Download - PROGRAM INSTRUCTION OItel ~l!illi]'Q' · The purpose of this Program Instruction is to transmit 2 copies of the revised version of the County Home Care Plan for the Functionally Impaired

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OItelN bullbullPROGRAM INSTRUCTION 86-P1 - S4 112586 ~lilli]Q

_am A OCSE 0111-8 0111-lt-1 NEW YORK STATE OFFICE FOR THE AGING 0111-lt-2 0 IVmiddotA 0 V 0 RPE 0 I-EAP

Bldg 2 Empire State Plaza Albany NY 12223 ll EISEP Contact Person(l) Pnone Number(s) To fiAREA AGENC( CJII AGdNG DIRECTORS

0 (518 )0 Andrea Hoffman 474-5673

Subject For Your IntormellonEISEP County Home Care Plan for the Functionally Impaired Elderly -- Issued 11 1986

Rpontl Due OIIt PI SuperMded tty tft documentl

86-PI-47

The purpose of this Program Instruction is to transmit 2 copies of the revised version of the County Home Care Plan for the Functionally Impaired Elderly (Issued November 19 1986) to those counties which did not attend the November 21st meeting of the Association of Area Agencies on Aging

The following are the major differences between this and the earlier version of the Plan

A new page 9 Current System Problems

New pages 12-13 EISEP Services Expansion Summary (for the three-month period and subsequent 12 month period )

These pages con sol idate and sunrnarize information that had been included on the intended action pages for each service

A new page 22 C1 ient Prioritization

A new page 24 Monitoring

This originally had been part of the intended action page on training and technical assistance

Pages 14-18 have been modified

The information regarding units of service and 1 of elderly served have been e1 iminated because they now appear on pages 12 and 13

Area Agencies who have already completed their Plan and are ready to submit it may do so using the earlier version However we are requesting that AAAs cross out the old page numbers and write in the new ones where there are page changes between the earl ier and 1atest version of the Plan These Area Agencies in order to have their Plan approved also must submit the additional pages included in the revised Plan as an addendum to their original Plan as soon as possible

lTUNITY EMPLOYER shy

---~_~-_-- ---- ~~------_ --_- -_ _ -------_- __ -- -~ -- --~- ---__---_~~ lt------ -__~-~--~------- __-- --------~-~~-- - -shy

D P A T

Issued November 19 1986

New York State Office for the Aging

I

I

()FA No 238 (185)

APPENDIX 1U T~r F UR YEfk rL~r~

D~ FT rCJr~ TH (111R86) OLDEr itiERlC NS ICI

-J- ~ f ND MYS CO~~lUNI-rY SER1ICES FOR ]Hf Et_OlRLY P~OGRA~lS

and AD81ication for St~tE Aid UndEr

Expanded 1I~J1ome Services for the ~lderly Progrilffi ~ ~__ ~ ~~~~__ _-~n~=~-_~~~~~------~-----~A~-gt----~-~~-----~-i

I(

I 1

Fot the County[ies] of

PrGgran1 Pf~riod FrDm _~

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II

I c e n t i fie d t 0 I bull bull bull

Stalldard Assurances DESCRIPTION OF CURRENT COUNTY

Plan Development Process Comprehells~ve Description of

Services and Providers

p 1 p p bull 2 - 5

HOME CARE SYSTEM 6

Serv-ices Delivery System p 7

CliGnt-Leve1 Service Delivery r--lechanisms p 8 Current System Probl ems p 9 Current System DevelopmentCoordination Activitie p 10

INTENDED ACTIONS ElSEP System DevelopmentCoordination Objectives p 11 ElSEr Sevices Expansion

Summary (January 1 1987 - March 31~ 1987) p 12 Summary (April 11987 -shy March 311988) p 13 Case ~lanagement

HomemakerPersona] Care HousekeeperChore Non-Institutional Respite Ancillary Services

OutreachTargeting Pro 9 a min at icE 1 i 9 i b i 1 itY Subsidy Eligibility Client Prioritization Technical Assistance and Tf~ainiJlg

rlonitoring 1~ a i n ten a nceo f Ef for tee r t of i cat 0 n Schedule of

BUDGET Area Agency Support i ng

NB THIS WITH

Subcontracts

Summary Budget Budget Sc hedul es

p 14 p 15 p 16 P II p 18 p 19 p 20 p 21 p 22 p 23 p 24

pp 25-2tJ p 27

p 28 p p bull 29-33

DOCUMENT MUST BE COMPLETED IN COMPLIANCE THE ACCOMPANYING DETAILED IfiSTRUCTIONS

02A ND 238 (118S)

t tsix [GJ copi(~- cf thl pplLetJon to Eh2rc1 Lo~~l SeI~ic2s N~w York St~Jte Office for t~e 1nipLLc Stj =- Plaza AgEcrlCy Bldg ~2 ilbany H~ YDr k

thLJ d(~~~~~~Jir~ c~~~~ j~~lC)~~(j~~f~~~~)~e~~-~-nq~2ct i ()n~c of

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- lrea Agency- ~

Name~

Zip Code

sTgnaCute--o[--Chlef-E--ecuflVf--------------------__--------shy

of Coulty Governn-1ent

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SIg-n a tureof--SDonSo~trn 9 Aqency -jrxec oJ t 02-----middot----shy - ~-----------shyif other then COUiity ~overment

Date-------shy

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Ofgt no~ 238 LtUG) -3

~ _----~----_ ___ -_-_ ----~-----~- --~ --_--~--------------- --~- __~- ~_-- ---~- _~-

ll---~~-~~ ~~~~~~L~i=~~ t~ nS~~~~i~7 r~~ I ~ ~~ ~C~~S~~~r t~~~~ ~y~~~J]r~m ~ffjS~~ se~iccs for th2 1~Jcle[Jy PregTaIn hJll ~ allLxatej a~J rTEnj~-j f~t nn--ins1iral in-shylcliw sCtices

Ti-~ lI-2a ~lg2ncy dill file claHns toL z Ll p3llonts en a tircr=Jy cssis m d th lTux---=EclL1rc~_- prcriU 19-de1 by U~- SLdt2 Crffic2 fur th- 119 il1]

n lpe ~r=-YI g2-ry srLlll Z1SSJrc -CI1(i t vincre Sate or L(cdl p-lblic jurisdictIons J~~qiJln

lJ~niur- 01 certifiGic[ for- t11t provisio1 oJ scltidl SLJiC~S th2 iL---t Jency afl]

its ftJ~AvtracblTS pUYvic1ing such ser-vices U-fJer S--K~ arp~cgtvcj County Heme Q-I~- Plrlll for 1112 Fu~ctionally Irnp~irej Elderly sh311 te so lic2nsE~ O)~ C2ltipoundic1 ~rCCfSrE

C~~ i l~rLng s~rvices ml)C t-e lpprGpri3t211 qUi11i fi~(i s~lcte-Jr trained C-l-J sul--2rvi~(-j

12 LJE r-~I2c-J Fq_1cy sh-il1 CS3ure 81021 aC2-S for l=drticip1tiot1 s2rvices r activities aq] infoDTl3Licn=1 ~--es3ions gt11 UJOU-[ rej3~cd tn p-Jxtisan affiliation refrain from usin1 flI1Cl to udvance cny pdrcisdn canchdate or E-tfort pre-Jent the use of officiaL a1Jthoritv inY12nce oc cCErcion to interfere vjtJ] or affet elections or nomin~1tj(jns

tor ()fTi~t~ aSSlJre nu cCcrcion nor cdvice L() adler p2sons to mntribute anything of vaJu0 to a j)3Xt)- COITrnittOt organiz-ltio ageD~ or p2rson for pJlitical r~llp)seSf

[101 2ngd~2 in p3rtisan activir12middotr

Ccntracts

a) The Arw Agenc gtsSUles Ulat it vrill mak2 affiLmatiV2 efforts to (Yll1t lact wi tl

mit10I i ty ard om2r-omiddotltJnd bJS ines enterQrisES~

b) The ampLl gency sllall dSure that sutcCii1tractors oimply (ith all applicaJle rederal State an lo~al lavls (inlading Title VI am VII of tlle civil Rigtts Act of 1964 the Rehabili tltion Act Ule Equal pay Act IT12 Age DiscrimirJ3tion in EmploilUeiA Act arid the New York State HUffian Fights L2W) 1 Governors Excutive Orders 16 (Prevertiol of Sexual Hurassment) anj 21 (Minority Business Enterprises) i PrOjral1 Instluctiors r re~lations arrl starJards that the prcgram ltJill leuro airrinisteed in accordance with the projrammatic mj fiscal data dD]

descriptior1S providED in tt~ dW10Vf31 Coult~l Home (are Plan for GJe ElDctiorBlly ImreirEd ElderlyA[1lication fot State Aid~

c) The Area Agen1 shall monitor and assess all suDOntractors to assure complianD~

vJith Section 5~1 of the ~x2culive La of NeVI York State and rUles and re-JUlations aY3 staJ-c3rds promulqataj thereurcer reJardiJ19 t1e uSeuro- of EXp3nJee In-HomE Srvic0s for D1C Elderly Frc9ctin State iid~

d) Th2 P-rffi AgerrJ will ensure that sul-contructQrs Elake -~i turES only for aUborize1 items of expense contained in tl~J2 aThJroveJ bLcqets ard -ill furth21 erlSlue that if 3Dj wrJo3l other than outhXl2eJ exFerriitlJrcs t-ccome re=essdry the subontractor Jill request am (THaL t Prea Agency approval b2fore ireurring such 2-FEDh tur~s Tne Area l~elv 1i11 slL-mit a C0[)J of thi- 12vision eo b---lo St--tte Office vii thin 30 days of its effective date

e) Ihe Arc3- A-~ency will formallY2nter into contramiddot-=ts in accordance ~Jith thO II

Schedule of Subcontracts of this PlanApplication All contracts shall be

JI

wrltten aC~Jrdi09 to State ol1j local star)12rds ard a CC]J of the fully-eel1tsj contract (including budj2tcry information) shall be for~ardsu to the State Office no larer rhan 30 days aft2r L~e effective Q2t2 of L~e contract

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9) Th2 all

2~lmiddot22_ ASJ2~--)- 11 utconLclcbrs S

(iccl Dcl illJ b--lag~cy iiipoundQCrrt i ()-l IDl LcLfrklti-_middotti-)) fOI 311 VCLlhrmiddot~cs L(ol[shy

2r CfC-1tL all SJL-CT1tJCCccs LJ

In sd fYrl a-] co1tJ1ninSI udj inEoccnltion t3 mmiddot-iY J) r=-llii0(l by tr-- Pmiddot~re--J ~~ler1c b the StaLe OfflC The ht=a -geny dUJ L2ltJJire aU suLxon~ri3ctcr~ to rnaintdin suj acDun_f n3 docu iE5TtS

alt- lill [-ltmiddotl2 tc p2rmit ~~=dj tiCL cleteiiiinFltion t r b= mxJ2 at ani time of lJ12

stoCl1S of hlLds vichin tllE altllrd l inclucJlrlq the r3isposit3on of 211 monies cccei le fLer) tl-2 lreiJ ~g-ncy iru Lh2 [3-Z-Jngt erd afnOL1L of all 2XFeni i rmiddotl[2S

cl3 i rna) to b-= dgmiddot1 ns-= 3uch ft~r1s

l4 E~1u~plTC~2~_ The SL1 bmiddot Off ice -)C the [9 in c~setcl23 the riS-lht to rC~ldre t[ansr~r of items 0 -jdlElIr-It lrKj (J llf 1_ ~~quislton C(lt of $200 or rnCLmiddot2 Jihicn are 2GmiddotiuirEd

lXlj21- this grarlt Tlls ri~111t nQrmally Iill L2 eX--lt~l __ ClS9~1 by the StcL2 Office fox tlle lgin if th2 rXu~1_-0e frr ~l-LLcl d12 fjllipTfert middot~13s tef-tirLJ i traDsferreJ to anot~lel

qcant2 di11 only cur tJpound~ fAICfGS2S of txanfecrul] the 6jcdpment to the De gI3Dte

for corrtlr~lJfi use of th2 project or ~Jrcxjran~

L5 FJbLic lnformabcr The ~r2EJ --Jfncy lill provide fm~ d contlnulDJ p~orrrr of pillLc TnfoCli12tTc~1 sP2Clfically to assure that informatj()ll ahJut prograrTLs an] activities CJrriECl out under +-11i8 PlanAfplication ~IL2 eff2Cti vely ard apprcltiately prolTll11gatecl throughout tre llcmnin~ 2IT1 servicxgts ac0i The fI~ra ligexy Hill prc)via-2 inrJrwation to the pJbl ic 1l-1(l1 request 1iJh2re 2pprop-icde the l-e3 tV-l1cy shcll ma~2 public informatlon available in longJages native to the clIent populati(ns~ Public ilJformation also -~1rall 12 Tcpoundie dC2ssible tQ F2LSOt1S Nitb disabilities~

16 H~~ition of th Ny] -~~ secttate Offic2 fCJJ- tlgtgt Aginq ThE Area Agenji -qG~2S that any pro-rrcFTl f f--Lb~L ic inEonnCit ion m~ter iaJ s 1 or -other prTnte= or p1101 ishel mater ials O1l the vlOrk of this pro-~rarn hih is SU[pJltO--d 1 i th EXf-r13ed In--Hotne Sellces for ihe Elderly Prcgr3m f 1JrDs -Jill giV2 dj2 C2ltc~jnition LJ tlY2 N2j York Scat~ Office for die Agirq

17 Direct =ervices Non-flEQical jI1-hom~ non--insUtutional respite and ancillary Services-call EB--IYCo-ida-l directly only 1I1en the State Office for the AgirJj grants prior appruval This ClEproval middotwill 12 grarned or~ly -lh~n it can h- slO-vn tat tb-= rea f-gency provide1 ITE service prjor to ar9rovcl of ~je Area Agencys first Cor~1rnllnit

Services for b1e E1dsrly Plan or t~ne direct provision of e-p3rx1eJ srvices try te desigreteJ aoency is rk~cSsary due to D12 31JS-2rlC2 of an existifB sui table provider to assure an adequat2 sllP1ly of services or to ensure tli2 qutlity of the seIJice pr(~

vid--L

18 NOt1vithstardinq St2nlard J-ssJrance 17 C2~e HEiJlagelT1etlt may te providEd ~ t-Jle Armiddot~a

~-geriCr without regard tn the ~scial restrictions on Jire--t p[oisicn of Seurorvic2s~

19 Ih2 Ar23 AcfCj hds complete] tLe ~)JclAfFmiddotlication in accordance li th SUDtitIe Y of Title 9 of tbe Official CoinpilJtioCl of tl12 exes Rule-3 arc Rsgul3tions of t~e St3te of N2ltl York (Exp3rrlEu In-Home S-2rvices fJ[ thmiddot~ Eld~r1y Pccgran Rpoundgulations)

OF~ No 238 (1186) -5shy

20 Tt(~ Area l]2nCY ltSSfes thd Lr-Jose to E S2rvLd in th 1~)qy[YJF-d L1-middot[-[ornc SeJ1(0s f1(

the Eld~Lly PruJram 3-e not eligible tD cecrive irl1ilar or lf3ntLcal SefYICCS Ivhio1 ar( Elail(ble ur3e- 1itG~s X1111 XIX ajlj of th- ~(xiiil middot=(~gturity t CC OtlKgtl gov-rrrri1cnc~l pr()-JEiil3~

~(l ~ Toe Ar-a NJE-1cy aGllr~ -avL iL oiill niJ= trjryetl1--1j sffots i ccorcaD--e IJitll U12

SOFAJ1~~q Joint PolIcy St3teqen~ )D TargetiITj iSSUe] ~J(Ierrb2r 198 via SDF1 PrCXjTaIn

lrstruciion 81-P~ middot-S~ SbjS2t rlcLLg-2til~r Ii) tcat j leG

22 Jhe Area lgeni agt-yen~J to con~~1y vlth f(2 ropobfsr rOluir1err-5 fcy dC ~1JJLdtj Iil- Harr-- Se-rvic-es for a-J2 ElceIly Proqram as Et fort-I by tjf~ StoJt2 Office pound0-shy Upound~ giD~

23 The New YOLk State COl1ptToller or representatlve~ including staff of the Office shaLL 1 until seven year-s after findl paYTc--rl~ rdV0 access to una right to exarnin boOk~1 clocuments l and all pertinent liicltlcri21s of the Area AgEmcy involving transactions relating to th2 pnqcarll

~ I]~ bullor i- Nu -- ~ i

OF~PCS2 -- GshyP1an

COUnTY HOME CARE Pl~~

DEVELOPM[r~T PROCESS

Des c ( i beT h e p j (] C f s us 2 d i1 n d 1 is t tho s e iJ 9 e n c i e son d Ll r 9 ] )1 i L (1 t i CJ~

(inlud-TnC] 21t ~ niniuITI the 50ci31 servires cI-isttict th2 local publ l health ajenCj~ and the C51 CJr CAS-like -qE~ncy if it e~~ists lri thE county) iihich r~ere actively involved rnciOf consulted thel(j

developmeflt Df the County Heme Cltire Plan for the Functionally Iinpcl-i(~d

E-lder~ly Attach approptiate GOCUmenT3t1on of such consu-tation

------------------~--I

D~~T

iJfA No ~~2 (1186) - 7shy

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OF Ni 23[ (11B6)

CiFjCS-2 p 1 () n

__-_-_--~-- ___---~--~ _- - ---__~-- _ __----------_- ---__~-_ ~----------~ --- - --_--__- _-----~--- -------___~-~---_--------_---_ -_~ CDUfrrv lJO~IE CARE Pi-AJJ

CONPREHE11SIVE DESCRIPTION

fUNSTI0NALL Y lJ-1PAJ RED E DLRL-l CLIEN1--LE~E~ S~kVICE DELIVERY NECHANIS~S

I_~ _ I

Oi- lltll 23G (11Ef)

OFCS- 09shy

_T~_ ~ _~~_v~~_~_ ~~raquo__

II middotmiddot-------~~-U ~ TY--H0 ~~_-~~ ~-~--~--~------------ ----------- ----------~ -----11

COMPREHENSIVE DESCRIPTI0f

I C S S I i-middot----middotmiddotmiddotmiddotmiddot-middot---middot--middotmiddotmiddotmiddot- - - ------------- ------- middot-middot--middotmiddot--middotlI

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COMPRE~lENSjVf DESCRIPTIOfJ

D[VELOPMFNTCOORDIihTlun

JfCTIV IllES

Cliht PLAtCOUnTY HO1E

CUR~ENl

----------

OFACS-2 - 1 J-AnDlication -------~-- _----shy

-------------------~-- -____-----_~-~lt_ ~~---__----_ --------~- --~--~--- _- --~ -~-__---__- _---_shy

_ NHNDFD ACTlCriS II

EISEP SYSTEM OEVElOPI1EN1CUORDINATIO~ GHJECfIVES

r-- ----~--- Des c r i be t ~~~~ go i -11 g--~-~~ e-~c ~-2 n~~n-~--I~-O c e -S---~-~~~~~---II i d ( V 2 lop III c n t coo r d -j n d tic il bull ------------~--_~-~----------------- ------I------------------------------------------- I

I ~--__-----------

B Describe the specific systeifi-level steps tJh1ch iill be taken using EISEP funds to augment and expand upon the system developricnt activities currently taking place in the county to promote the establ-ishment of a coordinated system of screening assessment) and caSE management which ensures the orderly delivery of Ilolne care in the county Jnd the urJifo-j] treatment of clients] regardless of the point at vlh i ch they access the system or their economic status 8e surr to describe in particular the specific steps which will be taken using ElSEP funds to establish effective linkages between the CAA aild the local social services district to ensure coordination between ElSEP and the Hedicaid Program ard the Title XX Prograrr with respect to client eligjbilit detetmination and assessment prccedures

Of A NQ 233 (11ES)

OF-i Smiddot~2

t [1 -Ii C Cl t - u n - ] 2shy

(JJnUdry ]007 - M~)ch 31~ ISS7)

For the three-lnontl1 period J~tlLIJry 1) 1981 through i~arch 31 1987I

r~~-middot--------I~-Hmiddot-I~-~~-~----~---middot-middot-~-------Tr~-~-~-n _--1----middot---_ -~--l

i CdS P 11 a e p r i Il Ca f - is t 1 t II - I F nCl I - Ilt0

I JlrPUCL2- I lJerscTlal I l-cper t l101111 1 ar j j

men I Carc jChol fZ2sj l te srV1CeS ------- --- --------+---~---f-- --------- -- ------+----------j---shy J

1EstlrrJterJ Nurnbcl- I 1 I II of Units of servieI I I i I XX I

I -- -------------t---------t--------l---------L------L-----I

1

I I

~~ t ~~~~~~ ~~~~~d I

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J I +

XX --1

II Estimated Number i) f tl i nor i t - Se r v e d

r--~i ill 0 r i ~~--~r veci -ilS

I

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II I I l----------r----shy

II

II

II

XX I I

--_--------~ a Proportion of j~ 1 I ~I 1 xx E1 derl y Set~ved 1

I ---r----------~-middoti-----lt-

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--l Total Cost of Service

1 1$

I 1$ S $

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--__-_1 t--~---i--J---I Service Cost as 0 j 1~r~Prtion of I i ~~ locatCost I I I I i1 I I

f-------c0 s t per Un i t JS------rs-r$----r----- i x----l _ j Jlt L- 1 --J

Indicate [x] j f Services ~i1l be Ie] I [] [J [] I [] Contracted I I I

) - shy - J J- r e C -~ -l f r n (116)

OFsClt-2 JI)~llcatmiddoton

- 1 j -

For the tV2) v~-month period P~p(i 1 1 ~ t987 th c)ug l harch 31 ~ 1983

UFi i( 23 (llgG) jrea f~JPj ~ -

D ipound~ CS- 2

i~~E~_j_~_c~ ~_~_q~

rISEr SER~I[[S EXANSION I I_-----__--__ -_ --__---- -~bull~---______~-_ _----__~_---j

Is the AAA requesting a Jcliver for use of an dSS~SSI~poundnL i nsirL1i-i1tn L otllrr than the PAT~ij [J yes [ J n J

1 f yes b f- S 1I r f- co inc 1 u d 2 2 1Js t i fie aLl 0 n G rl (1 (1 C 0 f i eft h e ins t t Umen t

Cli(llt to case ITiclnu(jer ratio

Caselo~d size

Description of Case Management

OFA No 238 (1185) A i e a ji q p n l

OFACS-~~

12 e-p_ ~~ ~_~ j_ ~_ ~~ -----~-----------__ __----__------__--__----__--_---_- --_ _--- _ ~--~-__--__-_ _- _--------------~--__-_ ------

I InHENDED HTICiiS

I EI S EP S ER1 I C[S EX P~ NS I G1 I I Ii

110MEnA(ERjPERSOlAL CARE

----------------__----------------__------------------------_ --- -----_-------_ -- ------------------ __ eon eocnocml cHn I

i

OFA ]10 23C (lJ86)

UFAC~middot-2

EISEP SfRV1CES EXPANSION

HDUSEKfEP[RCi~O~[ SERVICES

DeSC(lpr-jon of Housr-kftperChoff Servces

)

OFr~ )0 (~33 (1186) Area fgene)

[irA CS- 2 - 17shy

~eE~j_~_~~9_~

I INTENDED ACTIONS

I ElSE SERVICES EXPANSION I I _ jI NON-middotINSTITU110NAL RESPITE II i ~__ _----__-------------------------------------_------lt------ ----------------------1 I Descri ption of Non-Institutional Respite Service

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118C)

o- li C S - 2 - 1 L~ _

EISEP SERVICES EXPAtISlll1

AjCIlLARY SERVICES I _shy _-shy _ _ __ -__ - -_ ~ __ - _ middotmiddotmiddot---- middotmiddotmiddot1

[1 e C ( i P 1 i uno f P r LJ c e sse 5 and pro red Li rES f 0 pro v i d 1 ri g ~rilill2ry 1 SE~(vices i

I I

I)u 23[ (1186)

OFIgtjCS-2

~~ e-e- _2_ ~~ ~_ ~~~ ~

1----- --------------gt-------------~ - -~~-~------_-~-----------------------~-~lt- --~~-

I INTENDED ACTIGtlS II I

ou --nrrHI-D~E~T-H~ II Ifthl h)_l l~l I

1---middot-----------middot-----------middot--------~---- -----middot---- --------------------------jI Desc~ib~ ho the f1AA ~iill calI out outY~JChtdgcting actlvlL-ies I

Be sur e to d e ~ c rib e Jet i (i n j i (J bet a k e Tj t 0 imp 1 em e n t S0 FJ t a ( get l n 9

II policies I

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OF io 3U (11B6) tea Agency

01middot1 CS-- ( 2 I

~r 2l ~ c_ ~~_ ~_l~ [_ _ _ _- _-----_ _ -----_ _-_ bull____ ___ ---- _ ___

j InTENDED ACTions i

SUBSIDY ELIGIBILITY I 1middot--middotmiddotmiddotmiddotmiddot-_middotmiddotmiddotmiddot__middot_middotmiddotmiddot_middot__middot_-_middot__middot_---_ _-__---- _____ I

I c h ~~ ~- e-middot----middotmiddot----------1 -

i I Describe the adrni1istrative proccdures to be used to implement thr I cl ient cost sharing standards prescribed by the Stdt2 Office for the flglng ancJ t~le procedllf~s for coordinating EISCP el-gibility wmiddotith Iedicaicl and rlt1e XX eligibility

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(ir-JCS-

6F ~ -1_ ~_~ ~lr ~ i) n

ACTIGnS

Il_ _____ __ ______

I D2SC(-j~2 the process ano ctiLfria -lJh-ich i

IJhich 2i-~ibl~ EISEP clpplicariLs vlill receivc demdnd for EISEP servlces Exceeds the supply

11 be used to determ i rl2

EISE~ ervicps hhen th(~

UF~ i Ii n 8 (11J) Are] j)gency

8fjCSmiddot2

0E2l i_~_~-~_~_~ r--- -_middot~~-~~----~~-_middot_middot_-_ --~~J~--~~~~~i-~~~ 0------- -~----~--

1_-----___H C~L_5S~c~~~~ ~_~_--~--~ DE S c rib 2 the p( I) C e sse S 0 f (I eli V~ i i n 9 t c c h 11 ~ C 2 l d l ) I S ~ c nee a n J l 1 1 rl n i I

to 5ubcont(Dctors 0

i I

I I

I

II

i-tca i]ency

I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I

Des c r bE L he p u c e sse san d pol - c -j e s for m0 n -j t (1 r i n q 1 h c cj t l i 2 ry and 1Ij 01i 1i em f f hoc cc I

I

) Arlt~d ~q Lei __ _

CjJa

courrcies and (lesig~at~d

(1) r-181iJteTi~lEC[- of b35e-J-~~El[ (gtpcCd~tt2-l w_t~ 1) -2 c01-nty C- lt1 otl- fu~~od

s2vice pnJi~gtr ir-r(3p-~ctivl- of ~bc ~a72 )r tlrGS~ 1l1Jlt1sQ~Y8ar cxendituref hd1J

rlEm ro~ ~2el of e--Tfi2n-J1lICt3 Ln th ~-C ~r-i_OT to the first ypClr fmmiddot Trhich ~ ecunt pL1IT for CJ(ulluni[ Sltvlcec Lir tl--- 11L-Jy 26 2Jcmitted or in 3lcn C()]ltrs 1979

fiscaJ -3T l1L(h=-~0i ts (r~~~middotlt

(2) l-iltlincn3ne-~ of rot~l CDTmlFtity srile pcojectsxpeditures und2r the COL-tTity SEI~middotmiddotricC3 fer th~ poundlder-lJ P0grd1l for ttii fi2ricd pril 1 1985 thrGugh Harh n J 1986

(3) McLf1tfnH-c(~ 0 tocal cxjHndlrcC ~(lmiddot CJS~ m12geDent non-middotmiddot~edicltll LnHhorne tiEd

non-intit~LYal rcsJite st7-(~e~- U(1Lcshy th2 G)Cillunitr Services fD( the Elderl Program for rh2 period April l 1985 ll~~ugh narch )l 199b ~

I th~ -e Agp-ric is fujil12 th2 cE- 31V(e ~r(jv_L~lecs under this COUlty Hone CelLi

P ltn 23 Ul1d~r t_he 1986-87 COlrITlunity Ser-vicss PrDgram) coclplete secio~s 1222 and ~o

I new $ervice prQvider() ar9 irlc1urd CGlgt~2te la lb2 l 3 (~nd 4

i r iII che hasemiddot-year- =xpenditur-2 levil be laiucained ror April I 1987 through Harch i11 shy

3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1

i III- ____________________1 I Servic~ Pr0vidar(s) 0 be funded 1oj-llh 2~Cpandfd In-nome Services for he Elderly 1

SCatmiddot2 Aid April 11 987 throigh Narch 31 1 1988Ii--- --------------1--------~- Januar 1 1-Tj tliImgh D=ltZmbe 31) ~ 979 Expend cures tor

Planning Co 1rdinacioo and Administrative Act1vities and Services Eor the Eldery shy

~Aipound OF PROVIDER I 1 STATE I ~THE_R__+----_~D-1_-bullbull~L --ISERVICE FEDERLL LOCAL

-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----

~-ea 11 ~encj _ __ _CFA Nc 23pound) (1186)

the C)nm1Ed ty Services for the Eldetly Pcog1atl for 2~ Total commuJlty servic~ foJect

1985 tbLough 311936 $---~---~--

Hill ch~ COTIJzunt ty SQrvlce r~jeet ~pendit(~ lJ middotel srcn1 above beurol

mailltained far the per-iod April 1 1337 through ~LiTC-l 31 1988

( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I

3 Enter the total amC1mcs of CiJTI1-Jl1uicy poundmiddot2rices projects funds expended under the Cow~uniLY Services for the Elderly Logra~ for the r~riod April i l 1985 through March 311 1986 pound~H the followfog

Iserv1ces

Se-v-Lce Al110unt---- Ii

CdSeuro Management $------ shyHomem~~erFersocal Care I

i I

Total $

Will the total e~q)enditllre level far th~ se~vices sho~n above be l4Jintained for the period A~ril 1 987 through Maroh 3L L988 ( ) YES ( ) NO

~f no) p12ase explain

4 I certify chgt the maincenance of effQ~t equireroents under th~

Spa~ded In-Rome Services for the Elderly Program will be ~et during tht~ period April 11987 through Narch 31) 1988

Signature or ~rea Agency on Aging Director Date

AFE I r -

gt ()FA No 238 (1186) C

jAP]NDED IN-HCl1E SERVICES FOR THE EfDFf[Y PPCCFJl self [ 0 U l ~ OF SUB C 0 i~ T RAe T S

Sllbcontractor must- agreo 10 coniorm to all guidelInes oQvaoped by li0 rj8ll York Stell-a Office for ~h9 Aglna for ng-wnGtrb bFtlBlt3~j rG3 CnciG ~dS-~bc()rTcgtTS C~JiiS cf 5ui-cn

1r ~cts mllt j (j] ~ubl1l rHed to HII) Sta -e ott i C0 I-D lirrj~ THJ~ 30 DAYS tr-cm -rile oHeen VG dElta of ttl] cQntriJc1 fa r (-(e lo do so ma rampd j n i ass o~- f1lt10S

r -- Ii ~------------------------------------------------------~

It~ DrrlG ilnd Addr-es sol state n~CrlO NuT ILDcal ITotal I StwvctJ Corrlr flct SCjV(S So Iv~or r~roJcctkl-- ($ SulJC(YI k acter Funds

~~~~iIl I~~~~- ~~~c~f () jtoootcns ~~~-- r~~~------------middot~~ ~middot-Fmiddot~-gt--i--middot-Q~~--~- -~ ~F~II

r)Conk1- I I i f S-ir+-Up J ilo Scrv~lt j~

I

burlans I I I D~-j0 1f- bull~ 8 C I I 4- 10$- Imiddot t 1 l ~ l ltDy ---_~--

Sedr I I i JLcl r---------- --I --1---- I r---l~~~=~~-~====i~==j---- --- fe-_

I I t t r----middot-------- T----- -~-- -I I ---l=-~~-I=====~=l~~~~i~~-E~=---

1 _____ 1 1 l

I I

f i

~rlrH1Sf2r tot- - to (Jage J1

PerS-lne 1 FL- j If lJL(f i t i (_~( -ml LT t Pr-0SLiT Pecj OCi shy

-shy

Loc~nlon

each I lmnual Ch2middot-Sc b2

I+__~-~~~~J~ Ac- c-----1J-------~middot-middot--middotmiddotmiddot---middot middot---middot-~-middotmiddot _-- ~ ~---~~~--_~ ~- ~-~~- -~-~---- I I l---shyT 10 1 Iiii N---------------------------- -~ -- ---~ --~ - - ~- --- ~-~-- - - ------ -middot----T----middot-middot-middot-middot-~middotj

1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I

L =--==-=~=_=_=__=_=L-----L-l-------- lmiddot~lcmiddotoal

I I r-~~-----------------------------~---~----- _ __- ~ __lt_l _ ------~--I FriDge 3eneiits

~~-SOCld Set~U-i ty --~=_ i~-=---~DL ~~~~_~~~~_ -~~-~-----~~ -~~~--~---- -- ---~lt---l- -----------~--~-~-

I R~tJrerneIlt I riackll2ns COlGp2lS1ioll lt( I I 1 h ------- ----- I--ea t~ Ins--aUce LrE~lpl)TJ1ent Insurance __ I II Life Ilsurance __ k Otbcr (Specify)

I ------------------- --- I I Composit Pecentage -~__ I 1 - -~ ---lt--~-~--~--~---- ~----=-~-~ TOla~ __L-=---__=_~ _I C0nsultant3 ---------------~---------------~~-~----------------or -I~------------

II IT Il c(st I I 0 + ICONSUTTmiddot~J UnIT ~Ch ill 5 ~WUTIt

(List ale and Iitle for each entry) T))epound Sere ice 1 e~gJ r-e eg bull gtours I ~ I fJUi 1 sessIons I-----T~---------~----middot--_middot _--------------shy

------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy

S~)J_GEJ~_Ln EiDGt~ SCHEDULE -- J I ~- P Bquif=gtil(~n t T~a vT_lF~il f_

Pr__)sp-a P~ lcd ~ fl-~~-I Ln gt- -- - ~_bullltbull_--__---_~~-_bullbull __----~____bullbull---~-~--~~ ~ --

i~ f~qJiplqei t ~ (T j - on 1v i t c fl~lt- hl__-middoti_rbullt rost)lf $2CjV (- m(ire )~ t_chI J lmiddot C~ J ( = tmiddot Jmiddotmiddoto-middotmiddot - - - - - ---- - _ ~) eq-ipif1L rentgt21s att=-Ih copyI of_~lC~(~-~L __ _ _ _1middot--middot--------middotmiddot- gt~~i Y--C r --sr~ l Ft CJ - ----- - q~~~=~lf middot~middotii~middot~r-----middotmiddot-ll-middotft-l~middot~~iJ-l--middot 1~r ( _t -j-j

I Tiy l ~__bull ~~middot~~~--L~-S ~~n~ rlt~~ i (-i Cf)i-~C-gtJSL~ i ---_-_----gt--- __ TCi- PFt-x-~~ ~--~~~~~~~-~~_- - - _middotr_~middot~_lt~~__ ~~~~ __ ~_ -------~ ---_- ~ ~- -~rmiddot --middot ---l~ P __0-__ ----_0[ _T_~__ i- _--_~-lt - -- _ __~ ___+ + _ J__ +~ I----~-_~- _-- middotmiddot--imiddotmiddotmiddot-- ---------- -- ---- -- middot-Tmiddotmiddotmiddot middotmiddotmiddotmiddot lt - _ - -- - - -- -- shy

1-middot_ --- ~------_------------ --- middotmiddot middotmiddotmiddottmiddot---middotmiddot middot -middot1middotmiddotmiddotmiddot -- ----- j middot middotmiddotmiddotmiddotmiddot---l-middot -- --- l~~=middot~ __ =~====~_=_ _~_middot---middotmiddotmiddot--middot_-middotmiddotmiddot--middotmiddotmiddot-r------middotmiddot-1- ---+~ -----~-----r~-~ -_--- shyL--- __ ~- -- __ _~~~=~=middot~~~~~r_ 0 --I__=~~~_Jmiddot==~= __~- -- J-~=~== =- II Tot21 I Si-~~--_----~~~~~~~~~_gt~--bull~~-----~~~=--~--middot _~_middotmiddot~middot __~_~~middot-middot_~ __~_~~_~~_middot_~ __~middot~c ~~~_~~~~~~__ ~ ~ o~

1 IC2~1 (Stapound Voll1ntee1S~ Advioomiddotr Cct~iL~fe Tl3Dpo-rtatiomiddotc of Iil-ctiipants) _~ ___~_o_o_ __o_ __ __ __ o __~_ ____ ~____~_ o_~ I ~i l~af2~ __ miJ_es __bull ~s_ ~~r mile S~ ___ 4 bullbullU_ II

LgdgiuG amp heaLs ( _ =____ p(-- rieID gt __

PlDl~c TranspoTa~iGn $ ~__ l G250l-re amp Oil c

--shyOtjec Travel Costs (Specify)

------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy

-I l - I ot21 I I p~~-~--~~ n~~--~-~-~~ -~-~ t~- cop e-~ me inc~-middot_---=-------I -1 i ell of rJlt ch~rges fo a I I sponsor Ogti rd prltoperty ATtach COl copy of Jh3I 102se for al I rsntgd property arid d CODy of ~ha charge back breakdown for 1 - spOnSarfJ owred propil-ty~) r----~--~- o~ _ __o___ ltO~~--_-__ 1) Locatlol___ Owner 1

I Square F-cotage middot_ Sq~ Ft~ Check f t I-~-K i-~1-rl 1-=- g -~I Mon7h Iy RentalS X 12 = $ I ~~~~~C~-in-lieu of JcniTorlal S~rices ---------~--- 11rSlit S

2) Location Owner _

Square Foc-tageuro 5 S-Q F-r 6 Check I t I n-K i nd Mon~-h I Rel1t~ 1 s xmiddot12--S--middot-- Ii U-ti i ities j J~1itorl~i Servicos $ ~

jaintenClnce-in~1 leu of rnnt S~ w _

3 ) Loca t i Cn _-- bull --__ Q1i ner -- _

Square Foot~ge $ -- Sqe -t e Ch-eCK I f I n-( ind [

MonThly RenTal X 12 ~-----7-----Ut lit i as $_-_- -- jan i tor i a I Se~1 i ca $ _

Maintenanca-in-lieu of fSnT S

if there are mcr~ than 3 rent91 properties - compiete same ITotal IS

I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)

r~~ ~ e~_~~_~~ ~ ~ ~~~~~~~ -~I charge back bl sponSG~ or monthly chalgtgs per

middotphoneplus toll Ctill~~ 1

I Postage peGl~al-in~middot----middotmiddotmiddot~--- ----- 1

Cost for Special Bnlk Mailing __ _ Other ~ y---------- Total $ I

------------- -------------- - middot--middot-cl Prbting amp Supplies ~

~nting~ ~------lD~scr~ption ~Ite-~-----~~~ant~v-------~QU~t---------Imiddot

$

---ltgt___--shy

Supplies Office Prograo Janitorial $~== Tot2l s --j~

_II Other Exenses (List specific it~~ and cost) _ __------ shyM I Na~ A1~iRAT I eNS oS RENOVATlo-lS _------_

ECNO fI-G

EQUI~n~ ~vlNTENA1IcE B OATA PRCXaSS1NCfZEPAIR

~ 1ClE MAj lrr-~~ a REPAIR

MMaER~I SIJBSrR Jpj I eN

ccNr-=KENCES S2-l 1pound-lARS Eo TA I N I NG F1JJ~S II AUDITS

M~__ I ~~WbCon1cets ---------------==1 1 A box on +he Schedu Ie of Subcontr-~cts must be completed for- each t Subcontr-actoi

A copy of each subcantr-3c+ (rnciudlng budge+ary lnfoim~tJan) must be submitted to the St~te Otflce ~ LATER ~ ~O d~ys ~fter the etfectlve d~te at the contioct

Tota I Number of Subcontracts I

Tranefer total 1-_-------- shy

from Schgdule of SlJbcontra~t5-~ge 27 L

-----

i ~--_-- lt_bull-~-~-~

L~jT tCIFAr2~D n Imiddot---middot~middotmiddotmiddotmiddotmiddotmiddotmiddot-middotmiddotmiddot - -shy COST ~~~lifUJlt ~

I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

_~_~

I

~~~O~~~~~D~ C(~Le)~~~~i~~s o~~r_~~c~_ middot0~_~~ ~pound~~~-~~~~~~~1~U~~~gs~((middot6~~~~~ (~ )~_ -) ~ N~-l C0LT~rBCIICNS~

~ __~__ ~___bull_lt~~~~_~~~r~__ __~~~~ middot~ __lt __

STA1= FUNi)

__ _~~middot __ cmiddot~_~ ~

~====== T01TL IlJCCt~ ( 11) -$

_ _ ~~~lt ~ ~C~ J~__~~~~lt~_~~raquo__~__ M __ __ __ lt __ ~~ ~~_I _

______-1

II

___ __

1

1

r~~~~~~--c-~~~~~~~-~~~~-=~~-=-~~~ -~~-~~--~-_---~=-~-=~--~==~-- ~------~~-~--_ ~---JI~- I Servic8s SbCi -middoticl -- _ ____~_ J

I iDIAL 1$ 1

I ~~_____~~gt__~__~~ltgt_~bull N~__ ___~~~_~_~___~o~middot middot~lt-~_~o~==_~~_~_~ __ ~__ ~_ ~~_=bullbullmiddot_b____middot~_~bull___middot___middot_ ~~-~i

] t-iN[CUIlrElWDS

I ~_~_~_~~~~_~~-~__~_~-~__~- middot~-~--~~l=~~~-_~~~-_middot _~~~~ i~-middot~~ K~~-fl --_-- -------

I I

I I

Cortributions___-~ $

70TL

middot OFA No 238 (lJ86) Acea Agency ___

SUPPORTING BUDGET SCHEDULE - ElSEP Other Resources P~ogcam Peciod Fcom~ _ to _

I I lIHJGIIMI SUHVICE f_UIJIlAL 1~~lJS ~ STATU 1lJNIlS _WCAL IU~IllS TOTAL I

1$----------1$$ shy I

I 1 IIII I ~--

I

r------------

i$

roTA OTIIER IlESOUHCES IHOI-I SlIUCOIlTnACTS

I 1$ I__

$ i$ bull i I

TOTAL AIIEA AGENCY ANIl SlIilCONTACTOll OTHEll IIfSOllIlCES fOnt I $

i

I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~

I roTA I AREA AGENCY UHmR IWSOWlCE5 It_~-_-------------I-t-------------1I~_

0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF

COUNTY HOME CARE PLAN

FOR FUNCTIONALLY IMPAIRED ELDERLY


New York State Office for the Agi ng

D R AFT (111986)

EXPANDED IN-HOME SERVICES FOR THE ELDERLY PROGRAM

ADDUIDUM TO CONSOLIDATED GUIDE FOR COMPLETION

OF THE FUNDING APPLICATIONS

I NSTRU CT I OtiS FOR COMPLETION OF

COU~TY HOME CARE PLAN FOR FUNCTIONALLY IMPAIRED ELDERLY

I PREFACE

Botil tilese Instructions and tile County Home Ca~e Plan for unctional1y Impai red El deryEISEP Appl ication are simil arly rganized Following brief boilerplate (tile cover signature page nd standard assurances) they provide for three major programmatic gt=ctions first a fulJ description of the current services delivery ystem second a description of intended actions under EISEP to mprove the services delivery system and third a proposed budget

Prior to beginning development of the County Home Care Plan for Functionally Impaired ElderlyApplication for ElSEP State Aid be sure to

gt Review A Framework for Developing the t~~Il Home Care Plcn ~C ~~ri~ff~~~~[iT~Ififci1E~c~i ----shy

gt Review The Role of New York States Aging Network in Long i~c~ t~C~~- 8 fl~f~~~~ ~~f~Ci~~c-~c~E~~-QEfl~f~fIT~i~l~----

gt Be familiar with EISEP legislation rules and regulations and standards and

gt Read completely through these instructions

NOH The short instructions on the plan pages are for convenience on I y They are not a substitute for the detailed instructions-con~ faToed in this document

I

Please indicilte the name of the CQullty(ies) and the program period covered by the County Home Care Plan and Application This program period may be either

gt The IS-month time period from Janualy 11987 througll March 31 1988 or

gt The 12-month time peliod from April J 1987 through March 311988

This page requests basic informiltion concerning the Area Agency Please note To facilitate processing you are required to forward six (6) copies of the completed County Home Care Plan to

Edward J Kramer Assistant Director Division of Local Services New York State Office for the Aging Nelson A Rockefeller Empire State Plaza Agency Building 2 Al bany NY 12223-0001

Be sure to note the program period as discussed above

Under the Terms and Conditions tvlO or three signatures are required that of the AAA director and that of both the chief executive of county government and the sponsoring agency executive if other than county government One copy must be signed in ink by ~~~~~~~ ~~~~~C~~~~ ~~ ~~[~ ~~~ ~r~~[~iE~~~~I~~~- ------ -- --- -shy

These are the Standard Assurances for the Expanded In-Home Services for the Elderly Program (E1SEP) Some of these Standard Assurances differ from those for other programs for the aging which are administered by the State Office for the Aging and Area Agencies on Aging Therefore this section should be reviewed thoroughly To rem a i n eli g i b 1 e for Tun d In-g--i r-e--Ag e-n-c les--mus t --fulflTf- a 1 I requirements reflected in these Assurances

2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J

Describe the process which was util ized to develop the County Home Care Plan and list those agencies and organizations Ilhich ere actively involved andor consultec in its development A single letter from a consulted agency may cover both EISEP and CSEP if that letter makes specific reference to the role of that agency in the planning for each program

Give special attention to how input was obtained frum local agencies and organizations (consultatiun review and comment joint planning andor committee discussions for example) The AAA must consult ith the local social services district the local public health agency and the local CAS A (or CASA-like) agency if it exists in the county Attach appropriate documentation of such consul tat ion or involvement (letters and meeting mmiddotjnutes for example) Also describe any existing planning mechanisms andor processes hich were used as part of thi s pI an development process

III DESCRIPTION OF THE CURRENT COUNTY HOME CARE SYSTEM ---------------------_----------------_~------------ -----

This section of the County Home Care PlanApplication focuses on the planning aspects of the Expanded In-Home Services for the Elderly Program It includes a comprehensive description of the current services delivery system Throughout this Plan special ittention must be given to the Medicaid Program and linkages to that PrJgram

Authorizing legislation requires a comprehensive descrption of the current county home care services delivery system for the functionally impaired elderly including case management and respite IJhen completed these sections of the Plan vlill provide a full description of the current services delivery system Both medical and non-medical in-home services are to be included in the description because the services delivery system for the functionally ilnpaired elderly is composed of both kinds of services Both are integral parts of the services delivery system and are complementary to each other in meeting the full range of client needs

This section is designed to provide an inventory of the in-home services currently available in the community for the functionally impaired elderly

For each funding source provide the information asked for in the table e recognize that some of the information needed for a complete description will not be available Therefore if data are not

3

available please provide estimates (noting by asterisk that the figure is an estimate) 6~~Tff~I~~-I~~~ ~~ ~~~~~~ o_C ~I~~~c_~~~~

The flrst column lists the funding sources Each of the following is included f1edicaid Title XX Community Services for the Elderly Program Older Americans Act t1edicare and Other Public To complete the table provide the information requested for each fundmiddotjng source vlhich pays for a particular service [as listed across the top of the table HousekeeperChore (Personal Care Level I) HomeT1aker (Personal Care Level II) Institutional Respite Non-Institutional Respite Home Delivered Neals Home Health Aide (Personal Care Level III) and Skilled Nursing]

Total Funds is the total annual amount spent on functionally impaired elderly for that service from that funding source $ per Unit is the amount per unit charged to or paid by any given fundmiddotjng source Be sure to state the unlt-niour or vlslC- for example) If more than one paymentbillmiddotng rate is used please provide the range from loest to hi ghest

The table also asks for the of Units This means the number of units of that service which are delivered annually to functionally impaired elderly under the specified funding source of Clients is an annual figure of the functionally inpaired elderly served--an unduplicated count for the service

This section is designed to providE an inventory of existing client-level selvice delivery mechanisms in the county which affect the delivery of services to the elderly--those processes and techshyniques at the client level hich organ-ize structure and direct tile delivery of services For the current service delivery system tWG primary questions must be answered in this section (1) Jhat service del ivery mechanisms are now utilized and controlled by community agencies in order to determine or approve resource utilization and (2) hat are these agencies current relationships among themselves and to the Aging Network

In this descliption of client-level mechanisms limit the discussion to mechanisms which pertain to the functionally impaired elderly and which are similar to the ElSEP definiUons

Case management may be seen as a continuum from screening through discharge However for the purpose of this section of the Co~nty

Home Care Plan please provide disc~ete descriptions of the following mechanisms in your county screening assessment program eligibility determination ongoing case management and discharge planning You may want to cite other activities--such as case conferencing and preshyadmission screening In addition please state clearly the ~l-~~ECr of agencies or organizations responsible for each mechanism

You must include a description of the existing linkages between the AAA and the local social services dismiddotcrict to coordinate I~edicaid

4

----------------------------------------------------------

and other programs including Title XX vith respect to client eligibility determination and assessment procedures

middotIhen completed this section should provide a complete pictute of how the curlent services delivery system relates to clients in YOUI county

- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H

The purpose of this section is to set forth the 2~L~r problems lith the current local horne care services delivery system Specifically please describe the major system-Ivide problems which currently pose barriers in your county to achieving the goal of establishing a coordinated system of screening assessment and case management which ensures the orderly del Ivery of home care in the county and the uniform treatment of cl ients regardless of the point at which they access the system or their economic status (Do not describe intended actions to address these pro~lems since those actions will be covered in another section)

Please describe current cooperative efforts by agencies and organizations in the COU1ty to improve access to and the availability of appropriate and cost-effec11v~-T~~~me services for the elderly who are functionally impaired In your discussion give attention to interagency planning anCi coordination data and resource management program development reource development and publ ic relationscomshymunity education

Completion of this section of the County Home Care Plan provides a picture of current system developmentcoordination activities in the county

IV INTENDED ACTIONS

Given the previous Comprehensive Description of the local service delivery system describe in the the folloViing sections of the PlanApplication how the AAA ill use planning and implementation and EISEP services funds to foster systems developmentcoordination at the local level

EISEP System DevelopmentCoordination Objectives (page II)

The purpose of this section is to describe intended actions to bE taken under EISEP Use this section to describe the use of planning and impTementatlon funds to pursue system development objectives Note that these objectives will cover either a I5-month period if the Area

5

Pgency is applying for services funds to be effective on January 1 1987 or a 12-month period if the Area Agency is not applying for s~rvices funds--t-o--Se--effective before April 1 1987

The distinction between this section of the Plan and the previous section is that this section focuses on how EISEP will enhance or augment system developmentcoordination activities at the local level 8 e sur e tor e 1 ate t his sec t ion tot hem a j 0 r pro b 1 ems 0 f the cur E n t I~e-~r- T~Cv-ff~~~E~middot~c2 I2~JIlif-~tfie-tf-If~C~-~~~~_-~~~C -f~~cXfe_Cmiddot~ - - -- - __

Part A Describe the ongoing interagency planning process fer s y s t e iii - de veT0 I men t coo ) din at 0 n whie h vi ill be use d to imp r 0 v e ace e s s and the availabil ity of appropriate and cost-effective non-medical support services for the elderly who are functionally impaired (This process goes beyond the more limited County Home Care Plan development process descri bed earl i er on page 6 of the Pl an) I f a Long Term Care System Development Councilor similar entity will be utilized please describe that entity its membership and its expected activities

Part B Describe the specific system-level objectives vhich will be address-ed and the speci fie steps which will be taken during the plan period This information should essentially describe how the county 11 ans to use EISEP funds to augment and expand upon system devel opment activlties-currently-fakiiig-plac-e-in-fhe-county Tilese activities should all be designed to promote the goal of establishing a coordinated system of screening assessment and case management which ensures the orderly delivery of home care in the county and the uniform treatment of clients regardless of the point at which they access the system or their economic status

Be sure to describe -in particular the specific client-level objectives and the specific steps which will be taken during the plan period using E1SEP funds to establ isl1 effective 1 inkages between the AAA and -focal -soclal--s-e-r-vices district to ensure coordination betleen EISEP and the r~edicaid Program and the Title XX Program Ivith respect to cl ient el igibil ity determination and assessment procedures Refe~

also to requirements for coordination ith Medicaid and Title XX as described in the Programmatic Eligibility section (I 8) of these instructions

Coordination is an integral part of system development and management Give special attention to describing how current c~operashytive relationships will be improved and how new cooperative relationships will be forged Efforts to reduce or eliminate dupli shycation 01 gaps in the local services delivery system also should be

discussed Include a description of any ~OAsMOUs hich clarify expectations or other procedural tool s which will promote or enhance information sharing referral exchanges or other interagency linkages

6

The purpose of the Services Expansion section is to specify how the AIA intends tu util ize State aid dnd matching funds for services under the ElSEP All EISEP standards must be reflectcd in these descri ptions

Tie first two pages of this section are matrices to summarize EISEP services expansion for the three-month period January 11987 through March 31 1987 (page 12) andor the twelve-munth period April 11987 tilrough 11arch 31 1988 (page 13) The Aea Agency must complete page 13 covering the twelve-month period 2 -ill be completed only if the three-month services expansion funding is being requested for January through ~larch 1987

With few exceptions (designated by XX in the Ancillary Services column) Area Agencies must complete each cell of the matrix SOFAs definitions of services and units of service must be used

The estimated number of units of service must be indicated for each service Estimates of the total number of elderly to be served and the number of minority elderly to be served must be undupl icated c au n t s wit h i n e a c h s e r vic e cat ego r y bull Cal c u 1 ate the min a i t Y 5 e r v e d as a proportion of elderly served by dividing the estimated number of minority served by the estimated number of elderly served

For the purposes of completing this Plan for each selvice the total-co-sTciT-ser-rceT equars--tlle total--a-in-o-unt of State aid and matching funds proposed to be spent for that service The service cost as a proportion of total cost is calculated for each individual service by dividing the total cost of service for that service by the sum total costs of all services (That sum is computed by adding the row entitled total cost of service The cost per unit far each service is calculated by dividing the total cost of service for that service by the number of units of service for that service All estimates must be reasonabl~ and consistant with other portions of the Pl an

In-home services expenditures must be a minimum of 50 percent of all approved State aid and matching funds for services under EISEP

The total cost of all ancillary services may not exceed 10 percent of the approved State aid and matching funds for services under EISEP

Indicate [x] in the cell provided if the service will be contracted

7

To describe the proposed expansion of each USEP service pleas~

use the applopriate pages case management (page 14) hom e m a I( e t per SOil a 1 c a e (p age 1 5 ) and h 0 use k e e pet cliomiddot e (p age 1 6 ) bull If applicable also describe non-institutional respite (page 17) and ancilliHy services (page 18)

In each Services Expansion description be sure to discuss the role of informal caregivers If contracted include the name and tl

brief description of the contractor agency If provided directly include a justification for direct AAA provision of a service in the description of that service except for case management Note that with the exception ofcase management all services proposed to be directly provided by the AAA are subject to special limitations as noted in the Standard Assurances

Each Services Expansion description should reflect the needs and the current local system problems identified in the Comprehensive Description section and the system development and E1SEP objectives outlined earlier All proposed services should address unmet needs of functionally impaired elderly and support such persons continued residence in their homes

Tile description of case manageGlllent should be comprehensive and include activities and procedures for screening assessment and eligibility determination as ~ell as for ongoing case managelilfcnt Indicate the cl lent to case manager ratio and the program caselcad s i z e bull

The PIITH Assessment Instrument SOFA is requiring the use of i)

uniform assessment tool -- tile PATH Be sure to indicate whether the AAA is requesting a waiver for use of an assessment instrument other than the PATH Area Agencies proposing to use an equivalent instrument as allowable under the case management standards Inust request SOFA approval by including the reason(s) fer such request and a full description of that instrument in the case management expansion description In addition a copy of the surrogate instrument must be attached to the PlanApplication

Conditions For Granting A Waiver Of The Requirement That All Local ElSEP Programs Use The PATH Assessment Instrument

A waiver of the PATH use requirement i s approvable only if the following conditions are met

1shy The surrogate instrument already is in use in the county and

8

2- The surrogate instrument is being used by the local Department of Social Services system and

3- The surrogate assessment instrument contains data elements equivalent to those contained in the PATH

The section on ancillary services must describe the processes and procedures for providing ancillary services lhese must describe how ancillary SCI-vices will be approved and accounted for in a manner which ensures their appropriate utilization within the purposes of EISEP Refer to the EISEP administration standards for additional guidance

Describe how the AAA will carry out case finding activities to identify and serve the unserved and underserved population (including minority and low income persons)

By design the Expanded In-Home Services for the Elderly Program is targeted to functionally impaired elderly Describe the activities which will be undertaken to reach and serve minority and low income elderly persons who are functionally impaired (Low income is defined as 100 percent of the poverty level)

Discuss how these outreachtargeting efforts relate to the targeting initiatives of the Area Agency inclUding a full description of the policies and strategies under EISEP that the AAA will pursue to identify and appropl-iately serve minority and 10 income persons

SOFA expects that minorities will be represented on the EI SEP client caseload in a substantially higher percentage than their representation in the general elderly population in the PSA

Be sure to include a discussion of referral arrangements with cettitied Iome health agencies hospitals the local social services district and the CASA (or CASA-like) agency if present

Programmatic eligibility serves as the gate-keeping mechanism for entry into ElSEP Describe how program eligibility determination ill be carried out including whether screening will be done by the AliA contract agency or agencies or a combination and how the accuracy of the screening will be monitored by the AAA

Describe how persons ho appear to be ineligible tor ElSEP will be informed of their rights to a full assessment andor to be referred to other sources of assistance Also describe ho such persons will be informed of the reason for their apparent ineligibility and their opportunity to be heard regarding those reasons

9

Describe the arangements which the A~i has Ivorkcd out with the local social services district and the CASA where appl icable to coordinate the el igibil ity determination procedure for EISEP with tho s e use d for I e d i c aid d s II ell a s for Tit 1 e XXbull

Eligibil-ity determinations for ElSEP and Iiedica-id must be coordinated such tllat for applicants Iho have not been certif-ied for 11edicaid but who appear to be eligible for it EISEP case managers must assure

1shy That they receive services to meet their as rapidly as applicants who do not appear eligible

needs to be

at least Medicaid

2shy That they apply for Medicaid immediately and

3 shy That i f a p p 1 i can t s are sub seq u e n t 1 y f 0 un d to eligible rtedicaid funds and not ElSEP funds pay for all covered services delivered after application for EISEP

bel-I e d i c aid are used to the date of

The Plan must include a Ivritten statement signed by the local social services commissioner agreeing to implement procedures which will ensure that services provided to persons eligible for Medicaid or Title XX will be paid for by those programs not EISEP At a mininum this written statement must include a specific commitment by the local social services commissione~ to fully implement the procedures identified in Appendix II of the State Department of Social Services Information Letter 86 INF-32 entitled Joint Statement of the New York State Department of Social Services and the New York State Office for the Aging on EISEP Coordination with Medicaid

These procedures must be implemented before hOllle care services are provided to EISEP clients Therefore SOFA will not approve this portion of the EISEP County Home Care Plan and thus SOFA Vlill not reimburse any county for in-home non-institutional respite or ancillary services until the Area Agency and local social services district can document that the required reimbursment procedures are in pia c e ElS-E P--r-eTrilbu r sem-e riCwnronTy Ye--m-a-creTo-( c-a-se-rilanag en-m-e rif 5etC-vTce s d uri n g t his per i 0 d

Program subsidy eligibility serves as the mechanisn fOl determining appropriateness for cost sharing or full or partial subsidy of services to enable a functionally impaired elderly person to remain in hisher home Desc~ibe how subsidy eligibility proshycedures as set forth in the EISEP cost-sharing standards will be appl ied to persons determined to be in need of services by the case management process inclUding the agency or agencies to perform the determination and procedures for ensuring the accurate and fair

10

application of the established sliding fee scale Also describe how such persons middotIilmiddot be informed of the reason for their apparent ineligibility and their opportunity to be heard regarolng those reasons 1150 describe how persons ill be informed of the AAAs established mechanisms for making voluntary contributions to expand the capacity of the program

~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U

It is expected that the demand for EISEP services will exceed the supply Use this section of the Plan to describe the process and method that will be used to prioritize clients and potential clients who need EISEP services Be sure to describe the spec ific criteria (as well as the process) which will be used to select individual clients for immediate receipt of EISEP services for placelent on a waiting list or for referral to other service delivery arrangements etc

Describe technical assistance and training for subcontractors on ElSEP program specifications guidelines and requirements and on middotIocal procedures developed to implement and meet them and the provision of training on selected aspects of the program to community agencies as needed and appropriate

A major responsi bil ity of the AAA is to ensure that all ElSEr standards are met by its subcontractors This is essential

Describe AAA monitoring of the delivery and quality of care provided under the subcontracts including the development and implementation of a local system to collect and analyze State and locally required program data conducting regularly scheduled meetings with all subcontractors and other community agencies invol ved in the program and conducting periodic on-site client visits

~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l

The rlaintenance of Effort Certification is designed to provide the assurance that the three maintenance of effort requirements are being filet Sections 1a and 1b relate to the maintenance of base-year expenditures Complete only Section 1a if funding is provided to the same service providers under the County Home Care Plan as under the 1986-87 Community Services Program If new service provider(s) are included complete both sections 1a and lb

11

Sections 2 and 3 provide the necessary assurances related to maintenance of expenditllre levels under the Community Services for the Eldermiddotly Program Both sections are to he completed by all applicants regardless of the serviceproviders to be funded

Sectiorl 4 cOrltains a certification that must be signed by the Area Agency director

This page is generally the same as that contained in the C5E Application Tile only exception is tllat the incolile far each subconshytract must be split into cost-sharing and contributions

V BUDGET

~~lt_~[~(L~~IrI_ llt[~_~~ lt_~ l~ e~ r ~L~~lt [~_ ~(~~ lt ~_ L1~ ~_~~_ poundllE1 The budget pages are generally identical to those in the CSE

appl ication The instructions contained in the Consol iaated Guide for Completion bullbull for the CSE application should be followed with the following exceptions

Personnel Include the name title location annual salary and percenT-a-ej-e--ciT-time and salary amount chargeable to EISEP for each employee

Anticipated Income This section identifies income as eitl1el particTpan-t-coiitributToll-S- or cost-sllaring revenue Gnly participant contributions can be used as local match (with prior approval of SOFA) Cost-sharing revenue cannot be used as local match If costshys 11 a r i n g rev e n u e i s to bet r ailsfer red tot h e CS E bud get it In u s t be indicated in this section and a similar indication included middotin the income section of the CSE budget

~Q~c If applying for services expansion dollars for the period January 1 1937 through March 31 1987 a separate budget is necessary for that time period Be sure to complete the top of each page of the bUdget section with the name of the Area Agency and the period for which funds are being requested

A Subcontractor Budget SUlilmary and Supporting Budget Schedule also are included for your use ~here appropriate

i 2

OfA No 239 (1186) Page 1 New York State Office for the Aging

SUMMARY _ EXPANDED IN-HOME SERVICES FOR THE ELDERLY PRJGRAMSUBCONTRACTOR BUDCET SUBCONTRACTOR NAME __ AREA AGENCY __

ADDRESS _

CONTRACT PERIOD From To _

i I A IMPLEMamp1TATION EXPANDED IN-HOME

AcrIVITIES SERVICES ACrrVITIES

BUDGET TOTAL ClTEGORY BUDGETI

l Personnel $Is Fringe Benefits

3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications

I8 -r-inling u Supplies I

I I

9 Other Expenses I I

1O SubcontTac~s

11 TOTAi BUDGET I (Lines 1-10) $

I

I $ i $

12 Less Anticipated Inl Come (not used as local match) I

13 ~ET TOTAL (~irre 11 I Lass L~ne 1 1

1+ Area Agency Funds

15 Subcontractor Funds

~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy

SUBCONTRAcrOR _ Area Agency _

SUPPORTlNi BlJDGEr SCHEDULE - ElSEP PERSONNEL-SubcontraceoT Only

ATTACH OB OeSCRIPTIONS NEW T ITLES QII LY FOR rIONS USED AS IN-KINO WITH ASTERISK

FOR ElSEP Other 1 POSI- Annual I OtherNOTE 1Salary ~~ I Amoune Amount Amoune

Name I I IITitle II I I ILocation I I

IName I II Title I II

II I iLocation

Name I I

I ITitle - I

ILocation I I IName I

I Ideg1Title

I II Location

I Name

II ITitle I

I I Location I II Name I I

ITitle I I

ILocation I I

IName II IITitle I I

Location I I1

I

I I ISubtotal (this page) shy II I I Grand Total

-3shy Area ~ency bull ~~_

Subcontrac tor _ OFA No 239 (1186) SUPPORTING BUDGET SCHEDULE - EISEP PlISClmIEIFlW1GE llEgtE7lS CmlSlJrTltiITS - SlJllCOlITRACTOR

Pers~~ Complete Only If Page 2 Is Not Used

AMomrrs FRoi PERSOmrEI ROSTER

Imp1ement9tion Activities bull------shyServices Activities

Adjuscments (plus or minus)

Toeal Nee Personnel Costs $

Bilef DescrIption 01 AdJustmenTS 6eg raises and v~c~ncres

t=~e 5ancits

Social Secur ~ DisabiliCy I

ReciemeuC Workman 3 CoarpensaC1on I Eealth- Insur3nC2 crnem~lQ~en lIsurance ~ Lila Insuracce Other (Speclly)Ishy

bullt

CP0si ea Percencage $To~

Consultancs

CONSmTltill (Lise ]ame and irle tor -aach elery)

~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel

No of UniTs eg lJoul51

sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs

Subcontractor _ -4shyArea Agency _SUPPORTING BUDGET SCHEDUL~ - EISEP

EquipmentTravelRant - Subcontractor OPA No 239 (118amp)

Equiprent (List ooly items having a mit rost of $200 or rrore Attach justification as aIPropriate Por all equipment rentals attach roW of agreement)

LZIIIT ANNUAl UNITQUANshyITEM Nm OESCR IPTt crt

RElTAI FRIaPltJRCHASampTtTY

RIa

-

Total

Travel (Scaff Valunteers adv1sor- Cotmdttae rratLSp0r-3don of lareicipanes)

-ileage miles c per llile $ odg~g per diem $ -1 shy 11eals Public TransportaCi= $ Gasol~ OU $ Other Travel Cases (Spewy)

S $ $ $ $

ot31

Rene (Include I r1fo m~tlon below lor 11 rent property A I so I nc I ude malntenlnce-In -I i eu 01 rent chlrges lor 1 I sponsor ow ned property Atllch bull co py 01 th 0

I ease f 01 a I I rented properTy nd bull copy 01 tho ch ~Irg e baCk breakdown lor sponsored oned properTy )

I ) LocaTion Oner Square Footge I S ISo Ft Check I I In-Kind I I onthly Rental S X 12 middot S Utll1tlosS JanitorIal Services S aln1enance-ln-1 leu 01 renT S

2) LocaTion 0n8 Squ~r-e Footage I S ISo Ft CheCk I I In-Kind I I onthly Rental S X 12 middot S Uti Iities S Janltor-I~I Ser-vicEts S Malntenance-In-I leu of r-ent S

3) Loc~t Ion Owner- Squ~r-e Foot~ge I S ISo Ft Check I I tn-Klnd I I onthly Rental S X 12 Sbull Utilities S Janltor-I~I Ser-v Ices S ~Inten~nce-In-l leumiddot of rent S

use extr-~ sh eats I I th er-e ar-e mor-e tll~n 3 rental pr-oper-tles - complete s~me

i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S

Area Agency ~Subcontractor -5shy

OEA No 239 (1186 )SUPPORTING BUDGET SCHEDULE - EISEP CommunicationsP~inting SuppliesOther ExpensesSubcont~acts- Subcontractor

-shy

Briefly describe type and charge back by sponsor phone plu s toll calls

acount of charges eg t

or monthly charge per

Telephone Cost

Cost for Cost fo r Other

General Special

11ailing Bulk Mailing

$ $ $

Total $

Desc~iption of Item Quantity Amount

$

Janito-rial $ Total $

(List specific itel1 and cost)

M I NCR AL TERAT 1 CNS RElIOVATICNS

ptoiO ICCCFYT NG

MAl NTENANa DATA ~ING

MA I NTENANCZ amp 0TliER ( SPC I FY )

I

SlJSSCR I PTI eN

FUNCS

(List Each Contract Cost Use Extra Sheets If Necessary )

Total I$

I

Subcontractor

Total Number of Subcontracts

$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting

Suplies Office Program

Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ

~= SEloltINARS TRAINING

ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---

~UDCONTRACTOR -- shy AREA AGENCY

orA No 49 (0986)

SUPPORTIt-G BUllGEr SCHEDULE - ElSEP

OlilEn RESOURCES - SUBCONTRACTOR ONLY

-

TOTAL

OlliE II IWSOIJIlCES----- ~- -middot--------1------------ shy

IIIO(nMl LOCAL FUNDSSERVICIJ lmJlJIlAL FUNDS STATE IUNDS-----------_ _---shybull

I I

TOTAL SUBCONTRACTOR OTHER RESOURCES $ $ $ $

---~_~-_-- ---- ~~------_ --_- -_ _ -------_- __ -- -~ -- --~- ---__---_~~ lt------ -__~-~--~------- __-- --------~-~~-- - -shy

D P A T


New York State Office for the Aging

I

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HOME CARE SYSTEM 6









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pp 25-2tJ p 27

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IV INTENDED ACTIONS




5









6


Tie first two pages of this section are matrices to summarize EISEP services expansion for the three-month period January 11987 through March 31 1987 (page 12) andor the twelve-munth period April 11987 tilrough 11arch 31 1988 (page 13) The Aea Agency must complete page 13 covering the twelve-month period Page 12 -ill be completed only if the three-month services expansion funding is being requested for January through ~larch 1987







7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





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V BUDGET







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ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


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I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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-

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gt ()FA No 238 (1186) C




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I PREFACE








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-----

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-

TOTAL



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OFA ]10 23C (lJ86)

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1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

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i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




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INSTRUCTIONS

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D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



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IV INTENDED ACTIONS




5









6









7












8











9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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~Resources $

----------~---------------

------------------------

------------------------

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------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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------------------------

------------------------

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Name I I

I ITitle - I


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ILocation I I


Location I I1

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bullt


Consultancs


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-

TOTAL



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Total $






AFE I r -

gt ()FA No 238 (1186) C




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D R AFT (111986)






I PREFACE








I









2

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3










4

----------------------------------------------------------



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orA No 49 (0986)



-

TOTAL



I I



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OFA ]10 23C (lJ86)

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i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




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1 _____ 1 1 l

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f i



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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




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6









7












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9




needs to be

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~Resources $

----------~---------------

------------------------

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------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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------------------------

------------------------

------------------------

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I

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ls

~

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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


D~~T

iJfA No ~~2 (1186) - 7shy

FU~I

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j Il~ t i -f c-

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II i)

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I InHENDED HTICiiS




i

OFA ]10 23C (lJ86)

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)

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I I

I

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I I

I)u 23[ (1186)

OFIgtjCS-2

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II

i

I i

I II I

I I I I



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I i

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-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

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Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



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Loc~nlon



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------- $--------__-- shyI --------- $-------~--__-

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1

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0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



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IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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V BUDGET







i 2



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3 Consultants

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6 Rent

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~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

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------------------------

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------------------------

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------------------------

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------------------------

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------------------------

OFA No 239 (1186) -2shy







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I Name

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Cost -atel


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I

1

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$ $ $

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ptoiO ICCCFYT NG



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Total I$

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Total

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ls

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Printing Supplies ~

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I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


---------------- ------

OF Ni 23[ (11B6)

CiFjCS-2 p 1 () n




I_~ _ I


OFCS- 09shy

_T~_ ~ _~~_v~~_~_ ~~raquo__




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I InHENDED HTICiiS




i

OFA ]10 23C (lJ86)

UFAC~middot-2




)

OFr~ )0 (~33 (1186) Area fgene)

[irA CS- 2 - 17shy

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I INTENDED ACTIONS


I

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I

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I I

I)u 23[ (1186)

OFIgtjCS-2

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1----- --------------gt-------------~ - -~~-~------_-~-----------------------~-~lt- --~~-





II policies I

II

i

I i

I II I

I I I I



~r 2l ~ c_ ~~_ ~_l~ [_ _ _ _- _-----_ _ -----_ _-_ bull____ ___ ---- _ ___





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ACTIGnS

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to 5ubcont(Dctors 0

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3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





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-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



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-------------1 I I








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~

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1

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0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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V BUDGET







i 2



ADDRESS _






3 Consultants

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6 Rent

7 Corrnnunications


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I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

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Unit Etgbullbull

hour

Cost -atel


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lmoune

$

I

I

1

70t2l

I t

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IIs






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-

Total



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S



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$ $ $

Total $


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ptoiO ICCCFYT NG



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SlJSSCR I PTI eN

FUNCS


Total I$

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Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I



OFCS- 09shy

_T~_ ~ _~~_v~~_~_ ~~raquo__




I I

I_ __ ~~ ~-_~~_ t h~-~~~~_~O~~~~~_~~~ ~~I~~~~~~2~~~~_~~_~e~~~_~~~~~~_ j i I I I

II

I

II I i I

I I

1 r 2 a iJ 1= I C j

1 [I

fl r) I



JfCTIV IllES


CUR~ENl

----------


-------------------~-- -____-----_~-~lt_ ~~---__----_ --------~- --~--~--- _- --~ -~-__---__- _---_shy




I ~--__-----------


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OF-i Smiddot~2









I -- -------------t---------t--------l---------L------L-----I

1

I I

~~ t ~~~~~~ ~~~~~d I

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J I +

XX --1



I

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II

XX I I


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I


1 1$

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I

[$ i




) - shy - J J- r e C -~ -l f r n (116)


- 1 j -



D ipound~ CS- 2

i~~E~_j_~_c~ ~_~_q~





Caselo~d size



OFACS-~~

12 e-p_ ~~ ~_~ j_ ~_ ~~ -----~-----------__ __----__------__--__----__--_---_- --_ _--- _ ~--~-__--__-_ _- _--------------~--__-_ ------

I InHENDED HTICiiS




i

OFA ]10 23C (lJ86)

UFAC~middot-2




)

OFr~ )0 (~33 (1186) Area fgene)

[irA CS- 2 - 17shy

~eE~j_~_~~9_~

I INTENDED ACTIONS


I

I I

I

I

118C)

o- li C S - 2 - 1 L~ _




I I

I)u 23[ (1186)

OFIgtjCS-2

~~ e-e- _2_ ~~ ~_ ~~~ ~

1----- --------------gt-------------~ - -~~-~------_-~-----------------------~-~lt- --~~-





II policies I

II

i

I i

I II I

I I I I



~r 2l ~ c_ ~~_ ~_l~ [_ _ _ _- _-----_ _ -----_ _-_ bull____ ___ ---- _ ___





I

I i

I

(ir-JCS-

6F ~ -1_ ~_~ ~lr ~ i) n

ACTIGnS

Il_ _____ __ ______






8fjCSmiddot2



to 5ubcont(Dctors 0

i I

I I

I

II

i-tca i]ency

I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I


I


CjJa













3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I








------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy










------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy



2) Location Owner _








I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)







$

---ltgt___--shy



ECNO fI-G










-----

i ~--_-- lt_bull-~-~-~


I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

_~_~

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STA1= FUNi)


~====== T01TL IlJCCt~ ( 11) -$


______-1

II

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1

1


I iDIAL 1$ 1


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I I


70TL




1$----------1$$ shy I

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r------------

i$


I 1$ I__

$ i$ bull i I


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I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


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1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


1 r 2 a iJ 1= I C j

1 [I

fl r) I



JfCTIV IllES


CUR~ENl

----------


-------------------~-- -____-----_~-~lt_ ~~---__----_ --------~- --~--~--- _- --~ -~-__---__- _---_shy




I ~--__-----------


Of A NQ 233 (11ES)

OF-i Smiddot~2









I -- -------------t---------t--------l---------L------L-----I

1

I I

~~ t ~~~~~~ ~~~~~d I

I _1__

J I +

XX --1



I

I -shy

II I I l----------r----shy

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II

II

XX I I


I ---r----------~-middoti-----lt-

I I

I


1 1$

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I

[$ i




) - shy - J J- r e C -~ -l f r n (116)


- 1 j -



D ipound~ CS- 2

i~~E~_j_~_c~ ~_~_q~





Caselo~d size



OFACS-~~

12 e-p_ ~~ ~_~ j_ ~_ ~~ -----~-----------__ __----__------__--__----__--_---_- --_ _--- _ ~--~-__--__-_ _- _--------------~--__-_ ------

I InHENDED HTICiiS




i

OFA ]10 23C (lJ86)

UFAC~middot-2




)

OFr~ )0 (~33 (1186) Area fgene)

[irA CS- 2 - 17shy

~eE~j_~_~~9_~

I INTENDED ACTIONS


I

I I

I

I

118C)

o- li C S - 2 - 1 L~ _




I I

I)u 23[ (1186)

OFIgtjCS-2

~~ e-e- _2_ ~~ ~_ ~~~ ~

1----- --------------gt-------------~ - -~~-~------_-~-----------------------~-~lt- --~~-





II policies I

II

i

I i

I II I

I I I I



~r 2l ~ c_ ~~_ ~_l~ [_ _ _ _- _-----_ _ -----_ _-_ bull____ ___ ---- _ ___





I

I i

I

(ir-JCS-

6F ~ -1_ ~_~ ~lr ~ i) n

ACTIGnS

Il_ _____ __ ______






8fjCSmiddot2



to 5ubcont(Dctors 0

i I

I I

I

II

i-tca i]ency

I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I


I


CjJa













3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I








------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy










------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy



2) Location Owner _








I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)







$

---ltgt___--shy



ECNO fI-G










-----

i ~--_-- lt_bull-~-~-~


I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

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STA1= FUNi)


~====== T01TL IlJCCt~ ( 11) -$


______-1

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___ __

1

1


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I I


70TL




1$----------1$$ shy I

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r------------

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$ i$ bull i I


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I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6


Tie first two pages of this section are matrices to summarize EISEP services expansion for the three-month period January 11987 through March 31 1987 (page 12) andor the twelve-munth period April 11987 tilrough 11arch 31 1988 (page 13) The Aea Agency must complete page 13 covering the twelve-month period -ill be completed only if the three-month services expansion funding is being requested for January through ~larch 1987







7












8











9




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I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










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----------------------------------------------------------



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needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





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-

TOTAL



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AFE I r -

gt ()FA No 238 (1186) C




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D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





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-

TOTAL



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D ipound~ CS- 2

i~~E~_j_~_c~ ~_~_q~





Caselo~d size



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OFA ]10 23C (lJ86)

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1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

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f i



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1

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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










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----------------------------------------------------------



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-

TOTAL



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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



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IV INTENDED ACTIONS




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---


orA No 49 (0986)



-

TOTAL



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i

OFA ]10 23C (lJ86)

UFAC~middot-2




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gt ()FA No 238 (1186) C




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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




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needs to be

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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



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[irA CS- 2 - 17shy

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I I

I

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AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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orA No 49 (0986)



-

TOTAL



I I


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o- li C S - 2 - 1 L~ _




I I

I)u 23[ (1186)

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II

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1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


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i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

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II I

II

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I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







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ADDRESS _






3 Consultants

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~Resources $

----------~---------------

------------------------

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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


I)u 23[ (1186)

OFIgtjCS-2

~~ e-e- _2_ ~~ ~_ ~~~ ~

1----- --------------gt-------------~ - -~~-~------_-~-----------------------~-~lt- --~~-





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II

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-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

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f i



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1r Iii 11----------------- -----------------------------------1------------------- - --------~

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I I

II I

II

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I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



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IV INTENDED ACTIONS




5









6









7












8











9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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~Resources $

----------~---------------

------------------------

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------------------------

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------------------------

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------------------------

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$

I

I

1

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$ $ $

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ls

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I NSlRANC4

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ttUC ITS

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I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I




~r 2l ~ c_ ~~_ ~_l~ [_ _ _ _- _-----_ _ -----_ _-_ bull____ ___ ---- _ ___





I

I i

I

(ir-JCS-

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3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





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I I I I I1--_______1 - I ---------T I 1---------1

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-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

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-------------1 I I








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------- $--------__-- shyI --------- $-------~--__-

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1

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$

---ltgt___--shy



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I 5 tmiddot

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l

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I I


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i

I

I shy

I I

II I

II

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I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

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6 Rent

7 Corrnnunications


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I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

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I ITitle - I


I Ideg1Title

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I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

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t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

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hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

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-

Total



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Tocal I I

AMCtJNT 0iARGlUBIE

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$

S

S



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$ $ $

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Total I$

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$ $ $ $ $

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ls

~

Communjcations

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I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

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I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


(ir-JCS-

6F ~ -1_ ~_~ ~lr ~ i) n

ACTIGnS

Il_ _____ __ ______






8fjCSmiddot2



to 5ubcont(Dctors 0

i I

I I

I

II

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I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I


I


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3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I








------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy










------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy



2) Location Owner _








I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)







$

---ltgt___--shy



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-----

i ~--_-- lt_bull-~-~-~


I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

_~_~

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STA1= FUNi)


~====== T01TL IlJCCt~ ( 11) -$


______-1

II

___ __

1

1


I iDIAL 1$ 1


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I I


70TL




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I 1 IIII I ~--

I

r------------

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i

I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

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Unit Etgbullbull

hour

Cost -atel


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lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







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Tocal I I

AMCtJNT 0iARGlUBIE

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$

$

S

S



-shy




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General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



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Total I$

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$ $ $ $ $

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- --_

ls

~

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Postage

Printing Supplies ~

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I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I



8fjCSmiddot2



to 5ubcont(Dctors 0

i I

I I

I

II

i-tca i]ency

I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I


I


CjJa













3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





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-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I








------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy










------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy



2) Location Owner _








I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)







$

---ltgt___--shy



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-----

i ~--_-- lt_bull-~-~-~


I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

_~_~

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STA1= FUNi)


~====== T01TL IlJCCt~ ( 11) -$


______-1

II

___ __

1

1


I iDIAL 1$ 1


] t-iN[CUIlrElWDS


I I

I I


70TL




1$----------1$$ shy I

I 1 IIII I ~--

I

r------------

i$


I 1$ I__

$ i$ bull i I


i

I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


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lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

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Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


i-tca i]ency

I 10HJ TGr~ING i

1_____ ___ -_- -__ __ ------------ - ___ -- - _~_ J i

_-_~_ --__~-- ~----- - _ __I


I


CjJa













3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

I I I I I1--_______1 - I ---------T I 1---------1

_~ t I I I I I_____ I ----L- I

-----



1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

please

I_---------__-------_ _-----shy ------1I


Iserv1ces



i I

Total $






AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

I I

f i



-shy

Loc~nlon



1r Iii 11----------------- -----------------------------------1------------------- - --------~

-- - -- -- I I I ---- -- i I I

~--- -------~-~~~~--=-~~-=--=-=-~-=~~ =-~ =------- T--T----shy~--------------- --_----------- ------- L__-----l--- -------- -I T

-------------1 I I








------- i I I 1-shy------ ---------r------------------

11

~

T -------------------1 I I I ~ ----------------l~----I----r-~~~----_- _----- __-~- -------__-

Tetzl $ --- -----__--_------------- shy










------- $--------__-- shyI --------- $-------~--__-

S -__-------------------__-~- -------- shy

$-- shyI $--------shy



2) Location Owner _








I

1

~-3J - A2a 1Cj2Cy _OFA N~ 238 (1186)







$

---ltgt___--shy



ECNO fI-G










-----

i ~--_-- lt_bull-~-~-~


I -

i L 2

I 5 tmiddot

~ I ~ j5 (3

I I

I ~ 11 E

II l~ 11

l

_~_~

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STA1= FUNi)


~====== T01TL IlJCCt~ ( 11) -$


______-1

II

___ __

1

1


I iDIAL 1$ 1


] t-iN[CUIlrElWDS


I I

I I


70TL




1$----------1$$ shy I

I 1 IIII I ~--

I

r------------

i$


I 1$ I__

$ i$ bull i I


i

I

I shy

I I

II I

II

I I I

I I ------I I I I i I -I i I I I ~


0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I



CjJa













3l 1988 ( ) Eo ( ) NO i I

I f DOI I 1





-r-----r~-~---l$ rs--- 1$ i ----------+1-----r-----1-- 1 - I

-------------r ---------+---------- 1 _ i -l ~ -------- I I I I

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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



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---


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-

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I I


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1985 tbLough 311936 $---~---~--



( ) YES ( ) NO

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AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









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8











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needs to be

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~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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---


orA No 49 (0986)



-

TOTAL



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AFE I r -

gt ()FA No 238 (1186) C




r -- Ii ~------------------------------------------------------~




I




1 _____ 1 1 l

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f i



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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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-----

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orA No 49 (0986)



-

TOTAL



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Loc~nlon



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INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




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6









7












8











9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





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-

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0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




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6









7












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9




needs to be

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~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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~Resources $

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------------------------

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------------------------

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------------------------

------------------------

OFA No 239 (1186) -2shy







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-----

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-

TOTAL



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II I

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0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







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ADDRESS _






3 Consultants

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I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

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I Name

II ITitle I


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Location I I1

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t=~e 5ancits



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I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


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0 R AFT

INSTRUCTIONS

fOR COMPLETIO~ OF





D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












8











9




needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







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ADDRESS _






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I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

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I ITitle - I


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orA No 49 (0986)



-

TOTAL



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orA No 49 (0986)



-

TOTAL



I I


0 R AFT

INSTRUCTIONS

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D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








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orA No 49 (0986)



-

TOTAL



I I


D R AFT (111986)






I PREFACE








I









2

~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










4

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orA No 49 (0986)



-

TOTAL



I I










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-----

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---


orA No 49 (0986)



-

TOTAL



I I


~~_~~~-E2~~middot~_~-~~~_LEa~~_~J








3










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-----

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---


orA No 49 (0986)



-

TOTAL



I I











4

----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












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-----

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---


orA No 49 (0986)



-

TOTAL



I I


----------------------------------------------------------



- rr~I~_ ~E~~l _~r lti-~- lt~~_l e~~_H




IV INTENDED ACTIONS




5









6









7












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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I










6









7












8











9




needs to be

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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I










7












8











9




needs to be

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~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I













8











9




needs to be

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~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


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------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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------------------------

------------------------

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-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I












9




needs to be

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10


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~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







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------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

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I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I





needs to be

at least Medicaid







10


~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

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6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






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-

Total



S $ $ $ $

ot31







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$

$

S

S



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Telephone Cost


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$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I



~ ~_-~_t ~_ 1o_~_t E~~_ ~ _~U





~~~~~~~~_~_~f~~_~~~~~~~_t~~[~~_~~~~~l


11




V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

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$

$

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S



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Telephone Cost


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$ $ $

Total $


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ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

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Total I$

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Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

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Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I





V BUDGET







i 2



ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

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$

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S



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Telephone Cost


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$ $ $

Total $


$




ptoiO ICCCFYT NG



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SlJSSCR I PTI eN

FUNCS


Total I$

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Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I




ADDRESS _






3 Consultants

+ Equipment

~ Travel

6 Rent

7 Corrnnunications


I I


1O SubcontTac~s


I

I $ i $





~Resources $

----------~---------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

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$

$

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S



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Telephone Cost


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$ $ $

Total $


$




ptoiO ICCCFYT NG



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SlJSSCR I PTI eN

FUNCS


Total I$

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Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

------------------------

OFA No 239 (1186) -2shy







II I iLocation

Name I I

I ITitle - I


I Ideg1Title

I II Location

I Name

II ITitle I


ITitle I I

ILocation I I


Location I I1

I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

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$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I










t=~e 5ancits



bullt


Consultancs


~r-----------------I

yen-----------------j N IT-----------------l

P e of Ser7ice

Unit Etgbullbull

hour

Cost -atel


sessions

lmoune

$

I

I

1

70t2l

I t

I I I

IIs






RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I







RIa

-

Total



S $ $ $ $

ot31







i nfor-m~tlon

Tocal I I

AMCtJNT 0iARGlUBIE

TO~

$

$

S

S



-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I




-shy




Telephone Cost


General Special


$ $ $

Total $


$




ptoiO ICCCFYT NG



I

SlJSSCR I PTI eN

FUNCS


Total I$

I

Subcontractor


$ $ $ $ $

Cost

Total

- --_

ls

~

Communjcations

Telephone

Postage

Printing Supplies ~

P~inting


Other Expenses

I NSlRANC4

9CrI01NG

EQJ I FdENT EPAIR

JEl-i etE REAI~

MDtSERSHJ


ttUC ITS

Subcontracts

I I I I

-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


-----

------- -- --

---


orA No 49 (0986)



-

TOTAL



I I


Download - PROGRAM INSTRUCTION OItel ~l!illi]'Q' · The purpose of this Program Instruction is to transmit 2 copies of the revised version of the County Home Care Plan for the Functionally Impaired

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