score:

Is Nutrition Risk total score 0-5 or 6+? 0 - 5 6+

Declined to State
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 2]
CDA Sample 2, Cluster 1 Title III B, C-1, C-2, Registration-Assessment Form (2021) SAMPLE 2, CLUSTER 1
Provider Name: Unique Participate ID: ___________________________ Registration/Assessment Date: ___________________
Termination Date: *Reason:

Region/Site Name:

Service Categories (Titles IIIB and IIIC):
*Personal Care (IIIB) (A, I) *Homemaker (IIIB) (A, I) *Chore (IIIB) (A, I) *Home-Delivered Meals (A, I, N) *Adult Day Care/Health (IIIB) (A, I) *Case Management (IIIB) (A, I)

First Name:

Middle Initial:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Emergency
Contact:

Name:

Relationship:

Phone #: ( )
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Race:
(Check all that
apply)
White Black
American Indian/Alaska Native
Asian:

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 2]
CDA Sample 2, Cluster 1 Title III B, C-1, C-2, Registration-Assessment Form (2021) SECTION 2 – ADL and IADL (Activities of Daily Living and Instrumental Activities of Daily Living – Annual Assessment) *Required for (III-C): Home Delivered Meals; (III-B): Personal Care, Homemaker, Chore, Adult Day Care, Case Management ADLs: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
*Eating
*Bathing
*Toileting
*Transferring In/Out of
Bed/Chair
*Walking
*Dressing
Notes:

Is Nutrition Risk total score 0-5 or 6+? 0 - 5 6+

Declined to State

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 2]
CDA Sample 3, Cluster 2, Title III B, C-1, Registration-Assessment Form (2021) SAMPLE 3, CLUSTER 2
Provider Name: Unique Participate ID: ___________________________ Registration/Assessment Date: ___________________
Termination Date: *Reason:

Region/Site Name:

Service Categories (Titles IIIB and IIIC):
*Assisted Transportation *Congregate Meals (N) *Nutrition Counseling (N)

Notes: Requires N-Nutritional Assessments on Page 2
SECTION 1 (Client)
(*) Required for All Registered Programs
PERSONAL DATA (Please print):

First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Emergency
Contact:

Name:

Relationship:

Phone #: ( )
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Race:
(Check all that
apply)
White Black
American Indian/Alaska Native
Asian:

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated
Transportation Service Needs:

Walks with no assistance (Non-Assisted)
Walks with assistance (Assisted)
Wheelchair ramp/lift

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 2]
CDA Sample 3, Cluster 2, Title III B, C-1, Registration-Assessment Form (2021) SECTION 2 – Nutritional Assessment (Annual)
* Required for (IIIC): Congregate Meals, Nutritional Counseling *Nutritional Assessment: Circle if yes
I have an illness or condition that made me change the kind and/or amount of food I eat. 2 I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1
I take 3 or more different prescribed or over–the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the past 6 months? 2 I am not always physically able to shop, cook, and/or feed myself. 2 Total Score:

Is Nutrition Risk total score 0-5 or 6+? 0 - 5 6+

Declined to State

Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 2]
CDA Sample 4, Title III C-2, Home-Delivered Meals, Registration-Assessment Form (2021) SAMPLE 4, C-2
Name of Home-Delivered Meals
Provider This form is designed to be completed by
an intake staff. Items marked with an asterisk (*) are
required.

Route:

Intake Date: _________
Active Date: _________ Inactive Date: _________
Active Date: _________ Inactive Date: _________
Active Date: _________ Inactive Date: _________
*Unique Participant ID: *Termination Date: Reason:
*Date of Birth:
/ /
New client
Annual reassessment
Change in information
First Name: Last Name:

Home Address City: *Zip Code
Home Phone: ( )
Alternate Phone: ( )
Emergency Contact Name:

Address:

Phone: ( ) Relationship:
*Living Arrangement
# of household members:

Declined/not stated
*What is your approximate household income?
$ ___________________ per month year
Declined/not stated
*Rural Area:

Yes No
Declined/not stated
*What is your gender?
(Check only one)
Male Female
Transgender Male to Female
Transgender Female to Male
Genderqueer/Gender Non-binary
Not Listed, please specify:
______________________________
Declined/not stated
*What was your sex at
birth? (Check only one)
Male
Female
Declined/not stated
*How do you describe your sexual orientation or
sexual identity?
(Check only one)
Straight/Heterosexual
Bisexual
Gay/Lesbian/Same-Gender Loving
Questioning/Unsure
Not Listed, please specify:
______________________________
Declined/not stated
*Ethnicity: (Check one)
Hispanic Yes No Declined/not stated
Language:

English Speaking Need interpreter Non-English/Language *Race: (Check all that apply)
White Black American Indian/Alaska Native Asian:

Asian Indian Cambodian Chinese Filipino Japanese Korean Laotian Vietnamese Other Asian Hawaiian/Other Pacific Islander Guamanian Hawaiian Samoan Other Pacific Islander Declined/not stated
ADLs: ADLs and IADLs (Activities of Daily Living and Instrumental Activities of Daily Living) Please rate your functional abilities for the following activities.

ADLs Rated Value IADLs Rated Value IADLs Rated Value RATING SCALE

1 – Independent
2 – Verbal
Assistance
3 – Some Human
Help
4 – Lots of Human
Help
5 – Dependent
6 - Declined to
State
Feeding Meal Preparation Light Housework
Dressing Shopping Heavy Housework
Bathing Manage Medication Notes:

Transferring In/Out
of Chair Money Management
Walking Telephone
Toileting Transportation
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page2 of 2]
CDA Sample 4, Title III C-2, Home-Delivered Meals, Registration-Assessment Form (2021) Eligibility:

Are you homebound due to an illness, disability, or isolation? Are you a spouse of a home-delivered meal recipient?
Are you an individual with a disability who resides with a home-delivered meal recipient? Prioritization:

*Nutritional Risk Assessment: Circle if yes
I have an illness or condition that made me change the kind and/or amount of food I eat. 2 I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1
I take 3 or more different prescribed or over–the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the past 6 months. 2 I am not always physically able to shop, cook, and/or feed myself. 2 Total Score:
*Is Nutrition Risk Total Score 0-5 or 6+ ? 0-5 6+

Declined to State

Yes No Comments
Do you have any dietary restrictions?
Do you have a working refrigerator?
Do you have a working microwave?
Are you physically and mentally able to open the food containers? Are you physically and mentally able to reheat a meal?
Are there pets?
Have you recently been discharged from the hospital?

Referral(s) Made:

Nutritional education/counseling for at risk client
Other:

Other:

Notes:

____________________________________________________ _________________________ Staff Completing Assessment Date
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 2]
CDA Sample 5, Title III C-1, Congregate Meals, Registration-Assessment Form (2021) SAMPLE 5, C-1
Name of Congregate Meal Provider
{Provider Name}
Please complete this form to the best of your
ability. Items marked with an asterisk (*) are
required.
*Unique Participate ID: _________
Referred by: __________________
Intake Date: ___________________
Staff: ________________________
Beginning Date: ________________
*Termination Date: _____________
*Reason: _____________________
Eligibility:

Age 60+
Spouse of congregate meal
participant
Disabled person residing where
the congregate site is located
Disabled person who resides
with and accompanies a congregate
meal participant
Volunteer
First Name: Last Name: *Date of Birth:

Home Address City: *Zip Code
Mailing Address: Same As Residential? Yes City: *Zip Code Home Phone: ( )
Alternate Phone: ( )
Emergency Contact Name:

Address:

Phone: ( ) Relationship:
*Living Arrangement
# of household members:

Declined/not stated
*What is your approximate household income?
$ ___________________ per month year
Declined/not stated
*Rural Area:

English Speaking Need interpreter Non-English/Language *Race: (Check all that apply)
White Black American Indian/Alaska Native Asian:

Asian Indian Cambodian Chinese Filipino Japanese Korean Laotian Vietnamese Other Asian Hawaiian/Other Pacific Islander Guamanian Hawaiian Samoan Other Pacific Islander Declined/not stated
Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 2]
CDA Sample 5, Title III C-1, Congregate Meals, Registration-Assessment Form (2021) *Nutritional Risk Assessment: Circle if yes
I have an illness or condition that made me change the kind and/or amount of food I eat. 2 I eat fewer than 2 meals per day. 3
I eat few fruits or vegetables or milk products. 2
I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don’t always have enough money to buy the food I need. 4 I eat alone most of the time. 1
I take 3 or more different prescribed or over–the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the past 6 months. 2 I am not always physically able to shop, cook, and/or feed myself. 2 Total Score:

Is Nutrition Risk total score 0-5 or 6+ ? 0 - 5 6+

Declined to State

I understand that the information I am providing on this form is for registration purposes. I understand it will be kept confidential and that the Area Agency on Aging and service providers may use it to help identify other services for which may benefit.

_________________________________________________________ ____________________________ Signature of participant or person completing the form Date Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 4]
CDA Sample 6, Title III E, Caregivers of Older Adults, Older Elderly Relative, Registration-Assessment Form (2021) SAMPLE 6, TITLE III E CAREGIVERS OF OLDER ADULTS, OLDER ELDERLY RELATIVE

SECTION 1 – Service Information
Provider Name: Registration/Assessment Date:

*Termination Date: *Reason: Region/Site Name:

Service Categories:

Caregivers of Older Adults Caregivers of Older Adults
Notes: Check Eligibility criteria below to determine for which program caregiver qualifies

Title III E, Family Caregiver Support Program Services to be Provided Support Services:

Caregiver Assessment Caregiver Support
Caregiver Counseling Caregiver Training
Caregiver Peer Counseling Case Management

Respite Care Services:
(Care Receiver must have
2 or more ADL limitations, a
cognitive impairment, or be
grandparent/elder caregiver
to qualify)
In-Home Supervision
Homemaker Assistance
In-Home Personal Care
Home Chore
Out of Home Day
Out of Home Overnight
Supplemental Services: (Care Receiver must have 2 or more ADL limitations, a cognitive impairment, or be a grandparent/older caregiver to qualify)
Assistive Devices Home Adaptations for Caregiving Caregiving Services Registry Cash/Material Aid Access Assistance:

Information & Assistance Caregiver Outreach
Interpretation/Translation
Caregiver Legal Resources
Information Services:

Public Information on Caregiving
Community Education on Caregiving
SECTION 2 – Eligibility Criteria
Caregivers of Older Adults Eligibility Criteria

1. Is the Care Receiver an older individual (60 years of age or older) or an individual (of any age) with Alzheimer’s disease or related disorder with neurological and organic brain dysfunction? Yes No

If answered “yes” to both questions above, check “Family Caregiver Caring for Elderly” box in Section 1. If answered “no” check to see if individual qualifies for “Grandparent/Older Caregiver Caring for Child” component below.

Older Elderly Relative Eligibility Criteria

1. Is the Care Receiver an individual who is not more than 18 years of age or who is an individual (of any age) with a disability? Yes No

2. Is the Caregiver a grandparent, step-grandparent, or other older relative of a child by blood, marriage, or adoption who is 55 years of age or older, living with the child, and identified as the primary caregiver through a legal or informal arrangement. Biological and adoptive parents are excluded. Yes No If answered “yes” to both questions above, check “Grandparent/Older Caregiver Caring for Child” box in Section 1.

If the Care Receiver does not meet any of the criteria above, the Caregiver is ineligible to receive FCSP services, but may qualify to receive other services provided by the Area Agency on Aging.

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 4]
CDA Sample 6, Title III E, Caregivers of Older Adults, Older Elderly Relative, Registration-Assessment Form (2021) SECTION 3 (FCSP Caregiver)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated
*Race: (Check all that apply)
White Black American Indian/Alaska Native
Asian:

Husband Wife
Grandparent Domestic Partner
Daughter/Daughter-in-law
Son/Son-in-law
Brother Sister
Parents
Other Relative
Non-Relative
Declined/not stated
*Relationship
Status:

Single (never married) Married
Domestic Partner Separated
Divorced Widowed
Declined/not stated
*Employment:

Full Time Unemployed
Part Time Declined/not stated
Retired

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 3 of 4]
CDA Sample 6, Title III E, Caregivers of Older Adults, Older Elderly Relative, Registration-Assessment Form (2021) SECTION 4 (FCSP Care Receiver)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated
*Race: (Select all that apply)
White Black American Indian/Alaska Native
Asian:

Single (never married)
Married
Domestic Partner
Separated
Divorced
Widowed
Declined/not stated

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 4 of 4]
CDA Sample 6, Title III E, Caregivers of Older Adults, Older Elderly Relative, Registration-Assessment Form (2021) SECTION 5 – (FCSP Care Receiver)
ADL and IADL (Activities of Daily Living and Instrumental Activities of Daily Living) *Required for the Care Receiver only in Support Services, Respite Care, and Supplemental Services.

(Not required for Care Receivers in FCSP Older Adults/Relative) ADLs: 1 –
Independent
2 – Verbal
Assistance
3 – Some
Human Help
4 – Lots of
Human Help
5 –
Dependent
Declined to
State
*Eating
*Bathing
*Toileting
*Transferring In/Out of
Bed/Chair
*Walking
*Dressing
Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 4]
CDA Sample 7, Title III E, Caregivers of Older Adults, Registration-Assessment Form (2021) SAMPLE 7, TITLE III E, CAREGIVERS OF OLDER ADULTS

SECTION 1 – Service Information
Provider Name: Registration/Assessment Date:

*Termination Date: *Reason: Region/Site Name:

Title III E, Family Caregiver Support Program Services to be Provided Support Services:

Caregiver Assessment Caregiver Support
Caregiver Counseling Caregiver Training
Caregiver Peer Counseling Case Management

Information & Assistance Caregiver Outreach
Interpretation/Translation
Caregiver Legal Resources
Information Services:

Public Information on Caregiving
Community Education on Caregiving
SECTION 2 – Eligibility Criteria
Caregivers of Older Adults Eligibility Criteria

1. Is the Care Receiver an older individual (60 years of age or older) or an individual (of any age) with Alzheimer’s disease or related disorder with neurological and organic brain dysfunction? Yes No

2. Is the Caregiver an adult (18 years of age or older) family member or another individual (e.g., friend or neighbor) who is an informal (i.e., unpaid) provider of in-home or community care to an “elderly” Care Receiver? Yes No If the Care Receiver does not meet any of the criteria above, the Caregiver is ineligible to receive FCSP Caregivers of Older Adults services but may qualify to receive other services provided by the Area Agency on Aging.

Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 4]
CDA Sample 7, Title III E, Caregivers of Older Adults, Registration-Assessment Form (2021) SECTION 3 (FCSP Caregiver)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Husband Wife
Grandparent Domestic Partner
Daughter/Daughter-in-law
Son/Son-in-law
Brother Sister
Other Relative
Non-Relative
Declined/not stated
*Relationship
Status:

Single (never married) Married
Domestic Partner Separated
Divorced Widowed
Declined/not stated
*Employment:

Full Time Unemployed
Part Time Declined/not stated
Retired

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 3 of 4]
CDA Sample 7, Title III E, Caregivers of Older Adults, Registration-Assessment Form (2021) SECTION 4 (FCSP Care Receiver)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Single (never married)
Married
Domestic Partner
Separated
Divorced
Widowed
Declined/not stated

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 4 of 4]
CDA Sample 7, Title III E, Caregivers of Older Adults, Registration-Assessment Form (2021) SECTION 5 – (FCSP Care Receiver)
ADLs: ADLs and IADLs (Activities of Daily Living and Instrumental Activities of Daily Living):

Required for Support Services, Respite Car, and Supplemental Services.

Please rate your functional abilities for the following activities.

ADLs Rated Value IADLs Rated Value IADLs Rated Value RATING SCALE

1 – Independent
2 – Verbal
Assistance
3 – Some Human
Help
4 – Lots of Human
Help
5 – Dependent
6 - Declined to
State
Feeding Meal Preparation Heavy Housework
Dressing Shopping Light Housework
Bathing Manage Medication Notes:

Transferring In/Out
of Chair Money Management
Walking Telephone
Toileting Transportation
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 3]
CDA Sample 8, Title III E, Older Elderly Relative, Registration-Assessment Form (2021) SAMPLE 8, TITLE III E, OLDER ELDERLY RELATIVE

SECTION 1- Service Information
Provider Name: Registration/Assessment Date:

*Termination Date: *Reason: Region/Site Name:

Title III E, Family Caregiver Support Program Services to Be Provided Support Services:

Caregiver Assessment Caregiver Support
Caregiver Counseling Caregiver Training
Caregiver Peer Counseling Case Management

Information & Assistance Caregiver Outreach
Interpretation/Translation
Caregiver Legal Resources
Information Services:

Public Information on Caregiving
Community Education on Caregiving
SECTION 2 – Eligibility Criteria
Caregivers of Older Adults Eligibility Criteria

1. Is the Care Receiver an individual who is not more than 18 years of age or an individual (of any age) with a disability? Yes No

2. Is the Caregiver a grandparent, step-grandparent, or other older relative of a child by blood, marriage, or adoption who is 55 year of age or older living with the child, and identified as the primary caregiver through a legal or informal arrangement? Biological and adoptive parents are excluded Yes No If the Care Receiver does not meet any of the criteria above, the Caregiver is ineligible to receive FCSP Grandparent Caring for Child services but may qualify to receive other services provided by the Area Agency on Aging.

Notes:

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 2 of 3]
CDA Sample 8, Title III E, Older Elderly Relative, Registration-Assessment Form (2021) SECTION 3 (Grandparent/Older Caregiver)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Grandparent Parent
Other Relative
Non-Relative
Declined/not stated
*Relationship
Status:

Single (never married) Married
Domestic Partner Separated
Divorced Widowed
Declined/not stated
*Employment:

Full Time Unemployed
Part Time Declined/not stated
Retired

Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 3 of 3]
CDA Sample 8, Title III E, Older Elderly Relative, Registration-Assessment Form (2021) SECTION 4 (Child)
(*) Required for Family Caregiver Support Program Services

Caregiver Personal Data (Please print):
*Unique
Participant ID
First Name:

Middle Initial:

Home Phone: ( )
Residential Address:

Street:

City:
*Zip Code:

Mailing Address:

Same as Residential? Yes – Skip to Next Section
Street:

City:
*Zip Code:

Demographics:
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Federal Poverty
Level (FPL):

Single (never married)
Married
Domestic Partner
Separated
Divorced
Widowed
Declined/not stated
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 1]
CDA Sample 9, Information & Assistance Form (2021)
SAMPLE 9, INFORMATION & ASSISTANCE

Date: _______________________ Staff Completing Intake: ____________________________________

*Indicates optional demographic information that is kept confidential and anonymous. This information is important in understanding the people that we serve.

Demographic Data
*Unique
Participant ID:

Name:
*Birth Date:

Home Phone #: ( )
Email:

Address:
*What is your
gender?
(Check only one)
Male Female
Transgender Male to Female
Transgender Female to Male
Genderqueer/Gender Non-binary
Not Listed, please specify:
______________________________
Declined/not stated
*What was your
sex at birth?
(Check only one)
Male Female
Declined/not stated
*How do you
describe your
sexual
orientation or
sexual identity?
(Check only one)
Straight/Heterosexual
Bisexual
Gay/Lesbian/Same-Gender Loving
Questioning/Unsure
Not Listed, please specify:
______________________________
Declined/not stated
*Ethnicity:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Race:
(Check all that
apply)
White Black
American Indian/Alaska Native
Asian:

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated
Service Requested:

Action Taken/Referral:

Follow Up:

Type of I & A:

III B (If Requesting Services for an Older Individual)
III E Caregivers (If Requesting Services for an Older
Individual)
III E Relative (If Requesting Services for an Older
Individual)
Exhibit F: Sourcewise Provider Manual
DRAFT

[Page 1 of 1]
CDA Sample 10, Legal Assistance (2021)
SAMPLE 10, III B LEGAL ASSISTANCE

Date: _______________________ Staff Completing Intake: ____________________________________

*Required Information

PERSONAL DATA
*Unique
Participant ID:

Name:
*Birth Date:

Phone #: ( )
Email:

Not Hispanic/Latino
Hispanic/Latino
Declined/not stated
*Race:
(Check all that
apply)
White Black
American Indian/Alaska Native
Asian:

Yes (At or below FPL)
No (Above FPL)
Declined/not stated
*Lives Alone? Yes No
Declined/not stated
*Rural? Yes No
Declined/not stated

CASE INFORMATION
*Unique Case ID:
*Case Opened
Date:

*Case Closed
Date:

*Service Level:

Advice
Limited Representation
Representation
*Case Type:

Income
Health Care
Long Term Care
Nutrition
Housing
Utilities
Abuse/Neglect
Protective Services
Age Discrimination
Other/Miscellaneous
*Hours (Units):

Exhibit F: Sourcewise Provider Manual
DRAFT

SOURCEWISE SERVICE PROVIDER GRIEVANCE POLICY
I. Actions Subject to Appeal

A. A contracted or potential provider of service (service provider) has the right to appeal an adverse determination made by the Sourcewise (Area Agency on Aging).

The actions below shall be considered adverse determinations that are subject to appeal [Title 22 CCR §7704 (c)(1) – (c)(3)(C)]:

1. A reduction in the level of funding to an existing Contractor during an Agreement period; however, a reduction directly attributable to a reduction in the funding to Sourcewise by the State or federal government shall not be considered an adverse determination.

2. A cancellation or termination of an existing Agreement with the Contractor prior to the Agreement’s expiration date.

3. Denial of an application to provide services when any of the following exist:
a) The presence of a conflict of interest, real or apparent, as specified in 45 CFR 92.36(b)(3);
b) The occurrence of a procedural error or omission, such as the failure of Sourcewise to include a federal mandate in its solicitation request; c) The lack of substantial evidence to support an action by Sourcewise.

II. Method of Notification

A. The service provider shall provide notification of appeals, and Sourcewise shall provide notification of subsequent appeals determinations, by certified or overnight mail, return receipt requested, or by personal delivery in writing.

B. Notices to Sourcewise shall be addressed to:

Sourcewise
Att: Joe Flynn
Chief Operating Officer
3100 De La Cruz Blvd, Suite 310
Santa Clara, CA 95054

C. Sourcewise shall transmit notification to the address listed on the service provider’s appeal. Sourcewise shall include a copy of this Appeal Procedure for Service Providers with all notifications to service providers of adverse appeals determinations.

Exhibit F: Sourcewise Provider Manual
DRAFT
III. Process

A. The service provider shall give notice of intent to appeal to the CEO of the Sourcewise within ten (10) business days of the Agency on Aging’s notice of adverse determination. The notice of intent to appeal shall be in writing, must state the specific grounds upon which the action by Sourcewise is appealed, and must be accompanied by all supporting documents.

B. The CEO shall investigate the appeal and issue a written determination to the service provider within fifteen (15) business days of receipt of the appeal. The determination shall set forth the position of Sourcewise and specify applicable sections of the service provider’s Agreement with Sourcewise, government regulations, government statutes, or other provisions relied upon.

C. If the service provider is dissatisfied with the Sourcewise CEO’s determination, the service provider may appeal to Governing Board of Sourcewise within ten (10) business days of the date of the CEO of Sourcewise written determination. The appeal shall be in writing, shall specify the grounds upon which the determination is appealed, and must be accompanied by all supporting documents.

D. The President of the Governing Board of Sourcewise (Executive Committee) shall, within fifteen (15) business days of receipt of the service provider’s appeal:

1. Review the service provider’s appeal, considering any additional evidence or documentation provided by the CEO of Sourcewise;

2. Determine if the appeal should be denied, or if a recommendation should be made to the full Governing Board of Sourcewise at its next scheduled meeting to take action to grant the appeal; and

3. Provide written notification of its determination to the service provider.

E. If the service provider is dissatisfied with the Executive Committee’s determination, the service provider may request a hearing before the full Sourcewise Governing Board. The service provider must request the hearing within ten (10) business days of the Executive Committee’s written notification of determination. The hearing request shall be in writing, shall specify the grounds upon which the determination is appealed, and must be accompanied by all supporting documents.

F. If the Governing Board of Sourcewise does not accept and implement the Executive Committee’s recommendation to grant the service provider’s appeal:

1. Sourcewise shall provide written notification to the service provider of the Governing Board’s decision within two (2) business days following the decision;

2. The service provider may request a hearing before the Governing Board of Sourcewise. The service provider mus t request the hearing within ten (10) business days of the date of the notification of the Sourcewise Governing Board’s decision. The hearing request shall be in writing, shall specify the grounds upon which the determination is appealed, and must be accompanied by all supporting documents.

Exhibit F: Sourcewise Provider Manual
DRAFT

G. Upon receipt of the service provider’s request for a hearing before the Governing Board, Sourcewise will place the hearing on the agenda of the next regularly scheduled meeting of the Sourcewise Governing Board, and pro vide the service provider with a copy of the published agenda.

1. The hearing before the Sourcewise Governing Board shall consist of:

a) Receipt and review of all previously submitted documents concerning the appeal;
b) Submission in writing by the service provid er of any additional information or documentation supporting the service provider’s position;
c) An oral presentation by the service provider, not to exceed thirty (30) minutes; and
d) An oral presentation by the CEO of Sourcewise and/or Sourcewise staff, not to exceed thirty (30) minutes.

2. At the conclusion of the hearing, the Governing Board of Sourcewise shall vote to accept or deny the service provider’s appeal.

a) If the appeal is denied, the Governing Board of Sourcewise shall notify the service provider in writing of the reason(s) the appeal was denied, including a statement that all appeal procedures to Sourcewise and its Governing Board have been exhausted, and of the service provider’s right to appeal the Governing Board’s decision to the California Department of Aging. Such notification shall include a copy of Sections 7700 through 7710 of Title 22 of the California Code of Regulations, which contains the process for appealing the determination to the California Department of Aging.

Exhibit F: Sourcewise Provider Manual
DRAFT

Grievance Form
To help us ensure that we understand your grievance and can respond promptly, please return your completed form to:

SOURCEWISE
Attn: Joe Flynn
Chief Operating Officer
3100 De La Cruz Blvd. Suite 310
Santa Clara, CA 95054

Contract #: __________________
Contact Name:

Provider Name:

Address:

City, State, Zip Code:

Contact Number:

Please describe your grievance :

Be as specific as possible . Include any names or dates as this may help resolve your grievance.

You can use the back of this form or attach additional information.

Please describe how you would like to see your grievance resolved:

Signature Date ______________
Exhibit F: Sourcewise Provider Manual
DRAFT

STATE OF CALIFORNIA

DEPARTMENT OF AG ING

EQUIPMENT JUSTIFICATION FORM
CDA 7037 (REV
12/2022)
California Department of Aging Equipment Justification Form Instructions: Please answer the questions below; the responses must coincide with the budget.

AAA Name and Number:

AAA Procurement Contact:

Funding Source:

Question Response
Please describe the item or
items to be purchased and cost
of each item.

Select the procurement
method(s) used to select vendor
(i.e., price quotes, competitive
bids, auction site). Check all that
apply.
☐ Price Quotes
☐ Competitive bids
☐ Auction
☐ Other (Describe):

Where will the equipment be Direct Subcontractor
located?
Site name:

Address:

Please select the AAA program
the equipment will be funded by.

If more than one, please select
other and list all applicable
programs.

Program:

Other:

Please give a detailed justification
why the equipment is needed, and
how it will be used to benefit the
program.

The year the last time this item
was purchased and the quantity.

The expected refresh cycle of this
item.

Will the equipment be used solely
by the specified AAA Program(s)
from which the purchase will be
funded?
☐ Yes ☐ No
If requesting a vehicle, provide a
list of the existing fleet vehicles,
and the reason the existing fleet
cannot meet ongoing program
needs.

Exhibit G: Equipment Justification Form
DRAFT

City Council and Authorities ConcurrentJune 6, 2023

City Council and Authorities Concurrent
June 6, 2023