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
This 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, 2019, for the provision of Congregate Meal Services. The original contract was approved by the Board on June 18, 2019.

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

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

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

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

9. Add 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.

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

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COUNTY OF SANTA CLARA CONTRACTOR
Jeffrey Smith M.D., J.D., County Executive Office of City Manager Date: __________ Date: __________
ATTEST __________________________ ___________________________ , D Assistant City Clerk
Date: Date: __________

APPROVED AS TO FORM AND LEGALITY APPROVED AS TO FORM
Deputy County Counsel Office of the City Attorney
Date: __________ Date: __________
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
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 1965, as amended, P.L. 89-73, U.S.C. Section 3000 et seq., and all amendments, rules, and regulations pertaining thereto.

1. CONDITIONAL 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. TERM 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. BUDGET 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. COMPENSATION 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 Exhibit A-4 Program Provisions

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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 A121.

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 CONTRACTOR, 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 CONTRACTOR 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.
b. 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.

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. PARTICIPANT 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. ADVANCE 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 Exhibit A-4 Program Provisions
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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. ADJUSTMENT 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. ADJUSTMENT 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.

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. ADJUSTMENT 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.

SERVICE PROVIDED
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.

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

CONTRACTOR must assist in the coordination of and verification of eligibility for mobility management services for participants who use CONTRACTOR’S site as a home meal site.

CONTRACT REPRESENTATIVES
CONTRACTOR designates , Manager 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.

Exhibit A-4 Program Provisions
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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. To COUNTY: Social Services Agency
Office of Contracts Management
333 West Julian Street
San Jose, California 95110-2335
b. To CONTRACTOR: City of Santa Clara
, 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.

Exhibit A-4.1: Program Provisions
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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. SERVICE 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. CONDITIONAL 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.

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

4. MAXIMUM 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. BUDGET 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.

6. COMPENSATION TO CONTRACTOR
a. COST REIMBURSEMENT CONTRACT
Exhibit A-4.1: Program Provisions
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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. iii. CONTRACTOR must participate in a closeout period at the end of the COUNTY funding period. During the closeout period all funds awarded to CONTRACTOR 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. This provision survives the termination of this Contract.
b. COST 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. PURCHASE 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. ADJUSTMENT 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. ADJUSTMENT 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.

10. ADJUSTMENT 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. 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.

12. CONTRACT REPRESENTATIVES
Exhibit A-4.1: Program Provisions
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CONTRACTOR designates , 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.

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.

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

Exhibit B-4: Program Plan & Requirements
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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. SERVICE 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. PERMITS 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. ELIGIBLE 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. CONGREGATE MEAL SITES
Exhibit B-4: Program Plan & Requirements
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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 the 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. NUMBER OF MEALS, SERVING DAYS, AND HOLIDAYS
a. CONTRACTOR will provide the number of hot meals as specified in Exhibit C5: 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 Exhibit B-4: Program Plan & Requirements
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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. ADVISORY 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. SUPPORTIVE 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;
Exhibit B-4: Program Plan & Requirements
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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 participation 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. FOOD 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. DATA 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 NonExpendable 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 (4th) working day of the current month to their assigned registered dietitian.

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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 fifth (5th) 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 completion, evidence must be submitted to COUNTY to provide to Sourcewise.

12. PARTICIPANT 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 participant 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. VOLUNTEER, 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 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 at 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. MANDATORY 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. PURCHASES
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. NON-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. COMPETITIVE 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 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. OVERTIME WORK
Overtime work expenditures that are incurred by the CONTRACTOR will not be paid by reducing services or meals under this contract.

19. RESTRICTION 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. GRIEVANCE 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.

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 responding 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. FISCAL YEAR CLOSEOUT SUBMISSION
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.

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. SERVICE 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. POLICIES & 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. INTENT
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. BACKGROUND
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. PERMITS 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. PURCHASES
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 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. PURCHASING 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. NON-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. COMPETITIVE BID REQUIREMENTS
a. All equipment purchases by the CONTRACTOR exceeding five-thousand dollars ($5,000.00) 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 tenthousand 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 shall be maintained by CONTRACTOR showing the parties solicited and the bids submitted.

11. EQUIPMENT 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. EQUIPMENT 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. AUDIT
This funding could be subject to audits by the COUNTY, Sourcewise, the state government, and federal government.

14. RESTRICTION 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. FISCAL YEAR CLOSEOUT SUBMISSION
Due to fiscal reporting deadlines, CONTRACTOR must submit requested fiscal yearend closeout documents to COUNTY accounting staff by July 5, 2023.

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** $ 100% 27,022.00
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

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

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

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.

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: Mixer
Categories: Countertop
Floor
Type of Equipment: Kitchen 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 refrigerators and walk-in freezers are
excluded.)
Exhibit E: Title IIIC Capital Expenditure Approved List 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.

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 Cold) 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 for 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) must still be reported. * Per Title 2, Code of Federal Regulations, Section 200.439: "Capital expenditures for special purpose equipment are allowable as direct costs, provided that items with a unit cost of $5,000 or more have the prior written approval of the Federal awarding agency or passthrough entity." * Require CDA approval
Exhibit E: Title IIIC Capital Expenditure Approved List

SOURCEWISE PROVIDER MANUAL,
PLANNING SERVICE AREA, 10

SANTA CLARA COUNTY
Exhibit F: Sourcewise Provider Manual

PROVIDER MANUAL TABLE OF CONTENTS
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 1: INTRODUCTION
Exhibit F: Sourcewise Provider Manual
SECTION 2: GENERAL INFORMATION, REQUIREMENTS, & DUE DATES Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 3: SERVICE & CONTRACT COMPLIANCE REQUIREMENTS
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 4: GENERAL OLDER AMERICAN ACT PROGRAM REQUIREMENTS & LOCAL

REQUIREMENTS
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 5: SERVICE PERFORMANCE
Exhibit F: Sourcewise Provider Manual
SECTION 6: DATA & PROGRAM REPORTING
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 7: FISCAL, ACCOUNTING, RECORDKEEPING & AUDITS
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 8: PROGRAM MONITORING
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 9: GRANT MODIFICATIONS
Exhibit F: Sourcewise Provider Manual
SECTION 10: EQUIPMENT
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 11: CO-BRANDING AND MEDIA
SECTION 12: CONTRACTED SERVICES GRIEVANCE PROCEDURE & POLICY Exhibit F: Sourcewise Provider Manual
SECTION 13: GLOSSARY OF TERMS
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
SECTION 14: DATA & FISCAL TEMPLATES
Exhibit F: Sourcewise Provider Manual
Certificate of Completion Name:________________ This document certifies that the mentioned has completed CDA’s Privacy and Information Security Awareness TrainingDate Training Completed: _____________________ Employee Signature: _________________________ Exhibit F: Sourcewise Provider Manual

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

3. After selecting ‘Allow’ from the dropdown menu, click ‘Add’ within the row labeled ‘Internet Explorer mode pages’.

Exhibit F: Sourcewise Provider Manual

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

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

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
AAA Provider Workbook
Exhibit F: Sourcewise Provider Manual
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
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
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
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
6 CareAccess
Exhibit F: Sourcewise Provider Manual
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
Exhibit F: Sourcewise Provider Manual
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
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
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 Password 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
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
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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Lesson 2: Exploring the Q Workspace
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Exhibit F: Sourcewise Provider Manual
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" checkbox in the lower left corner of the Launcher.

In this workbook we will use the Launcher in list view.

Exhibit F: Sourcewise Provider Manual
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
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
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 visible. 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
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
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 displayed.

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
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
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
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
Lesson 3: Navigating with Q Grids
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Exhibit F: Sourcewise Provider Manual
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
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
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 , 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.

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26 CareAccess
Lesson 4: The Client Record
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Exhibit F: Sourcewise Provider Manual
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
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
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 client'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.

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Lesson 6: Client Service Plans
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Exhibit F: Sourcewise Provider Manual
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
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
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!
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Exhibit F: Sourcewise Provider Manual
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
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 Logging 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 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
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 prepopulated 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
38 CareAccess
Lesson 8: Other Service Unit Entry Methods
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Exhibit F: Sourcewise Provider Manual
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
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
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 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
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
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 service(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
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 category.

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
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 (rightclick on name).

Special Functions: Mass Disenroll and Mass Copy.

Exhibit F: Sourcewise Provider Manual
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 (rightclick 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
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 (rightclick on name).

Special Functions: None
Exhibit F: Sourcewise Provider Manual
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
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 presented.

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
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
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 applications.

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 document.

Exhibit F: Sourcewise Provider Manual
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
Lesson 12: Printing Reports
52 CareAccess
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Exhibit F: Sourcewise Provider Manual
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
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
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
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
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
58 CareAccess
Lesson 14: The Waiting Room
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Exhibit F: Sourcewise Provider Manual
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 and then Waiting 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
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 message! To create a new folder and move the message there:

Create a new email folder5. 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
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
Lesson 15: Q Extras
6 CareAccess
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Exhibit F: Sourcewise Provider Manual
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
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 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 or
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 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
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
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
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).

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
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
August 2010: Fi
Client 1 2 3 4 5 6 7 8 9 10 1
111111111111 11111111111111111111111 Andrews,Julie
56 111111111111 11111111111111111111111 Beatty, Warren
32 111111111111111111111 11111111 Bennett, Tony
60 11111111111111111111111111111111111 Brooks, Mel 15
Illl IIIllllllllllllllllllllll
Connery, Sean
27 Exhibit F: Sourcewise Provider Manual
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. by 2
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
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
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 service) 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
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
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
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 follows:

Base Station
COMM1

4. After making sure the proper selections are chosen, click on Transfer Application.

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 format and contents are described in detail in 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, last name, and 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
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 standard manual entry functions (including Service Unit Entry and Service Unit Logging). Additionally, batches and their accompanying units can be completely deleted and resubmitted until the units are posted for accounting purposes (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
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
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 provided 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 from Care (which is the default selection) as well as any funding sources for the selected agency/service combination that has the Schedule Cap 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
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
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
CareAccess
www.careaccess-ca.com
[email protected]
877-262-9322
Exhibit F: Sourcewise Provider Manual
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. 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
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
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
Caregiver Quick Reference Page 4
Step 3
Caregiver record
The Caregiver record is completely different 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. have to fill in address, DOB, or other fields. You will synchronize this record with this Client record.

Click the Save button to save the record, but do not close the record.

Exhibit F: Sourcewise Provider Manual
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.

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
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 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 .

Exhibit F: Sourcewise Provider Manual
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
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 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
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 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 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 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
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
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
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
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 (rightclick 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
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 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 and Client record (right-click on name) Special Functions: None
6 Q System Administrator Workbook
rev 1/07 ME
Exhibit F: Sourcewise Provider Manual
Title III - Intake and Assessment
Forms Guide

CALIFORNIA DEPARTMENT OF AGING

HOME AND COMMUNITY LIVING DIVISION
www.aging.ca.gov
July 2021
Exhibit F: Sourcewise Provider Manual
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 ..................................................................................................................... 3 Legal Assistance Service Category - Case Information ............................................................................. 3 Optional Client Level Detail ...................................................................................................................... 3 Required Title III B, C, D and VII B (Cluster III), Non-Registered Client Fields........................................... 4 Required Title III E, Non-Registered Client Fields ..................................................................................... 4 Data Performance References .................................................................................................................. 4 Exhibit F: Sourcewise Provider Manual
Overview
Introduction
Data and the information created from data elements contribute to valuable knowledge aboutservice 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.

Background
AAA staff spends a large percentage of their time reading, completing, processing, and retrieving forms created or received by the agency.

Forms are an important part of the 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 t help AAAs evaluate and design agency intake forms.
his guide does not address Community Based Service Programs (CBSP), Health Insurance Counseling and Advocacy Program (HICAP), Long-Term Ombudsman Program, Senio Community Services Employment Program (Title V), or fiscal forms.

Exhibit F: Sourcewise Provider Manual
Purpose
The Older 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 Performance 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 within 10 days, AAA staff mus 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
NAPIS Validation
As part 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 reviews 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
Introduction
The arrangement 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.

Databases may have separate data entry screens for
Client Detail Identification
Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), and/or Nutritional Risk Assessment
Establish Item Sequence
Arrange 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 required data elements clear and visible. Design forms to clearly define form fields with bound boxes and headers.

What is Reviewed?
CDA reviews AAA forms to ensure all required data collection elements are integrated. See Chart Guidelines.

Exhibit F: Sourcewise Provider Manual
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 4 for NonRegistered fields.

CARS Title 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 Client
Required Client Level Detail
Participant I to
Determine
Unduplicated Count
Birth Date
Zip Code
Rural
Gender
Sex at Birth
Sexual Orientation or
Sexual Identity
Race
Ethnicity
Poverty Status
Living Arrangement
Exhibit F: Sourcewise Provider Manual
2 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 Functional Impairment Rating Scale
(1) Independent: 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 default, report only three levels: 1, 3, or 5 (and 6 – Declined to State). 3 Nutritional Risk - Required Score
(1) Yes: Nutritional risk with score 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 reportin 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
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 for Non-Registered fields.

CARS Title III E, FCSP Caregivers of Older Adults/Older Elderly Relative, Required Registered Caregiver 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 Birth
Sexual Orientation or
Sexual Identity
Race
Ethnicity
Poverty Status
Living Arrangement
Relationship Status
Employment Status
Caregiver Relationship
Exhibit F: Sourcewise Provider Manual
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 the Care Receiver in the Title III E, Family Caregiver Support Program (FCSP), 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 Required Element
Participant ID to
Determine
Birth Date
Zip Code
Gender
Sex at Birth
Sexual Orientation or
Sexual Identity
Race
Ethnicity
Poverty Status
Living Arrangement
Relationship Status
Exhibit F: Sourcewise Provider Manual
3 ADL/IADL Required Functional Rating Scale for each of the following:

Exhibit F: Sourcewise Provider Manual
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 an reporting elements for the Care Receiver in the Title III E FCSP 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
Determine
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 Child Exhibit F: Sourcewise Provider Manual
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, FCSP caregivers and care receivers.

Title III B, C, and D, Supportive and Nutrition Services Personal 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 & Care Receiver

SUPPLEMENTAL 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
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
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
Required Registered Client Level Detail, Continued
Ethnicity
The following reflects the OMB’s ethnicity reporting requirement. Hispanic or Latino origin is Ethnicity CARS Options
Not Hispanic/Latino
Hispanic/Latino
Declined to State
Missing
Living Arrangement
ACL defines “living alone” as a one-person household (using the Census definition of household) the householder lives by his or herself in an owned or rented place of residence in a noninstitutional setting.

Living Arrangement CARS Options
Alone
Not Alone
Declined to State
Missing
Exhibit F: Sourcewise Provider Manual
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
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, particular attention to low-income minority individuals.

Under the OAA, “greatest economic need” means the need resulting from an income level at or poverty levels established by OMB.

ACL uses the Federal Poverty Guidelines for targeting and reporting.

Service Categories Required
The following are the programs that require collecting that require collecting poverty status for registered clients, or FCSP caregivers and care receivers.

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
What to Include?
Create a question to determine if the client, caregiver, or care receiver is at or below 100 percent of the federal poverty level.

Information is self-reported and collected annually.

What is Reviewed?
CDA will review demographic 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 Household 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
Living 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.

CDA Title III Forms Guide (July 2021
Exhibit F: Sourcewise Provider Manual
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 functional impairment scale to identify individuals with functional limitations. AAAs must also review functional limitations to determine eligibility for the provision of FCSP Caring Elderly Respite Care and Supplemental Services.

The OAA preference 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) physical 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 uses ADL and IADL characteristics for targeting frail older individuals and reporting purposes.

Service Categories Required
The table below lists the programs that require ADL and IADL limitation status for registered clients.

Title III B and C-2, Supportive and Nutrition Services
Personal Care
Homemaker
Chore
Home-Delivered Meals
Adult Day Care/Health
Case Management
Exhibit F: Sourcewise Provider Manual
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 Caregivers of Older Adults (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
What to Include?
Create six (6) ADL and eight (8) IADL questions with the functional ability rating scale to determine the impairment level of the applicant or client.

Information is self-reported and collected annually. Conduct reassessment as needed, based on changes in the client’s status within the year.

NOTE: Arrange questions to match database entry sequence.

How to Determine Score?
ACL defines “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 defines “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
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.

What is Reviewed?
CDA will review demographic data to determine if the AAA is reaching individuals who are functionally impaired.

To qualify 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
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?
INSTRUMENTAL 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
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
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................................................. 3 5 Meal Preparation............................... 3 5 Bathing .............................................. 3 5 Shopping ............................................ 3 5 Toileting............................................. 3 5 Medication Management.................. 3 5 Transferring In/Out of Bed/Chair...... 3 5 Money Management......................... 3 5 Walking.............................................. 3 5 Using Telephone ................................ 3 5 Dressing............................................. 3 5 Heavy Housework .............................. 3 5 Ligh Housework ............................... 3 5
Declined to State Transportation .................................. 1 3 5 Example 5:

Displays ADL and IADLs with descriptive functional ability rating scales.

ADLs and IADLs (Activities of Daily Living and Instrumental Activities of Daily Living) Please rate your functional ability for the following activities.

Client/Elderly Care Receiver 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.

Independent (able to feed self)
Verbal assistance (able to feed self but needs verbal assistance such as reminding or encouragement to eat)
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 required) Lots of human help (able to feed self but cannot hold utensils, cups, glasses, etc., constant presence of another person is required)
Dependent (unable to feed self at all)
Declined to State
Exhibit F: Sourcewise Provider Manual
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.

Independent (able to bathe self safely)
Verbal assistance (able to bathe self with direction or intermittent monitoring; may need reminding to maintain personal hygiene)
Some human help (generally able to bathe self, but needs assistance) Lots of human help (requires direct assistance with most aspects of bathing; would be at if left alone)
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.

Independent (no assistance needed)
Verbal assistance (requires reminding and direction only) Some human help (requires minimal assistance with some activities, but the constant of the provider is not necessary)
Lots of human help (unable to carry out most activities without assistance) 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 a wheelchair, or sofa, coming to a standing position and/or repositioning to prevent skin breakdown.

Independent (able to do all transfers safely)
Verbal assistance (able to transfer but needs encouragement or direction) Some human help (requires some help from another person; e.g., routinely requires a boost or assistance with positioning)
Lots of human help (unable to complete most transfers without physical assistance; would at risk if unassisted)
Dependent (totally dependent upon another person for all transfers) Exhibit F: Sourcewise Provider Manual
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.

Independent (no assistance needed)
Verbal assistance (able to walk or move with encouragement, or reminders to watch for , or to use a cane or walker)
Some human help (requires minimal assistance from another person to negotiate a or to steady the person or guide them in the desired direction) Lots of human help (requires constant attention from another person, at risk of being lost or unsafe if not accompanied)
Dependent (totally dependent upon another person, must be carried, 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
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
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
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 Declined to State ADL and IADL Functional Abilities Resources
The OAA 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
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 following 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 nutrition 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 question has a weighted point value. The sum determines the reported nutritional risk score.

Exhibit F: Sourcewise Provider Manual
What is Reviewed?
CDA will review 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 ercentage 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 following 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
Case Information
Effective 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
Case Opened Date
Case Closed Date
Service Type
Service Level
NOTE: Legal 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
Introduction
There may 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 types (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 data management systems may use any combination of name, address, phone number, or the last four digits of the participant’s Social Security Number for record identification. This avoids duplicating information by recording client level detail for each participant and will enable tracking the client’s services by provider and program.

First Name
Middle Name
Last Name
Other name(s)
Home Address
City
Mailing if Different
Telephone Number
Cell Number
Email Address
Exhibit F: Sourcewise Provider Manual
Optional Client Level Detail, Continued
Living Arrangement with thers
This section can help to identify the following client living arrangements when not living alone:

Lives w/Spouse
Lives w/Child
Lives w/Relative
Lives w/Other(s)
Senior Apartment
Source of Support
This section can help to identify the following various types of caregiving support:

Family
Friend/ Neighbor
Paid Help
Unsure
None
Transportation Services
The following options 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 options can help to identify if other conditions or assistance are needed.

CHECK AIDS CURRENTLY 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 RECEIVE HELP FROM OTHER ORGANIZATION(S)?
Yes
No
If so, which
one(s):

Exhibit F: Sourcewise Provider Manual
Emergency Identification
This section 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 considered 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 pplicable
Eligibility for Title III B Registered Services
To determine 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
Eligibility for Title III C-1 & C-2
To determine eligibility for Congregate Meals (Title III C-1) and Home-Delivered Meals (Title III C-2) the following questions can be asked.

QUESTIONS 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? QUESTIONS 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
Eligibility for Title III E
To determine eligibility for Title III E, FCSP Caregivers of Older Adults or Elderly Relative, the following questions may be asked.

CAREGIVER CARING OF OLDER ADULTS CRITERIA
Is the n individual (of any age) with
Alzheimer’s disease or related disorder with neurological and organic brain dysfunction? Yes No
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 answered “yes” to both questions above, the individual is qualified for “Family Caregivers of Adults.” If requesting “Respite Care” or “Supplemental Services,” the Care Receiver must also have two or more ADL deficiencies or a cognitive impairment.

OLDER ELDER RELATIVE ELIGIBILITY CRITERIA
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
In the case of a caregiver for a child, is the Caregiver a grandparent, step-grandparent, parent, or other older relative 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
In the case of a caregiver for an individual with a disability, is the aregiver a parent, grandparent, or other relative by blood, 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 and 3 above, the individual is qualified for der Elderly Relative Services.”
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 AAA.

Exhibit F: Sourcewise Provider Manual
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. www.aging.ca.gov/Data_and_Statistics/#Statistical
www.aging.ca.gov/Providers_and_Partners/Area_Agencies_on_Aging Exhibit F: Sourcewise Provider Manual
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?
Report 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 reviews the estimated enrollments and service units on a quarterly and annual basis.

Exhibit F: Sourcewise Provider Manual
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
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
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
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
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
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
[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: 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
[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 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
[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) Notes: 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:

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
[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
[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:

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
[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 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
[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
[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 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
[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:

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
Notes:

Exhibit F: Sourcewise Provider Manual
[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 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
[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 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- Yes No
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 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
[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
[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
[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
[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:

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 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- 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
[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
[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
[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
[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:

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
[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
[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
[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
[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

SOURCEWISE SERVICE PROVIDER GRIEVANCE POLICY
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual
Exhibit F: Sourcewise Provider Manual

STATE OF CALIFORNIA

DEPARTMENT OF AGING

EQUIPMENT JUSTIFICATION FORM
CDA 7037 (REV /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:
:

Question Response
Please describe the item or
items to be purchased
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
located?
Site name:
:

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

City Council and Authorities ConcurrentOctober 10, 2023

City Council and Authorities Concurrent
October 10, 2023